When “High-Functioning” is Harmful

(This article was published on The Mighty on October 3, 2016.)

Photo by Caleb Betts, Unsplash

“I have to say, you’re the most high-functioning autistic I’ve ever met,” my neuropsychologist said with a smile. “I’ve treated hundreds of people with autism and you really took me by surprise.  You must have learned to adapt very well at a young age.”

I was 37 years old and finally, after a lifetime of questions about why I struggled with things other people seemed to take for granted, here was an answer.  Autism.  The reason why I struggled to keep the “flow” in conversations.  The reason why eye contact felt forced, almost painful at times.  The constant sensory overload, the barrage of smells, sounds, and light. The prosopagnosia which caused me great embarrassment in my professional life as I struggled to remember colleagues’ faces.  The stimming I cleverly learned to hide by the time I got to high school, aware that my teachers and other kids thought it was odd.  Autism. Finally, it all made sense.

“There’s not really much I can do for you,” my neuropsychologist continued.  “You know, your autism may have been a problem for you when you were a kid and if we’d caught it then, we’d have some more options to help you.  But as I see it, you’ve learned to cope very well.  You’re holding down a job, a relationship, and you’re highly educated.  If you want to continue seeing me to talk about your depression, you can.  But I think you’re doing a great job. You are extremely intelligent and high-functioning.”

I sat there, stunned. I had finally received the answer I’d been searching for most of my life and at the same time I was being told there was no help available at my age. I had no idea what to do next.

I started by reading every blog and book on autism and Asperger syndrome I could find.  I found it especially helpful to read about the experiences of women on the autism spectrum, as currently autism is still seen as a “boys’ club” with the disorder being 4.5 times more common in boys than in girls.  I learned that many people, like myself, had been misdiagnosed with social anxiety and ADHD before receiving the correct diagnosis.

Despite having this newfound knowledge about myself, I still struggled with the same issues as before. Talking to people was hard.  I fumbled through conversations, never sure of how social interactions were supposed to work.  I could fake it pretty well, but it took a lot out of me. I still felt as though everyone else had been given a copy of some secret Social Rulebook and I was left constantly guessing at the rules. My significant other continued to complain about my flat affect, never knowing how to tell what I was feeling.  I tried to explain that oftentimes I struggled to label my own feelings and I couldn’t seem to force my face to reflect what I felt.

Even with a diagnosis, I still felt like an outsider in my own world.

I contacted my county’s board of disabilities and was told I was over the age limit to receive autism services unless I was “low-functioning” enough to receive disability.  I contacted a private autism services agency in my area and was told they had no services available for someone my age. I called my insurance company to ask about available services and was informed that they do not cover any autism-related services for adults. More dead ends.

Yes, I am “high-functioning” enough to call agencies and my insurance company. Yes, I can hold down a job and a relationship.

That doesn’t mean I don’t need help with certain things.  Being “high-functioning” should not be worn as a badge of honor or taken as a compliment.  Being “high-functioning” means I’ve learned to cope with my challenges on my own when help should have been available. Being a “high-functioning” autistic person has contributed to my “high-functioning” depression because I can  easily pass as “normal” in society.  My challenges are, for the most part, hidden.

And ironically, being able to “pass” is just what society wants us to do.

Developing a Substance Abuse Prevention Program for Hospital Emergency Departments in South Carolina

Developing a Substance Abuse Prevention Program for Hospital Emergency Departments in South Carolina

Karen Harper

National University

December 15, 2014

Abstract

The proposed Communities Acting Together (CAT) coalition would address narcotic pain reliever use in South Carolina. As a partnership between hospitals, churches, and community organizations, CAT would implement education about pain relievers to patients in the emergency department and community support through churches.

Developing a Substance Abuse Prevention Program for Hospital Emergency Departments in South Carolina

Hospital emergency department visits related to prescription painkiller abuse more than doubled nationwide from 144,644 in 2004 to 305,885 in 2008 (Kleffman, 2010). Emergency department physicians continue to prescribe opioid pain relievers despite the fact that the recommended route of administration for narcotic pain relievers is intravenous (Kelly, 1999). The three most commonly abused painkillers were oxycodone, hydrocodone, and methadone. The state of South Carolina ranked 23rd in the nation for opioid painkiller prescriptions and overdose deaths, with 30 percent of Medicaid recipients receiving a prescription for opioid painkillers in 2010 (Haley, 2014). Opioid painkiller abuse has economic consequences for the state as well as emotional consequences for families. South Carolina Governor Nikki Haley issued an executive order to address this public health problem in 2014, calling on local coalitions to address the issue of prescription painkiller abuse in their communities. I am proposing that a new coalition be formed in South Carolina to specifically target patients receiving treatment for pain in hospital emergency departments. The target demographic will include South Carolina adults over age 18 who were seen in hospital emergency departments for pain resulting in a prescription for narcotic pain relievers.

Assessing Community Readiness and Mobilizing for Action

Because healthcare providers will primarily be involved in implementing this program, a community readiness survey should be administered to physicians, nurse practitioners, physician assistants, nurses, social workers, and other healthcare providers in South Carolina. This survey can be used to measure the healthcare community’s attitudes toward the problem of opioid dependence. It is possible that some providers may be in Stage 2 (Denial) of readiness, as it is common practice to prescribe opioid painkillers and some providers may not want to acknowledge their role in the problem.

In mobilizing for action, a coalition should be formed in each county including hospitals, outpatient providers, the local county drug and alcohol abuse authorities, and other community organizations such as churches. Churches play an important role in the lives of many South Carolinians and their support can help mobilize the effort outside of the healthcare setting.

Assessing Risk Factors and Protective Factors

Each county coalition will complete a needs assessment using the Validated Archival Indicators to assess the level of risk. Some expected areas of high risk might be economic and social deprivation as well as low commitment to school. In 2013, 18.1 percent of South Carolina residents were below poverty level (US Census Bureau, 2013). South Carolina had a 2.8 percent high school dropout rate in 2011 (South Carolina Department of Education, 2012). One protective factor we may expect to see would be community laws or norms. As stated above, church involvement is an important part of life for many South Carolinians and many churches condemn drug use or encourage treatment. The United Methodist Church states, “In response to the alcohol and other drug crisis, The United Methodist Church commits itself to a holistic approach, which emphasizes prevention, intervention, treatment, community organization, public advocacy, and abstinence” (United Methodist Church, 2012). This is a common viewpoint expressed by many churches and can be considered a community norm.

Translating Data into Priorities

A 2013 report by Trust for America’s Health found that South Carolina received 5 out of 10 possible points for using strategies to curb the prescription painkiller epidemic. One risk factor identified is that South Carolina did not accept Medicaid expansion under the Affordable Care Act, leaving many South Carolinians without affordable access to substance abuse treatment (Trust for America’s Health, 2013). In addition, the state does not require the prescriber to educate patients about medications. Protective factors included requiring a photo ID in order to dispense medications, requiring a physical exam or ongoing physician/patient relationship in order to prescribe narcotic pain medications, and the existence of a prescription drug monitoring program.

Based on this information, the proposed coalition should address the need for patient education about narcotic pain relievers. If possible, the coalition should also work with county alcohol and drug authorities to help indigent patients afford substance abuse treatment.
Community Resources and Model of Addiction

As already stated, churches are a main community resource in South Carolina. Church leaders should be surveyed and interviewed when possible to assess their readiness to participate in the coalition. The county drug and alcohol authorities should also be included to assess what prevention services they may be able to provide.

The public health model best fits the coalition’s efforts since it aims to integrate the patient, the environment, the social and physical context of use. Prevention strategies would include health education in the emergency department for patients receiving narcotic pain relievers, as well as support from faith-based organizations and other community groups. The public health model includes the entire community as well as strategies such as legislation to help ensure that prescription drugs are not misused.

