Identifying Feasible Interventions to Prevent Long-term Health Consequences

Identifying Feasible Interventions to Prevent Long-term Health Consequences
of Psychotropic Medications Prescribed to Children at the Baird School
Arkhipova-Jenkins I1, Harris A1, Kleeman L1, Meyendorff A1, Victor J1, Winikor J1, Wright K1, and Kessler R1
1University
•Many children with behavioral needs
struggle in traditional classroom
settings. Children receive help
through specialized educational
institutions, pharmacotherapy, and
psychiatric counseling.
•While substantial information exists
about drug indications and side
effects, there is little literature
documenting the barriers caregivers
face in addressing side effects.
•Our group conducted a literature review to identify
the side effects and associated comorbidities of the
six most frequently prescribed psychotropic drugs
at the Baird School.
•We designed a survey to assess the caregivers’
resources and barriers to minimizing these side
31 surveys
effects, and then offered a collection of feasible
sent to
recommendations.
caretakers
•Our survey contained questions
about physical activity, nutrition,
sleep hygiene, medication
administration, access to
medical care and community/
state programs.
•Surveys were mailed to the
caretakers of the 31 students at
Baird School; responses were
collected for 2 weeks.
•Due to low initial survey
response, all 31 caretakers were
called to complete more surveys
by phone.
•Caretakers that were initially
unavailable were called a second
time. No messages were left.
12 surveys
returned to
Baird School
9 surveys
completed
via phone
of Vermont College of Medicine
Figure 1:
Why A Child Misses
A Dose of Medication
Figure 2: Bedtime and
Difficulty Falling Asleep
100%
n=5
80%
80%
60%
40%
20%
0%
n=9
60%
n=7
No Set Bedtime
40%
n=3
Figure 3:
Awareness of
Medication-Specific
Nutritional Needs
Yes
29%
(n=5)
n=3
20%
n=2
n=1
Caregiver
Child forgot to Caregiver ran
forgot to give it
take it
out of pills
No
71%
(n=12)
n=3
Set Bedtime
0%
Difficulty falling
asleep
Other
No Difficulty
falling asleep
Figure 4: Amount of
Physical Activity
30%
25%
20%
15%
10%
5%
0%
NOT meeting CDC
Recommendations
n=5
n=4
n=4
n=4
n=3
0-2
2-4
4-6
6-8
>8
Borderline
Meeting CDC
Recommendations
Physical Activity Outside of School (Hours/Week)
21 surveys
completed
total
•Survey responses were tabulated
and data analysis was performed.
Figure 1: 56% (9/16) of respondents reported missed doses
of medication at least once per month.
Figure 2: There is a relationship between having a set
bedtime and less difficulty falling asleep.
Figure 3: 71% (12/17) of caregivers are not aware of specific
nutritional needs related to their children’s medications.
Figure 4: The CDC recommends 7 hours of physical activity
per week (60 minutes per day).
Figure 5: 71% (15/21) of children were reported to not be
involved in community programs offering physical activity;
caregivers cited a number of barriers.
•Survey data identified areas for health
improvement in Baird students.
•Baird students most often miss a dose of medication
because a caregiver forgot to administer it. Methods for
remembering when to give each dose may help reduce
adverse side effects associated with missing a dose.
•Since most children who experience sleep difficulties do not
have a bedtime routine, improving sleep hygiene may
improve overall health.
•Most caregivers were unaware of their children’s medicationspecific nutritional needs. Recommendations should promote
awareness about medications’ effects on appetite and activity.
•The majority of Baird students are not meeting the CDC
recommendations for physical activity.
•Behavioral problems are the most significant barrier to
involvement in community programs. Recommendations for
improving physical activity should include individual or
specialized forms of exercise.
•The sample size (31) & number of surveys completed (21)
were too small to reach statistical significance.
•Low initial survey response required follow-up phone calls,
but 15/31 caregivers were unreachable.
•Families with the greatest barriers may not have been
reached due to lack of access to phone/mail, lack of time or
motivation to complete the survey, or illiteracy.
•The current CDC recommendations for physical activity,
nutrition, & sleep are not specific to children taking
psychotropic medications.
•The most common drugs prescribed to students at the
Baird School include: Clonidine1, Riperidone2,
of Baird students are
3
4
5
Guanfacine , Lisdexamfetamine , Methylphenidate
NOT fulfilling the CDC’s
& Quetiapine6.
recommendations for physical activity
•These drugs are prescribed to treat various pediatric
conditions, including attention-deficit hyperactivity
Figure 5: Barriers to Participation in Community Programs
disorder (ADHD), oppositional defiant disorder (ODD),
60%
mood disorder, anxiety/depression, reactive attachment
50%
n=9
disorder, and post-traumatic stress disorder (PTSD).
40%
•Some of the most common side effects reported with
30%
Based on the barriers identified in this
4,5,7
8
n=5
these drugs include insomnia , restlessness ,
20%
n=4
project, future work could include
9,10
7,3
n=3
10%
weight gain , decreased appetite ,
n=2
n=2
n=2
caregiver education on physical
3,11
2
11
0%
somnolence , depression , and bradycardia .
activity, nutrition, and sleep hygiene,
Behavioral problem
Too expensive
Not offered in
Child not interested
Lack of
Lack of Time
Other
community
transportation
•Studies suggest that these side effects can lead to
as well as identifying more accessible
References:
arrhythmias1, hyperlipidemia6, impaired social or
Davis WB et al. Clonidine for Attention-deficit/Hyperactivity Disorder: II. ECG changes and adverse events analysis. J Am Acad Child Adolesc. Psychiatry, Feb 2008; 47(2): 189-198. Bishop JR and Pavuluri MN. Review of risperidone for the treatment of pediatric and
and specialized community programs.
adolescent bipolar disorder and schizophrenia. Neuropsychiatric Disease and Treatment, 2008; 4(1); 55-68. Sallee FR, et al. Long-term safety and efficacy of guanfacine extended release in children and adolescents with Attention-deficit/Hyperactivity Disorder. Jour of
3
7
academic performance , malnutrition , and diabetes Child and Adolesc Psychopharm, Nov 2009; 19(3); 215-226. Najib J. The efficacy and safety profile of lisdexamfetamine dimesylate, a prodrug of d-amphetamine, for the treatment of attention-deficit/hyperactivity disorder in children and adults. Clinical Therapeutics,
2009 Jan; 31(1):142-76. Barkley, RA, et al. Side effects of Metyliphenidate in children with Attention Deficit Hyperactivity Disorder: A systemic, Placebo-Controlled Evaluation. Pediatrics, 1990; 86; 184-192. Consesus Development Conference on Antipsychotic Drugs
Acknowledgements: A sincere thank you to Michele Phelps and Alyssa
mellitus6,12 with decreased health status.
and Obesity and Diabetes. Diabetes Care, Feb 2004; 27(2); 596-601. Wolraich ML, et al. Treatment of attention deficit hyperactivity disorder in children and adolescents. Drug Safety, 2007; 30(1); 17-26. Wender EH. Managing Stimulant Medication for Attention-
60%
1
2
3
4
5
6
7
8
deficit/Hyperactivity Disorder. Pediatrics in Review, 2001; 22; 183-190. 9Stigler KA, et al. Weight gain associated with atypical antipsychotic use in children and adolescents. Pediatric Drugs, 2004; 6(1); 33-44. 10Bishop JR and Pavuluri MN. Review of risperidone for the
treatment of pediatric and adolescent bipolar disorder and schizophrenia. Neuropsychiatric Disease and Treatment, 2008; 4(1); 55-68. 11Klein-Schwartz W. Trends and Toxic Effects from Pediatric Clonidine Exposures. Arch Pediatric Adolescence Med, April 2002; 156;
392-396. 12Non-pharmacological management of antipsychotic-induced weight gain: systematic review and meta-analysis of randomized controlled trials.
Cioffi at the Baird School, Dr. Rodger Kessler, and Dr. Jan Carney for all their
advice and assistance with the project.
Advance Directives and End-of-Life Care:
Completion, Conversations, and Concerns of Burlington Housing Authority Residents
Katherine Clark1, Gwendolyn Fitz-Gerald1, Claire Frost1, Benjamin Goldstein1, Eric Kalivoda1, Sarah Persing1, Damian Ray1, Sarah Russell2, Claire Rutenbeck2, and Gerald Davis1
1University
Introduction
Objectives
The objectives of this project were to:
•Determine rates of Advance Directive use by residents living in
Burlington Housing Authority complexes.
•Identify barriers to completion of Advance Directives and
interventions that might help with end-of-life care planning.
•Assess attitudes and concerns about end-of-life care.
•Increase knowledge and awareness of Advance Directives.
Table 1: Demographic Information of Survey Respondents
Respondent Demographics
%
18-39
2
5
40-54
6
14
55-64
13
30
65-74
14
32
75-84
5
12
85+
3
7
Male
12
28
Female
31
72
Less than High School/GED
6
14
High School/GED
20
46
Associate's degree
9
21
Bachelor's degree
6
14
Post-graduate degree
2
5
Age
Gender
Education
Figure 2:
25
5%
20
15
23
10
17
5
7
Never had one
1
Family or
Friend
Doctor or
Nurse
Religious Figure
43 respondents- could select more than one answer
Figure 3:
What Would Help You With Your End-of-Life Care
Planning?
When was your last end-of-life
care conversation?
%a
Blank Advance Directive Forms provided to you
37
Yes
Conversation with family and friends
35
No
Informative pamphlet about Advance Directives
35
Never had an End-of-Life
planning conversation
≤ 3 months ago
Educational session about Advance Directives
26
4-12 months ago
Discussion with a doctor/medical coordinator
26
> 1 yr ago
30%
33%
62%
With whom have you discussed end
of life care?
0
Figure 1: AD Completion Rates Table 2: Improving Completion Rates
Have you completed an
Advance Directive?
• About 1/3 of participants had already completed an Advance
Directive; the majority had not.
• The most common barriers to Advance Directive completion
were lack of knowledge about Advance Directives, being too
busy to fill one out, and that health care providers had not
broached the subject. Only 16% of respondents had ever
discussed end-of-life care with their health care provider, and
26% reported that a conversation with their doctor would be
helpful for their advance care planning.
• 35% of participants had never had an end-of-life care
conversation while an additional 30% had not discussed it in the
past year.
• 35% of respondents indicated that more information about
Advanced Directives would help them and 26% requested
educational sessions..
• The vast majority of participants have significant worries about
end-of-life care regardless of whether they are having end-oflife conversations.
• The results of our survey may not be representative of the
surveyed population due to a low response rate, n= 43, and
possible selection bias such that people with some previous
knowledge of Advance Directives may have been more likely to
fill out the survey distributed on this topic.
End-of-Life Discussions
n=43
Don't
know
a
Methods
Participants: Study participants were individuals currently
residing in three Burlington Housing Authority (BHA)
apartment complexes located in downtown Burlington,
Vermont.
Survey: An anonymous five item survey about experiences,
barriers, and concerns related to end-of-life care and Advance
Directives was drafted (2). The survey was distributed door-todoor in each of the BHA Complexes. Additional surveys were
distributed at one-hour educational sessions in each of the
buildings to participants who had not previously completed the
survey. Surveys were collected by the wellness coordinator in
each building and at the educational sessions. A total of 43
surveys were collected.
Data: Data were compiled and analyzed based on number or
percentage of responses using Microsoft Excel software.
Discussion and Conclusions
Results
Number of responses
•An Advance Directive is a document that allows patients to
declare their wishes regarding medical care and decision
making should they become unable to communicate their
preferences due to an accident or illness.
•The Patient Self Determination Act, passed in 1991, requires
that health care institutions, such as hospitals and nursing
homes, inform patients of their rights to make health care
decisions, the hospitals policies regarding recognition of
Advance Directives, and educate the staff and community about
advance care planning.
•Despite the passage of this legislation, completion of Advance
Directives remains low. It is estimated that less than 25% of
adults nationwide have completed an Advance Directive (1).
of Vermont College of Medicine and 2Burlington Housing Authority
35%
12%
23%
Percentage of respondents out of total returned
surveys (n=43)
Lessons Learned
Table 3: Barriers to Completion of Advance Directives
Figure 4: Concerns About End-of-Life Care
Barriers to Completion of an Advance Directive (AD)
What Worries You About End-of-life Care?
