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  Subjects -> HEALTH AND SAFETY (Total: 1421 journals)
    - CIVIL DEFENSE (23 journals)
    - DRUG ABUSE AND ALCOHOLISM (88 journals)
    - HEALTH AND SAFETY (620 journals)
    - HEALTH FACILITIES AND ADMINISTRATION (389 journals)
    - OCCUPATIONAL HEALTH AND SAFETY (106 journals)
    - PHYSICAL FITNESS AND HYGIENE (113 journals)
    - WOMEN'S HEALTH (82 journals)

HEALTH AND SAFETY (620 journals)                  1 2 3 4 | Last

Showing 1 - 200 of 203 Journals sorted alphabetically
16 de Abril     Open Access  
A Life in the Day     Hybrid Journal   (Followers: 12)
Acta Informatica Medica     Open Access   (Followers: 1)
Acta Scientiarum. Health Sciences     Open Access   (Followers: 1)
Adultspan Journal     Hybrid Journal   (Followers: 1)
Advances in Child Development and Behavior     Full-text available via subscription   (Followers: 10)
Advances in Public Health     Open Access   (Followers: 25)
African Health Sciences     Open Access   (Followers: 3)
African Journal for Physical, Health Education, Recreation and Dance     Full-text available via subscription   (Followers: 7)
African Journal of Health Professions Education     Open Access   (Followers: 6)
Afrimedic Journal     Open Access   (Followers: 2)
Ageing & Society     Hybrid Journal   (Followers: 43)
Air Quality, Atmosphere & Health     Hybrid Journal   (Followers: 4)
AJOB Primary Research     Partially Free   (Followers: 3)
American Journal of Family Therapy     Hybrid Journal   (Followers: 11)
American Journal of Health Economics     Full-text available via subscription   (Followers: 15)
American Journal of Health Education     Hybrid Journal   (Followers: 32)
American Journal of Health Promotion     Hybrid Journal   (Followers: 30)
American Journal of Health Sciences     Open Access   (Followers: 8)
American Journal of Health Studies     Full-text available via subscription   (Followers: 11)
American Journal of Preventive Medicine     Hybrid Journal   (Followers: 28)
American Journal of Public Health     Full-text available via subscription   (Followers: 240)
American Journal of Public Health Research     Open Access   (Followers: 28)
American Medical Writers Association Journal     Full-text available via subscription   (Followers: 5)
Analytic Methods in Accident Research     Hybrid Journal   (Followers: 5)
Annals of Global Health     Open Access   (Followers: 10)
Annals of Health Law     Open Access   (Followers: 3)
Annals of Tropical Medicine and Public Health     Open Access   (Followers: 13)
Applied Biosafety     Hybrid Journal  
Applied Research In Health And Social Sciences: Interface And Interaction     Open Access   (Followers: 3)
Apuntes Universitarios     Open Access   (Followers: 1)
Archive of Community Health     Open Access   (Followers: 1)
Archives of Medicine and Health Sciences     Open Access   (Followers: 3)
Arquivos de Ciências da Saúde     Open Access  
Asia Pacific Journal of Counselling and Psychotherapy     Hybrid Journal   (Followers: 10)
Asia Pacific Journal of Health Management     Full-text available via subscription   (Followers: 4)
Asia-Pacific Journal of Public Health     Hybrid Journal   (Followers: 9)
Asian Journal of Gambling Issues and Public Health     Open Access   (Followers: 4)
Atención Primaria     Open Access   (Followers: 1)
Australasian Journal of Paramedicine     Open Access   (Followers: 3)
Australian Advanced Aesthetics     Full-text available via subscription   (Followers: 4)
Australian Family Physician     Full-text available via subscription   (Followers: 3)
Australian Indigenous HealthBulletin     Free   (Followers: 7)
Autism & Developmental Language Impairments     Open Access   (Followers: 9)
Behavioral Healthcare     Full-text available via subscription   (Followers: 7)
Bijzijn     Hybrid Journal   (Followers: 1)
Bijzijn XL     Hybrid Journal  
Biomedical Safety & Standards     Full-text available via subscription   (Followers: 8)
Birat Journal of Health Sciences     Open Access  
BLDE University Journal of Health Sciences     Open Access  
BMC Oral Health     Open Access   (Followers: 7)
BMC Pregnancy and Childbirth     Open Access   (Followers: 22)
BMJ Simulation & Technology Enhanced Learning     Hybrid Journal   (Followers: 10)
Boletin Médico de Postgrado     Open Access  
Brazilian Journal of Medicine and Human Health     Open Access  
Buletin Penelitian Kesehatan     Open Access   (Followers: 2)
Buletin Penelitian Sistem Kesehatan     Open Access  
Bulletin of the World Health Organization     Open Access   (Followers: 18)
Cadernos de Educação, Saúde e Fisioterapia     Open Access   (Followers: 1)
Cadernos Saúde Coletiva     Open Access   (Followers: 1)
Cambridge Quarterly of Healthcare Ethics     Hybrid Journal   (Followers: 11)
Canadian Family Physician     Partially Free   (Followers: 13)
Canadian Journal of Community Mental Health     Full-text available via subscription   (Followers: 10)
Canadian Journal of Human Sexuality     Hybrid Journal   (Followers: 2)
Canadian Journal of Public Health     Hybrid Journal   (Followers: 21)
Cannabis and Cannabinoid Research     Hybrid Journal   (Followers: 1)
Carta Comunitaria     Open Access  
Case Reports in Women's Health     Open Access   (Followers: 3)
Case Studies in Fire Safety     Open Access   (Followers: 15)
Central Asian Journal of Global Health     Open Access   (Followers: 2)
CES Medicina     Open Access  
Child Abuse Research in South Africa     Full-text available via subscription   (Followers: 1)
Child's Nervous System     Hybrid Journal  
Childhood Obesity and Nutrition     Open Access   (Followers: 11)
Children     Open Access   (Followers: 2)
CHRISMED Journal of Health and Research     Open Access   (Followers: 2)
Christian Journal for Global Health     Open Access  
Ciência & Saúde Coletiva     Open Access   (Followers: 2)
Ciencia e Innovación en Salud     Open Access  
Ciencia y Cuidado     Open Access   (Followers: 1)
Ciencia y Salud Virtual     Open Access  
Ciencia, Tecnología y Salud     Open Access   (Followers: 2)
Clinical and Experimental Health Sciences     Open Access  
ClinicoEconomics and Outcomes Research     Open Access   (Followers: 2)
Clocks & Sleep     Open Access   (Followers: 1)
CME     Hybrid Journal   (Followers: 2)
CoDAS     Open Access  
Community Health     Open Access   (Followers: 3)
Conflict and Health     Open Access   (Followers: 7)
Contraception and Reproductive Medicine     Open Access   (Followers: 1)
Cuadernos de la Escuela de Salud Pública     Open Access  
Curare     Open Access  
Current Opinion in Behavioral Sciences     Hybrid Journal   (Followers: 8)
Day Surgery Australia     Full-text available via subscription   (Followers: 2)
Digital Health     Open Access   (Followers: 4)