Target Population

According to Healthy People 2020, in 2008 4.8 percent of people ages 12 and over reported using pain relievers for non-medical purposes in the past year. The objective is to reduce the past-year use of pain relievers for non-medical purposes, although a specific target number was not set due to the low percentage.

People who seek and abuse painkillers may be attempting to meet their basic safety needs (according to Maslow’s hierarchy of needs). These individuals may seek treatment in the emergency department for any number of reasons- fractures, headaches, injuries, or abdominal or chest pain to name just a few (Kelly, 1999). These patients must have their basic needs (to be free from pain) met before they can move on to address potential addiction or misuse. For this reason, it is critical that healthcare providers provide appropriate information and, when necessary, referrals to pain management. It is important to recognize that although some individuals will misuse narcotic pain medications, they have a legitimate need to be free of pain.

In South Carolina, the target population is predominantly Caucasian and African-American. Many are living below poverty level and have limited access to health care. There is a high incidence of obesity, heart disease, and diabetes. Tobacco use has traditionally been more culturally acceptable in the Southern United States because many families work on tobacco farms, and thus there is a high incidence of tobacco use and associated diseases such as COPD.

Applying Guiding Principles and Best Practices

The proposed coalition will address opioid pain reliever abuse. The coalition’s name will be Communities Acting Together (CAT). CAT’s main focus will be on providing education to patients in the emergency department. CAT will help ensure that healthcare providers talk to their patients about the abuse potential of narcotic pain relievers and screen patients for potential abuse at every ED visit. Patients who are suspected to be abusing medications will be referred to the county alcohol and drug authority for an assessment. In addition, the ED staff will identify patients at increased risk, such as those with chronic conditions and low socioeconomic status. Those patients will be connected with local Access Health programs to assist them with healthcare costs. CAT will partner will local churches to provide support for people suffering from chronic pain and/or substance abuse. All coalition partners will follow the NAPPA Code of Ethics and ensure confidentiality. Church partners should also assure participants that their information will be kept confidential and they shall not discriminate based on race, religion, national origin, sex, sexual orientation, age, economic condition, or physical or mental disability.

Marketing can be done internally by church groups and hospitals. The coalition can also write press releases and do interviews on local TV and radio. Social media such as Facebook can also be useful in making the public aware of the campaign. The four P’s are the Product (reducing frequency of emergency department visits for opioid pain relievers), Price (possibility of inadequate pain relief), Promotion (overuse of narcotic pain medications is dangerous and possibly fatal), and Place (social media, radio, hospital and church newsletters and seminars).

One goal for the program is to reduce the number of emergency department visits related to narcotic pain medication. The strategies are patient education and medication abuse screening provided by emergency department staff and community support provided by church groups. The target group is adults age 18 and older who visit the emergency department for pain-related complaints. If education and screening are provided by emergency department personnel, then at-risk patients can be identified and directed to appropriate services. A short-term outcome is a reduction in the number of ED visits for pain medications. A long-term impact is economic savings due to fewer ED visits and reduced health problems due to prescription drug abuse.

Evaluation

External evaluators should be used to evaluate the CAT program as they may be more objective. Pre- and post-test data collection with a comparison group (such as a state that does not have a similar prevention program) can be used to measure the program’s effectiveness. Since we are collecting data on existing hospital patients, the information can be pulled from the hospitals’ databases. Existing records can be reviewed to determine which patients went to the ED for narcotic pain relievers. The results of the evaluation should be communicated to all stakeholders (hospitals, church and community groups) as well as the South Carolina council appointed to address the issue of pain medication abuse. The program should be evaluated two years after implementation to determine its effectiveness.

Funding

In North and South Carolina, the Duke Endowment (http://dukeendowment.org/grants/overview) provides funding to 501(c)(3) organizations in the areas of healthcare, child care, rural church, and higher education. The Duke Endowment funds Access Health programs across South Carolina. Since Access Health is also a partnership between healthcare providers and community organizations, Duke Endowment may also be interested in funding an organization like CAT.

Conclusion

The CAT program has the potential to reduce frequency of emergency department visits due to narcotic pain relievers by increasing patient education and community support. In order for the program to be successful, healthcare providers and community partners must be motivated to participate and believe in the program’s efficacy.

References

Haley, Nikki. (2014). Executive Order 2014-22. Retrieved from http://governor.sc.gov/ExecutiveOffice/Documents/2014-22%20Establishing%20the%20Prescription%20Drug%20Abuse%20Prevention%20Council.pdf

Healthy People 2020. (2008). Reduce the past-year nonmedical use of pain relievers. Retrieved from https://www.healthypeople.gov/node/5215/data_details

Kelly, A. (2000). A process approach to improving pain management in the emergency department: development and evaluation. J Accid Emerg Med 2000;17:3 185-187 doi:10.1136/emj.17.3.185

Kleffman, S. (2010, Jul 22). Painkiller drug abuse soaring, CDC chief warns. Oakland Tribune Retrieved from http://ezproxy.nu.edu/login?url=http://search.proquest.com/docview/649392918?accountid=25320

South Carolina State Department of Education. (2012.) Report on student dropout rates 2010-2011. Retrieved from http://recs.sc.gov/Documents/StateDropoutReport2010-11.pdf

The United Methodist Church. (2012). Alcohol and other drugs. Retrieved from http://www.umc.org/what-we-believe/alcohol-and-other-drugs

Trust for America’s Health. (2013). South Carolina scored five out of 10 on new policy report card of promising strategies to help curb prescription drug abuse. Retrieved from http://healthyamericans.org/reports/drugabuse2013/release.php?stateid=SC

United States Census Bureau. (2013). South Carolina state QuickFacts. Retrieved from http://quickfacts.census.gov/qfd/states/45000.html

The PRECEDE-PROCEED Model and Eating Disorders in Adolescents

The PRECEDE-PROCEED Model and Eating Disorders in Adolescents

Karen Harper

National University

January 11, 2015

The PRECEDE-PROCEED Model and Eating Disorders in Adolescents

According to Healthy People 2020, 14.9 percent of adolescents engaged in disordered eating behaviors in an attempt to control their weight in 2009. The target goal for 2020 was to reduce this number to 12.9 percent; however, the percentage has instead increased to 16.7 percent in 2013. Eating disorders affect both males and females, with 10.4 percent of males and 23.0 percent of females in grades 9-12 reporting disordered eating behaviors in 2013. Eating disorders include diagnoses such as anorexia nervosa, binge eating disorder, and bulimia and may lead to cardiovascular and neurological complications as well as impaired physical development (National Institutes of Health, 2007). Eating disorders are often co-occurring with other psychiatric disorders.

Phase 1- Quality of Life Diagnosis

Adolescents with eating disorders may have lower quality of life than their peers with other psychiatric conditions (Leung, Ma, & Russell, 2013). In one study, patients being treated for eating disorders presented with low self-esteem, low sense of belonging, low self-image, impairment in life skills and leisure activities, poor financial situation and living conditions, and a lack of sense of purpose. Another study found that former patients treated for eating disorders continued to have a poor quality of life (Leung, et al, 2013).

Phase 2- Epidemiological Diagnosis

The overall mortality rate for anorexia nervosa is 5.9 percent. For bulimia and eating disorder not otherwise specified, the mortality rate is 1.9 percent (Marti, Rohde, & Stice, 2013). There is also a high mortality rate due to suicide among adolescents affected by eating disorders. The suicide rate for those with anorexia is 4.7 and it is 6.5 for those with bulimia and eating disorder not otherwise specified (Marti, et al, 2013). The average duration of a single eating disorder episode was 8 years, while one study showed a 100 percent remission rate after 2 years (Marti, et al, 2013). The lifetime prevalence of any eating disorder by age 20 was 13.1 percent. Peak age of onset for eating disorders is between 16-20. Depression and anxiety are often comorbid conditions with eating disorders (Leung, et al, 2013).