%a
I have never heard of this (an AD) before
19
100%
I haven’t gotten around to it / too busy
19
90%
My doctor never brought it up
14
80%
I am in the process of completing it now
12
70%
Some other reason
12
60%
Someone else will take care of it
5
50%
Too upsetting to discuss with family / friends
5
40%
The document is too hard to understand
2
30%
I am too young to need it now
0
20%
Too upsetting to discuss with my doctor
0
I don’t understand why I should complete one
0
a
Percentage of responses out of total returned surveys (n=43)
n=43
3
4
7
15
14
3
4
9
6
6
14
9
7
18
11
References
18
14
21
19
13
10%
0%
Wishes not being
followed
• Barriers to completing Advance Directives in this population are
largely due to a lack of knowledge about what Advance
Directives are.
• Providing information about Advance Directives should be the
responsibility of health care professionals.
• Conversations about end-of-life care initiated by health care
providers have the potential to help improve Advance Directive
completion rates.
Being in
pain/discomfort
Very Concerned
Who will take care of
me
Somewhat Concerned
Dying alone
Not Concerned
Poor quality of life
No answer
1) Salmond, S.W. and E. David. 2005. Attitudes toward advance
directives and advance directive completion rates. Orthop. Nurs.
24:117-27.
2) La France SV, Solloway M, et.al. End-of-Life Care planning in
New Hampshire: A statewide survey (2000).
Emergency Department Use
Among Vermont Homeless Families
Ameli, J; Crook, E; Kennedy, A; Gray, M; Sutherland, J; Thomas, J; Chi, G; Farnham, P; Smith, L; Hawkins, A
Background
Results
Committee on Temporary Shelter (COTS) houses
homeless individuals and families from the
Burlington area. COTS believes that a high
proportion of their residents use the Fletcher Allen
Health Care Emergency Department (FAHC ED) for
their health care more frequently compared to the
general population. There are many other primary
care services offered in the Burlington area, such as
Safe Harbor Clinic, Community Health Center, and
private offices, which are more appropriate for nonemergent health concerns and are readily
accessible to the homeless population.
By surveying the population of homeless families in
Burlington and conducting a focus group with the
COTS staff, we hoped to discover the reasons for
ED usage, potential barriers to primary health care,
and any possible changes that could ameliorate the
health care of this population.
TABLE 1: Sample Demographics
ADULTS
Total #
17
% Females
64.71
Average Age
27.40
% Completed
High School
88.24
Methods
This study was administered through COTS in
Burlington, VT. It was targeted at homeless families
living in the shelter, and included multiple choice
and write-in questions about their use of the ED.
Questions were based on background research
from previous studies dealing with ED usage by
homeless families, and from consulting staff from
Safe Harbor Clinic, Community Health Center and
COTS. The survey also allowed for multiple ED
visits by multiple family members. We consulted a
statistician for advice on formatting and question
design. Surveys were taken to COTS and given to
staff to distribute to families at the shelter during
weekly required meetings. We also held focus
groups with the staff at COTS to discuss perceived
use of the ED by the resident families. We received
12 completed surveys in total, encompassing 35 of
70 people living at the shelter. Given the narrow
target population, it was not possible to obtain a
larger sample size.
Discussion
CHILDREN
18
72.22
13.15
N/A
TABLE 2: Healthcare-Insurance and Utilization
ADULTS
CHILDREN
% Insured
100.00
94.44
% with PCP
82.35
94.44
Locations patients have accessed
healthcare in past year
16
14
#
Responde 12
10
nts
8
Accessing 6
Within
4
12 months 2
0
TABLE 4: PCP Utilization
ADULTS
CHILDREN
# Visits:
8
8
Mean Severity:
2
1.63
Example
Reasons:
"Check-Up"
"Check-Up"
"Flu"
"Asthma"
"Pneumonia"
"Flu"
Note: Severity is on a scale of 1-5, with 1 = mild and 5 =
life-threatening
Reasons for ED Visits
(Note: Respondents could pick more than
one reason. Interestingly, all respondents
selected "Emergencies Only" as one of their
choices)
Other, 4
See MD After
Hours, 4
Used once or
more?
Average # visits
Emergencies
Only, 12
Other: Quality of Health Care (1), Trust MD's (1), Easy access (1), Pain
COTS Staff Opinions: Focus Group
Locations
Note: "Other" includes Specialist
(2 times), UHC (not indicated), and
1 did not access healthcare recently
TABLE 3: ED Utilization
ADULTS
5
2.40
# Visits:
Mean Severity:
Example
Reasons: "Smashed fingers"
CHILDREN
4
2.75
"Sprained leg"
"Head
"Asthma/Breathing injury/lacteration
Problems"
"
"Stomach
"Gave birth"
problems"
Note: Severity is on a scale of 1-5, with 1 = mild and 5 =
life-threatening
“It is a proximity issue…It’s a lot of ease of
access. Hours are restricted [at primary care
clinics], appointments are limited.”
“Lack of planning ahead. Most of our clients are not
thinking two weeks down the road. They’re thinking
survivability and that’s the ‘now’, and that’s what the
ED is for.”
Acknowledgements
A sincere thank you to the Committee On Temporary Shelter
(COTS @ Burlington, VT), Dr. Jan Carney, Dr. Thomas Delaney,
Dr. Grace Chi, Pamela Farnham RN, Liz Smith, Annika Hawkins,
Aaron Hurwitz, and Raj Chawla of the UVM COM.
The results of our study shed light on the medical needs
of Burlington’s homeless family population.
We
hypothesized that the Burlington homeless population
misused the ED because of multiple factors: lack of
insurance, primary care, and understanding of proper ED
usage. The study showed instead that most families
understood that the ED was for emergencies only, had
insurance, and had a primary care provider.
A theme that emerged from the focus group was the
issue of proximity and transport. COTS offers bus
vouchers for primary care visits whereas it offers taxi
vouchers for ED visits. This may be influencing more
homeless families to go to the ED, which is an issue that
could be investigated further.
It is important to note that only 50% of the people
residing at COTS completed the survey. A bias may also
have arisen from miscommunications between the
participants and the survey proctors. The survey was
designed to be open-ended, and many participants did
not completely fill out the write-in sections of the survey,
possibly implying a flaw in the survey design.
Conclusion
Homeless families have different medical needs and
behaviors than homeless individuals. They tend to have
insurance, a primary care provider, and have medical
needs focusing on their dependents.
Misuse of the ED by homeless families may be a
misconception. However, possible misuse could be due
to proximity issues or voucher incentives.
Homeless families seem to understand the proper use of
the ED, and qualitatively, use the ED only for
emergencies.
References
(1) Seeking care for nonurgent medical conditions in the
emergency department: Through the eyes of the patient.
Journal of Emergency Nursing: 2000 Dec;26(6):554-63. Koziol-McLain
J, Price DW, Weiss B, Quinn AA, Honigman B.
(2) Out-of-hospital and emergency department utilization by adult
homeless patients.
Annals of Emergency Medicine. 2007 Dec; (6):646-52. Epub 2007 Oct
24. Pearson DA, Bruggman AR, Haukoos JS.
Assessing Barriers to Community Pediatric Dental Needs
Elisabeth Anson1, Aaron Burley1, Samantha Couture1, Katherine Irving1, Stephen Morris1, Darryl Whitney1, Pam
Fenimore2, Jill Jemison1
University of Vermont College of Medicine1 and Ronald McDonald House2
Introduction
Results
Oral health is an often overlooked aspect of healthcare with many
effects on an individual’s well-being. Dental caries is the most
common chronic disease in children, and most dental problems are
preventable. Barriers to accessing dental care for low income
children include: oral health beliefs of parents, transportation
issues, and difficulty locating providers who accept Medicaid (1, 2).
Investigation of the pediatrician’s role showed an increase in dental
visits among children who were recommended for care by their
primary care providers (3).
Recent data indicates that 67.1% of Vermont Medicaid enrolled
children received dental care within one calendar year(4). While
indicating a gap in services, this is the highest rate in the U.S. A
comprehensive national survey found that 85% of Vermont children
received preventive care in the past year(5), while recent state data
shows that 18% of Vermont children on Medicaid and 16% of
children overall have untreated dental decay (6). In 2009, The
Ronald McDonald House Charities, along with the Health Center of
Plainfield, implemented the Vermont Ronald McDonald Care Mobile
(RMCM), a traveling dental clinic providing dental care for
Vermont’s underserved children. In
one year, the RMCM visited 15
Vermont schools and treated 214
children, only 9% of the 2400 children
projected. The RMCM currently serves
sites in three Counties: Grand Isle,
Orange, and Lamoille. The objective of
our study was to investigate barriers to
access to Dental care among Vermont
children, with particular regard to the
RMCM. The underutilization of the
RMCM was assessed by researching
current data on Vermont oral health
and by surveying overall attitudes
Towns the RMCM visited in the past year
toward both the RMCM and
pediatric dental care in Vermont.
“We all noticed
so many of our
kids were walking
around with huge
smiles after the
van’s visit. It has
made such a
difference for
some of our
students’ self
confidence.”
-School Nurse
Do you believe there is a use for the
RMCM or a related program in your
community?
Yes
No
From
the Pediatrician Survey
Number of Dentists
How could the Ronald McDonald Care
Mobile best work with you to better serve
your community?
Methods
A combination of surveys and standardized interviews were used
to collect data for this project:
•A survey assessing satisfaction with the RMCM and general
attitudes toward pediatric dental care was distributed to all
parents at Alburgh Elementary and Bradford Elementary schools.
Survey questions focused on children’s current and past dental
care, use of the RMCM, satisfaction with RMCM dental services,
and opinions about the Mobile’s visits to school settings.
•A standardized telephone interview was conducted with each
school nurse at the school sites visited by the RMCM. Familiarity,
satisfaction, and areas for improvement with the RMCM were
assessed.
•A survey assessing attitudes toward the RMCM and opinions of
availability of pediatric dental care in Vermont was distributed to
Vermont dentists. A telephone interview was also conducted with
a Vermont dentist discussing her experiences with the RMCM
services.
•The RMCM and its services were presented to Vermont
pediatricians at the Vermont Chapter of the American Academy
of Pediatrics’ Fall Meeting. A survey assessing pediatric dental
care in Vermont and potential Vermont pediatrician involvement
with the RMCM was conducted.
Vermont Oral Health Initiatives
• Vermont exceeds Healthy Vermonter 2010 oral health goals.
• Among National leaders in oral health outreach access and positive oral
health outcomes for children of all incomes.
14
12
10
8
6
4
2
0
“[Local dentists]
are getting run
over by the bus.”
–Northeast
Kingdom dentist
Recommendations
Come to town
more often
Focus on
education
Allow me/my Not come to
Screen and
Initial
the
refer
treatment and practice to be
involved with community
referral
Care Mobile
care
From the Dentist Survey
Do you wish your child could
visit a dentist more often?
“My "local“ dentist is over
30 minutes away. There
are 2 dentists in town
taking new patients...[We]
need more dentists in town.”
-Parent
but not
Yes
No
Conclusions
From the Parent Survey
Pediatricians
• Responded positively to the RMCM in communities where there are few
dentists for children under 5 years. They are in high support of the
RMCM as long as parent education and finding a dental home for
children are key components.
Dentists
• Few dentists see absolutely no role for RMCM in Vermont.
• Dentists see value in education, screening, and referral services.
Parents
• Those that have used the RMCM are satisfied with the service.
• The vast majority of parents at the two schools surveyed who did not use
the RMCM have a dental home for their children.
RMCM
• RMCM was successful in reaching a large proportion of underserved
children in target schools, but was underutilized overall due to small total
target population and other strong outreach measures already in place.
School Nurses
• Impressed with dental services provided by the RMCM and that the
program is gaining momentum as word spreads.
Focus on high risk groups
• Target 1-5 year old population & those without a dental home
Broaden the scope and support of outreach efforts.
• Collaborate with pediatricians.