Disaster Medicine and Public Health Preparedness     Hybrid Journal   (Followers: 13)
Diversity of Research in Health Journal     Open Access  
Dramatherapy     Hybrid Journal   (Followers: 2)
Drogues, santé et société     Open Access   (Followers: 1)
Duazary     Open Access   (Followers: 1)
Düzce Üniversitesi Sağlık Bilimleri Enstitüsü Dergisi / Journal of Duzce University Health Sciences Institute     Open Access  
Early Childhood Research Quarterly     Hybrid Journal   (Followers: 21)
East African Journal of Public Health     Full-text available via subscription   (Followers: 4)
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity     Hybrid Journal   (Followers: 21)
EcoHealth     Hybrid Journal   (Followers: 4)
Education for Health     Open Access   (Followers: 6)
electronic Journal of Health Informatics     Open Access   (Followers: 6)
ElectronicHealthcare     Full-text available via subscription   (Followers: 3)
Elsevier Ergonomics Book Series     Full-text available via subscription   (Followers: 5)
Emergency Services SA     Full-text available via subscription   (Followers: 2)
Ensaios e Ciência: Ciências Biológicas, Agrárias e da Saúde     Open Access  
Environmental Disease     Open Access   (Followers: 3)
Environmental Sciences Europe     Open Access   (Followers: 1)
Epidemics     Open Access   (Followers: 5)
Epidemiologic Perspectives & Innovations     Open Access   (Followers: 5)
Epidemiology, Biostatistics and Public Health     Open Access   (Followers: 19)
Ethics, Medicine and Public Health     Full-text available via subscription   (Followers: 6)
Ethiopian Journal of Health Development     Open Access   (Followers: 7)
Ethiopian Journal of Health Sciences     Open Access   (Followers: 8)
Ethnicity & Health     Hybrid Journal   (Followers: 13)
Eurasian Journal of Health Technology Assessment     Open Access  
European Journal of Investigation in Health, Psychology and Education     Open Access   (Followers: 3)
European Medical, Health and Pharmaceutical Journal     Open Access   (Followers: 1)
Evaluation & the Health Professions     Hybrid Journal   (Followers: 10)
Evidence-based Medicine & Public Health     Open Access   (Followers: 8)
Evidência - Ciência e Biotecnologia - Interdisciplinar     Open Access  
Expressa Extensão     Open Access  
Face à face     Open Access   (Followers: 1)
Families, Systems, & Health     Full-text available via subscription   (Followers: 9)
Family & Community Health     Hybrid Journal   (Followers: 13)
Family Medicine and Community Health     Open Access   (Followers: 9)
Family Relations     Partially Free   (Followers: 13)
Fatigue : Biomedicine, Health & Behavior     Hybrid Journal   (Followers: 2)
Finnish Journal of eHealth and eWelfare : Finjehew     Open Access  
Food and Public Health     Open Access   (Followers: 16)
Food Quality and Safety     Open Access   (Followers: 1)
Frontiers in Public Health     Open Access   (Followers: 7)
Gaceta Sanitaria     Open Access   (Followers: 3)
Galen Medical Journal     Open Access   (Followers: 1)
Gazi Sağlık Bilimleri Dergisi     Open Access  
Geospatial Health     Open Access  
Gesundheitsökonomie & Qualitätsmanagement     Hybrid Journal   (Followers: 9)
Giornale Italiano di Health Technology Assessment     Full-text available via subscription  
Global Challenges     Open Access  
Global Health : Science and Practice     Open Access   (Followers: 7)
Global Health Promotion     Hybrid Journal   (Followers: 15)
Global Journal of Health Science     Open Access   (Followers: 10)
Global Journal of Public Health     Open Access   (Followers: 13)
Global Medical & Health Communication     Open Access   (Followers: 2)
Global Mental Health     Open Access   (Followers: 8)
Global Reproductive Health     Open Access  
Global Security : Health, Science and Policy     Open Access   (Followers: 1)
Globalization and Health     Open Access   (Followers: 5)
Hacia la Promoción de la Salud     Open Access  
Hastane Öncesi Dergisi     Open Access  
Hastings Center Report     Hybrid Journal   (Followers: 3)
HEADline     Hybrid Journal  
Health & Place     Hybrid Journal   (Followers: 15)
Health & Justice     Open Access   (Followers: 5)
Health : An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine     Hybrid Journal   (Followers: 10)
Health and Human Rights     Free   (Followers: 10)
Health and Social Care Chaplaincy     Hybrid Journal   (Followers: 8)
Health and Social Work     Hybrid Journal   (Followers: 57)
Health Behavior and Policy Review     Full-text available via subscription   (Followers: 3)
Health Care Analysis     Hybrid Journal   (Followers: 15)
Health Equity     Open Access  
Health Inform     Full-text available via subscription  
Health Information Management Journal     Hybrid Journal   (Followers: 23)
Health Issues     Full-text available via subscription   (Followers: 2)
Health Notions     Open Access  
Health Policy     Hybrid Journal   (Followers: 43)
Health Policy and Technology     Hybrid Journal   (Followers: 4)
Health Professional Student Journal     Open Access   (Followers: 4)
Health Promotion International     Hybrid Journal   (Followers: 22)
Health Promotion Journal of Australia : Official Journal of Australian Association of Health Promotion Professionals     Full-text available via subscription   (Followers: 8)
Health Promotion Practice     Hybrid Journal   (Followers: 16)
Health Prospect     Open Access   (Followers: 1)
Health Psychology     Full-text available via subscription   (Followers: 53)
Health Psychology Bulletin     Open Access   (Followers: 1)
Health Psychology Research     Open Access   (Followers: 20)
Health Psychology Review     Hybrid Journal   (Followers: 42)
Health Renaissance     Open Access  
Health Research Policy and Systems     Open Access   (Followers: 14)
Health SA Gesondheid     Open Access   (Followers: 2)
Health Science Reports     Open Access  
Health Sciences and Disease     Open Access   (Followers: 2)
Health Security     Hybrid Journal  
Health Services Insights     Open Access   (Followers: 1)
Health Systems     Hybrid Journal   (Followers: 4)
Health Voices     Full-text available via subscription  
Health, Culture and Society     Open Access   (Followers: 12)
Health, Risk & Society     Hybrid Journal   (Followers: 14)
Healthcare     Open Access   (Followers: 3)
Healthcare in Low-resource Settings     Open Access   (Followers: 1)
Healthcare Quarterly     Full-text available via subscription   (Followers: 8)
Healthcare Technology Letters     Open Access  
Healthy Aging Research     Open Access  
HERD : Health Environments Research & Design Journal     Full-text available via subscription  
Highland Medical Research Journal     Full-text available via subscription  
Hispanic Health Care International     Full-text available via subscription  