Phase 3- Environmental Diagnosis

Risk factors for eating disorders include dieting, elevated body mass, body dissatisfaction, perceived peer pressure to be thin, and modeling of disordered eating behaviors ( Presnell, Spangler, & Stice, 2002). Binge eating was predicted by negative affect (depressive symptoms and low self-esteem) in adolescent girls, possibly because the girls used food as a means of comfort (Presnell, et al, 2002). Body dissatisfaction was the highest predictor of eating disorders, with adolescent girls reporting the highest level of body dissatisfaction at a fourfold higher risk than their peers (Durant, Marti, & Stice, 2011).

Predisposing, Enabling, and Reinforcing Factors

Predisposing factors, as noted above, include body dissatisfaction, dieting, perceived pressure to be thin, and modeling of disordered eating behaviors. Depressive symptoms are also a predisposing factor. Enabling factors can include media portrayals of thinness as desirable, as well as lack of adequate treatment facilities and mental health providers specializing in eating disorders. Reinforcing factors may come from the family, such as parents who are overly critical, overprotective, shaming, or family members who also engage in disordered eating behavior (Treasure, Sepulveda, MacDonald, Whitaker, Lopez, Zabala, Kyriacou, & Todd, 2008). Family members’ compulsivity, rigidity, and focus on detail can also be enabling factors (Treasure, et al, 2008).

Phase 4- Intervention Alignment and Administrative and Policy Assessment

Positive results have been attained among at-risk teen girl athletes who attended health education programs targeting eating disorders. The girls were taught about healthy eating behaviors, self-esteem, exercise, resisting peer pressure, and body image (Langmesser & Verscheure, 2009). Because athletics are an important part of middle and high school life for many adolescents, school athletic departments should consider implementing eating disorder prevention programs for young athletes, who are especially at risk due to the competitive nature of sports and focus on being thin in some activities such as gymnastics or dance (Langmesser & Verscheure, 2009).

Phase 5- Implementation

A health education program will be implemented in public schools for grades 9-12. This program will be specifically targeted at adolescents participating in school athletic programs. It will include topics such as body image, healthy eating and exercise habits, peer pressure, body image, and self-esteem. Students will be encouraged to share their own experiences with their peers and instructors. Instructors should assure the students that if they have concerns about eating disorders and would like help, the instructor will keep their concerns confidential from their peers. Coaches and physical education teachers will be trained to teach the program and to be aware of warning signs of eating disorders. If the instructor feels that a student may be showing signs of an eating disorder, he or she should speak to the student individually and make a referral to the school psychologist or social worker as appropriate. School mental health workers also need to be aware of the program and have adequate training in identifying and treating eating disorders.

Financial costs of implementation should be relatively low, as the program will be taught by existing school staff. Funding will be required at the federal level to plan and coordinate program implementation.

Stages 6, 7 and 8- Evaluation

The program shall be evaluated on an annual basis. Data will be collected about the number of eating disorder cases identified in schools and the overall prevalence of eating disorders in the grade 9-12 population. Instructors will complete an annual survey to evaluate any potential problems in the process. The curriculum will be re-evaluated annually based on instructor feedback. If by 2020 a decrease in the prevalence of eating disorders among adolescents grades 9-12 has not been achieved (per Healthy People 2020 goals), the program shall be discontinued.

References

Chavez, M., & Insel, T. R. (2007). Eating Disorders: National Institute of Mental Health’s Perspective. The American Psychologist, 62(3), 159–166. doi:10.1037/0003-066X.62.3.159

Healthy People 2020 Objective Data Search. (n.d.). Retrieved January 12, 2015, from https://www.healthypeople.gov/2020/data-search/Search-the-Data?nid=4811

Langmesser, Lisa,M.S., A.T.C., & Verscheure, Susan, PhD,A.T.C., C.A.T.(C.). (2009). Are eating disorder prevention programs effective? Journal of Athletic Training, 44(3), 304-5. Retrieved from http://ezproxy.nu.edu/login?url=http://search.proquest.com/docview/206652233?accountid=25320

Leung, S., Ma, J., & Russell, J. (2013). Enhancing quality of life in people with disordered eating using an online self-help programme. Journal of Eating Disorders, 1, 9-9.

Stice, E., Marti, C., & Durant, S. (n.d.). Risk Factors For Onset Of Eating Disorders: Evidence Of Multiple Risk Pathways From An 8-year Prospective Study. Behaviour Research and Therapy, 49(10), 622-627.

Stice, E., Marti, C. N., & Rohde, P. (2013). Prevalence, incidence, impairment, and course of the proposed DSM-5 eating disorder diagnoses in an 8-year prospective community study of young women. Journal Of Abnormal Psychology, 122(2), 445-457. doi:10.1037/a0030679

Stice, E., Presnell, K., & Spangler, D. (2002). Risk factors for binge eating onset in adolescent girls: A 2-year prospective investigation. Health Psychology, 21(2), 131-138. doi:10.1037/0278-6133.21.2.131

Treasure, J. G. (2008). The assessment of the family of people with eating disorders. European Eating Disorders Review, 16(4), 247-255.

A Literature Review of the Safety and Efficacy of DDT

A Literature Review of the Safety and Efficacy of DDT

Karen Harper

National University

December 20, 2015

Abstract

Malaria infects approximately 350 million people per year and kills one million people per year, mainly in tropical areas. Sub-Saharan Africa is an area of particular concern, with 86 percent of deaths occurring there. Pregnant women, children, and the poor are disproportionately affected.

DDT has long been shown to be effective against mosquitoes carrying malaria, but due to health concerns raised by Rachel Carson in her book Silent Spring, DDT was banned in many countries. DDT has been shown to linger in the environment and can bioaccumulate in fish. It also has the potential to impact fetal development and can be passed to infants via breast milk. Prior to the publication of Carson’s book in 1962, DDT was sprayed outdoors, resulting in the deaths of fish, birds, and other wildlife.

After DDT was banned, malaria rates rose exponentially. In 2006 the World Health Organization recommended that DDT be sprayed indoors via a method known as indoor residual spraying (IRS). While IRS has largely been shown to be cost-effective and its implementation has dramatically reduced the number of new malaria cases, its long-term health effects are still unclear and many people remain skeptical about its use.

Much research needs to be done on the effects of DDT and the environment, as well as its long-term effects on human health. Public health officials in tropical areas affected by malaria also need to be aware of their population’s wariness about IRS and find ways to present accurate information to the public so that more people will adhere to treatment recommendations.

A Literature Review of the Safety and Efficacy of DDT

In 1962, Rachel Carson’s classic environmental treatise Silent Spring was published. This book was groundbreaking in its criticism of the pesticide dichlorodiphenyltrichloroethane (DDT). Up until that time, DDT was seen as a panacea for insect-borne diseases, particularly malaria. Carson’s book offered up the dark side of widespread DDT usage: dead birds, dead fish, and death and damage of other sensitive marine life (Berry-Caban, 2011). The public outcry against DDT was so strong after the publication of Silent Spring that pesticide companies including Monsanto and American Cynamid launched counterattacks against Carson. Since then, DDT has often been viewed as dangerous by the public. However, much new research has been done about the health and environmental effects of DDT since 1962.

After the publication of Carson’s book, many countries banned DDT use altogether. Some of these countries were in Africa, where the anopheles mosquito is prevalent and carries malaria. In South Africa, the number of malaria cases had leveled off by 1996 when DDT was banned; from that point on, the number of new cases skyrocketed. This was in contrast to nearby Swaziland, where DDT use was never interrupted, and malaria remained a minor problem (Bocking, 2004). Now, the conundrum was clear: widespread spraying of DDT caused harm to the environment, but also seemed to be vital in controlling the spread of malaria.