• Bridge connections between Care Mobile, community referrers
(pediatricians, school nurses), and dentists
Expand beyond the direct care model
• Focus on parent and child education and prevention
Improve collaboration, communication, and intake process
• Streamline the registration process and forms
• Employ a social worker to travel ahead and coordinate care
Communicate with local dentists
• Determine from dentists the needs of specific communities
• Begin staff-initiated scheduling of follow-up visits with a local
dentist and confirm care was received
Reassess business plan when contract expires in 3 years
• Revisit the map of communities RMCM serves and current data
on underserved areas
• Establish collaboration with state agencies
• Reduce overlap with existing strategies designed to reach
underserved children
References
1. Kelly SE, Binkley CJ, Neace WP, Gale BS. Barriers to care-seeking for children’s oral health among
low-income caregivers. Am J Public Health. 2005 Aug;95(8):1345-51.
2. Mofidi M, Rozier RG, King RS. Problems with access to dental care for Medicaid-insured children:
what caregivers think. Am J Public Health. 2002 Jan;92(1):53-8.
3. Beil HA, Rozier RG. Primary health care providers’ advice for a dental checkup and dental use in
children. Pediatrics. 2010 Aug;126(2):e435-41.
4. Pew Center On the States. The Cost of Delay: State Dental Policies Fail One in Five Children, 2010.
Pew Charitable Trusts, Washington, DC
5. U.S. Department of Health and Human Services. The Oral Health of Children: A Portrait of States and
the Nation. 2005
6. Vermont Department of Health: Keep Smiling Vermont Oral Health Survey 2002-2003
Factors Identified by Lapsed Donors that Might Influence
Donor Return
Buckley, K.1 , Jafferji, M.1, Larochelle, M.1, Mook, L.1, Pantel, H.1, Sturgill, L.1, Vierthaler, L.1, Dembeck, C. 2, Frenette, C. 2, Carney, J. 1, Fung, M.K. 1
1 University of Vermont College of Medicine, Burlington, VT; 2 American Red Cross- Northern New England Region, Burlington, VT
Introduction
The Burlington Chapter of the American Red Cross
estimates that 8,000 donors a year become "lapsed," or fail
to return for further donation. To better target this population
and retain current donors, it is essential to identify reasons
for lapsed donation.
Several studies have been conducted on the barriers to
retaining blood donors, revealing these common factors: past
physical reactions1,2, convenience3, previous deferrals4-7, lack
of awareness5,7, medical reasons5, time5, satisfaction with the
experience8,9, too impersonal7, and personal benefit10.
While many studies have identified reasons for lapsed
donation, the majority have not used free text as their
data source, have been conducted in a wide range of
geographic locations not specific to Vermont residents, and
have focused on reasons for discontinuing donations, rather
than positive factors. Using free text limits the question bias
and eliminates constraints that predefined answers enforce.
In 2007, Balderama et al conducted a study identifying
common motivations for donating blood, which included an
unanalyzed free text portion. We used this free text to
answer the question, “What factors identified by lapsed
donors might influence donor return?”
Results
Discussion
.
“If a quick iron prick could
happen before the lines
to determine whether or
not blood donor criteria
were met, that would
greatly increase my
attendance.”
“I have small veins,
so it is not easy for
me to donate.”
“Criteria for Hgb/Hct
was always borderline
for me- so I would
take the time to fill out
paper/wait and then
not be able to donate3x this happened.”
“I suffered from prostate
cancer. It has been 5+
years since I had a
prostectomy, no sign of
recurrent cancer. Can I
give blood again?”
“It takes way too long to give
blood. I often don’t have an
hour to spend at the
center. Any way to
streamline for frequent
donors would really improve
my ability to donate
regularly.”
Methods
An anonymous survey of 1668 randomly selected lapsed blood
donors from Burlington chapter of American Red Cross (900
general lapsed, 768 disaster) was mailed in Fall 2007. A lapsed
donor was defined as a subject who has donated in the past,
but has not donated for at least 2 years. The survey contained
26 questions (19 5-point Leikert scale, 4 demographic, 2 open
ended text) which assessed subject’s motivators, barriers to
blood donation, and some demographic information.
In the primary analysis, free text responses were assigned to
pre-defined categories based on key phrases and words (see
Appendix A for categories and key phrases). Each response
was categorized by two independent research teams. 28
discrepancies were resolved by consensus. We calculated the
percentage of respondents citing each primary category and
cross referenced these with demographic data and self reported
intention to return. In the secondary analysis, responses in each
primary category were assigned to pertinent subcategories and
percentages analyzed using same method.
“Blood drives close to
my home usually are
noon or 1pm to 5 or 6
and I can’t get out of
work to get there.”
Study results were similar to recent previous studies, for
example Duboz et al., found that medical reasons were the most
important factor influencing donor return, followed by
convenience and fear respectively.
Potential ways to increase donor return:
oEducation and awareness about medical reasons that
disqualify potential donors:
•Travel restrictions – locations that prohibit donation
•Time periods of ineligibility after traveling to certain parts of
the world
•Medication restrictions
•Health restrictions
oEfforts in improving the experience of giving blood:
•Ability to request a more skilled phlebotomist for donors
with difficult veins
•Provide information regarding potential side effects from
donation and how to cope with or prevent them (dizziness,
fatigue, etc.)
oDecreased length of donation:
•Reduced wait time for repeat donors
•Anemia screen as first step
Study limitations:
oInterpretation of free text presents the potential for bias
oCategorization of free text may result in misinterpretation or
misrepresentation of donor responses
oWritten free text can be ambiguous (legibility, syntax)
oNumber of responses with free text that met the methods
criteria were small (N=144)
oThe population studied may not represent the greater donor
population as it is homogenous, potentially limiting its use
outside the state of Vermont.
Appendix
Category
Recruitment
tactics
Convenience
“Email requests to
donate rather than
phone calls at
home.”
Motivation
*
*Of those who mentioned other factors, 50% wanted more
notification about future blood drives or reminders to donate.
1Duboz
P et al. Transfusion Medicine, 2010. 20: 227-236.; 2France CR et al. Transfusion, 2010. 50: 85-91.; 3Schlumpf KS, et al. Transfusion, 2008. 48: 264-272.; 4Custer B, et al
Transfusion, 2007. 47: 1514-1523.; 5Marantidou O, et al. Transfusion Medicine, 2007. 17: 443-450.; 6Halperin D, et al. Transfusion, 1998. 38: 181-183. ; 7Mathew SM, et al. Transfusion,
2007. 47: 729-735.; 8Germain M, et al. Transfusion, 2007. 47: 1862-1870. ; 9Nguyen DD, et al. Transfusion, 2008. 48: 742-748. ; 10Steele WR, et al. Transfusion, 2008. 48: 43-54.;
Balderama G, et al. Transfusion, 2008. 48 (suppl): 38A-39A.
Process of
giving
Safety/ fears
Perceived
medical
reasons
Other
Keywords
level of awareness, advertising, word of mouth, knowledge of
shortage/need, outreach, workplace endorsed giving, solicitation
time-which day, what time of day, location, transportation, cost of
travel, lost time, lost wages, impact on daily activities
knowing where blood goes, helping community, altruism, personal
satisfaction, crisis/disaster, prizes/gifts/rewards, peer
influence/social activity, past experience of personal need or
family/friend need for blood, lack of initiative
wait time, friendliness of staff, ease of procedure
privacy of actual donation, privacy of personal health information,
fear of fainting/passing out, infection/disease, training
level/competency of staff, pain/difficulty of procedure
deferral, travel, age, sickness/illness-present or recent, iron
deficiency, low hematocrit/anemia, duration between blood
donations
other
Understanding Factors Contributing to Suboptimal Rates of Childhood Vaccinations in Vermont
Adam Bensimhon1, Kuang-Ning Huang1, Paul Jarvis1, Jonathan Jolin1, Catherine Kelley1, Kurt Schaberg1,
Cristine Velazco1, Marianne Burke1, Christine Finley2
1 University
of Vermont College of Medicine Burlington, VT; 2 Vermont Department of Health, Burlington, VT
Introduction
Methods
Nationally, childhood immunizations have proven themselves
invaluable in preventing contagious diseases and their
associated morbidity and mortality.[1] [2] Nonetheless,
vaccines have become increasingly controversial, with a
growing number of parents refusing to vaccinate their
children.[3] Primary reasons given for vaccination refusal
include fears of side effects and the belief that the target
diseases are not harmful.[4] Those parents who refuse to
vaccinate their children generally have higher levels of
education and income.[5] An additional population of undervaccinated children who have received limited recommended
vaccinations has been identified and often comes from a
lower socioeconomic level.[5] Unimmunized children have
been associated with recent disease outbreaks, placing other
individuals at risk and increasing the controversy about
childhood vaccinations.[6] Nationally, Vermont has one of the
highest rates of unvaccinated children with recent data
showing these rates are continuing to increase.[5, 7]
• 1,614 surveys were mailed to caregivers of children ages
zero to five in the Women Infant and Children’s Program
at the Barre and Morrisville district health offices.
• Caregivers ranked their confidence or concern about:
• knowledge of children’s healthcare
• health benefits of immunizations
• the risk their child may contract an infectious disease
• Caregivers were asked about vaccination safety concerns
• Caregivers were asked if their child was current on
vaccines, reasons why not, and intent to vaccinate in the
future.
• Results were summarized as percentages and analyzed
using multivariate regression (SPSS v. 19) to assess
predictor-outcome relationships (α=.05).
Objectives
• To assess parents’ attitudes and behaviors about
immunizations to identify possible strategies to increase
childhood vaccination rates.
Results
“I hear a lot about immunizations
causing autism. I'm not quite sure what
to believe. I also feel that giving so many
all at once may tax the immune system
too much .” –Caregiver
• 386 surveys were returned
• 82% of respondents said their child(ren) had received
all the recommended vaccinations for their age.
• As single predictors, younger respondent age ( ≤30) and
lower education level (some college or less) were more
likely to report their children as current on vaccinations
(p=.01 and p<.01, respectively).
• Having children current on vaccinations was
significantly associated with high rating of child
healthcare knowledge (p=.01) and confidence about the
safety of the immunizations (p<.01).
• Intent for future vaccination was predicted by high
knowledge about child healthcare (p=.005) and
confidence about the safety of immunizations (p=.019).
“I strongly support childhood vaccinations
and believe we should do everything
possible to protect this vulnerable segment
of our population.” –Caregiver
Discussion
• Our study supports previous literature that vaccine safety
and the effect of multiple vaccinations administered during
a single visit are primary reasons why caregivers choose not
to vaccinate.[4, 8]
• The link between vaccination and autism was a common
concern among respondents despite numerous studies
indicating no relationship.[2]
• Respondents whose child was less likely to be current on
vaccinations primarily sought information from the internet
and/or literature.
• For respondents whose child was current on vaccinations,
the major sources of information were primary care
providers and family.
Conclusions and Implications
80%
80%
60%
60%
• Caregivers reporting younger age and lower education level
are associated with being up-to-date on their child’s
vaccines. Those who reported higher confidence in child
healthcare knowledge and/or safety of vaccinations were
associated with higher rates of current vaccinations and
intent to vaccinate in the future.
• Health campaigns to improve Vermont vaccination rates
should counter misinformation concerning autism and
safety with primary care providers playing a key role.
• These findings can be used for further inquiry to implement
measures to improve immunization rates in Vermont.
40%
40%
References
Reasons for not vaccinating
What is your primary source of information?
100%
Fully vaccinated
Not fully vaccinated
100%
20%
20%
0%
0%
Primary Care
Provider
Books and
Magazines
Internet
Friends
Family
Vaccine safety
Too many
vaccines at one
time
Delayed some
vaccinations
Vaccine not
important to
child's health
Believe in natural
immunity
Other
1. Omer, S.B., et al., Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. N Engl J Med,
2009. 360(19): p. 1981-8.
2. Taylor, B., et al., Autism and measles, mumps, and rubella vaccine: no epidemiological evidence for a causal association.
Lancet, 1999. 353(9169): p. 2026-9.
