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Craig A. Molgaard explores the origins, spread and impact of the deadly influenza pandemic of 1918–1919, and how the outbreak intersected with the end of the First World War

Do you want to improve the professional climate, environment, or culture of your workplace? Here are some basic concepts—diversity, equity, inclusion, inclusive leadership, and culture change—that will help you and other statisticians, data scientists, or STEMM colleagues to plan for inclusive excellence.

Background Marshallese living in the Republic of the Marshall Islands (RMI) experience significant health disparities, with high rates of type 2 diabetes mellitus. In addition to health disparities, the RMI experienced nuclear testing that exposed inhabitants to nuclear fallout, unethical research practices, and contaminated natural food sources. Objectives This research uses a community-based participatory research (CBPR) approach to effectively engage community partners and honor their contributions in all stages of the research. A CBPR approach will leverage culturally situated knowledge and practices of the Marshallese community in the RMI to ensure the success of the research. Methods This manuscript describes the methods used to test the feasibility of delivering a culturally adapted family model of diabetes self-management education and support in faith-based organizations in the RMI. Conclusions This manuscript describes the protocol for creating working with community partners and implementing a feasibility study in the RMI.

Social capital, or a sense of partnership leading to shared goals, provides a means for addressing today's public health workforce challenges. This concept is particularly important in underserved rural areas, though efforts to intentionally generate social capital have been limited. Within the rural state of Kansas, the Kansas Public Health Leadership Institute (KPHLI) has implemented a social capital pre/post assessment to quantify the impact of KPHLI training on social capital within the state's decentralized public health system. This paper discusses 38 assessment items related to bonding, bridging and linking social capital. The assessment was completed pre and post training by 130 of 148 scholars (87.8%) in six KPHLI training cycles. Data were analyzed using Wilcoxon paired t-tests in SPSS. Thirty-five of 38 items demonstrated statistically significant increases at post-test, across all 10 sub-domains. Leadership training by the KPHLI fosters quantifiable increases in characteristics of social capital, which are essential for public health systems to cope with increased workforce demands and prepare for accreditation. This study represents a key first step in examining the deliberate generation of social capital within a decentralized rural environment.

Previous public health leadership training research has assessed regional or national programs or evaluated program effectiveness qualitatively. Although these methods are valuable, state-level program impact has not been evaluated quantitatively. Public health core and leadership competency assessments are administered pre and post Kansas Public Health Leadership Institute training (N = 94). Wilcoxon signed rank tests note significant increases by each competency domain. Data are stratified by years of experience, level of education, and urban or rural status, and correlations calculated using Spearman’s rho tests in SPSS/PC 14.0. Post training, participants improve significantly in all competency domains (p < .001). Participants with lower education, fewer years of experience, and rural status improve more in certain core competency domains. Lower education and rural status correlate with greater improvement in certain leadership competency domains. Similar assessment methods can be used by other public health education programs to ensure that programs appropriately train specific workforce populations for national accreditation.

As individuals directly impacted by their experience of epilepsy and others’ responses to it, epilepsy patients’ opinions about education and awareness issues are needed. A community-based participatory approach was used to develop a survey of public and patient attitudes and perceptions about epilepsy, which was administered to persons with epilepsy. The majority of the 165 respondents (34% response rate) indicated they perceive misperceptions and stigma related to epilepsy in the general public, which they thought could be ameliorated through educational interventions. Respondents indicated potential avenues of educational intervention for the general public as well as for those with epilepsy, with recommended content and intervention type depending on target audience. The community-based participatory research process and the patients’ perceptions gathered through the resulting survey indicate potential activities for overcoming stigma and increasing education and awareness related to epilepsy. 2007 Elsevier Inc. All rights reserved.

Despite increasing attention to academic-practice partnerships for health practice and workforce development, guidelines for how to implement such partnerships are few. The Kansas Public Health Workforce and Leadership Development (WALD) Center provides a successful example of such a partnership. The WALD Center implements public health education and training projects through a collaborative process of health needs identification, program conceptualization, research, and program evaluation. Such coordination allows for continuous practitioner-oriented program development and the sharing of a rural state's scarce resources between interconnected projects. The WALD Center's methods provide a model for academic-practice partnerships for community health practice and workforce development, even in environments with scarce health resources.