Studies about DDT’s toxicity to humans and wildlife continue to be done with varying results. A 2012 study in Bangladesh, where DDT is officially banned but is nevertheless still being used in agriculture, showed that DDT bioaccumulates in fish as a result of runoff from farming. The DDT levels in “dry fish” popular as a food staple in Bangladesh were considered to be toxic to humans (Siddique & Aktar, 2012). However, in considering the validity of this study it is also important to note that some commercial fisheries in Bangladesh use DDT as a preservative, which is not standard practice in other countries. This may have increased DDT concentration beyond levels which would have been found due to agricultural runoff alone. Thus, it important to keep in mind that different levels of toxicity may have been found if different preservatives had been used.

A long-term study of pregnant women and their daughters in Oakland, CA showed a positive correlation between prenatal DDT exposure and risk of developing hypertension later in life (Merrill, Cirillo, Piera, Terry, Krigbaum, Nickilou, Flom, & Cohn, 2013). A limitation of this study is that participants were asked to self-report their other medical conditions such as diabetes, and thus there is no way to know whether some coexisting conditions could have been incorrectly or under- reported and potentially raised the likelihood of participants having hypertension independently of DDT exposure.

Indoor residual spraying (IRS) of DDT has been suggested as a safer alternative to widespread, outdoor spraying. IRS has been used mainly in tropical countries where exposure to disease vectors is high. One study compared DDT concentrations among human populations in the Arctic versus tropical populations. In the Arctic marine mammals are a common food source and may contain residual DDT, whereas in tropical areas homes are frequently sprayed with DDT to reduce mosquito and other vector exposure. The study found that DDT concentrations were higher in people living in homes treated via IRS (Ritter, Scheringer, MacLeod, & Hungerbuhler, 2011). However, it is unclear from this study what health effects, if any, DDT exposure resulted in.

In 2011, the World Health Organization stated that more research needed to be done on the effects of IRS in women of childbearing age and their fetuses and infants. Several studies have already indicated that DDT is present in breast milk and can then be passed to nursing infants. Firstborn infants are at risk for ingesting higher amounts of DDT than their siblings. In studies of IRS-treated villages, pregnant women and nursing mothers had toxic levels of DDT in their blood, which is a concern not only for the mothers but also their developing fetuses and infants. DDT has been shown to be an endocrine disruptor and can also affect urogenital development in fetuses. The study did not find any correlation between DDT exposure and length of lactation (Bouwman, Kylin, Sereda, & Bornman, 2012). Although the study did not come up with specific health risks for infants exposed to DDT via breast milk, it is worth bearing in mind that exposure to any chemicals during a child’s early development may be risky. At the same time, it is important to note that malaria disproportionately affects pregnant women and children, and thus the benefits of IRS may outweigh potential risks (Danley, 2002).

Danley (2002) also notes that alternatives to DDT are not always safer or as effective. Bed nets are frequently treated with pyrethroids, which mosquitoes have become resistant to in some areas. While mosquitoes can also become resistant to DDT, it is less common. Using biological controls such as mosquito-eating fish can also threaten biodiversity if not managed correctly. Draining marshes and wetlands can also be harmful to the environment. DDT is in many cases a simpler, cheaper, and more effective way to control mosquitoes, despite its risks to environmental and human health.

DDT is known to linger in the environment, which is one reason IRS is a concern. Another option, though not nearly as cost-effective, is treating bed nets with DDT. This would potentially reduce the chemical’s impact on the environment. However, bed nets may not prevent as many malaria infections as IRS (Pedercini, Blanco, & Kopainsky, 2011).

In 2006, the World Health Organization recommended IRS as a preventative measure in areas with high rates of malaria infection (WHO, 2006). They noted that one million people die from malaria infection every year, and 86 percent of these deaths occur in sub-Saharan Africa. In these areas, the poor are disproportionately affected. Following this recommendation, a study in Mozambique found that a household’s socioeconomic status impacted their perception and adherence to IRS recommendations. In general, households with lower socioeconomic status had less trust in the public health authority and did not believe IRS worked well against mosquitoes. People in these households favored bed nets over IRS. By contrast, households with higher socioeconomic status were more likely to view IRS favorably and were more likely to comply with treatment recommendations. People were also more likely to allow their homes to be sprayed if they personally knew the person spraying. There was also a misperception among many people that it did not make sense to spray indoors since mosquitoes live and breed outdoors (Munguambe, Pool, Montgomery, Bavo, Nhacolo, & Fiosse, 2011). This study illustrates the importance of education and developing trust among the population in order to improve outcomes.

Conclusion

More research needs to be done on the health effects of DDT, particularly in women of childbearing age and their infants. Since DDT lingers in the environment and can bioaccumulate in fish, more research needs to be done on the implications for the environment and humans. Public health campaigns in malaria-prone areas should also address IRS adherence issues such as distrust of the government and fears of the insecticide.

References

Bocking, Stephen. (2004). One cheer for DDT? Forty years after Silent Spring, resurgent malaria gives new life to an old killer.(Political Science). Alternatives Journal, 30(4), 28.

Bouwman, Hindrik, Kylin, Henrik, Sereda, Barbara, & Bornman, Riana. (2012). High levels of DDT in breast milk: Intake, risk, lactation duration, and involvement of gender. Environmental Pollution, 170, 63-70.

Cristobal S. Berry-Caban. (2011). DDT and Silent Spring: Fifty years after. Journal of Military and Veterans’ Health, 19(4), Journal of Military and Veterans’ Health, 01 October 2011, Vol.19(4).

Danley, J. (2002). Balancing Risks: Mosquitoes, Malaria, Morality, and DDT. Business and Society Review, 107(1), 145-170.
Merrill, Michele La, Cirillo, Piera M., Terry, Mary Beth, Krigbaum, Nickilou Y.,

Flom, Julie D., & Cohn, Barbara A. (2013). Prenatal exposure to the pesticide DDT and hypertension diagnosed in women before age 50: A longitudinal birth cohort study.(Research)(Clinical report). Environmental Health Perspectives, 121(5), 594.

Munguambe, K., Pool, R., Montgomery, C., Bavo, C., Nhacolo, A., Fiosse, L., . . . Alonso, P. (2011). What drives community adherence to indoor residual spraying (IRS) against malaria in Manhiça district, rural Mozambique: A qualitative study. Malaria Journal, 10, 344.

Pedercini, M., Blanco, S. M., & Kopainsky, B. (2011). Application of the malaria management model to the analysis of costs and benefits of DDT versus non-DDT malaria control. PLoS One, 6(11) doi:http://dx.doi.org/10.1371/journal.pone.0027771

Ritter, Roland, Scheringer, Martin, MacLeod, Matthew, & Hungerbuhler, Konrad. (2011). Assessment of nonoccupational exposure to DDT in the tropics and the North: Relevance of uptake via Inhalation from indoor residual spraying.(Research)(Report). Environmental Health Perspectives, 119(5), 707.

Siddique, M., & Aktar, M. (2012). Detection of health hazard insecticide dichlorodiphenyltrichloroethane (DDT) in some common marine dry fish samples from Bangladesh. Health, 4(4), 185-189.

WHO gives indoor use of DDT a clean bill of health for controlling malaria. (2006, September 15). Retrieved December 20, 2015, from http://www.who.int/mediacentre/news/releases/2006/pr50/en/

Cost-effectivess of Colonoscopy as a Screening Tool for Colorectal Cancer

Cost-effectivess of Colonoscopy as a Screening Tool for Colorectal Cancer

Karen Harper

National University

March 27, 2016

Cost-effectiveness of Colonocopy as a Screening Tool for Colorectal Cancer

Colonoscopy is widely regarded as the “gold standard” for colorectal cancer screening in the United States. During this procedure, the clinician can remove polyps in the colon which may be precancerous (adenomas). Although many clinicians continue to recommend colonoscopy for colorectal cancer screening, questions arise as to the procedure’s efficacy and cost-effectiveness. Colonoscopy is a highly invasive procedure, requiring the patient to be either sedated or placed under general anesthesia while the colon is examined. Preparation for the procedure is uncomfortable and inconvenient for many patients as a large amount of laxative must be consumed to flush out the bowel. In addition, colonoscopy is a very expensive procedure. Although many adenomas have been identified and removed via colonoscopy, most adenomas do not eventually become cancerous, again bringing into question whether this invasive procedure is really cost-effective. This paper will compare two studies in which the efficacy and cost-effectiveness of colonoscopy were examined.