3. Park, A. (2008) How Safe Are Vaccines? Time.
4. Fredrickson, D.D., et al., Childhood immunization refusal: provider and parent perceptions. Fam Med, 2004.36(6):p.431-9.
5. Smith, P.J., S.Y. Chu, and L.E. Barker, Children who have received no vaccines: who are they and where do they live?
Pediatrics, 2004. 114(1): p. 187-95.
6. N Cocoros, R.H., N Harrington, (2010) Notes from the Field: Measles Transmission Associated with International Air
Travel --- Massachusetts and New York, July--August 2010. Morbidity and Mortality Weekly Report (MMWR).
7. Vermont Immunization Program Goal Tracker. August 2010, Vermont Department of Health
8. Kennedy, A.M., C.J. Brown, and D.A. Gust, Vaccine beliefs of parents who oppose compulsory vaccination. Public Health
Rep, 2005. 120(3): p. 252-8.
Emergency and Scheduled Respite Care for Caregivers
`
of Persons with Dementia: a Proposed Program
Carpinello, O.1; Collins, B.1; Covino, J.1; Fischer, D.1; Santos, A.1; Schoppel, K.1; Tadevosyan, A.1; Pendlebury, W., MD1, Martinez, L., RN2
1University of Vermont College of Medicine, Burlington, VT
2Visiting Nurse Association of Chittenden and Grand Isle Counties, VT
INTRODUCTION
Respite care is defined as providing the primary caregiver with relief
or a reprieve from care commitments on a short-term or emergency
basis. (cite 1) Despite a demonstrated interest (cite 2) in and need
for respite care programs, our research has shown that scarce
resources exist via a statewide dementia respite program
administered by Vermont’s five Area Agencies on Aging (cite 3).
Grants are small and many families do not fall within the eligibility
requirements. In FY2010, only 290 families across the state met
eligibility requirements (physicians’ diagnosis of dementia, income
less than 300% of poverty line, unpaid caregiver, primary residence
in VT) and were awarded limited funding for the provision of outside
care (up to $750.00 each). For many of these families, this money is
typically used to provide substitute care when the primary caregiver
is not available. To date, there is no true emergency respite
program in place for caregivers. This has placed a strain on families
and day facilities, particularly when situations arise in which a
caregiver is unable to pick up their family member due to an
emergency situation. Our goal was to demonstrate the feasibility of
a respite program to address this need.
METHODS
We began with a literature review and
discussions with key agencies invested in the well-being of patients
with dementia and their caregivers. These agencies included: The
Visiting Nursing Association (VNA), Dept. of Disabilities, Aging and
Independent living (DAIL), Vermont Chapter of Alzheimer’s
Association, and the Vermont Area Agencies on Aging. Based on
the input of existing community agencies, we drafted a program
proposal for emergency and scheduled respite. Recognizing the
paucity of funding sources as a chief limitation to current models, we
developed a survey to assess the feasibility of a volunteer-based
program. An electronic survey was sent via Survey Monkey to the
volunteer pool at Fletcher Allen; members of the UVM community;
AARP; and the United Way of Chittenden County, which includes the
RSVP Program with volunteers >55 years old. In an effort to reach
as large a volunteer pool as possible, we cast a broad net with no
expectation that the effort would yield a large number of responses,
but rather to assess volunteer support and project feasibility. In
addition, we investigated potential funding opportunities that the
administrating agency (VNA) could pursue to provide administrative
and volunteer expense reimbursement. The results of our survey,
our proposed program, and suggested community and financial
resources are detailed below.
REFERENCES
1. Jeon YH, et al. Respite Care for Caregivers and People with Severe Mental Illness: Literature Review.
Journal of Advanced Nursing. 2005;49(3):297–306.
2. Gupta, P.; King, B.; McBride, K.; Rejaei, D; Springer, J; Stewart, T.; Swett, D.; Pendlebury, W., MD, Martinez, L., RN.
Emergency and Scheduled Respite Care for Caregivers of Persons with Dementia: a Model. January 2010
3. http://www.ddas.vermont.gov/ddas-programs/programs-dementia-respite-default-page
Additionally, we surveyed willingness to participate in a training
program and background check (100%), interest in coverage of
emergency and/or scheduled respite care (graph 1), timing of care
(chart 1), regular commitments (chart2), and donated hours (graph
2).
RESULTS
PROPOSED PROGRAM
Expenses Pd
Expenses + Nominal Fee
UVM Community
27
19
United Way
15
8
Other
0
2
Based on our results and investigations into
local resources we would propose the
following program and community partners:
Table 1: Volunteer Interest by Group
60
Emergency vs. Scheduled Care
50
40
30
20
10
0
Scheduled Care
On Call, Emergent Basis
Graph 1: Willing to provide emergency vs. scheduled care
Overnight
8%
Timing of Care
Volunteer Commitment
Montly
21%
Day
42%
Bi-monthly
34%
Evening
50%
Weekly
45%
Chart 1: Timing of Care
Chart 2:: Volunteer commitment
Model
*Provision of service: < 72 hours for on-call emergency care or
scheduled respite
*Program Administration by the Visiting Nurse Association of
Chittenden and Grand Isle Counties
*Utilization of community volunteers
-Background Checks
-Training Program
-Reimbursement of out-of-pocket expenses
*Specialized training in caring for patients with dementia
Budget
Our proposed budget includes the costs of annual administrative
oversight (VNA), training (ElderWise), and estimated annual
reimbursement costs for a pilot of 20 volunteers
VNA Admin. Coordinator (salary + overhead)
$61,114
Training Costs
$4,000
. Gas Costs (est. 30 miles at 2.8 gallon at 4Xmth)
Food Costs (est. $20/day at 4X mth)
TOTAL
Volunteer Time Donation
$2,688
$960
$68,762
50
COMMUNITY RESOURCES AND
POTENTIAL FUNDING
40
30
20
10
0
0-4 hours
4-8 hours
8-12 hours
12-24 hours
24-48 hours
48-72 hours
Graph 2: Volunteer Time Donation (# hours)
DISCUSSION
The results from our survey demonstrate feasibility for a volunteerbased program. Of 95 responses to our survey, 71 individuals
responded that they would be willing to volunteer. Within that group,
42 individuals were willing to volunteer with expenses paid and an
additional 29 were willing to participate if provided a nominal fee in
addition to their expenses (Table 1).
Potential Community Partners:
• Administration: Visiting Nurse Association of Chittenden and
Grand Isle Counties
• Training:
• ElderWise system of Caregiving: adaptation of current 70
hour curriculum geared to non-medical caregivers.
Development of standardized reporting and medication
forms for consistent volunteer documentation and reporting
to families. In addition, background checks could be
provided through this service.
• Alzheimer’s Association: classroom and online training
program
Volunteer Recruitment:
• RSVP Program (United Way of Chittenden County) has
resources to recruit volunteers for the program pending
established collaboration and supervision by an external
agency.
• Legacy Corps is funded through the Corporation for
National and Community Service (CNCS) as an
AmeriCorps project.
www.sph.umd.edu/hlsa/aging/legacy_corps/index.html
Funding Sources for Consideration:
• Administration on Aging: Lifespan Award:
www.aoa.gov/AoARoot/AoA_Programs/HCLTC/LRCP/ind
ex.aspx#Grantees
• Medicaid Home and Community-Based Services Waiver
Program:
www.cms.gov/MedicaidStWaivProgDemoPGI/05_HCBS
Waivers-Section1915(c).asp
• Philanthropic support should be further explored with the
potential for a named program.
Limitations: Although we demonstrated a viable volunteer
interest base in our program, our selection of groups that we
thought might have an interest in volunteering and our choice
of an electronic survey were likely limitations in ascertaining
broad interest in the program (including individuals in the
RSVP program who lack computer access). In addition,
although our data is based on 71 individuals who positively
responded to our survey, 78 individuals (7 who said no to
participation) went on to answer our survey questions. Finally,
we worked to reach out to key agencies throughout this
process but recognize that there may be additional community
resources that were not identified in our efforts.
CONCLUSION
Previous research has demonstrated a need for additional
services for caregivers of patients with dementia. Our group
has demonstrated the feasibility of a volunteer-based program
for the provision of emergency and scheduled respite care. In
addition, our group has identified potential community
partners and fiscal resources that should be further pursued to
bring this much needed service to the community at large.
ACKNOWLEDGMENTS
Raj Chawla, Maria Mireault, MA (DAIL), Jeanne Hutchins, MA
(Center for Aging, UVM), Martha Miller (ElderWise), Maggie Lewis
(Alzheimer’s Association ,Trish Shabazz (United Way of
Chittenden County),Fletcher Allen Volunteer Services, and Kofi
Mensah, UVM SGA President.
Heads Up: Using Your Brain When Tackling Concussions
Ashley, C. , Davies, M. , Diamond, S. , Gilligan, L. , Gutierrez, A. , Karr, L. , Pedro, C. , Perkins, B. Wise, C. , Carney, J.
1
2
University of Vermont College of Medicine, Burlington, VT; Chittenden East Supervisory Union (CESU), Jericho, VT
A concussion is a type of traumatic brain injury (TBI) typically caused by biomechanical forces inflicted on the head that change the way the brain works. Concussions can also result from a blow elsewhere in the body causing an impulsive force
transmitted to the head. These types of injuries often involve a sudden onset of neurologic function impairment such as confusion, amnesia, or loss of consciousness
that quickly dissipates and is generally not life-threatening. Unfortunately, these
seemingly “mild” symptoms have led numerous primary care providers to undermine
its potential risks, often leading to inadequate evaluation, premature return to play,
and poor psychological management. Complications of severe or repeated concussions include migraines, depression & mood changes, sleep disorders, convulsions,
coma, and in some instances even death. The goals of our study were to evaluate public awareness and knowledge of concussion, identify common misconceptions, assess
barriers to proper management, and propose uniform guidelines for education, prevention, diagnosis, and treatment to be used in the Vermont school system.
Methods:
Survey Design: A 14-question survey was designed in order to assess community
member’s knowledge and attitudes about concussion and the treatment of concussion in Middle School and High School athletes. Our target population included
parents, coaches, athletic trainers, teachers, school nurses, and health care providers
who are associated with students in the Chittenden East Supervisory Union school
district.
Data was collected using an online-based survey website called Survey Monkey, and
also by administering a paper form of the survey to parents and coaches who attended a Concussion Meeting that took place at Mount Mansfield Union High School.
The online survey was sent to coaches and parents via an e-mail which contained a
link to the survey. In order to include physicians and other health care practitioners
in the survey, we called, faxed and emailed 11 local pediatric and family medicine offices to encourage them to take part in our survey.
The paper surveys that were filled out at the Concussion Meeting and via fax by Physicians were entered into Survey Monkey in order compile all of the results into one
database.
1
1
“It needs to be out there in all media to become part of our
normal information system. People understand broken bones,
head injuries need to be as clear to us as that.”
--Anonymous Survery Participant
Which of the following best describes you (Select one):
Answer Options
Parent
Coach
Athletics Volunteer
Nurse
Teacher
Athletic Trainer
Physician
Physician's Assistant
Nurse Practitioner
Response Percent
74.4%
5.2%
1.1%
3.4%
12.8%
0.0%
2.7%
0.0%
0.4%
answered question
Response Count
332
23
5
15
57
0
12
0
2
446
Response Percent
29.4%
70.2%
0.5%
answered question
skipped question
Response Count
129
308
2
439
7
What is your gender?:
Answer Options
Male
Female
Prefer not to specify
Which of the following best describes you (Select one):
Answer Options
Under 25
26-45
46-65
Over 65
Response Percent
1.1%
37.5%
60.3%
1.1%
answered question
skipped question
Response Count
5
166
267
5
443
3
"I believe the school district should have a uniform
guideline on how to recognize, treat and manage
concussion."