Background: In an emergency, the pharmacists' role lies in obtaining access to pharmaceuticals and other crucial supplies necessary to ensure that injured or ailing people are treated quickly and effectively. Objective: To assess pharmacist reactions regarding the emergency preparedness program, “Can it Happen in Kansas: Response to Terrorism and Emerging Infections,” before and after training. Methods: A terrorism preparedness questionnaire was developed to self-assess changes in participants' confidence. These were measured before, immediately after, and 3 and 10 months after training. Results: At pretest, pharmacists reported feeling more alert to agroterrorist attacks in Kansas, better able to describe their roles in incident response, more alert to symptoms of emerging infections, and better able to recognize radiation symptoms than at posttest (all p < 0.001). Similar statistical patterns can be found in almost all content areas covered. Conclusions: It is difficult to measure competencies and skills needed in emergency preparedness training. Future training will involve more objective measures. Since pharmacists are well positioned to detect emerging and unusual patterns of disease or medical conditions, it is imperative that they are included among professionals who are trained to recognize symptoms of exposure to biological, nuclear, or chemical agents.

Continuing education events addressing terrorism preparedness must be evaluated to measure their impact on knowledge acquisition and to assess changes in perceptions, attitudes, and beliefs. The purpose of this focus group study was to evaluate the effectiveness of a terrorism-preparedness training program. The majority of participants thought the training content was extensive, detailed, informative, and practical. Participants reported feeling increased confidence in their abilities to anticipate, recognize, and respond to a terrorist event, and said they made changes related to terrorism preparedness in their homes, workplaces, and communities. This evaluation was useful in identifying strengths and weaknesses of a statewide continuing education program and describing future training needs. Results may be useful to others who are planning terrorism-preparedness training.

The Kansas Statewide Farmworker Health Program (KSFHP) has developed a unique set of culturally competent health interventions in response to the pressing public health needs of the state's underserved farmworker population. Key among these are its health education and translation efforts on behalf of the fast-growing Low German-speaking Mexican Mennonite farmworker population. Linguistic, religious, and cultural values have created unique and complex health disparities and barriers to care that can be broken down only through innovative approaches. KSFHP first conducted a health needs assessment survey of the farmworker population in 2003, which indicated prenatal care practices as a significant health disparity, especially among the Low German-speaking Mexican Mennonite population. In response, KSFHP successfully lobbied the state health department to implement a new standard of health behavior data collection that includes primary language data as a method of delineating population subgroups, making Kansas one of the first two states in the country to collect this information. KSFHP also developed culturally competent Low German-language recordings on health topics such as prenatal care in accordance with the information delivery needs of the Low German-speaking Mexican Mennonite farmworker population. Currently, a pilot program is in progress that offers additional outreach, health education, and interpretation, among other services. The work of the KSFHP has significant implications for further research into health disparities, specialized minority populations, and culturally competent data collection methods.

This study describes the evaluation of a 2-year plan to train 10 percent of Kansas' multidisciplinary health professionals for response to terrorism and emerging infections. This project was part of a national effort covering 19 states funded by the Health Resources and Services Administration in 2003.The initial training occurred in six 2-day workshops. A terrorism preparedness questionnaire was developed to assess Health Resources and Services Administration terrorism response competencies/learning objectives. These were measured before, after, and 3 months after training in a hybrid cross-sectional and cohort follow-up design.Health professionals' mean scores significantly improved on all four Health Resources and Services Administration terrorism self-reported competencies from pretest to posttest. Three months posttraining, health professionals' mean scores decreased slightly but remained significantly higher than their pretest scores.This project prepared healthcare professionals to respond to the medical consequences of terrorism. The integration of core competencies into the evaluation plan allowed for trainees to evaluate their confidence and abilities. The evaluation plan and curriculum may serve as useful tools for preparation of healthcare workers nationwide, with the potential to rebuild the public health infrastructure to assume preparedness responsibilities.