Study by Sonnenberg, Delco, and Inadomi

Amnon Sonnenberg, Fabiola Delco, and John Inadomi published a study in 2000 with the objective of examining the cost-effectiveness of colonoscopy in comparison to other screening tests (fecal occult blood testing and flexible sigmoidoscopy). This study used a hypothetical sample of 100,000 adults age 50 and older. This hypothetical cohort was followed until death. Computer models used a Markov process to randomly determine whether each of the study participants received screening via annual fecal occult blood testing, flexible sigmoidoscopy every five years, or colonoscopy every ten years starting at age 50 until death. For those who had positive fecal occult blood tests or adenomatous polyps discovered during sigmoidoscopy, a colonoscopy was then performed every three years until all polyps were gone. Data for the computer model came from published U.S. vital statistics and cancer statistics on specificity and sensitivity of the screening methods, as well as efficacy of each method. Costs were estimated based on Medicare reimbursement rates for the screenings and cancer care.

Results of this study showed that although fecal occult blood testing was the least expensive of the three methods, it saved fewer life-years than colonoscopy. Flexible sigmoidoscopy was also found to be less cost-effective than fecal occult blood testing or colonoscopy. Low patient compliance with annual fecal occult blood testing also contributed to colonoscopy every ten years being a more cost-effective screening tool.

Statistical analyses of potential risks involved with each method were included as part of the study. Sensitivity of each method was also taken into consideration. Although colonoscopy was associated with higher rates of complications (perforation and bleeding) than the other two methods, it was far superior at detecting and removing polyps. Even when the cost of colonoscopy was taken into account, the study’s authors still concluded that colonoscopy is more cost-effective than flexible sigmoidoscopy or fecal occult blood testing.

This study does have some limitations. It is based on a computer model and uses a Markov process, which seems appropriate for this scenario in determining efficacy in a controlled environment, but the results may not translate to effectiveness within the larger population. The study also did not take into account patients who opted to receive no screening at all. It also used Medicare reimbursement rates to estimate costs, which may be misleading as the authors started following the cohort at age 50, when most participants would have been ineligible for Medicare. Other sources such as Medicaid or private insurance may have had lower or higher reimbursement rates which should have been taken into account when estimating costs. Finally, this study was done in 2000 and is now sixteen years old. It is possible that factors such as cost, sensitivity, and risks of each procedure may have changed since then as technologies evolved. Therefore, I would hesitate to apply this study’s results to the population at large.

Study by Hassan, Rex, Zullo, and Kaminski

A 2015 study by Cesare Hassan, Douglas Rex, Angelo Zullo, and Michal Kaminski used a similar Markov computer model with a hypothetical sample size of 100,000 participants. The objective was to estimate the impact of adenoma detection rate on the long-term colorectal cancer prevention rate. The authors used the computer model to estimate the adenoma detection rates of endoscopists who had a history of low adenoma detection rates versus those who had average or high detection rates. The theoretical cohort consisted of 100,000 American men and women ages 50-80. They received colonoscopies every ten years. As in the previous study, costs were estimated using available Medicare reimbursement data.

A relative risk of 1.5 was assumed between endoscopists with low and average adenoma detection rates, and a relative risk of 11 was assumed between endoscopists with average and high adenoma detection rates. The impacts and costs of providing additional training to the endoscopists who had lower detection rates were also taken into account.

Unlike the previous study, this one did take into account the costs associated with receiving no screening at all (and costs and mortality associated with colorectal cancer). Those who received no screening had no reduction in rate of colorectal cancer detection, while overall rate of colorectal cancer detection in those who received colonoscopies was 75%. This percentage was lower for endoscopists with low adenoma detection rates (70%) and higher for those with average detection rates (71-77%). The best outcome occurred when endoscopists had high adenoma detection rates (92%).

The authors concluded that colonoscopy is a cost-effective method of screening for colorectal cancer, but that its usefulness at preventing colon cancer is significantly impacted by the clinician’s success rate at detecting adenomas. The efficacy of the colonoscopy can vary by 7-21% depending on the endoscopist’s skill level. The authors conclude, therefore, that it is also cost-effective to invest in adequately training endoscopists so that there will be a higher adenoma detection rate overall.

The authors acknowledge that a limitation of the study is that they do not have sufficient data to determine the long-term effect of regular screening colonoscopies (every ten years) by a clinician with a high adenoma detection rate. As in the previous study, I would also add that another limitation could be that this is a computer simulation which may not be applicable to the general population. The research may also be biased as the four authors of the study used their own adenoma detection rates as models for the computer simulation. It is not clear from the study what criteria were used to rate each clinician as “low,” “average,” or “high.” Also, as in the previous study, Medicare reimbursement rates were used to estimate costs. At the time the study took place, most people under age 65 were not eligible for Medicare unless disabled, so this leaves an age gap of ages 50-64 in the study who may have had other sources of payment (self-pay, Medicaid, or private insurance).

Comparison of the Two Studies

Both studies conclude that colonoscopy is a cost-effective method of screening for colorectal cancer. The second study by Hassan, et. al., also concludes that the endoscopist’s rate of adenoma detection is also crucial to the effectiveness of colonoscopy. Both studies used a theoretical sample size of 100,000 using a Markov process via computer simulation. It is difficult to know whether this simulation is representative of the population as a whole. Neither study took into account payer sources other than Medicare, which may have skewed the data on costs. Because the study by Hassan, et. al is more recent than the previous study I would hesitantly be more comfortable in applying the results to the general population.

If I were to design a study examining the efficacy and cost-effectiveness of colonoscopy, I would do a cohort study of participants ages 50 and older. I would continue to follow them until death and compare rates of colon cancer among the groups who had no screening versus those who had colonoscopy, flexible sigmoidoscopy, or fecal occult blood testing. I would consider stratifying the data by payer source such as Medicare, Medicaid, private insurance, or self-pay in order to get a more accurate measure of cost. I would collect the data via medical records and hospital bills, including bills for cancer care. I would also adjust for possible risk factors which may contribute to development of colorectal cancer. The disadvantage to this type of cohort study is that it might take a long time to get results since we are using actual patients in the study instead of a computer simulation. Another way to do this might be a retrospective cohort study, although it may be more difficult in this case to ascertain risk factors for colorectal cancer, especially among those patients who are no longer alive. Regardless, I feel that using actual patient data, including reimbursement rates from the patients’ various payer sources, would give more accurate results of cost effectiveness than a computer model.

References
Hassan, C., Rex, D., Zullo, A., & Kaminski, M. (n.d.). Efficacy and cost-effectiveness of screening colonoscopy according to the adenoma detection rate. United European Gastroenterology Journal, 3(2), 200-207.

Sonnenberg, Amnon, Delco, Fabiola, & Inadomi, John M. (2000). Cost-Effectiveness of Colonoscopy in Screening for Colorectal Cancer. Annals of Internal Medicine,133(8), 573.

A Domestic Violence Program Proposal for Georgetown County, South Carolina

A Domestic Violence Prevention Program Proposal for Georgetown County, South Carolina

Karen Harper

National University

January 29, 2016

A Domestic Violence Prevention Program Proposal for Georgetown County, South Carolina

Introduction

The state of South Carolina ranks first in the nation for the number of homicides caused by domestic violence. Of the 39 deaths in 2014, 74 percent were women and 26 percent were men. 54 percent of victims were White, 44 percent were African-American, and 2 percent were Hispanic. 67 percent of victims died from gunshot wounds, 23 percent died from knife wounds, and 7 percent died from other causes (South Carolina Attorney General, 2015).