[66.5%] STRONGLY AGREE
[30.5%] AGREE
[2.1%] DISAGREE
[0.9%] STRONGLY DISAGREE
1
1
1
2
2
1
Knowledge of Early Concussion of Symptoms
HEALTH CARE WORKERS
30
Percent of Surveyers
Introduction:
1
ALL OTHERS
25
20
15
10
5
0
6
5
4
3
2
1
0
Concussion Symptom Knowledge Score
Knowledge of Late Symptoms of Concussion
Percent of Surveyers
1
45
40
35
30
25
20
15
10
5
0
HEALTH CARE WORKERS
ALL OTHERS
Discussion/Conclusion:
There are many states within the US that have passed laws relating to concussions in
high school athletics. The results of our survey highlight some very important points
about sport-related concussions in the Chittenden East Supervisory Union:
6
5
4
3
2
1
•97% of those surveyed strongly agreed, or agreed that there should be a uniform
guideline for the management of sport-related concussions in the CESU.
•More education is needed about the use of helmets and the risk of concussions.
•There is a wide range of knowledge on how to detect a concussion based on the
early and late symptoms.
•67% would like more information on the detection/management of concussions. 0
Concussion Symptom Knowledge Score
Responses were converted to overall scores by adding +1 for a correct sign and -1 for an
incorrect sign, selection of “none” was weighed as 0.
Early Signs:
* Correct Signs: nausea, vomiting, confusion, vision changes, sensitivity to light
* Incorrect Signs: fever
Late Signs:
* Correct Signs: headache, general tiredness, memory loss, sensitivity to light, depression, neck pain
* Incorrect Signs: stomach pain
Coaches and Althletic Trainers response to
"If a player is wearing the proper equipment,
the risk of concussion is minimal."
6 "Would you like to receive more information
on concussion in sports?"
Parent's response to "I have been well
informed on recognizing the signs and
symptoms of concussion and feel I could
recognize them in a student athlete."
296 AGREE
145 References:
1. McCrory, P., W. Meeuwisse, K. Johnston, J. Dvorak, and M. Aubry. “Consensus Statement on concussion in sport - The 3rd In15 110 172 35 ternational Conference on concussion in sport, held in Zurich, November 2008.” Journal of Clinical Neuroscience. 16. (2009):
755-763.
2. Makdissi, Michael, David Darby, Paul Maruff, Anthony Ugoni, and Peter Brukner. “Natural History of Concussion in Sports:
Markers of Severity and Implications for Management.” American Journal of Sports Medicine. 38.3 (2010): 464-471. Print.
0%
STRONGLY AGREE
1. Coach and Student Athlete (and possibly parent) education about concussion prior to the start of the sport season.
2. What to do if a player is suspected of receiving a concussion.
3. When a player is allowed to return to play after being diagnosed with concussion.
With the implementation of such a protocol, there will be no ambiguity about when
and how to take action if a player receives a head injury. The hope is that this will
prevent further head injury to those already injured, and allow the injured player to
get back into the game as soon as he/she is healthy and ready. We recommend using
evidence based guidelines, such as the ones recommended by Fletcher Allen Health
Care. It is important to remember the most crucial rule when managing concussions, “When in doubt, leave them out.”
4 17 From the results of our survey, nearly all respondents in the CESU support a standardized approach to the management of sport-related concussions. From our research, we recommended this guideline include specific instructions pertaining to:
20%
DISAGREE
40%
60%
80%
STRONGLY DISAGREE
100%
3. Kirkwood, Michael, Keith Yeates, and Pamela Wilson. “Pediatric Sport-Related Concussion: A Review of the Clinical Management of an Oft-Neglected Population.” American Academy of Pediatrics. 117.4 (2006): 1359-1371.
Menu Planning and Grocery Shopping for People Living
with Psychiatric Disabilities
Nkem Aziken1, Michael Boggs1, Leslie Bradbury1, Christopher Cahill1, Sara Higgins1, Lynsey Rangel1, Sandra Steingard MD 1, 2
1University
of Vermont College of Medicine and 2HowardCenter
INTRODUCTION
•
METHODS
The HowardCenter in Burlington, Vermont is designed to empower and
improve the lives of individuals with mental illness throughout Chittenden
County.
•
•
•
People living with chronic psychiatric disabilities have higher mortality
rates and earlier onset of medical illness1. It has been observed that
many of the risk factors for chronic conditions revolve around nutrition,
implying a chance to intervene.
•
Understanding the various ways people with psychiatric disabilities eat,
buy, cook, and value a healthy diet is fundamental for the HowardCenter
to address increased mortality in this population.
Our goal is to identify barriers and develop a resource to improve
nutrition in this population.
Literature review and research assessed the problem and examined
evidence based interventions that could aid our resource development.
Emotional/Energy Barriers
•
Research and information was collected from HowardCenter clients with
the permission of UVM College of Medicine and associated healthcare
providers.
The survey was administered on paper at the HowardCenter and
Lakeview House. Data was analyzed using Microsoft Excel.
15 ounce can of kidney beans
15 ounce can of black bean
15 ounce can of pinto beans
28 ounce can of diced tomatoes
1 ½ pounds of ground turkey
1 onion chopped
2-3 cloves of garlic chopped
1 tablespoon Cumin
1 tablespoon Chili Powder
Cayenne to taste
“worrying about fire safety”, “phone harassment”, “I
have a fear of stoves, oven, and getting burned”
0%
Optional: can of crushed jalapeno pepper
or diced fresh jalapeno for added spice
Shopping List: Kidney beans, Black beans, Pinto beans, Diced
tomatoes, Ground turkey, Onion, Garlic, Cumin, Cayenne pepper
“I have a fear of stoves, oven,
and getting burned.”
10%
15%
20%
25%
30%
35%
Percentage of Respondents
Figure1. The majority (60%) of respondents cited emotional, energetic, logistical, or financial barriers to cooking
more often.
CONCLUSION
•
The survey results identified several barriers to cooking and eating healthy
such as finances and meal time preparation. Based on the needs and
desires of this population, we created a resource titled, Cooking with
Wholesome Food: Quick, Simple, and Affordable for Everyday of the
Week. It emphasizes eating healthy on a low budget.
34 surveys were collected from a population of 650 clients of
HowardCenter's Community Support Program (~5% of the total group).
•
The book contains a week’s worth of recipes for breakfast, lunch, and
dinner, shopping lists, financial budgets, healthy snacks, and suggestions
for eating and living healthy.
•
The survey showed that the majority (92%, 31/34) want to eat healthier.
However, the majority (62%) also had difficulty finding the time, energy,
or money to do so.
•
Our research group advocates further research to be conducted on the
population subset to assess the use and efficacy of our recipe book.
Preferred Meal Preparation
Time
Instructions:
Chop onion and garlic
Heat 1-2 tablespoons olive oil in big sauce pan
Add onion and garlic.
Cook on medium heat for 5 minutes
Add turkey and cook until no longer pink.
Add spices. Stir and heat for 2 minutes.
Rinse beans thoroughly. Add beans and 28 ounce can of
diced tomatoes.
• Stir and cover. Let simmer on low heat for 30 minutes. Stir
periodically.
5%
•
Eating Habits
•
•
•
•
•
•
•
“I live alone”, “dishes”, “I don’t know”, “back pain”,
“I don’t like my gas stove”, “I have a swallowing
problem”, “easier to buy…at deli”
Fear Barriers
The survey assessed the population’s available finances, knowledge of
nutrition, and willingness to change current habits. Key questions included:
• What do you think eating healthy means?
• How much money do you spend on food every week?
• What problems keep you from eating more healthy foods?
• What cooking appliances do you have access to?
THREE BEAN TURKEY CHILI
•
•
•
•
•
•
•
•
•
•
“money”, “no money”, “the price of food”, “time”,
“don’t have time until 6pm”, “the time it takes is
longer than making”, “no room”
Other
RESULTS
Ingredients:
“depression”, “laziness”, “patience”, “stress”, “I
don’t feel like it”, “energy”, “tiredness”, “I have no
energy”,
Logistical/Financial Barriers
•
•
Barriers to Cooking More
How often do you eat
fast food?
Less than
once a week
Time Spent
on Breakfast
1-2 days a
week
How often do you eat
vegetables?
10-20 min
Time Spent
on Lunch
3-5 days a
week
How often do you eat
meat?
50%
40-60 min
100%
Figure 2. The 70% of respondents reported eating fast food
less than once a week, but only 24% eat meat less than once
a week and only 15% eat vegetables less than once a week.
over 60 min
0%
Percentage of Respondents
50%
2) Am J Prev Med. 2009 Apr;36(4):341-50. Obesity among those with mental disorders: a National
Institute of Mental Health meeting report. Allison DB, Newcomer JW, Dunn AL, Blumenthal JA,
Fabricatore AN, Daumit GL, Cope MB, Riley WT, Vreeland B, Hibbeln JR, Alpert JE.
100%
Percentage of Respondents
Figure 3. The majority of respondents wanted to spend
less than 20 minutes preparing either breakfast or lunch,
but were willing to spend more time preparing dinner.
“Vegetables spoil so quickly; I end up
throwing so much away.”
1) Parks J, Svendsen D, Singer P, Foti M, Mauer B. Morbidity and Mortality in people with serious
mental illness. National Association of State Mental Health Program Directors, 2006.
20-40 min
Time Spent
on Dinner
6-7 days a
week
0%
5-10 min
REFERENCES
3) Arch Gen Psychiatry. 2007 Feb;64(2):242-9. Relative risk of cardiovascular and cancer mortality in
people with severe mental illness from the United Kingdom's General Practice Rsearch Database.
Osborn DP, Levy G, Nazareth I, Petersen I, Islam A, King MB.
“I am an emotional eater.”
“I have trouble eating portionsized meals.”
Assessing Barriers to Healthy Living in Economically
Challenged Communities of the Greater Winooski Area
Idil Aktana, Catherine E. Nabera, Shetal M. Patela, Phillip R. Perrineza, Joshua J. Pothena, Alexandra L. Swartza, Janice Gallanta, Hal Colstonb
aUniversity of Vermont College of Medicine, Burlington, VT; bNeighborKeepers, Winooski, VT
Introduction
NeighborKeepers (Winooski, VT) is a non-profit, anti-poverty
organization that focuses on building supportive friend networks
that direct families and individuals toward the resources they
need to improve their health, get training and education, find
jobs, and discover a sense of purpose and belonging. Keeping
with the NeighborKeepers philosophy of giving those in need the
tools to help improve their own circumstances, our project goals
were to:
Gender
Male
Female
Age
18-34
34-59
60+
Percent
61
34
Percent
52
36
11
Healthcare Concerns
4%
• Engage community members
22%
19%
• Connect individuals with community resources geared toward
healthy living and improved healthcare access
• Identify health needs and potential areas for intervention or
further inquiry
Race
White
Asian
African American
Native Hawaiian
8%
1%
22%
11%
13%
Percent
36
52
2
2
Lack of insurance
coverage
High cost of health
insurance
High cost of
prescription drugs
Difficulty getting
appointment
Lack of doctors and
nurses
Lack of prevention
programs/services
Lack of dental/vision
insurance
Other
General Health Perception
Excellent
Good
Fair
Poor
Total No. Participants
Physical Health Concerns
2%
5%
5%
11%
8%
9%
11%
33%
16%
Percent
21
20
22
7
44
Obesity
Poor nutrition/poor
eating habits
Lack of time to prepare
healthy foods
Lack of knowledge to
prepare healthy foods
Lack of exercise
Barriers to Exercise*
Discussion
• The VNA flu clinic was an enormous success - 108 adults and
children received free flu shots.
• The large Bhutanese turnout (not necessarily representative of
NeighborKeepers) may have been due in part to our prior
involvement in health education outreach for their community.
• Advertising through online forums and electronic newsletters
may be helpful for recruiting greater participation from
community members.
• The length and complexity of the survey were barriers for both
native and non-native English speakers.
• Language and literacy barriers made it difficult for Bhutanese
participants to take full advantage of the resources available at
the fair.
Lack of awareness of
existing exercise options
Body image
Other
* high cost, lack of facilities, motivation, time, exercise options
Economic Concerns
2% 3%
Methods
We organized a community health resource fair, “Community
Health Connections,” at the O’Brien Community Center in
Winooski. In order to reach the larger NeighborKeepers
community, we:
3%
7%
28%
8%
4%
21%
13%
14%
23%
Hunger
Other
Obesity/physical
activity
Substance
abuse
Mental health
Teen pregnancy
Homelessness
• Encouraged members to invite their friends and families
The survey administered at the fair was adapted from the
Fletcher Allen 2007 Community Needs Assessment1.