Improving Medicaid program effectiveness for underserved populations is hampered by low survey response rates. This study determined how to maximize Medicaid consumer satisfaction survey response rates to the Consumer Assessment of Health Plans Study (CAHPS) survey. In a public immunization clinic, 8 focus groups and 15 extended interviews were used to assess consumer-preferred survey design features and incentives. To test hypotheses, we conducted the following trial. Out of 10,733 total participants in a Kansas Medicaid managed care plan, 3,685 eligible for CAHPS were unduplicated by household. After randomization of the 968 households with valid addresses to one of three groups, a controlled trial was conducted to assess response rates to CAHPS survey formats and incentives. Response rates were 35% for a standard mailing, 44% for a user-friendly low-literacy mailing, and 64% for a user-friendly low-literacy mailing with a $10 contingent incentive. Both experimental arms significantly improved response compared with the control; the response rate of the mailing group with the incentive was higher than the response rate of the group receiving that mailing without any incentive (p0.0001). Using consumer-based preferences significantly increased response rates to this Medicaid satisfaction survey. Raising CAHPS response rates may increase validity of Medicaid consumer satisfaction information.

Nurses are in a strategic position to influence their patients to stop smoking, but factors affecting their likelihood of assessing and counseling are unknown. The purpose of this cross-sectional survey study was to identify predictors of tobacco use assessment and smoking cessation intervention by office-based nurses employed in private physician practices in Kansas. A 43-item questionnaire was mailed to all family practice, internal medicine, and pediatric private practice offices located throughout the state of Kansas with a final sample of 415 completed surveys. Logistic regression was performed to identify predictors of three dependent variables: (1) tobacco use assessment, (2) patient interest in smoking cessation, and (3) delivering smoking cessation counseling. Nurses were more likely to assess patient tobacco use, assess patient interest in tobacco cessation, and provide tobacco cessation counseling if they believed they had the skills, and had attended tobacco-related continuing education in the...

Community-based organizations often capacity build to successfully enable themselves to be adaptable and responsive to constantly changing environments. However, community-based organizations are stretched for time, staffing, and funding, and the added obligation of regularly performing management planning tools, such as strategic planning, needs assessments, program evaluations, or market demand forecasting, strain limited resources. Through case studies, this article illustrates how collaborations between universities and community-based organizations can result in the development of successful management planning tools through the use of geographic information systems and secondary resources. Such collaborations produced maximization of production and effectiveness in an environment characterized by limited resources.

In this study, we examined the tobacco cessation efforts of nurses working in primary care settings. A 43-item questionnaire was mailed to 1,036 office-based nurses located throughout Kansas. With a response rate of 50.1%, 415 questionnaires were available for analysis. Although 89% of respondents encountered patients who smoked on a daily or weekly basis, only 51% reported documenting their patients' tobacco use, and 38% assessed patients' readiness to quit. Two thirds (66%) of nurses believed that tobacco management was part of their role but only 35% provided cessation advice, 23% recommended nicotine replacement therapy, and 14% provided coping techniques. Nurses cited barriers such as perceiving patients as disinterested or unmotivated to quit (65%) and having little time (55%), skills (32%), or knowledge (25%). Most (91%) agreed that they needed additional tobacco control education. Nurses who were advanced registered nurse practitioners or clinical nurse specialists were more likely to feel confident about their smoking cessation counseling skills compared to nurses with less education (66.7 vs. 31.2%, p =.010). Office-based nurses identified specific barriers that could be addressed through professional education about tobacco management.

Anecdotal reports suggest school nurses and staff treat increasing numbers of public school students with chronic diseases. However, professionals know little about actual disease burden in schools. This study measured prevalence of chronic disease medication administration rates in a large, urban midwestern school district. Data from daily medication logs were recorded by school nurses during a single week. Medications and administrations were sorted by disease type. Prevalence rates were calculated for six chronic diseases: asthma, diabetes, seizures, attention deficit/hyperactivity disorder, other mental/behavioral disorders, and other diseases/conditions. Separate rates stratified by school grade, poverty level, and type of school were calculated. Overall, 3.12% of students received medication for chronic diseases, including 2.13% for psychiatric/mental disorders and 1.91% for attention deficit/hyperactivity disorder alone. These rates were lower than estimates from other states. Factors that contributed to this finding are reviewed.