Georgetown County, South Carolina reported one death due to domestic violence in 2014. The victim was a 60 year old white male who died from a gunshot wound (South Carolina Attorney General, 2015).

Georgetown County has one domestic violence shelter serving women and children, the Family Justice Center. This shelter is also available to victims in neighboring Horry County, which has no shelter of its own. Horry County also reported one death due to domestic violence in 2014.

Georgetown County is a rural county with the total population in 2014 estimated at 60.773 people (United States Census Bureau, 2014). There are many factors contributing to the domestic violence issue in this county. Because of its rural nature and high poverty rate (19.6 percent of county residents were at or below the federal poverty level in 2014, as compared to 14.8 percent of the United States population on average), lack of transportation is a major issue for many county residents. The county’s Family Justice Center cited lack of transportation as one of the main barriers to accessing needed services for women and children (South Carolina Department of Social Services, 2013).

While the overall employment rate in the United States grew by 2.0 percent from 2012-2013, the employment rate in Georgetown County actually fell by 0.4 percent during the same time period (United States Census Bureau, 2014). One of the area’s largest employers, a steel mill, closed during this time period and many people were left unemployed in an area with few other opportunities.

Substance abuse is also a major issue throughout South Carolina. The state’s cultural norms are generally very permissive of alcohol use, which is a reinforcing factor. A 2002 telephone survey by the South Carolina Department of Alcohol and Other Drug Abuse Services found that 8 percent of teenagers and 6 percent of adults met diagnostic criteria for alcohol abuse or dependence. When combined with Georgetown County’s other predisposing environmental risk factors- high rates of poverty and unemployment and isolation from community resources due to lack of transportation- the behavioral factor of alcohol and drug use adds to the deadly mix of risk factors contributing to the county’s domestic violence problem. As of now, the county has no standardized screening process or referral protocol for domestic violence.

Proposed intervention

The various social service and health agencies in Georgetown County currently do not have a unified domestic violence screening and referral protocol to identify individuals at risk. The proposed intervention will create a domestic violence screening tool to be used by all social service agencies and health clinics in the county, as well as a standardized referral process to guide agency staff in directing clients/patients to appropriate community resources.

The proposed screening tool is intended to be used by agency clinicians, staff, and volunteers working with adult clients and/or patients receiving services in any of the county’s social service or healthcare agencies. All adults, both male and female, should be screened at every visit to the agency as the client’s relationships and home environment can change over time. The screening tool includes questions about safety in relationships as well as questions about substance use, anger, and mental health. An open-ended question (“Is there anything else bothering you that you would like help with today?”) is also included as this may give clients the opportunity to discuss other life stresses such as unemployment and lack of financial resources which are also risk factors for domestic violence. By screening for various domestic violence risk factors at once, the individual risk factors themselves can then be addressed (such as a referral to mental health services for someone who indicates he might be depressed, or information about how to apply for SNAP benefits for someone who can’t afford food). Attachment 1 at the end of this paper shows the sample screening tool and protocol for referrals when a client/patient screens “positive” for risk factors. Process objectives include not only identifying adults at risk for domestic violence and making appropriate referrals, but also targeting the risk factors contributing to domestic violence and providing appropriate referrals/intervention before violence begins or escalates.

To start with, the intervention will need one paid full-time program manager with a Master degree in either Social Work or Public Health. This employee will be responsible for training the various partner agencies and clinics on the use of the screening tool as well as evaluating the intervention’s success. “Success” in the initial six-month period of training and implementation will be defined as achieving at least a 60 percent total screening rate of all adult clients/patients at each partner agency. After this initial six-month period, the program manager will meet with each partner agency to discuss results. If a partner agency has not met the objective of screening at least 60 percent of clients/patients, the reasons for this will need to be addressed with both the staff who provide the screenings and the agency’s administration. The initiative program manager will work with the partner agency to develop an action plan to help ensure that the objective will be met during the next six months.

Given South Carolina and Georgetown County’s high rates of domestic violence and associated risk factors, it is expected that within the first six months of implementation a total of at least ten referrals countywide to the Family Justice Center will be made. It is also expected that at least 5 percent of individuals being screened will be referred for substance abuse treatment and at least 8 percent will be referred for mental health treatment. Because of the county’s high poverty rate and the fact that the state did not accept Medicaid expansion under the Affordable Care Act, 21.5 percent of Georgetown County residents lack health insurance and may be unable to pay for substance abuse or mental health treatment (United States Census Bureau, 2014). For this reason, uninsured individuals who screen positive in these areas should be referred to the Tidelands Community Care Network, a charity organization run by the local hospital system which helps uninsured individuals pay for mental health and substance abuse treatment services.

During the next phase of implementation (6-12 months), it is expected that all partner agencies will by this time be adequately trained and familiar with the screening tool. Thus, after the initial six month period another program evaluation will be conducted to further measure the success of the initiative. “Success” at the twelve-month mark will be defined as achieving at least an 80 percent screening rate of all adult clients/patients at each partner agency. We can also expect to see referral rates rise for the Family Justice Center, mental health and substance abuse treatment, and various social services as more clients are screened.

After the one-year mark, impact evaluation should be measured by determining whether clients who screened positive and were given referrals to other agencies actually followed up on those referrals. It is common for clients not to follow up on treatment referrals for a variety of reasons and thus a 20 percent referral followup rate would be considered a successful outcome objective, demonstrating that a significant number of Georgetown County residents are being identified as having domestic violence risk factors and a significant number of these are receiving primary interventions (mental health or substance abuse treatment, referrals to social services, et cetera).

Conclusion

This domestic violence prevention initiative will require a significant commitment of time from partner agencies and clinics as their staff’s objective is to screen every client/patient. Additional funding for this initiative may be needed for additional training in areas such as motivational interviewing for those conducting screenings. After the six-month or one-year mark, it may also be necessary to hire at least one other paid staff person to help record data and track referral outcomes. Ultimately, this initiative is well worth the costs involved as the outcome objective is to reduce the incidence of domestic violence in Georgetown County and its associated risk factors. The initiative benefits the community not only by addressing family violence but also co-occurring issues such as poverty, substance abuse, and mental health treatment needs.

Attachment 1. Sample Screening Tool with Protocol.

Question 1. Have you ever felt unsafe around your partner or family members?
Protocol: If answer is yes, gather more information. If the individual discloses that they have been or are currently being abused, consult with supervisor as to whether police involvement and/or referral to Family Justice Center is appropriate at this time.

Question 2. How many days a week do you drink alcohol?
Protocol: If the individual discloses that they drink alcohol, ask how many drinks they have on a typical day when they are drinking. If the answer is more than 4 for men or 3 for women, ask whether they feel their drinking is or has ever been a problem. If they indicate that it is, consider a referral to Drug and Alcohol.

Question 3: Are you currently or have you ever felt depressed or anxious?
Protocol: If answer is yes, discuss a referral to mental health treatment. Also ask whether they have had any thoughts of dying or suicide, and if they are at immediate risk, consult with supervisor at once.

Question 4: Have you ever felt so angry you have hurt someone else, destroyed others’ property, or picked a physical or verbal fight with someone else?
Protocol: If answer is yes, refer to mental health treatment.

Question 5: Is there anything else bothering you that you would like help with today?
Protocol: Depending on the answer, such as financial difficulties or food insecurity, give information about local food banks or applying for SNAP. Refer to community resource list for additional needs. If answer indicates that the individual may be at risk for abuse, gather more information and determine whether police involvement or referral to the Family Justice Center is needed.