        1 2 3 4 | Last

Similar Journals
Journal Cover
Frontiers in Public Health
Number of Followers: 7  

  This is an Open Access Journal Open Access journal
ISSN (Online) 2296-2565
Published by Frontiers Media Homepage  [70 journals]
  • Measuring Human-Animal Attachment in a Large U.S. Survey: Two Brief
           Measures for Children and Their Primary Caregivers

    • Authors: Regina M. Bures, Megan Kiely Mueller, Nancy R. Gee
      Abstract: One challenge faced by researchers in the human-animal interaction (HAI) field is generalizing the impact of pet ownership and companion animal interaction to larger populations. While researchers in Europe and Australia have included measures of pet ownership and attachment in surveys (e.g., the Avon Longitudinal Study of Parents and Children) for some time, survey researchers in the United States have been slow to incorporate questions related to HAI in population representative studies. One reason for this may be that many of the current HAI-related measures involve long, complex scales. From the survey administration perspective, using complex scales is costly in terms of both time and money. The development and validation of brief measures of HAI are important to encourage the inclusion of these measures in larger surveys. This paper describes the psychometric properties of two brief attachment measures used in the 2014 Panel Study of Income Dynamics (PSID) Child Development Supplement (CDS), the first population-representative study of child development in the United States that includes HAI items. We use two measures derived from the 36 item CENSHARE scale. For children aged 8-17, a 6-item measure was included; for the primary caregiver, a 3-item measure was included. The results suggest that such brief measures of attachment to pets are psychometrically valid and may be a practical method of measuring attachment in larger surveys using a smaller number of survey items. We encourage HAI researchers to work with other ongoing surveys to incorporate these and comparable measures.
      PubDate: 2019-05-14T00:00:00Z
       
  • Are Insomnia Type Sleep Problems Associated With a Less Physically Active
           Lifestyle' A Cross-Sectional Study Among 7,700 Adults From the General
           Working Population

    • Authors: Rúni Bláfoss, Emil Sundstrup, Markus Due Jakobsen, Hans Bay, Anne Helene Garde, Lars Louis Andersen
      Abstract: Background: Sleep problems are common in the general population and negatively affect both private and work life. A vicious circle may exist between poor sleep and an unhealthy lifestyle. For example, poor sleep may drain the energy to do health-promoting physical activity during leisure-time after work. The aim of the present study was to investigate the association between sleep problems and the duration of low- and high-intensity leisure-time physical activity in sedentary and physical workers. Methods: This cross-sectional study employ data from the Danish Work Environment Cohort Study in 2010, where currently employed wage-earners in Denmark on daytime schedule (N=7706) replied to questions about sleep quality (Bergen Insomnia Scale) and participation in low- and high-intensity leisure-time physical activity. Associations were modeled using general linear models controlling for various confounders. Results: Workers with high levels of sleep problems reported less high-intensity leisure-time physical activity. Specifically, the weekly duration of high-intensity leisure-time physical activity was 139 (95%CI 111-168), 129 (95%CI 101-158) and 122 (95%CI 92-151) mins in sedentary workers with sleep problems
      PubDate: 2019-05-14T00:00:00Z
       
  • Behavioral Counseling Training for Primary Care Providers: Immersive
           Virtual Simulation as a Training Tool

    • Authors: Adam G. Gavarkovs
      Abstract: Behavioral counseling represents an efficacious approach for improving health behaviors on a population level, and the primary care setting is an appropriate context in which to implement this approach. However, evidence suggests that the utilization of behavioral counseling techniques in primary care, including those informed by motivational interviewing, is sub-optimal. Insufficient training has been cited as a barrier to utilizing counseling in the primary care setting. Recent work has evaluated the effectiveness of virtual simulations that can provide access to ‘virtual’ patients while retaining the scalability inherent to a digital medium. However, these educational interventions have been limited to simulations delivered through a two-dimensional screen. More immersive simulations delivered through a head mounted display can create a realistic practice environment that encompasses a learner’s entire field of view, which may confer additional benefits with respect to training outcomes. The purpose of this short article is to briefly review the relevant literature across disciplines to conceptualize the potential effectiveness of this technology as a training tool for behavioral counseling. Immersive virtual simulations are designed to induce a psychological phenomenon referred to as presence, whereby a learner perceives themselves as existing within the virtual environment. As such, immersive virtual simulations can provide opportunities for practice, coaching, and feedback in an environment that closely approximates the clinical setting in which counseling will be delivered. Through its effects on presence, this technology may be particularly useful for developing empathy, which is an important component of counseling. Recommendations for future research are also provided.
      PubDate: 2019-05-09T00:00:00Z
       
  • Temporal Trends in Cardiovascular Hospital Discharges Following a Mass
           Chlorine Exposure Event in Graniteville, South Carolina

    • Authors: Ashley V. Howell, John E. Vena, Bo Cai, Daniel T. Lackland, Lucy A. Ingram, Andrew B. Lawson, Erik R. Svendsen
      Abstract: Background: On January 6, 2005, a train derailed in Graniteville, South Carolina, releasing nearly 60,000 kg of toxic chlorine gas. The disaster left nine people dead and was responsible for hundreds of hospitalizations and outpatient visits in the subsequent weeks. While chlorine gas primarily affects the respiratory tract, a growing body of evidence suggests that acute exposure may also cause vascular injury and cardiac toxicity. Here, we describe the incidence of cardiovascular hospitalizations among residents of the zip codes most affected by the chlorine gas plume, and compare the incidence of cardiovascular discharges in the years leading up to the event (2000-2004) to the incidence in the years following the event (2005-2014). Methods: De-identified hospital discharge information was collected from the South Carolina Revenue and Fiscal Affairs Office for individuals residing in the selected zip codes for the years 2000 to 2014. A quasi-experimental study design was utilized with a population-level interrupted time series model to examine hospital discharge rates for Graniteville-area residents for three cardiovascular diagnoses: hypertension (HTN), acute myocardial infarction (AMI), and coronary heart disease (CHD). We used linear regression with autoregressive error correction to compare slopes for pre- and post-spill time periods. Results: A significant increase in hypertension-related hospital discharge rates was observed for the years following the Graniteville chlorine spill (slope 8.2, p
      PubDate: 2019-05-08T00:00:00Z
       