Participants were asked to check up to 3 items in each of the 12
categories, covering health, wellness, and community concerns.
We obtained a Nepalese translation for the Bhutanese
population. As an incentive to complete the survey, we raffled off
two $25 gift certificates to City Market.
Community Health Concerns
Poverty
20%
• Promoted the event at community dinners over several months
• Advertised through fliers posted around downtown Winooski
Lack of affordable
housing
High cost of health
care/insurance
Lack of employment
opportunities
High cost of living
26%
28%
Contraception
Other
Results
Attendance at the health fair was estimated at ~ 150 adults and children. The data analysis revealed
specific concerns regarding health/vision/dental insurance (41%), high cost of health insurance (22%),
lack of exercise (16%), barriers to exercise (41%), lack of affordable housing (28%), employment
opportunities (23%), mental health (28%), and substance abuse (26%).
Lessons and Future Directions
• Overwhelming demand for flu shots suggests significant need
for accessible, affordable clinics in Winooski.
• Flu clinics can be used as opportunities to provide health
education in areas of concern for this community (e.g. physical
activity, substance abuse, health care access).
Acknowledgements
Thanks to Khem Kuikel, Healthy Living, City Market, Community Health
Center, 3SquaresVT, BikeRecycle VT, Ladies First, UVM Substance Abuse
Clinic, Fletcher Allen Health Access Program, the VT VNA, and Africa
Jamono .
References
1Community
Assessment - Community Resources - Fletcher Allen. Fletcher
Allen – Burlington, Vermont's University Hospital & Medical Center. Web. 12
Sept. 2010.
Exploration into Expanding the Burlington
SASH (Seniors Aging Safely at Home) Program
Areson R.1, Dindwall V. 1, Duncan C. 1, Hayes E. 1, Keller E1., Kuo T. 1, Thach S. 1, Varga S. 1, Delaney T. 1, Dugan M.2, Berry P1.
University of Vermont College of Medicine1, Cathedral Square Corporation2
Background
Methods
In 2009, the Cathedral Square Corporation partnered with
community provider organizations* to design a model for
in-home services and support known as Seniors Aging Safely at
Home (SASH). This comprehensive program, implemented at
Heineberg Senior Housing in the New North End of Burlington,
VT., combines health support, education, and social activities to
create a safe and fulfilling environment for participants.
Cathedral Square plans to extend their
SASH program to New North End (NNE)
seniors residing in their own homes.
However, the current and future needs of
the NNE senior population (defined here
as individuals age 50 and older) are not
well known.
Data collection was divided among the following:
•Surveys distributed to Burlington’s NNE residents ≥ age 50
•Personal interviews conducted with local health providers
•Personal interviews with senior community members.
NORCs are communities in which the population has aged in
place, resulting in a high proportion of seniors living in one
area. Neighborhoods with this
dynamic have begun to organize
programs which provide a variety of
services to their seniors, including
yard-work, educational workshops,
social opportunities, and access to
health care services. Village models
are similar, but tend to be designed
more intentionally as senior-supporting
neighborhoods rather than arising
naturally as the local population ages.
By looking into current community
models and by investigating the needs of the NNE senior
population, Cathedral Square will be further equipped to offer
important services to those who are interested.
SURVEY DESIGN
•41 questions
•Assessed demographics, current lifestyle, and desire/need
for assistance
•Based on suggestions found at www.norcblueprint.org
•Distributed in two ways:
1) By hand
•108 surveys total placed at a local pharmacy,
recreation center, church, senior center (each with
drop boxes for deposition of completed surveys), or
distributed to voters on voting day.
2) By third party distribution
•4 electronic surveys emailed by request
•29 distributed to Meals on Wheels participants by staff
•50 surveys distributed by an active community senior
INTERVIEW DESIGN
Using the topics touched upon in the survey, we interviewed
a local physician, the director of the Heineberg Senior Center,
a nurse with the PACE organization, and a case manager
with the CVAA. Each community provider was asked his/her
view on what area seniors need in order to age safely at
home. Selected senior community members were also
interviewed.
Male
Female
Mean Age (SD)
Mean Age Male (SD)
Mean Age Female (SD)
Years in Community (SD)
Support in Close Proximity
Fine to Excellent Health
Willing to Pay for SASHa
48 (70%)
Support in proximity & interest in SASHb*
36 (54%)
No proximate support & interest in SASHc*
3 (43%)
Expect Future Challenges
Attended Workshops
*Cathedral Square partnered with Champlain Valley Agency on Aging (CVAA), the Visiting Nurse
Association of Chittenden and Grand Isle Counties, and the Program for All-Inclusive Care for
the Elderly (PACE).
REFERENCES:
1. Bronstein, L. Gellis, ZD. Kenaley, B. A Neighborhood Naturally Occurring Retirement Community: Views from Providers and
Residents. Journal of Applied Gerontology.
Nov. 23, 2009. Published online.
<http://jag.sagepub.com/content/early/2009/11/23/0733464809354730>.
2. Cohen-Mansfield, Jiska, and Frank, Julia. (2008). Relationship between perceived needs and assessed needs for services in
community-dwelling older persons. The Gerontologist, Vol 48, No.4, pp.505-516.
29 (41%)
33 (42%)
Interest in Workshopse
30 (41%)
Need Help Managing Medicine f
Adequate post-hospital care g
Need help with meal preparation
Need help with shopping
Adequate Exercise options
5 (6%)
60 (80%)
6 (8%)
9 (12%)
70 (92%)
a: n=69; b: n=67; c: n=7; d: n=70; e: n=74; f: n=77; g: n=75
*Chi-Square Tests Done: Proximity of Support and Interest in SASH had no association (X^2 =
0.3, DF = 1, p >0.5); Age and Interest in SASH had no association (X^2 = 4.61, DF = 7, p>0.7)
Highlights from Community Provider Interviews
Agency
CVAA (Champlain
Valley Agency on
Aging)
Senior Interest in Specific Services
40
35
30
25
20
15
10
5
0
d
Role with
Agency
Heineberg Senior
Center
Appletree Bay Medical
Center
•seniors don’t like to be singled out from their neighbors
in receiving services
•she feels many of them “just give up” and accept how
things are
•transportation concerns
•not knowing what services are available
•even if they afford a house they can't afford to keep up
Center Director their house
•lack of access to good nutrition
•the shift for people to participate in their own health
care is confusing to many seniors
Physician
Discussion
Many NORC and Village models throughout the nation have
been successful in creating senior-centered communities. It is
important to note that these communities are not solely
designed for seniors who require a lot of help in order to
remain in their homes—they also provide “concierge” services
(grocery shopping, transportation, yard-work, etc.) to those
seniors who are more independent. According to current
literature, many seniors emphasize that access to reliable,
consistent resources for home maintenance is paramount to
their ability to continue to live in their own homes. Our survey
results confer a similar interest in these “concierge” services
over more intensive health-related services.
Similar to the community providers’ perspectives, our survey
results indicate that some seniors (but not all) anticipate future
challenges. Also, most seniors (70%) reported their health as
“fine to excellent”. To what degree this % represents the
actual health status of the seniors is unclear. Research has
shown that many older adults perceive their needs to be less
than what they really are. If overall the surveyed group views
itself as relatively healthy, it may be more difficult for them to
anticipate future needs and appreciate how a community
based SASH program could truly benefit them. This was
substantiated by responses such as “[this is] not necessary at
this time” or “[I am] not old enough yet.”
Comments Regarding Seniors' Needs
•It’s a challenge for seniors to learn about the various
services;
Case Manager
•overall big barriers: transportation, housework,
medication management
PACE (Program for AllInclusive Care of the In-take Nurse
Elderly)
Results
Number of Seniors (n=78)
PROJECT AIM
We have collaborated with Cathedral Square to better determine
the needs of the NNE senior population and investigate how the
SASH program compares to other aging community models
already in existence. NORCs (Naturally Occurring Retirement
Communities) and Villages are models growing in popularity
across the nation, undoubtedly due to people’s desire to age
independently in their own home.
Response (% of total
respondents)
20 (26%)
58 (74%)
74.12 (9.3)
74.05 (8.45)
74.14 (9.64)
34.68 (21.85)
71 (91%)
55 (70%)
Survey Question (n=78)
•many seniors need a case manager for
efficiency/thorough evaluations of needs and the use of
multi-disciplinary care
•it's important to work with existing service
providers/organizations
•the largest obstacle is COST
•family members should take on a more active role to
help offset the need for outside services
3. Gross, J. Aging at Home: For a Lucky Few, a Wish Come True. New York Times. Feb. 6, 2009.
4. Jewish Federations of North America, Inc. Meyer Balser NORC. 2011. <http://www.jewishatlanta.org/page.aspx?id=207677>.
5. McWhinney-Morse, S. Beacon Hill Village. Generations-Journal of the American Society on Aging. Vol. 33, No. 2. 2009.
6. Thomas, WH. Blanchard, JM. Moving Beyond Place: Aging in Community. Generations-Journal of the American Society on Aging. Vol.
33, No. 2. 2009.
7. United Hospital Fund. NORC Blueprint: A guide to Community Action. <http://www.norcblueprint.org/norc>.
Study Limitations
•The survey did not clearly capture seniors’ projected
concerns due to the wording of the questions
•Our analysis lacked seniors most isolated from the
community
•The method of survey distribution was not consistent
among all sites
•Time constraints limited the number of community
members that we could contact
CONCLUSION
Our survey data and interviews support the establishment of a
community based SASH program for seniors in the New North
End. Among those interested are seniors of a wide range of
age, health status, and social support. Allowing this
population to safely and happily age in their own homes will
require coordinated effort among a variety of organizations.
ACKNOWLEDGMENTS:
A sincere thank you to the members of the SASH team at Heineberg Senior Housing —
particularly Ken Bridges, Wendy Critchlow, and Paula Fitzpatrick. Thank you also to Gail
Moreau and to Dr. Frank Landry. Additional thanks to Aaron Hurwitz and Raj Chawla for
their technical support. Last, but not least, a big thank you to all the area seniors that took
the time to participate in this project.
Removing Barriers to Health Care: Healthy Starts for New Americans
French D1, Graf M1, Korsh J1, Kreider H1, Pasciullo E1, Shean K1, Wood E1, Bourgo2, Maltby H1, Carney, J1
1. University of Vermont, 2. Community Health Center of Burlington
• To determine if refugees completing a Medical Orientation
Program for New Americans are better with several aspects of
medicine in the US, such as making appointments; knowing more
about diet and hygiene; and understanding the implications of
mental and chronic illnesses.
• To determine if Medical Passports provided to these individuals
to improve continuity of care are useful and effective.
• To make recommendations for improvements to the Medical
Orientation Program for New Americans to the Community
Health Center of Burlington (CHCB).
Background
• Language barriers, cultural differences, and low health literacy
in immigrant populations lead to decreased health care
quality and outcomes (Chao, 2009; Morris, 2009).
• Language barriers cause the treatment responsibility to shift
heavily toward the patient (Weiss, 2007).
• Community-based participatory action research (CBPAR) used
by health care clinicians is shown to successfully identify the
most pressing needs of community health center populations,
and improve medical practices as well as overall patient
health (Culhane-Pera et al, 2009).
• CBPAR studies assessing Somali Bantu refugee populations in
Southwest Idaho revealed a high degree of vulnerability and
increased risk for health disparities (Springer et al, 2010).
• Clinics for refugees can be held for patient education when
appropriate medical translation staff is present (Smith, 2008).
• Refugee communities rely on community health centers for
health care, as those centers provide for uninsured and
underserved communities where refugees are
disproportionately represented (Probst et al, 2009).
References
Lessons Learned
Methods
• Design a survey to determine whether the learning
objectives of each of the Medical Orientation classes were
met, and whether or not the Medical Passport met its
goals.
• Interview Bhutanese refugees individually with an
interpreter, asking these survey questions.
• Make recommendations to CHCB based on these findings.