References

Georgetown County, South Carolina Quickfacts. United States Census Bureau. (2014). Retrieved from http://www.census.gov/quickfacts/table/PST045215/00,45043 on January 29, 2016.

State of South Carolina Office of the Attorney General. (2015). The South Carolina Silent Witness Story: Report on Domestic Violence Homicide Victims from 2014. Retrieved January 29, 2016, from http://www.scag.gov/wp-content/uploads/2011/03/Internal-Report-2015-00722504xD2C78.pdf

The Domestic Violence State Report, Federal Fiscal Year October 2012-September 2013. (2013). Columbia, S.C.: South Carolina Department of Social Services.

The South Carolina Survey, School Year 2002. (2002). Columbia, S.C.: South Carolina Department of Alcohol and Other Drug Abuse Services.

“Healthy Decisions” Sex Ed Curriculum for Grade 10

Healthy Decisions for High-school Sophomores

Karen Harper

National University

May 1, 2016

Healthy Decisions for High-school Sophomores

Introduction/Problem Statement

High school is a time when many young people begin experimenting with their sexuality. It is also a time when young people experience significant peer pressure and the desire to appear “cool” or fit in with the crowd. When high school students do not receive appropriate, comprehensive education on the physical and emotional aspects and risks of choosing to have sex, they may be more likely to make unhealthy decisions. This could include feeling pressured to have sex before being ready and not using adequate protection against pregnancy and sexually transmitted infections (STIs). The Centers for Disease Control and Prevention found that nearly 50 percent of all new cases of STIs were diagnosed in young adults ages 15-24 (2016).

Target Audience Needs

The target audience for this Healthy Decisions curriculum will be high-school sophomores (approximately ages 15-16). This is an age when many young people start experimenting with sex. Many may also brag about their sexual experience in order to appear “cool” and fit in with their peers. Many teens at this age may also lie about having had sex, leading their peers to falsely believe that “everyone” is doing it and increasing peer pressure. In truth, the average age for first sexual experience in the United States is 17 and only about half of high school students have ever had sex (Planned Parenthood, 2014). Because many teens (including those who have actually never had sex) boast about their sexual experience, those who haven’t had sex yet may feel left out of their peer group and may therefore decide to have sex for unhealthy reasons. Besides wanting to fit in with peers, other reasons teens may choose to have sex before they are ready include: fearing that a boyfriend or girlfriend will break up with them if they don’t have sex, wanting to feel older or more popular, and wanting to “get it over with.” Teens need to be reassured that not everyone their age is having sex, and moreover, that it is normal for many young people to feel uncertain about or not ready for sex. It is also important that educators normalize teenagers’ curiosity about (and possible desire to have) sex. Teens should be educated that the decision to have or not have sex is a personal one and both are respectable choices when made for healthy reasons.

Another important issue faced by the target population is STI and pregnancy prevention. As approximately half of all new cases of STIs occur in young adults ages 15-24, it is clear that additional prevention efforts are needed. One issue affecting the high incidence of STI transmission in this population is insufficient or incorrect condom usage. A 2013 Centers for Disease Control survey of high school students found that among the sexually active teens, only 41 percent reported using a condom the last time they had sex. Although many teens do use condoms, they may not have learned to put them on properly, reducing their effectiveness and increasing the likelihood that the condom will break (Centers for Disease Control and Prevention, 2013). Teens should be instructed on the proper way to put on and remove a condom. In addition, they should be taught that even with proper condom use, there is still a risk of contracting STIs, especially human papilloma virus (HPV). Young women in the target population are at an appropriate age to receive HPV vaccination and should be provided with information about this (Centers for Disease Control and Prevention, 2013). Parents should also be educated on the benefits of the vaccine.

Young people need to also be aware of high-risk and lower-risk sexual activities which put them at risk for STI infection. This is important information for everyone in the target population but is especially relevant to gay and bisexual young men, who accounted for 19 percent of new HIV infections in the United States in 2010 (Centers for Disease Control and Prevention, 2013).

All students in the target population should be taught the importance of regular STI screening. They should also be educated about the various birth control methods available and given accurate information about the male and female reproductive systems, including the menstrual cycle.

Health Behavior Theory

The Health Belief Model focuses on individual beliefs about health, perceived susceptibility, perceived severity, perceived benefits of action, perceived barriers to action, cues to action, and self-efficacy (Rural Health Information Hub, 2016). The Health Belief Model can be applied to our target population by focusing on the teens’ beliefs about sexual health via open discussion and individual self-assessments. Discussion and assessments can help examine teens’ attitudes and beliefs about sexual behavior, peer pressure, and perceived susceptibility to and severity of STIs. Education can then focus on benefits of action (such as using condoms or choosing abstinence), possible barriers to implementing healthy behaviors (such as inability to obtain condoms or peer pressure to have sex), and possible cues to action (learning that condoms are available for free at many clinics or learning that many teens choose not to have sex). The goal of the Health Belief Model is to promote self-efficacy. Teens should be presented with enough information to make their own informed choices based on their own values and beliefs about sex. A previous study of 203 teens ages 13-17 found the Health Belief Model to be highly effective in increasing knowledge of safer-sex practices, even among teens who were already having sex or had taken sex education classes in the past (Eisen & Zellman, 1986).

Program Objectives and Content Outline

The program objective is to provide teens with comprehensive, accurate information about sexuality in order to reduce STI and unwanted pregnancy rates among the target population. The program will use the Health Behavior Model to increase self-efficacy in the target population.

Educational Objective 1: Increase knowledge of the male and female reproductive systems, including anatomy and the female menstrual cycle. This module will take one week to complete and increased knowledge of this topic will be measured by a self-assessment (not counting towards the student’s grade) prior to beginning of the module and a test (graded) at the end of the module. Content will include textbook reading assignments about the reproductive system, videos about conception and birth, a quiz where students will be asked to label diagrams of male and female anatomy, and discussion of gender versus biological sex.

Educational Objective 2: Increase knowledge of the various STIs and how they are transmitted, as well as prevention. This module will take two weeks to complete and increased knowledge will be measured by a self-assessment prior to beginning the module and a graded test at the end of the module. Students will also be able to successfully demonstrate how to put a condom on a banana. Module content will include a PowerPoint presentation about STIs (including graphics showing what infection looks like), videos about HIV/AIDS and its particular relevance to gay and bisexual young men, discussion about safer sex specific to the LGBTQ population, and hands-on practice using condoms on bananas.

Educational Objective 3: Increase knowledge of pregnancy prevention and birth control methods. This module will take one week to complete. Increased knowledge will be measured by a self-assessment prior to beginning the module. At the end of the module, each student will write a brief essay on which birth control method(s) they would choose and the reasons why. Module content will include videos of real-life experiences of teen parents, such as the MTV program “16 and Pregnant,” and open discussion about pros and cons of choosing to become a parent while still in high school versus waiting until later in adulthood.

Educational Objective 4: Students will be able to assess their own values and motivations for choosing whether or not to have sex. This module will take two weeks to complete and will cover topics such as peer pressure, healthy relationships, emotional aspects of sex and relationships, and weighing pros and cons of choosing sex versus abstinence. Students will demonstrate increased self-knowledge and self-efficacy by writing an essay about their values and beliefs about sex and healthy relationships at the conclusion of the course. Module content will include open discussion about peer pressure to have sex and what it means to “lose your virginity,” values clarification worksheet, healthy versus unhealthy relationships worksheet, and PowerPoint presentation about choosing to have sex versus abstinence and various types of sexual activities besides intercourse.