  • Application of PRECEDE-PROCEED Planning Model in Transforming the Clinical
           Decision Making Behavior of Physical Therapists in Myanmar

    • Authors: Phyu Hnin Hlaing, Patricia E. Sullivan, Pakaratee Chaiyawat
      Abstract: Introduction Physical therapists in Myanmar use a prescriptive model of Clinical Decision Making (CDM). Improving CDM effectiveness is one essential factor in professionalizing practice and enhancing patient outcomes. This study assesses the changes in CDM skills and behaviors using the PRECEDE-PROCEED planning Model (PPM). Methods In the PRECEDE planning phases, we investigated the current clinical decision making knowledge and process, clinical practice culture and contributing factors of CDM among Myanmar physical therapists. A qualitative approach consisted of 18 in-depth interviews and one focus group discussion was used. In the PROCEED evaluation and implementation phases, we developed and presented the CDM educational book at CDM workshop, which was a 4-day intensive program in Yangon, Myanmar with 34 participants. The participant’s CDM knowledge and processes were assessed before and after the educational program to explore the potential impact on implementing CDM which can ultimately improve patient care in the health settings of Myanmar. Results In the PRECEDE phases, we explored the predisposing and reinforcing factors of Myanmar physical therapists’ CDM. We found that deliberative decision making process that is used internationally were not followed by Myanmar physical therapists who followed the physician’s prescriptions. Teaching and learning emphasize a stimulus-response-repeat-outcome cycle without internal processing or application to clinical situations. Using the PROCEED model, we developed a 14 chapters CDM workbook and a four-day workshop as a behavioral change intervention. Participants’ prior technical CDM behavior was transformed into professional CDM behavior that included an understanding of clinical practice models and improvement in the cognitive process of CDM processes. The workbook coupled with the intensive active-learning, hands-on workshop of examination and intervention procedures were effective in improving CDM. Discussion The application of PPM provided a thorough understanding of current CDM process of Myanmar therapists and aided in the development of the tailored CDM educational program to improve participants’ CDM. Using the PPM model for developing a set of Physical Therapy educational content and curriculum was new. The application of PPM was beneficial to use accepted clinical practice models, standardized tests and measures, set goals and clinical outcomes, reassessed to determine change and implement evidence-based practice.
      PubDate: 2019-05-08T00:00:00Z
       
  • Clustering of Vibrio parahaemolyticus Isolates Using MLST and Whole-Genome
           Phylogenetics and Protein Motif Fingerprinting

    • Authors: Kelsey J. Jesser, Willy Valdivia-Granda, Jessica L. Jones, Rachel T. Noble
      Abstract: Vibrio parahaemolyticus is a ubiquitous and abundant member of native microbial assemblages in coastal waters and shellfish. Though V. parahaemolyticus is predominantly environmental, some strains have infected human hosts and caused large outbreaks of seafood-related gastroenteritis. In order to understand differences between clinical and environmental V. parahaemolyticus strains, we used high quality DNA sequencing data to compare the genomes of V. parahaemolyticus isolates (n=43) from a variety of geographic locations and clinical and environmental sample matrices. We used phylogenetic trees inferred from multilocus sequence typing (MLST) and whole-genome (WG) alignments, as well as a novel classification and genome clustering approach that relies on protein motif fingerprints (MFs) to assess relationships between V. parahaemolyticus strains and identify novel molecular targets associated with virulence. Differences in strain clustering at more than one position were observed between the MLST and WG phylogenetic trees. The WG phylogeny had higher support values and strain resolution since isolates of the same sequence type could be differentiated. The MF analysis revealed groups of protein motifs that were associated with the pathogenic MLST type ST36 and a large group of clinical strains isolated from human stool. A subset of the stool and ST36-associated protein motifs were selected for further analysis and the motif sequences were found in genes with a variety of functions, including transposases, secretion system components and effectors, and hypothetical proteins. DNA sequences associated with these protein motifs are candidate targets for future molecular assays in order to improve surveys of pathogenic V. parahaemolyticus in the environment and seafood.
      PubDate: 2019-05-08T00:00:00Z
       
  • Radon and Thoron; Radioactive Gases Lurking in Earthen Houses in Rural
           Kenya

    • Authors: Margaret Chege, Nadir Hashim, Catherine Nyambura, Amidu Mustapha, Masahiro Hosada, Shinji Tokonami
      Abstract: In this paper, documented studies on radon and thoron concentrations in earthen dwellings and 238U and 232Th concentrations in soil in Kenya are reviewed. High concentrations of the isotopes were recorded in the earthen dwellings despite being generally well ventilated. Mrima Hill in the Coast region recorded the highest thoron levels with a mean of 652 Bq m-3. 25 % of dwellings had thoron concentration in excess of 1000 Bq m-3. Notably high indoor radon levels were recorded in Taita Taveta also in the Coast region, and in Kenyatta University situated in Nairobi in the Central region of the country. Radon concentration in the Rift Valley region was found to be too low to contribute significantly to radiation exposure. Based on studies on the concentration of 238U and 232Th in soil, the Southwestern region of the country was anticipated to have elevated radon/thoron concentrations in earthen dwellings. Existing studies involving measurement of indoor radon and thoron, and 226Ra and 232Th in soil are relatively few and of a small scale. More extensive studies are therefore necessary not only to corroborate the risk projections but to also generate sufficient data to enable countrywide mapping of indoor radon/thoron risk-prone areas.
      PubDate: 2019-05-08T00:00:00Z
       
  • Visualization and Quantification of the Oral Hygiene Effects of Brushing,
           Dentifrice Use, and Brush Wear Using a Tooth Brushing Simulator

    • Authors: Ruth G. Ledder, Joe Latimer, Sarah Forbes, Jodie L. Penney, Prem K. Sreenivasan, Andrew J. McBain
      Abstract: Standardized, reproducible brushing regimes were applied to typodonts coated in simulated or biological plaques to assess the effects on tooth cleaning of toothbrush/dentifrice regimens. Replicated typodonts were coated with OccludeTM or GlogermTM indicators to simulate plaque, and brushed reproducibly using a mechanical brushing simulator to compare the cleaning of occlusal surfaces before and after brushing with water or a dentifrice. An in vitro model using salivary inocula to cultivate oral biofilms on typodont surfaces was then developed to evaluate removal of disclosed plaque by new toothbrushes in comparison to toothbrushes with wear equivalent to three months of use. Analyses of typodonts brushed under controlled conditions significantly (p
      PubDate: 2019-05-08T00:00:00Z
       