Level of acculturation and the relationship to functional impairment was examined among a group of Chinese (n = 50) and Vietnamese (n = 50) 45 years and older in San Diego County, California. Prevalence of functional impairment and level of acculturation, one-way analysis of variance and Pearson correlations were utilized to examine differences between ethnicity, gender and age groups, as well as significant relationships between various dimensions of impairment and levels of acculturation. Findings indicated that lack of English language skills and lack of use and exposure to English were associated with social and economic resource impairment, mental and physical health impairment, and ADL impairment, as measured by a modified OARS instrument. Data suggested that the visibility and extensiveness of the Vietnamese community may serve to buffer the negative effects associated with the acculturation process for the Vietnamese.

In this paper, key barriers to providing smoking cessation services for low income individuals are illustrated using epidemiologic data from a population which was enrolled in a Medicaid managed care plan in Kansas during 1998. The Plan served 623 pregnant women who could potentially benefit from assistance in avoiding tobacco exposure. The prevalence of smoking among adult clients was 44.8%. twice the national average. Only 52.3% of adult smokers were advised by a provider to quit in the previous year. Most individuals in the client population (81.7% of the 10,733 members) were children, suggesting the importance of targeting environmental tobacco smoke exposure in order to reduce morbidity from asthma. The adult household member who needed smoking cessation services, however, was unlikely to qualify for health care benefits through Medicaid. The median length of enrollment was only 1.9 months, providing very little client contact time for tobacco control initiatives. The literature suggests that some providers may lack skills in treating tobacco as an addiction. It would be a major task for the managed care organization to train the 2,000 physicians in 68 of the 105 counties of Kansas who cared for this population. Potential solutions include improving reimbursement for smoking prevention and treatment, and developing cheaper smoking cessation services which are effective and acceptable among low-income individuals. The managed care organization could provide patient education materials and staff training for physicians and other members of the office staff.

The US EPA's Integrated Exposure Uptake Biokinetic (IEUBK) Model is a physiologically-based, multicompartment model which simulates lead uptake, distribution within the body, and elimination in order to predict children's blood lead levels. This study used the IEUBK to quantify the relative importance of dietary lead exposure from ceramic bean pots (as opposed to other environmental sources including soil, water, air and indoor dust) in children from San Diego County, CA, the majority of whom had been identified (by actual measurements) to have elevated blood lead levels. The EUBK modeling suggested that dietary lead exposure from beans prepared in Mexican pottery may account for a major fraction of the blood lead burden in children (all of Hispanic ethnicity) whose families used such ceramic ware. The IEUBK model tended to be overpredictive of actual values for blood lead levels, but this was most probably due to uncertainties in the exposure variables in the risk assessment. The results of this model si...

The prevalence and incidence of human T cell leukemia virus type I/II (HTLV-I/II) and hepatitis A, B, and C virus infection were determined among US Marines stationed in Okinawa, Japan. Of 2875 personnel, 2 (0.07%) had antibody to HTLV-I/II. After 1-3 years, no HTLV seroconversions were observed, although 23% reported sexual contact with Okinawans. Of 1010 hepatitis-tested marines, 121 (12%) had antibody to hepatitis A virus (anti-HAV), 26 (2.6%) had antibody to hepatitis B core antigen (anti-HBc), and 2 (0.2%) had antibody to hepatitis C virus (anti-HCV). On follow-up, 1 subject seroconverted to anti-HAV, 8 to anti-HBc, and none to anti-HCV. Most marines with recent hepatitis B infection were young, single, and enlisted and had been on short deployments to other countries in Southeast Asia. Marines stationed in Okinawa are not at high risk for HTLV infection but are at increased risk for hepatitis B infection and should be considered for vaccination.

The use of cigarettes and other forms of tobacco poses a major and growing health threat to populations of developing countries. The present study examined the onset of cigarette use among public school students in Tijuana, Mexico. Fifty-four percent of the males and 34 percent of the females had experimented with smoking. Maternal smoking was more strongly associated with smoking among girls, while peer smoking had a relatively stronger association with future intentions to smoke among boys. Rates of smoking behavior among Mexican-American school children in nearby San Diego more closely resembled the higher rates of their Tijuana than those of their Anglo-American counterparts.