Click for accompanying PowerPoint presentation: HealthyDecisions

References

Booher, K. (2013). Not Everyone’s Doing “It” Retrieved May 01, 2016, from http://www.pamf.org/teen/sex/virginity/notdoingit.html

Eisen, M., & Zellman, G. L. (1986). The Role of Health Belief Attitudes, Sex Education, and Demographics in Predicting Adolescents’ Sexuality Knowledge.Health Education & Behavior, 13(1), 9-22. doi:10.1177/109019818601300102

Fact Sheet for Public Health Personnel. (2013, March 25). Retrieved May 01, 2016, from http://www.cdc.gov/condomeffectiveness/latex.html

How To Know If I Am Ready For Sex | Planned Parenthood. (2014). Retrieved May 01, 2016, from https://www.plannedparenthood.org/teens/sex/am-i-ready

Rural Health Information Hub. (2016). Retrieved May 01, 2016, from https://www.ruralhealthinfo.org/community-health/health-promotion/2/theories-and-models/health-belief

Sexual Risk Behaviors: HIV, STD, & Teen Pregnancy Prevention. (2016, February 16). Retrieved May 01, 2016, from http://www.cdc.gov/healthyyouth/sexualbehaviors/

The Office of Adolescent Health, U.S. Department of Health and Human Services. (2016, April 7). Retrieved May 01, 2016, from http://www.hhs.gov/ash/oah/adolescent-health-topics/reproductive-health/stds.html

Autism Spectrum Disorder (slideshow)

ASD

Schizophrenia: Epidemiology and Community-based Treatment Approaches

Schizophrenia: Epidemiology and Community-based Treatment Approaches

Karen Harper

National University

May 14, 2016

Schizophrenia: Epidemiology and Community-based Treatment Approaches

Introduction

Although schizophrenia is one of the less common mental disorders in the United States, is is often one of the most debilitating. Schizophrenia is considered to be a severe and chronic mental illness. It changes the way a person thinks, acts, and feels (National Institute of Mental Health, 2016).

Some of the “positive” symptoms associated with schizophrenia include hallucinations, delusions, thought disorders, and movement disorders. “Negative” symptoms may include flat affect, anhedonia, reduced communication with others, and lack of motivation. Cognitive problems such as poor executive function, poor working memory, and trouble focusing may also be present in varying degrees (National Institute of Mental Health, 2016).

Symptoms of schizophrenia typically begin between the ages of 16-30, with men often having an earlier onset than women. There are several risk factors associated with the development of schizophrenia. The disorder has been shown to run in some families. It is also possible that differences in the brain’s development before birth may play a role. One current theory holds that the development of schizophrenia occurs as a result of the combination of genetic factors plus environmental factors such as prenatal exposure to viruses, prenatal malnutrition, complications during birth, or psychosocial factors (National Institute of Mental Health, 2016).

Because schizophrenia affects the way a person thinks, feels, and behaves, it can be extremely disabling. The first line of treatment for schizophrenia is usually medication. Once a person’s symptoms have stabilized on medication, other approaches such as psychotherapy can be included in the care plan. Often, a person with schizophrenia will require additional support and coordination of services from family and possibly a case manager. Some people may also benefit from vocational or educational support (National Institute of Mental Illness, 2016). Many people with schizophrenia struggle to keep stable jobs or housing and substance abuse is also common among this population.

Schizophrenia is a highly stigmatized disorder and it is rare to hear a “success story” about a positive outcome such as an individual returning to work or school after an episode of schizophrenia. A 2011 survey conducted by Lysaker, Tunze, Yanos, Roe, Ringer, & Rand found that the majority of patients being treated for schizophrenia in a Veterans Administration clinic had internalized stigma and stereotypical beliefs about the disorder, making it hard for them to envision a positive outcome. This self-stigma did not diminish over time (Lysaker, et al, 2011).

Epidemiology

According to the Centers for Disease Control and Prevention (2013), worldwide prevalence of schizophrenia ranges from 0.5 to 1 percent. Males are 1.4 times more likely than females to develop the disorder and overall tend to have a more severe course of illness. Schizophrenia is a life-threatening illness, with approximately one-third attempting suicide at some point during the course of the illness and one in ten people completing the act of suicide. People with schizophrenia have a two- to threefold risk of dying compared with the general population. This is not only due to the high suicide rate among people with schizophrenia but also accounts for comorbid conditions likely to accompany schizophrenia (McGrath, Saha, Chant, & Welham, 2008). The economic cost of schizophrenia is especially high after the initial episode leading to diagnosis (with an average age of 21 for males and 27 for females) compared to the third year after diagnosis onwards. This suggests that greater monitoring is needed after an initial diagnosis is made (Centers for Disease Control and Prevention, 2013).

The 2008 study by McGrath, Saha, Chant, & Welham found that schizophrenia is more prevalent in urban areas than in rural ones. It is not clear why this is the case, but it is suspected that stress due to overcrowding and environmental pollutants found in cities may be contributing factors.

Rangaswamy and Greeshma (2012) identify several factors leading to better outcomes in people with schizophrenia. Among these are female gender, married status, early treatment, acute onset of illness, cohesive family, “good premorbid personality and adjustment,” and short duration of first episode. Factors identified by the authors as leading to poor outcomes include insidious onset, delayed or irregular treatment, lack of social support, many negative symptoms (such as flat affect and decreased socialization), history of substance abuse or alcohol dependence, and poor social or occupational functioning before onset of the illness.

Conclusion

Based on what we know about schizophrenia, its risk factors and debilitating effects, and the stigma surrounding this illness, it is reasonable to conclude that more research needs to be done on all aspects of the disease. We also have enough information to identify those most at risk for poor outcomes, and thus public health interventions should be directed at these subgroups of individuals and their families.

Because men are more likely to have a more severe course of illness with an earlier onset, they may be at higher risk for poorer outcome. The average age at onset in males is 21, a time when many young men are not yet married and have not completed their education or started careers. We know that being unmarried is in itself a risk factor for a poor outcome, and with little work experience these young men are particularly vulnerable to disability. The importance of family and social support should be emphasized to those who are newly diagnosed. Family and other support groups such as those provided by the National Alliance on Mental Illness (NAMI) can prove to be beneficial for both the person with mental illness and their family members/caregivers.

Early and consistent treatment is also necessary for a good outcome. Due to the symptoms and thought disturbance of the illness itself, many people with schizophrenia may not understand why treatment with medication and/or psychotherapy are beneficial. Because of the delusions that often accompany the illness, some people may believe that medication or other treatment may be poison or a form of mind control. It can also be difficult for people with schizophrenia to keep track of appointments and arrange transportation. The nature of the illness itself makes adhering to treatment difficult. This is where intensive case management can be useful in assisting with coordinating treatment, transportation, and other needs such as housing and vocational rehabilitation. It is important that after an initial episode the person is referred for ongoing community-based treatment. There should also be follow-up from the referring doctor or hospital to ensure that the person has attended the initial outpatient appointment.

The problem of stigma regarding mental illness is one that continuously needs to be addressed, not only by patients and treatment providers but also by the community at large. It is necessary to change the public’s attitudes about mental illness in order to reduce the self-stigma suffered by many with schizophrenia and other mental illnesses. This can be done through advocacy campaigns such as those by NAMI and Mental Health America. It is also important for those with schizophrenia to learn to feel empowered to make their own choices about their lives and treatment. Peer-led self-help groups and mental health community centers can be good resources for building self-reliance and promoting a vision of recovery. Certified Peer Support Specalists are employed in many mental health clinics and can act as “recovery coaches” by sharing their own experiences of mental illness with patients. It is important that as a community, we promote the idea that recovery from mental illness is possible and lift up those in recovery as role models for others. By doing so, we may be able to reduce the death and disability caused by schizophrenia and other mental illnesses.

References

Burden of Mental Illness. Centers for Disease Control and Prevention (2013). Retrieved from http://www.cdc.gov/mentalhealth/basics/burden.htm on May 14, 2016.
Lysaker, P., Tunze, C., Yanos, P., Roe, D., Ringer, J., & Rand, K. (2011).

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Slideshow- Domestic Violence in the LGBT Population

Domestic Violence in the LGBT Population