  • Preliminary Indoor Radon Measurements Near Faults Crossing Urban Areas of
           Mt. Etna Volcano (Italy)

    • Authors: Marco Neri, Salvatore Giammanco, Anna Leonardi
      Abstract: The slopes of Etna are crossed by numerous active faults that traverse various towns and villages. These faults pose a two-fold problem for the local people: on one hand, they cause frequent damage to houses and breakage of roads, while on the other they constitute a preferential route for the rising of crustal and sub-crustal gases, including radon, towards the surface. Various recent studies on the volcano confirm a high level of radon degassing measured both in the soil (> 10,000 Bq/m3), and inside homes (> 2,000 Bq/m3). For this reason, we felt the need to deepen our knowledge on the radon present in the Etnean area, focusing in particular on indoor radon pollution that, as widely recognised, is among the main causes of cancer largely (but not exclusively) of the respiratory system. Firstly, since 2005 we made a broad surface survey that revealed very high radon emissions from soils near active faults on Etna. Typical background soil activity on Etna were 1,000 Bq/m3 for several consecutive months, highlighting a potential health problem for those living in such environments. In other cases, the construction features of the houses and/or the materials used seemed to play an important role in the mitigation of indoor radon accumulation, even in the presence of intensely degassing soils. These preliminary data demonstrate the need to deepen the studies, extending indoor radon measurements to other urban areas, in order to monitor the health hazard for the Etna population, amounting to about one million people.
      PubDate: 2019-05-03T00:00:00Z
       
  • An Integrative Review on Teen Distracted Driving for Model Program
           Development

    • Authors: Sherrilene Classen, Sandra M. Winter, Charles Brown, Jane Morgan-Daniel, Shabnam Medhizadah, Nithin Agarwal
      Abstract: Distracted driving, especially driver inattention, is associated with high levels of crash-related fatalities and injury. Teen novice drivers are one of the groups most likely to drive distracted and to suffer its consequences. Teens have a higher risk of engaging in texting or secondary tasks, e.g., eating while driving. Distracted driving interventions to date aim to improve teen and societal safety, but few have achieved effectiveness. A need exists for effective evidence-based distracted driving interventions. We used an integrative review to identify rigorous evidence, and inform the development of a teen distracted driving educational intervention. This five-step review included: identifying the research problem; collecting literature; evaluating literature; synthesizing data; and presenting results. We searched 6 databases, identifying 185 articles. Following three rounds of inclusion screening (title, abstract, and full-text), captured according to a PRISMA flow chart, 17 studies met inclusion. We categorized these studies, conducted in the U.S., as five intervention types that used approaches including presentations, videos or instructional programs, education or training programs, driving simulator training, in-vehicle monitoring or feedback, and integrated programs. Study designs included randomized controlled trials pre-post, quasi-experimental, and experimental designs with prospective longitudinal cohorts. The studies were heterogeneous in design, intervention and outcome. However, three core themes emerged across studies: i.e., hazard awareness, hazard mitigation and attention maintenance are primary critically necessary skills to prevent distracted driving; engaging a parent or adult as a partner in the intervention process from classroom to car contributed to the effectiveness of the intervention; and leveraging technology in training enhanced the effectiveness of the intervention. Study limitations pertained to a focus on short-term effects; sampling distributions that did not account for gender, age, race and/or ethnicity; types of interventions; and bias. The limitations affect the generalizability of included study findings and, potentially, the review findings, as they may not apply to populations or contexts outside those synopsized. Strengths included our team’s expertise in conducting evidence-based reviews, support of a health science librarian, and use of international review guidelines. As an outcome, we are applying findings of the integrated review to develop a computer-based training addressing teen distracted driving.
      PubDate: 2019-05-03T00:00:00Z
       
  • Prenatal Depression and Its Associated Risk Factors Among Pregnant Women
           in Bangalore: A Hospital Based Prevalence Study
    • Prenatal Depression and Its Associated Risk Factors Among Pregnant Women in Bangalore: A Hospital Based Prevalence Study

      B. Sheeba 1 *, Anita Nath 2, Chandra S. Metgud3, Murali Krishna4, Shubhashree Venkatesh1, J. Vindhya1 and Gudlavalleti Venkata Satyanarayana Murthy5
      • 1 Research Assistant, Indian Institute of Public Health Hyderabad, Public Health of Foundation of India, Bangalore, India
      • 2 Wellcome Trust DBT India Alliance, Intermediate Fellow in Clinical and Public Health, Indian Institute of Public Health Hyderabad, Public Health Foundation of India, Hyderabad, India
      • 3 Professor, Department of Community Medicine, Pt. Jawahar Lal Nehru Memorial Medical College, Belgavi, India
      • 4 Consultant, FRAME, Mysore, India
      • 5 Indian Institute of Public Health Hyderabad, Public Health Foundation of India, Hyderabad, India

      Background: Depression is the commonest psychological problem that affects a woman during her perinatal period worldwide. The risk of prenatal depression increases as the pregnancy progresses and clinically significant depressive symptoms are common in the mid and late trimester. There is a paucity of research on depression during the prenatal period in India. Given this background, the present study aimed to assess the prevalence of prenatal depression and its associated risk factors among pregnant women in Bangalore, Southern India.

      Methods: The study was nested within an on-going cohort study. The study participants included 280 pregnant women who were attending the antenatal clinic at Jaya Nagar General Hospital (Sanjay Gandhi Hospital) in Bangalore. The data was collected by using a structured questionnaire which included. Edinburgh Postnatal Depression Scale (EPDS) to screen for prenatal depression.

      Results: The proportion of respondents who screened positive for prenatal depression was 35.7%. Presence of domestic violence was found to impose a five times higher and highly significant risk of developing prenatal depression among the respondents. Pregnancy related anxiety and a recent history of catastrophic events were also found to be a positive predictors of prenatal depression.

      Conclusion: The high prevalence of prenatal depression in the present study is suggestive of its significance as a public health problem. Health care plans therefore can include screening and diagnosis of prenatal depression in the antenatal care along with other health care facilities provided.

      Introduction

      The relationship between a pregnant woman and her developing fetus is possibly the most earnest and overwhelming but perplexing of all human relationships. Pregnancy entails physiological, hormonal and psychological changes which could increase the probability of mental and emotional changes resulting in depression, anxiety or psychological distress in the pregnant mother (1).