An analysis from the Finnish East and West Cohort of the Seven Countries Study tested the hypothesis that front line service during modern warfare is associated with depression later in life. World War Two-era Finnish combat veterans were compared to Finnish veterans who were non-combatants. Both groups were followed from 1959 to 1984. Dependent variables were the Zung depression scale and other measures of psychosocial adaptation and mental health. Analysis of variance of Zung scores by combat exposure was close to statistical significance (p = 0.0501). Even if statistical significance had been reached, it is felt that the absolute magnitude of the differences between the populations appear quite trivial. A significant association was found for those who had participated in over nine battles and when grouping depression, sleeplessness, paranoia, hallucinations, schizophrenia, and other mental illness into the general category of any mental illness (O.R. = 4.414; 95% C.I. = 1.113, 17.503). This seems to support the residual stress hypothesis pertaining to modern combat exposure.

The overall purpose of the present study was to identify differences between the early retired and the nonretired among three ethnic groups: Whites, Blacks, and Mexican Americans. Analysis focused on a community-based sample of 1,146 residents of San Diego County aged 45 to 64 years. Three categories of variables that were hypothesized to contribute to early retirement were examined: demographic characteristics, self-reported health measures, and Older American Resource and Service (OARS)based objective summary ratings of functional impairment. Results were consistent with the literature and indicated that functional impairment was higher for the early retired within each of the ethnic groups. For both retirement status groups, Mexican Americans reported the most impairment of the three ethnic groups. Discriminant analysis was used to identify the predictive value of the three categories of variables for early retirement status and yielded the following results: age, gender, and the mental health OARS objective functional-impairment score were the only significant discriminators for all groups. Mexican Americans appeared to have the greatest variety of factors contributing to early retirement status, with fewer variables involved for Blacks and fewer still for Whites.

To assess changes in knowledge, attitudes, and intentions among childcare workers before and after an asthma-management-education session.Between May and August 2004 five asthma-education sessions were provided for childcare workers from Sonoma County, California. A total of 71 childcare workers came to the sessions. Before and after each session we assessed the participants' knowledge, attitudes, and intentions about asthma.Participant knowledge of asthma causes (eg, air quality, common cold) and interventions (eg, bronchodilators), asthma trigger control plans, ability to identify a child who needs medical attention for asthma, and comfort level with caring for a child with asthma increased significantly. Their knowledge about asthma triggers, early warning signs, and asthma control plans was high before and after the asthma education intervention. Their stated intentions to utilize their asthma knowledge were high before and after the training, which may indicate willingness to implement knowledge and attitude change.Asthma education can improve childcare workers' knowledge about asthma-control strategies and attitudes toward asthma interventions.

Psychosocial assets of 37 adults with cystic fibrosis (CF) and 46 of their healthy peers were assessed by mailed questionnaire. Major sociodemographic variables did not differ significantly between the two groups, nor did indices of emotional social support, social network density, self-esteem, or current life satisfaction. This study revealed adults with CF to function on a par with their healthy peers in nearly all respects, a finding at odds with those from uncontrolled studies and which suggests to us that many previous conclusions about the psychosocial health of adults with CF have been unwarranted. Future psychosocial studies involving patients with CF should include control groups and inferences about the effect of these patients' physical illness on their psychosocial health should not be made in the absence of normative data.

A total of 561 residents of San Diego participated in an evaluation study of the effectiveness of the San Diego County Colorectal Cancer Education and Screening Program. The study design was a separate sample pre-test/post-test administration of a telephone questionnaire. The education project focused on clarifying misconceptions and informing the public of early detection measures for colorectal cancer. A significant difference existed at the P < .05 level between the pre-test and post-test groups for seven of 15 items on the questionnaire. Evaluation of the San Diego program indicated that it was more successful in providing the public information about early detection of colorectal cancer (fecal occult blood test, digital rectal exam, and proctosigmoidoscopic examination) than in clarifying misconceptions about the disease. Despite such a program, however, reduction in morbidity and mortality may not occur if public education to clarify misconceptions about colorectal cancer is not reinforced ...