Medical Orientation Program for New Americans Example
The Patient-Provider Relationship, Confidentiality, and the
Role of Interpreters
Objectives for this Lesson:
• Understand the roles of different health care
professionals
• Understand why it is important to talk openly with your
doctor
• Learn what “confidentiality” means for you and your
doctor
• Learn about “consent”
• Understand the role of an interpreter
• Discuss different methods of interpretation that may be
used when you visit the doctor
Survey Example
• When it’s not an emergency, who should you see when
you’re sick?
• What does patient-doctor confidentiality mean?
• What does “informed consent” mean?
• Interpreters have different styles that may influence a survey
• Survey could be provided ahead of time so that the interpreters can coordinate
their explanation of difficult concepts
• Pressure to get answers correct: some of us stated “it’s okay if you don’t know the
answers”, but it is not clear that this message was conveyed consistently
Results
• Majority (12/21 = 57%) knew to make an appointment with their
own doctors if they are sick (versus going to the emergency room)
• Majority (16/21 = 76%) knew the meaning of chronic disease
• Majority receive help from English-speaking relatives in making
appointments (14/21 = 67%)
Recommendations
Better differentiation about what does constitute an emergency
Decrease the size of the medical passports (already done)
Remind people that while many may not be curable, they are treatable
Encourage more practice with verbal (English) assertions about health (making an appointment;
or, saying “I am a diabetic”) so that New Americans have basic skills to inform people about their
health when they do not have access to a translator
• Make the clinical vignettes in the surveys (e.g. chests pain, child vomiting) more clearer
• Clarify the consequences of a chronic disease
•
•
•
•
# of respondents
Objectives
Conclusion
•
•
•
•
•
The CHCB is dedicated to providing care to people who have a
limited English language and reduced ability to pay.
Assuring that New Americans receive necessary health care,
including primary and preventative care, is challenging.
Barriers to care may include administrative, cultural, language,
knowledge, and transportation.
Efforts to improve health care access must focus on the
specific needs of diverse populations.
Though it is clear that this population benefited from the
Orientation, there are improvements that could be made for
future sessions.
Chao S et al. Toward Health Equity and Patient Centeredness integrating health literacy, disparities reduction, and quality improvement. National Academic Press. 2009: 1-102., Culhane-Pera KA ,et al. Improving health through community-based participatory action research. Giving immigrants and refugees a voice. Minn Med. 2010; 93(4):54-7., de Anstiss H, et al. Help-seeking for mental health problems in young refugees: a review of the literature with implications for policy, practice, and research. Transcultural Society 2009; (46)4: 584-607., Dussán KB, et al. Effects of a refugee elective
on medical student perceptions. BMC Medical Education 2009; (9):15., Fennely K. Listening to the experts: provider recommendations on the health needs of immigrants and refugees. Journal of Cultural Diversity 2006;13(4):1-90., Guendelman S, et al. Overcoming the Odds: Access to Care for Immigrant Children in Working Poor Families in California. Maternal and Child Health Journal 2005; 9(4): 351-362., Morris MD, et al. Healthcare Barriers of Refugees Post-resettlement. J Community Health 2009;(34):529–538., Probst JC, et al. Association between community health center and rural
health clinic presence and county-level hospitalization rates for ambulatory care sensitive conditions: an analysis across eight US states. BMC Health Serv Res 2009 ;31(9):134., Refugee Health Program. Minnesota Department of Health. http://www.health.state.mn.us/divs/idepc/refugee/hcp/healthguidesom.pdf, Refugee Health Program. Vermont Department of Health website. http://healthvermont.gov/local/rhealth/refugee.aspx#about, Rust G, et al. Presence of a community health center and uninsured emergency department visit rates in rural counties. J Rural Health. 2009,
Winter;25(1):8-16.,Scherer TM, et al. Follow-up to a federally qualified health center and subsequent emergency department utilization. Acad Emerg Med. 2010;17(1):55-62., Simbiri KOA, et al. Access Impediments to Health Care and Social Services Between Anglophone and Francophone African Immigrants Living in Philadelphia with Respect to HIV/AIDS. Journal of Immigrant and Minority Health 2009;12(4):569-579., Smith SR. The case of a city where 1 in 6 residents is a refugee: ecological factors and host community adaptation in successful resettlement. Am J Community Psychol
2008;42:328-342., Smith-Campbell B. Emergency department and community health center visits and costs in an uninsured population. J Nurs Scholarsh. 2005;37(1):80-6., Springer PJ, et al. Somali Bantu refugees in southwest Idaho: assessment using participatory research. Advances in Nursing Science. 2010;33(2):170–181 ., Sullivan CH. Partnering with community agencies to provide nursing students with cultural awareness experiences and refugee health promotion access. Educational Innovations 2009;48(9)., Uba L. Cultural barriers to health care for southeast Asian
refugees. Public Health Report 1992;107(5):544-8., Vahabi M. Knowledge of Breast Cancer and Screening Practices Among Iranian Immigrant Women in Toronto. Journal of Community Health 2010; 02 September., Weiss BD. Health Literacy and Patient Safety: Help Patients Understand; a manual for clinicians. American Medical Association 2007.
Puppets in Education
Bakhit, M.1, Clem, J.1, Fujii, M.1, Garcia-Webb, M.1, Lincoln, T.1, Nesbit, A.1, Schwartz, A.1, Vakhshoorzadeh, J.1, Lyons, D.2, Contompasis, S.1
1University of Vermont College of Medicine, Burlington, VT; 2Puppets In Education, Burlington, VT
Introduction
• Autism spectrum disorders (ASD) are a group of related brain-based
disorders that affect a child's behavior, social and communication skills.
• In 2009, approximately 1,000 Vermont students received special
educational services for ASD.
• Puppets in Education (PiE) is a non-profit group that teaches kids how to
keep themselves safe and healthy and to appreciate each other’s differences.
• PiE’s Friend 2 Friend Program (F2F) addresses ASD in fun and interactive
puppet and workshop presentations, promoting empathy for individuals on
the autism spectrum by modeling, labeling, explaining and normalizing
differences, and teaching prosocial communication and friendship skills.
• Last year, UVM COM students collaborated with PiE to determine how the
use of puppets could best educate the community regarding ASD.
•This year our goals were to elicit:
the perceived effectiveness of current ASD education in the
classroom
the perceived effectiveness of including children with ASD in the
classroom; and
the most important aspects of ASD to address in the Puppets in
Education (PiE) curriculum
Objectives
Results
“I think children are very accepting of
differences when educated to do so. I feel it
is important so students develop empathy,
become reflective concerning their own
behaviors, and learn about becoming a
responsible citizen.”
“I have many students on the
autism spectrum on my caseload
and I feel under qualified to work
with them. I really want to take a
course on this subject to better serve
these students.”
To conduct a survey to assess the effectiveness of current curriculum
approaches to Autism Spectrum Disorder (ASD) education and to assess the
educational impact of including students with Autism in the classroom.
“There needs to be more
education and acceptance
taught to all the children. It
needs to be a constant and
regular part of their social
learning….how to coexist and
integrate/play/accept all
children with or without
differences/disabilities.”
“[PiE is an] innovative/effective approach to delivering content;
entertaining and inspiring to both children and adults”
Discussion
Methods
A survey was emailed out to a total of 1,420 VT educators and 5,671
community members on 10/10/10, creating a total survey population of
7,091 individuals from all counties across the state of Vermont.
Population surveyed :
1) Families with a child with ASD (ages 2 to adult)
2) Families without a child with ASD
3) Educational professionals
Data Analysis
• Quantitative data was analyzed using Chi2 distribution and multinomial
logistical regression where appropriate. Qualitative data (responses to openended survey questions) were evaluated using a simplified qualitative data
analysis technique and included the reporting of trends.
• Divisions were noted across all sampled populations on the topic of
inclusion. Educational professionals discussed difficulties of knowing when
and how to implement inclusive practices.
• While more educators than families felt the current approach to inclusion
(regarding children with differences/disabilities) was effective, all sample
populations expressed a desire for more information and education on how to
implement it effectively.
• While curricula for inclusion within the schools exist, parents of children
with ASD feel that they are the main source of information on the disorder.
• There is a further need for ASD and social skills education.
• Issues with confidentiality were cited as a potential barrier to further
education.
• Educators felt more confident about their school’s ability to balance the
needs of children with ASD and their peers than families.
• Families with ASD felt more confident than families without ASD
addressing the topic of autism spectrum disorders with their child’s school.
• Families with ASD felt more confident addressing the topic of autism
spectrum disorders than educators did addressing the topic with parents of
typically developing peers.
• Educators who teach children with ASD felt more confident addressing
ASD with parents.
• Families who felt that their school effectively included children with
differences/disabilities were more likely to be confident in their school’s
ability to balance the needs of children with and without ASD.
• As each child with ASD is different, having flexibility in structured support
systems improves classroom behaviors for children with ASD.
• Families and professionals can share in the challenges and successes in
educating children with ASD.
Further Study Recommendations
1. Survey the children who participate in PiE’s Friend 2 Friend
programs to document their understanding of ASD and their
behavioral response to peers on the autism spectrum.
2. Find a way to target more parents of children with and without
autism to gather further information from their perspectives.
3. Write survey questions that fit more clearly into a formal
matrix for qualitative data analysis.
Universally, parents and educators felt that more education was necessary to
effectively work with students with ASD.
• There are curriculums currently available that teachers can adopt.
Including works by Michelle Garcia Winner.
The issue of confidentiality in the classroom becomes an issue when working
with a child with ASD.
• Teachers and Parents need to work together to not inadvertently “out”
a student with disability when presenting social skills programs.
Families are the main source of information on Autism Spectrum Disorder in
their schools.
• Effective communication between families and their teachers can help
bridge the gap, and families should be involved in educating their
teachers about the needs of their specific child.
There is no “One-Size Fits All” approach to working with a student on the
spectrum.
• Each student is different, programs need to be flexible and
individualized to fit the specific needs of each child on the spectrum.
WELL WATER SAFETY: A STUDY IN PUBLIC AWARENESS
Barbosa, N1; Boll, G1; Hemsley, C1; Hoyt, J1; Lahey, M1; Hoffman-Contois, R2; Bress, W2; Carney, J.1
1University
RESULTS
Although 30-50% of Vermont citizens rely on
private wells for drinking water, there is no state
requirement for regular contaminant testing5. As a
consequence, it is possible that private well users
may be exposed to a variety of potential health
hazards, including bacteria, arsenic, fluoride, and
radionuclides5. Our group sought to better
understand public awareness of testing
recommendations, how often private well users have
their wells tested, and what obstacles may be
keeping them from doing so. With this information
we hope to learn more about how Vermonters are
using private wells, and how we can better serve
public health in Vermont.
DISCUSSION
Figure 1: Private Water Source Testing Frequency
Figure 2: Testing by Children in the Household
Yates chi-square = 5.627; Yates p-value = 0.018
Every Year
13 (11%)
Every 5 Years
17 (15%)
Never
63 (55%)
Every 10 Years
22 (19%)
Percentage of Private Well Users Who
Tested
INTRODUCTION
of Vermont College of Medicine; 2Vermont Department of Health
80%
70%
60%
50%
40%
30%
20%
10%
0%
With Children (n = 79)
Figure 3: Testing by Education Level
METHODS
Figure 4: Reasons for Not Testing by Education Level
Percentage of Private Well Users Who
Have Not Tested
Yates chi-square = 6.732; Yates p-value = 0.009
Percentage of Private Well Users Who
Tested
80%
70%
60%
50%
40%
30%
20%
10%
0%
30%
Less than Bachelor's Degree (n = 46)
Bachelor's Degree or More (n = 19)
20%
REFERENCES
10%
0%
Less than Bachelor's Degree (n = 68)
Landlord's
Responsibility
Bachelor's Degree of More (n = 46)
Unaware
of Recs
Cost of
Testing
Unsure
of How
Not
Concerned
Yates chi-square = 8.915; Yates p-value = 0.030
50%
Private Source (n = 127)
40%
30%
20%
10%
0%
Percentage of Private Well Users
50%
Public Source (n = 140)
Could Require Not Enough Could Impact
Installation
Time
Property Value
Figure 6: Preferences for Additional Information by
Education Level
Figure 5: Use of Bottled Water by Water Source
Percentage Using Bottled Water
•Surveys were distributed at Department of Health local
offices across the state, Vermont state voting locations
and at the Thomas Chittenden Health Center and were
voluntarily completed in October and November, 2010.