      Maternal and Child Health Programmes in developing countries are commonly focused upon improving the nutritional status and less importance is given toward a woman's emotional and mental health during and after pregnancy (2, 3). Poor mental health of the woman during pregnancy could have profound consequences for the mother and her child in terms of adverse pregnancy outcomes and offspring development (47). Most of the existing data, research, and practice policies with regard to perinatal mental disorders center on the postnatal period and there is less research related depression during pregnancy (8, 9).

      Depression is the most common psychological problem that affects a woman worldwide during the perinatal period (3, 10). About 15 % of women are known to be depressed at some point during their lifetime and more predominantly during pregnancy and after childbirth (11). The risk of prenatal depression increases significantly as the pregnancy progresses and clinically significant depressive symptoms are common in the mid and late trimester (12). The prevalence rates of prenatal depression differ between high, middle and low—income countries. Studies from various countries around the world show a prevalence rate ranging from as low as 4% to as high as 81% (1316). The prevalence rate is reported to be lower in high income countries like Australia 7% (17), Hong Kong 4.4% (18), Finland 7.7% (19), and higher in many of the low-income countries like Pakistan 64.6% (20), Bangladesh 18% (13), Nigeria 24.5% (14), and Ethiopia 24.94% (15). The prevalence of depression in India is varies from 9.18% in one study to 36.7 % reported in another study (21, 22).

      Even though prenatal depression is an important public health problem, most studies related to maternal depression are focused on post-natal depression and its outcomes; hence there is paucity of research on depression during the prenatal period, especially from India (8). The importance of screening for depression during pregnancy is that prenatal depression, if not treated and diagnosed early, may continue as postnatal depression (2325) later on and could also result in an adverse influence on birth outcomes and offspring development. Given this background, the present study aimed to assess the prevalence of prenatal depression and its associated risk factors among pregnant women in Bangalore, Southern India.

      Materials and Methods

      Study Setting and Participants

      The study sample included of pregnant women who were attending the antenatal clinic at Jaya Nagar General Hospital (also known as Sanjay Gandhi Hospital), which is a public sector hospital in Bangalore. The study was nested within an ongoing cohort study, the study protocol of which was published earlier (26). The eligibility criteria included women above or equal to 18 years of age, with confirmed pregnancy of <6 months (<24 weeks) and having no obstetric or medical complication in the present pregnancy. The study analyzed the data of 280 pregnant women who had enrolled and completed the baseline visit for the study between August 2017 and April 2018.

      Data Collection

      Data was obtained from the pregnant women by means of an interview, after obtaining written informed consent. A participant information sheet that explained the purpose and nature of the study was issued to those who were willing to participate in the study. The respondents were ensured about privacy and confidentiality of data. The interview process employed the use of a structured questionnaire installed in an Android tablet App. The App included questions about socio-demographic data, obstetric history, medical history and measures for depression, social support, marital discord, domestic violence, and pregnancy related anxiety described below. Data related history of any mental illness and recent catastrophic event was also recorded. Calibrated instruments were used to measure height and weight and calculate the Body Mass Index (BMI). Data on hemoglobin estimation was obtained from hospital records. Depression, being the outcome variable was measured using Edinburg Postnatal Depression Scale (EPDS).

      Study Measures

      Depression

      EPDS is a widely used 10-item self-reporting instrument, specifically designed for assessing both prenatal as well as postnatal depression. It has a sensitivity of 86%, specificity of 78% and positive predictive value of 73% (27). EPDS has been validated for detecting depression in both antepartum and postpartum mothers in many countries. This scale consists of 10 short questions with a choice of four answers that closely reflects about how she was feeling over the past 7 days. Scores are recorded as 0, 1, 2, and 3 according symptom severity. Certain question items (i.e., 3, 2, 1, and 0) are scored in a reverse manner. Respondents who score 13 and above are likely to be suffering from depression and should seek medical attention.

      Social Support

      The Multidimensional Scale of Perceived Social Support Scale (MSPSS) used to measure social support includes 12 questions, and is validated for use in the South Asian population (28, 29). These questions directly address the adequacy of social support and have a 7-point rating scale ranging from “very strongly disagree” to “very strongly agree.” The scale assesses the perceptions of social support adequacy from three specific sources: family, friends, and “significant other.” A score of <2 is considered as low support, a score of 3–5 as moderate support while score of more than five indicates high support.

      Marital Discord

      The Revised Dyadic Adjustment Scale (30, 31) measures seven dimensions of relationship among partners within three categories: decision making, values and affection. It consists of 14 items in which the respondents can rate their relationship on a 6-point scale. Scores range from 0 to 69; higher the score greater, is the relationship and vice versa. The cut- off score was taken as 48.

      Spouse Physical and Sexual Violence

      Spouse physical and sexual violence was measured using the Modified Conflict Tactics Scale (32). It is effective and useful in measuring domestic violence in diverse cultural settings. The scale has 9 questions wherein the respondents affirm whether domestic violence was present or absent.

      Socio Economic Scale

      The socio-economic class of the respondents was measured by the Modified Kuppuswamy Socio Economic Scale (33). The scale uses education, occupation of the head of the family and monthly family income to calculate socio-economic status. The scores awarded to education and occupation of the head of the family remains unchanged. Revised Consumer Price Index–IW (industrial workers) is used to calculate the monthly income range. The socio-economic status is classified as upper class, upper middle class, lower middle class, upper lower class and lower class.

      Pregnancy Related Anxiety

      The 10-item Pregnancy Related Anxiety Questionnaire (PRAQ) was used to screen for pregnancy anxiety (34). It appears to have good psychometric and predictive validity for child-birth and childhood outcomes. Each item is scored on a 4-point scale with cut-off scores of 28 and 24 for nulliparous and multiparous women and the internal consistency (Cronbach's alpha) of PRAQ was seen to be 0.79. A score of more than 28 was considered as anxious.

      Statistical Analysis

      Data were retrieved from the data server. This was followed by data cleaning and analysis using SPSS version 22. Descriptive statistics such as percentage, means and standard deviation were used to summarize the socio demographic data. An EPDS score of 13 and above pointed toward the likelihood of presence of depression. The independent variables were categorized to analyze the association between each independent and outcome variable using a bivariate analysis to calculate the Crude Odd's Ratio with 95% Confidence Interval. Those variables that were associated at a P-value of <0.2 in the bivariate analysis were entered into a multivariate logistic regression model to calculate the Adjusted Odd's Ratio and to eliminate the effects of confounding. Variables with a P-value of <0.05 in the multivariate analysis were considered to be significant.