The present study extended the results of previous research in applying the “stages of acquisition” model to the onset of smokeless tobacco as well as cigarette use. Three expert judges classified an initial pool of items as to whether they represented “precontemplation,” “contemplation,” “action,” or “maintenance” stages of smokeless tobacco acquisition. Fifty items with adequate inter-rater reliability were combined with 21 previously developed items pertaining to cigarette smoking acquisition in an overall tobacco acquisition questionnaire, which in turn was administered to 358 junior and senior high public school students. Three distinct components labeled precontemplation, action, and maintenance were delineated through principal component analyses. Coefficient alphas and discriminant analyses according to self-reported use demonstrated adequate reliability and validity for the new smokeless tobacco- and previously developed smoking-acquisition scale.

Much research has been done into tobacco use portrayals in film since the mid-twentieth century, but the earlier years of Hollywood history have been overlooked. Yet the first decades of the twentieth century saw annual per capita cigarette consumption increase from under 100 in 1900 upto 1,500 in 1930. The current study looks at frequency and context (gender, age range, socioeconomic status, type of portrayal) of tobacco use in 20 top-grossing silent films spanning the silent feature era (1915-1928). The sample averaged 23.31 tobacco uses per hour. Tobacco use was most often associated with positive characterizations, working/middle class status, masculinity, and youth. Previous research has verified the influence of the film industry on tobacco consumption in modern years, and this potential connection should not be ignored for the silent film era. Top-grossing silent films set a precedent for positive media portrayals of substance use that have persisted to the present day.

INTRODUCTION To assess the impact of regionalization of Kansas counties associated with emergency preparedness since 2002 via local health departments (LHDs). METHODS Three focus groups were conducted in May 2005 with 31 Kansas health department employees. Most participants were public health administrators, women, and 40 years or older. RESULTS Regionalization was perceived as "absolutely necessary" by participants and resulted in improved collaboration and communication among LHDs. The process supported the development of relationships, trust, and mutual respect among LHDs and other governmental agencies. Participants agreed that LHD functioning has improved the delivery and availability of public health services, increased the efficiency and timeliness of operations, and enhanced public health's visibility in emergency preparedness efforts. Moreover, regionalization added resources to LHDs including personnel, knowledge, technology, technical expertise, and fiscal resources. Dissatisfaction with regionalization was associated with insufficient funding, frustration with changing preparedness guidelines, and differences between state and local expectations. Participants identified four issues necessary to sustain regions: funding, documented benefits, commitment from LHDs and their communities, and engagement from local elected officials. DISCUSSION The regionalization process has been beneficial for LHDs and produced tangible and intangible benefits. Barriers to regionalization expansion should be addressed for additional collaborative ventures.

Introduction:Since the terrorist attacks of 11 September 2001, the amount of terrorism preparedness training has increased substantially. However, gaps continue to exist in training for the mental health casualties that result from such events. Responders must be aware of the mental health effects of terror-ism and how to prepare for and buffer these effects. However, the degree to which responders possess or value this knowledge has not been studied.Methods:Multi-disciplinary terrorism preparedness training for healthcare professionals was conducted in Kansas in 2003. In order to assess knowledge and attitudes related to mental health preparedness training, post-test surveys were provided to 314 respondents 10 months after completion of the training. Respondents returned 197 completed surveys for an analysis response rate of 63%.Results:In general, the results indicated that respondents have knowledge of and value the importance of mental health preparedness issues. The respon-dents who reported greater knowledge or value of mental health preparedness also indicated significantly higher ability levels in nationally recognized bioterrorism competencies (p Conclusions:These results support the need for mental health components to be incorporated into terrorism preparedness training. Further studies to determine the most effective mental health preparedness training content and instruction modalities are needed.