•In total 284 surveys were included in the study,
including 127 using private water sources.
•Graphs were created using Excel. Analytical statistics
were completed using an online chi-square calculator
from the University of Kansas.1
Without Children (n = 36)
Less than Bachelor's Degree (n = 79)
Bachelor's Degree or More (n = 47)
40%
30%
20%
Weekly
Rarely
Never
1. Calculation for the Chi-Square Test. University of Kansas
Website. 2010. Web.
<http://www.people.ku.edu/~preacher/chisq/chisq.htm>.
2. Jones, Andria, Catherine Dewey, Kathryn Dore, Shannon
Majowicz, and Scott McEewn. "Public perceptions of
drinking water: a postal survey of residents with private
water supplies." BMC Public Health 6.94 (2006)
3. "Radioactivity - Naturally Occurring in Rock, Soil and
Water." Vermont Geological Survey. the Division of
Geology and Mineral Resources in the Department of
Environmental Conservation, 2002. Web.
<http://www.anr.state.vt.us/dec/geo/radindex.htm>.
4. "Testing Your Water." Vermont Department of Health.
Vermont Government Website, 2005. Web.
<http://healthvermont.gov/enviro/ph_lab/water_test.aspx >.
10%
0%
Daily
• Our study shows that over half of private water
users do not test their water, which puts them at risk
of potential exposure to drinking water
contaminants.
• Education level seems to play a significant role in
water testing, awareness of testing
recommendations, and the barriers to testing.
•Less educated populations may be more likely to
rely on a landlord for testing, to not be concerned
about water quality, and to be unaware of testing
recommendations.
• According to the respondents, having free water
testing and more information available through
flyers and the internet would be most helpful.
•Study results indicate that additional education
should be focused on households with children, as
children may be especially vulnerable.
•Visible public education, specifically using flyers
and internet, is needed.
Flyers
Internet
Newspaper
TV
Radio
5. Vermont Department of Health. Vermont Government
Website, 2010. Web. <http://www.healthvermont.gov/>.
Increasing Senior Enrollment in 3SquaresVT
Mohammed Almzayyen1, Mark Dammann1, Javier De Luca-Westrate1, William Jeffries1,
Jeffrey McLaren1, Diana Mujalli1, Stell Patadji1, Melissa Romero1, Angela Smith-Dieng2
University of Vermont College of Medicine1, Hunger Free Vermont2
“…I don’t think people realize that 3 squares
money is federal money that comes into VT
that’s not accounted for in the state budget,
therefore if people realize that they can say
“well, I’m doing my part to help VT’s
economy…”
80
*
70
Individual Estimates
Actual Percentages
60
40
30
27.4
Home visits to help with application
Provide Registration help at grocery
stores
Train family members to complete
application
Provide transportation to application
centers
Translate application
Host enrollment days
Application Help Line
•
•
•
•
•
•
Include application with yearly tax
forms
•
Educate Medical Centers about
Hunger
Word of mouthSpread the word
Train caregiver network about program
 Educational workshops for
care givers
Teach organizations about program
 Provide online access to
3SQVT eligibility information
 Hold staff meetings at health
centers
 Work with VT Medical Society
to increase awareness
•
•
•
Figure 1: Focus group
participant estimations of food
insecurity, 3SquaresVT eligibility, and
3SquareVT enrollment of Vermont
seniors.
Enrolled
Figure 2: What can be
done to increase
enrollment in 3SQVT?
Answers provided from
focus groups all fell
within one of the
following categories. Text
in bold indicates
examples that were
mentioned in at least 2 of
the groups. Underlined
text are ways that the
Campaign can
collaborate with specific
community organizations
as to increase enrollment
in 3SQVT.
Educate
Eligible
Recruit
Family
Media
•
•
•
•
•
•
Advertise
Data analysis
Audio recording, data transcription, and observers.
Solutions were categorized under one of three major
categories: simplify application, educate, and
advertise.
Application
Assistance
•
•
11.4
Insecure
Focus group
Representatives from community, health care, home
based, and religious organizations that work daily with
seniors in Vermont were invited to participate via email, phone, or referral.
17of 34 invited organizations participated in three 90
minute focus groups of 4-9 participants; 15
standardized questions were discussed.
Make application 1 pg with larger font
29.2
0
Methods
•
20
10
Discussion
Length
Increase
Access
Educate the
Community
50
Estimated Percentage (%)
Hunger Free Vermont’s mission is to feed more
Vermonters, teach the community about healthy food and
nutrition and lead advocacy and education efforts to end
hunger in Vermont. In Vermont 11.4% of all seniors are
considered food insecure. To address this issue, Hunger
Free Vermont has taken on the task of increasing
enrollment in 3 Squares Vermont, the state food stamps
program. 68% of people in VT who are eligible for 3SqVT
are enrolled. Surprisingly, only 29.2% of eligible seniors
are enrolled.
Our study focuses on the leaders of community
organizations who impact seniors. Through focus groups
we assessed their:
Knowledge of the 3SqVT program
Knowledge of senior enrollment and food insecurity
Ideas about the barriers leading to low enrollment
Solutions
Solutions
Results
Simplify Application
Background
Public
Spaces
•
•
•
•
•
•
Senior advocates/champions
Politicians
Train caregivers
Train children of seniors
State-wide campaigning (how can
enrollment help VT)
Social networks to reach out to
children of seniors
Provide personal stories
Target radio stations
Rebrand the program
Flyers at post office, grocery store
Shopping bag stuffers
Change name of campaign (childhood
hunger to seniors)
Most representatives from participating community
organizations knew that the Food Stamp program in VT was
rebranded as 3SquaresVT. However, most participants were
unaware of specific eligibility requirements to obtain benefits.
Surprisingly, despite the fact that most group participants work
closely with seniors, they did not accurately estimate 1) The
number of seniors who are food insecure in VT, 2) The number
of seniors who qualify for 3SQVT benefits, and 3) The number
of eligible seniors enrolled (Fig1).
We asked participants what they thought the barriers were
for seniors not enrolling in 3SQVT. Each group constructed a
list of barriers that they ranked starting with what they thought
most adversely affected senior enrollment. When compiling the
lists, we found that generational pride was the highest ranked
barrier, which is consistent with previously published literature.
Finally, each group brainstormed ways to increase
enrollment.
Our findings are summarized in Figure 2.
According to results, leaders within the senior care community
would benefit from additional education concerning 3QVT.
This could lead to increased senior enrollment and decrease
senior food insecurity in Vermont.
Conclusion
There was a general lack of awareness about the extent of
elderly food insecurity and participation in 3SQVT. Most
participants underestimated or overestimated both issues.
The top five barriers to low participation in 3SQVT were
generational pride, application difficulty, lack of awareness,
insufficient advertising, and the assumption that they are
ineligible. Solutions to increasing participation in 3SQVT
consisted of: simplifying the application process, educating the
community, and increasing exposure to the program.
Reference
Wolfe, Wendy, et. al. Journal of Nutrition Education : Understanding Food
Insecurity in Elderly". 1996.
Coe, Richard. Journal of Nutrition Education : “Understanding Food
Insecurity in the Elderly: A Conceptual Framework.". 1983.
Wilde, Parke, Food Review: Food Stamp Participation by Eligible Older
Americans Remains Low. 2002.
Haider, Steven, Journal of Human Resources: Food stamps and the
elderly. 2003.
Promoting Physical Activity and Nutrition in Adolescents
Bahadue F.1, Chang S.1, Clark B.1, Lindstrom V.1, Nyotowidjojo I.1, Rosenberg J.1, Smith A.1, Drucker N.1, Offer S.2
1
University of Vermont College of Medicine, Burlington, VT; 2Greater Burlington YMCA, Burlington, VT
Introduction/Background
In the United States, childhood obesity has become the
leading pediatric chronic disease. Increased caloric intake
and decreased energy expenditure is hypothesized as
contributing to the upward trend of obesity.1 Independent
of adult weight, obese children have increased morbidity
and mortality from metabolic syndrome as adults.2 Individuals engaging in exercise programs as short as 6
months have shown improvement in risk factors including
body fat mass, waist/hip ratio, ambulatory systolic blood
pressure, fasting insulin, triglycerides, and low-density
lipoprotein ratio.3
In our study, adolescents were taught a foundation of
health and well-being that incorporated regular exercise.
Nutrition was taught through an evidence-based systems
approach, including lessons about the cardiovascular,
musculoskeletal, and gastrointestinal systems. Our aim
was to improve adolescent food choices and increase
physical activity through interactive educational sessions.
Methods
We held 6 teaching sessions for 11 middle school-aged
children in an after-school program at the Greater Burlington YMCA. Each lesson consisted of:
• 30 minutes of organized exercise activities
• 30 minutes of systems- and nutrition-based education
Surveys were distributed to parents via paper copies
and e-mail at the beginning and conclusion of the project.
• Both surveys had the same 15 questions about behavior,
nutrition, and exercise
• The second survey had additional questions about participants’ learning experiences
Results
The 11 pre-intervention surveys showed this population
generally made healthy nutritional choices and had good
Students made
specific promises
to maintain a
healthy lifestyle
during the last
learning session.
exercise habits. Most ate whole wheat bread and did not
drink soda frequently. 64% of our adolescents ate 3 or more
servings of fruit a day compared to survey results of Vermont
youth, with 34% of students consuming 2 or more servings
of fruit a day (Graph 1).4 Ten of our participants were at or
near the American Academy of Pediatrics recommendation
that children receive at least 60 minutes of physical activity a
day (Graph 2).5 The survey revealed that students were curious about the healthfulness of their food choices as well as
the workings of their bodies. Most did not skip meals or eat
fast foods on a routine basis.
Only 2 follow-up surveys were received, precluding comment about possible alteration in healthy lifestyle habits resulting from the teaching sessions. Sample parent comments, such as: “Yes, he learned something: he has insisted
that he needs vitamins and will randomly spit out facts about
bones,” and “He loved it—should do more!” have led us to believe that this sort of educational session was beneficial.
Graph 2
Graph 1
Discussion
This study focused on increasing physical activity and
health education to promote a healthier lifestyle. We were
able to create a 6 week lesson plan that could easily be incorporated into a school curriculum. This sample group had
fairly healthy lifestyles at baseline, and as a result, might not
have benefited as much as a more diverse population. Fruits
and vegetables were consumed frequently and almost all
participants met or were near published recommendations
for daily physical activity.
A small sample size combined with the difficulties of collecting follow-up surveys hampered assessment of our
impact. Other challenges included an inability to directly
measure the students’ knowledge of diet and nutrition,
the lack of personal contact between researchers and parents, and an inconsistent sample population due to varied
attendance at each session.
Recommendations
• Meet parents personally to discuss project: adds personal
connection and motivation for survey completion
• Obtain IRB approval for future study: allows direct assessment of initial student knowledge and the impact of our
teaching
• Implement program in a population with less healthy
baseline lifestyle habits
• Investigate the development of this sample population’s
healthy lifestyles and integrate lessons learned into future
educational sessions
References
1
Nemet D. and et al. “Short- and long-term beneficial effects of a combined dietary-behavioral-physical
activity intervention for the treatment of childhood obesity.” Pediatrics 115.4 (2005):e443-9. 2Must A. and et
al. “Long-term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study
of 1922 to 1935.” New England Journal of Medicine 327.19 (1992):1350-5. 3Meyer A. and et al. “Improvement
of early vascular changes and cardiovascular risk factors in obese children after a six-month exercise
program.” Journal of American College of Cardiology 48.9 (2006):1865-70. 42009 Vermont Youth Risk Behavior
Survey. 2009. 5 Jan 2011. <http://healthvermont.gov/research/yrbs.aspx>. 5Physical Activity Guidelines
Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, D.C.: U.S.
Department of Health and Human Services, 2008. 5 Jan 2011. <http://www.health.gov/paguidelines>.