      Ethical Considerations

      The study was approved by the Ethical Committee of Indian Institute of Public Health Bangalore campus (IIPHHB/TRCIEC/118/2017). Written informed consent was obtained from the pregnant mothers and they were assured of confidentiality and privacy of records.

      Results

      Socio Demographic Characteristics of the Respondents

      Table 1 shows the frequency distribution of socio demographic characteristics of the respondents. Of the 280 pregnant mothers, majority (72.9%) of them belonged to the age group of more than 20 years, the mean age of the respondents being 23.02 ± 3.40 years. Over two-thirds among them (72.1%) were Muslim and 40.4% had completed High school. While 92.1% were housewives, the spouses of over half of the respondents (51.8%) were semi-skilled workers. According to the Kuppuswamy Socio economic status scale, more than half of the respondents (57.5%) belonged to Upper Lower class. Nearly seventy percent of the pregnant mothers had no blood relationship with their husbands, where as a notable 13.2% said that their husbands were a first cousin from their mother's side.

      TABLE 1
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      Table 1. Socio demographic characteristics of the study participants (N = 280).

      Prevalence and Magnitude of Prenatal Depression Among the Pregnant Women

      Of the 280 pregnant mothers, the proportion of those who screened positive for prenatal depression was 35.7% (100) suggesting a high probability of clinical depression (Figure 1). The mean EPDS score among the respondents was 10.61± 7.48.

      FIGURE 1
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      Figure 1. Prevalence of prenatal depression among the pregnant women (N = 280).

      Association of Prenatal Depression With Socio-Demographic Characteristics

      The association of socio-demographic factors like age group, educational qualification, occupation, and socio-economic status of the respondents with depression was non-significant on bivariate analysis (p-value >0.05). This is seen from Table 2.

      TABLE 2
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      Table 2. Association of socio demographic characteristics with depression among the pregnant women (N = 280).

      Association of Prenatal Depression With Obstetric History (Table 3)

      On bivariate analysis, the number of pregnancies (gravida) and unplanned pregnancy showed an association with depression at a P-value of < 0.2. However, there was no significant association observed from multivariate logistic regression analysis.

      TABLE 3
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      Table 3. Association of depression with obstetric history of the pregnant women (N = 280).

      Association Between Social Support, Marital Discord, Domestic Violence, Prenatal Anxiety, Consanguinity, and Catastrophic Events With Prenatal Depression (Table 4)

      Association with low social support and presence of marital discord was significant on bivariate analysis but not in multivariate logistic regression. Presence of domestic violence was found to impose a five times higher and highly significant risk of developing prenatal depression among the respondents (COR = 5.438; 95% CI: 1.6–17.5, AOR = 5.916; 95% CI: 1.7–20.5). Pregnancy related anxiety was also found to be a positive predictor of prenatal depression (COR = 1.731; 95% CI: 1.05–2.8, AOR = 2.016; 95% CI: 1.13–3.5). The blood relationship with the husband did not show any significant association with prenatal depression on bivariate analysis and multivariable analysis. Presence of catastrophic events over the past 1 year imposed a two times higher and significant risk of developing prenatal depression among the respondents (COR = 1.969; 95% CI: 1.14–3.37, AOR = 2.148; 95% CI: 1.20–3.83, p-value = 0.010). History of mental illness was not included in the analysis because only one respondent had history of this kind and was undergoing treatment with medications.

      TABLE 4
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      Table 4. Association of maternal depression with social support, marital discord, and domestic violence among the pregnant mothers (N = 280).

      Association of Prenatal Depression With Physiologic Parameters (Table 5)

      Table 5 shows the association between physiologic parameters with prenatal depression. Presence of anemia (COR = 1.621; 95% CI: 0.9–2.7, AOR = 1.586; 95% CI: 0.91–2.75) showed some strong association with prenatal depression although this was not statistically significant. No association found between BMI and depression.

      TABLE 5
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      Table 5. Association of prenatal depression with physiological parameters (N = 280).

      Discussion

      In this study we have measured the prevalence of prenatal depression among pregnant women and its association with certain risk factors such as socio-demographic characteristics, obstetric history, social support, marital discord, spouse physical and sexual violence, and physiologic measurements which included body mass index and hemoglobin level.

      The mean age of respondents was 23.02 ± 3.40 years, which reflects upon the Indian cultural tradition of early marriage and parenthood. The prevalence of depression during pregnancy was 37.8% which is suggestive of a high probability of depression (using an EPDS cutoff score ≥13) among the respondents. The prevalence of prenatal depression makes it a significant public health issue in the study region. EPDS has been validated for use in India and Karnataka (26). Our study used a cut off score of more than or equal to 13 to identify women with depression; this yields a sensitivity of 100% and specificity of 84.9% in Indian settings (27). Another study from Karnataka showed an almost similar prevalence of 36.8% (21) whereas George et al., Ajinkya et al., and Bavle et al. observed much lower prevalence rates of 16.3% in coastal south India (35), 9.18% in Navi Mumbai (22), and 12.3% in Bangalore (36), respectively. This difference could be attributed to diversity in the socio-economic status, socio-cultural and psychosocial factors such as social support which might vary across different regions in the country. Moreover, this study was conducted in a public sector hospital setting, which in itself could pose as a risk factor and predictor for prenatal depression (28) due to inadequate quality of care in such settings.

      In our study, majority of the study participants belonged to the low income group. Although we could not document a significant association with socio-economic status, the risk of depression during, and after pregnancy is higher among the socially disadvantaged group (10, 37, 38). It is hypothesized that low income increases the likelihood of poor living conditions, financial struggle and influences interpersonal relationships which could lead to psychosocial stress. Over a third of the study participants were high school graduates though over 90% were not working; however there was no association of education and occupation with depression. Bavle et al. (36) in their study among pregnant women in Bangalore observed that being educated but not employed outside the house could predispose to depression during pregnancy. Study findings from other low income settings point toward a significant association of a woman's occupation with depression: women who were housewives or employed in the private sector or as a laborer or merchant business were prone to get depressed during pregnancy (39, 40). Other socio-demographic factors such as age, husband's education, and occupation did not predict the occurrence of depression in the present study even though some studies have identified young age as a risk factor (41, 42). In Asian settings, having an unemployed or uneducated husband increases the probability of depression (43, 44).

      Among the obstetric history variables, unplanned pregnancy increased the odds of depression on bivariate analysis. However, no significant association was observed on multivariate logistic regression analysis. Other studies show that the chance of getting depressed is higher in case of an unplanned pregnancy (15, 37, 45). Similarly multigravidity appeared to be risk factor for depression on bivariate analysis but not on logistic regression analysis although some studies do report a significant relationship (36, 46).