Many terrorism preparedness trainings occur throughout the United States, yet few qualitatively examine trainees' needs and interests, reactions to training, or suggestions for training improvement. Eleven posttraining focus groups were conducted with 31 training participants at six sites. Participants were stratified by health profession discipline, and discipline-specific moderators conducted each session to better understand and probe for feedback. One additional moderator attended all sessions to increase consistency in methods across sessions. Focus group participants assessed changes in their perceptions, knowledge, and beliefs about terrorism preparedness. Participants reported perceiving terrorism as a potential threat but less likely than natural disasters. All-hazards crossover training for responding to terrorism and natural disasters was requested. The training was viewed positively, including the enrollment process, training content, and reference materials. Participants reported increased confidence in abilities to recognize a terrorist event. Participants stated they would like the training repeated annually with more first responders in attendance. Participants from rural areas had unique training needs based on limited resources and multiple roles of staff. While most participants wanted a longer, multispecialty conference with in-depth, discipline-specific breakout sessions, physicians requested shorter, separate training. Multispecialty training methods were successful and appreciated. This pilot study may serve as a template for qualitative evaluation of terrorism preparedness conferences for health professionals.

Recent studies have assessed preparedness training and the resource needs of public health and clinical professionals in responding to a crisis, but few have assessed the needs of the general public, especially in rural areas. The present study, based in a risk assessment and information-seeking theoretical framework, assessed the preparedness awareness, knowledge, and attitudes of the general public in a rural state through a series of focus groups. Six focus groups were conducted with 34 participants in 4 locations in Kansas (2 urban and 2 rural). Focus group interviews followed a standardized script. Participants from all 4 locations reported training and knowledge needs and desired training, knowledge, and emergency preparedness plans. Certain groups also reported a lack of familiarity with preparedness terminology, as well as different ideas about trusted sources and agencies responsible for providing preparedness training or information. Some diverging opinions from these focus groups were stratified by urban/rural status, indicating possible implications for future all-hazards training in rural regions of the nation. These results may be used for planning and improving training for the general public in both urban and rural areas.

education centered on the social determinants of health for both Ugandan and international health professional students engages the contentious topic through structured intercultural dialogue. The methodology utilized provides Ugandan and international students alike the opportunity to not only examine the neglected and controversial global health issue but to develop the critical ability to constructively dialogue. Structure/Method/Design: SocMed’s intercultural dialogue on sexual orientation aims to challenge students to engage in effective communication and develop an attitude and skill-set associated with inquiry rather than one that reinforces ideologies. SocMed utilizes Freirian pedagogy to create an innovative learning environment inwhich students participate as both learners and teachers to advance understanding of social determinants of health, social experience of illness, effective models for intervention, and applicable models for health advocacy. To discuss sexual orientation, SocMed utilizes a structured intercultural dialogue process, in which students develop skills of activelistening, inquiry, social analysis, and respectful articulation of personal beliefs. After defining terms and soliciting anonymous questions, students are broken into small groups with diverse representation. A series of questions are provided that prompt students to reflect on their own experiences of marginalization, their own socialization to sexual orientation, and health-related concerns of LGBTQpersons. Furthermore, in small groups, students are given the text of recent Ugandan legislation on the topic and are asked to read it, discuss it, and explore explanations for why the bill was introduced in Uganda. Outcomes & Evaluation: To gauge the impact of the sexual orientation dialogue along with other sessions taught in the 4-week immersion course, a formal self-assessment evaluation tool is utilized at the end of the course. Seventy-nine percent of the students stated that they “agreed” or “strongly agreed” that they found the [sexual orientation] section of the course interesting and [they] learned a considerable amount. Given the polarizing indications of students prior to the session, this represents significant impact. Furthermore, ethnographic observation indicates that students continue to effectively dialogue on sexual orientation outside of class. Going Forward: Creating safe spaces of trust and mutuality are central in SocMed’s evolution; it is an essential dimension for sensitive dialogue to be fruitful. An ongoing challenge is SocMed’s capacity to measure the impact of the dialogue on students and on their communities to which they return after the course. Funding: None. Abstract #: 01ETC030

Objective: Rising health care costs, increased demand for clinical services, and reimbursement difficulties created a funding shortage among local health departments in the state of Kansas. This intervention established regional billing groups to provide professional support and increase third-party reimbursement. Design: Through feedback sessions, billing clerks provided qualitative responses about training needs. These informed the process of establishing billing groups in each state health district. Sample: All billing clerks in the state's 6 regional health districts were invited to participate, as were insurance and billing software representatives. Intervention: Between April 2002 and September 2004, 6 collaborative groups were established. Billing clerks received professional support and training from peers, insurance representatives, and software providers. An interagency billing advisory team was established to coordinate training activities between groups. Results: These groups have allowed local health departments to increase reimbursement revenue by 50%–75%, allowing for the provision of expanded health services to client populations. Conclusions: These methods can serve as a model for other states, particularly those with considerable rural populations or decentralized health care systems. Still, funding shortages persist, and public health billing clerks will continue to need ongoing training in the most current and effective billing methods.

Over 70% of the estimated 5 million office visits per year for migraine headache are to family physicians. Both the number of visits and proportion of migraine patients seeking medical care are increasing rapidly. Patient satisfaction with migraine care by primary care physicians is reported to be low but most data are obtained from patients referred to subspecialists or entered in clinical trials. We surveyed patients who consulted family physicians in 10 Kansas practices during 2002 to assess patient satisfaction and investigate any differences between satisfied and unsatisfied migraine patients. Of our 447 respondents, 74% were "satisfied" or "very satisfied" with migraine care by family physicians. Dissatisfied patients were significantly more likely to report moderate or severe migraine-related disability and less likely to use triptans or to have most medications paid by insurance. Dissatisfied patients were twice as likely to have discontinued taking triptans than satisfied patients. Patient satisfaction with migraine treatment in family practice is substantially higher than generally reported. Statistically significant differences exist between satisfied and dissatisfied patients.

Social capital is an increasingly popular construct in research examining social and behavioral determinants of health and well-being. Yet, comparing the results of social capital research is inhibited by inconsistencies in labeling, different definitions and subsequent disagreement on level of analysis, and limited evaluation of the psychometric properties of measures of social capital. This study examined the psychometric properties of the Social Capital Questionnaire (Journal of Applied Behavioral Science 36(1) (2000) 23). In the current study, the original Australian-based instrument was modified for telephone administration with a US sample. Exploratory factor analysis revealed a similar factor structure to that found during initial survey development. These findings lend support to the notion of social capital as a meaningful construct and suggest the Onyx and Bullen instrument deserves further attention as a practical tool for health researchers and community agencies interested in social capital.

Background: Medicaid-insured asthmatic children frequently use emergency rooms (ERs). The reasons are unclear and have predominantly been studied in inner-city populations. Methods: We used billing data and focus groups to clarify reasons for frequent ER use by Medicaid-insured children with asthma living in rural areas and 23 towns in Kansas. Results: High ER utilization was concentrated in a small percentage of provider practices and children with asthma. Parents expressed strong preference for primary care treatment, and identified real or perceived difficulties in using primary care as the principal reasons for ER use. Difficulties included trouble contacting primary care physicians or obtaining urgent appointments, limited continuity of care, practice systems poorly adapted to patient needs, a perception that physicians preferred patients to use emergency services, and difficulties in obtaining medications. Parents were not aware of preventive measures or case management but reported high interest in these. Parents did not recall provider discussion of asthma risk factors/preventive strategies during primary care visits, although all children with high ER utilization had multiple risk factors, including exposure to high levels of household smoking. Conclusions: Reducing ER utilization by Medicaid-insured asthmatic children depends on overcoming barriers to effective treatment in primary care and in greater attention to preventive services.

Many countries have maternity protection laws for women who need job modification or medical leave during pregnancy. This approach will prevent birth defects only if maternal job changes can be made before the critical period of organogenesis, which begins at three weeks' gestation. The authors studied the gestational ages at which pregnant women working with chemicals, radiation, and noise presented for occupational safety and health consultations. The work setting promoted early presentation because the consultation was free, convenient, mandatory, and would not result in job loss. Among the 213 pregnant women evaluated between 1996 and 2000, most (89.5%) had their occupational safety evaluations in the first trimester. Although this sounds ideal, the mean gestational age at presentation was 7.5 weeks, and only 3.3% of occupational health evaluations were initiated by three weeks' gestation. Environmental and biological monitoring showed that none of the women was exposed over occupational limits. These data suggest that a workplace free from reproductive hazards needs to be provided before conception.