      In this study, among the psychosocial factors, presence of spouse physical and sexual violence and pregnancy related anxiety were significant risk factors for prenatal depression in the multivariable analysis. Earlier research has also reported a strong relationship between domestic violence and the risk of depression in pregnancy in high as well as middle to low—income settings (47, 48). Moderate and low social support were significantly related on bivariate but not on multivariate analysis. The linkage between poor social support and prenatal depression has been well-documented (49, 50). Low social support may increase mental stress by inducing feelings of insecurity, predispose toward substance abuse (51), and promote interpersonal conflict (52). The findings from the present study are concurrent with the study results reported by Nongrum et al. India (53), George et al. in Southern India (35), Silva et al. in Brazil (42), and Bernard et al. in Jamaica (54). Depression and anxiety show frequent co-existence and anxiety may emerge as a strong predictor for depression (24, 37). Mohamad et al. (55) and Edward et al. (56) also demonstrated that anxiety strongly increased the risk of suffering from depression during pregnancy. Even a history of mental illness can pose as a risk factor for depression (57, 58); however in our study only one respondent appeared to have such a history. Marital discord appeared predict presence of depression on bivariate but not on multivariate analysis; other studies report that this is e a well-established risk factor due to its influence on social support (59, 60). Likewise consanguinity seemed to be associated with depression only on bivariate testing. Consanguineous marriages are fairly prevalent in South India and clinical observations have reported a high prevalence of depression in such communities (61) which could be genetically driven (62). A major catastrophic event in the past 1 year was an important risk factor which was significantly associated with prenatal depression in this study; this is consistent with the study results reported by Leigh et al. (63) and Shakeel et al. (58). Another study reported that negative life events may lead to persistent higher levels of depressive symptoms since positive life events can decrease the severity of depression over time (64).

      Among the physiologic measurements, anemia was significantly associated with depression on bivariate although not so on multivariate analysis. This is in agreement with the study findings reported by Lukose et al. (65); however Yilmaz et al. depicted the existence of such an association between depressive symptoms and anemia in the third trimester of pregnancy (66). Body mass index was not linked with the risk of prenatal depression in the present study. Research done in other countries reportedly point toward an interconnection between obesity and depression (67, 68). The causal pathway could include inflammation (62), hormonal imbalance (69), or sleep disturbance (70).

      Study Strengths And Limitations

      This study focuses on prenatal depression which has received less attention than postnatal depression. All the instruments/scales used to measure the study variables had good psychometric properties. Our study had few a limitations. Antenatal care at such hospitals is mostly availed by pregnant women from the lower and middle—income groups in a community. Hence the findings from this study cannot be extrapolated to pregnant women belonging to the high income group as there could be variations in the psychosocial factors and standard of living. As a part of the cohort study protocol, we excluded women with high risk pregnancies and those with a history of intake of steroidal medication over the past 1 year; this could limit the generalizability of the study findings. Adverse obstetric complications during pregnancy can modulate the mental health of a woman during pregnancy. In the south-east Asian context, conflict with in-laws is also a significant risk factor, although this item was not recorded in the present study but will be included in future data collection. We used the EPDS scale which is a self –reporting screening measure for identifying women at risk for depression. Even though EPDS has a high sensitivity and specificity and can be easily administered by a trained health worker, it is important to confirm the presence of depression by using a structured clinical interview to confirm diagnosis.

      Conclusion

      The present study showed a high prevalence of prenatal depression which is suggestive of its public health importance in the study region. Spouse physical and sexual violence, pregnancy related anxiety and a history of catastrophic events were important predictors of prenatal depression. Obstetric practice should include screening and diagnosis of prenatal depression as a part of routine antenatal care in low and middle—income countries.

      Ethics Statement

      This study was carried out in accordance with the recommendations of the Ethical Committee of Indian Institute of Public Health Bangalore campus (IIPHHB/TRCIEC/118/2017) with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Ethical committee of Indian Institute of Public Health Bangalore campus.

      Author Contributions

      AN and MK: conceptualization. BS, SV, and JV: formal analysis. AN and GM: funding acquisition. CM: methodology. AN and SB: writing-original draft preparation.

      Funding

      This project is funded by Welcome Trust DBT India Alliance (Clinical and Public Health Research Fellowship), grant number IA/CPHI/16/1/502634.

      Conflict of Interest Statement

      The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

      Acknowledgments

      We would like to extend our sincere thanks to the staffs of Jaya Nagar General Hospital for supporting us during data collection.

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      The New Runner's High' Examining Relationships Between Cannabis Use
             and Exercise Behavior in States With Legalized Cannabis
      • The New Runner's High? Examining Relationships Between Cannabis Use and Exercise Behavior in States With Legalized Cannabis

        Sophie L. YorkWilliams 1 *, Charleen J. Gust 1, Raeghan Mueller 1, L. Cinnamon Bidwell2, Kent E. Hutchison1, Arielle S. Gillman 1 and Angela D. Bryan1
        • 1 Department of Psychology & Neuroscience, University of Colorado Boulder, Boulder, CO, United States
        • 2 Institute of Cognitive Science, University of Colorado Boulder, Boulder, CO, United States

        Scientific literature examining cannabis use in the context of health behaviors, such as exercise engagement, is extremely sparse and has yielded inconsistent findings. This issue is becoming increasingly relevant as cannabis legalization continues, a situation that has been associated with increased initiation of use among adults, and increased potency of available products in legalized states. Physical activity is among the most important health behaviors, but many Americans do not meet minimum exercise recommendations for healthy living. Common issues surrounding low exercise rates include inadequate enjoyment of and motivation to exercise, and poor recovery from exercise. It is unclear whether cannabis use shortly before and/or after exercise impacts these issues, and whether this co-use affects exercise performance. The present online survey study examines attitudes and behaviors regarding cannabis use with exercise among adult cannabis users living in states with full legal access (N = 605). Results indicated that the majority (81.7%) of participants endorsed using cannabis concurrently with exercise, and those who did tended to be younger and more likely to be males (p < 0.0005 for both). Even after controlling for these differences, co-users reported engaging in more minutes of aerobic and anaerobic exercise per week (p < 0.01 and p < 0.05, respectively). In addition, the majority of participants who endorsed using cannabis shortly before/after exercise reported that doing so enhances their enjoyment of and recovery from exercise, and approximately half reported that it increases their motivation to exercise. This study represents an important step in clarifying cannabis use with exercise among adult users in states with legal cannabis markets, and provides guidance for future research directions.

        Introduction

        As evidenced by the increasing legalization of both medical and recreational cannabis in the United States (1), public acceptance of cannabis use is growing. Despite this, there is a relative lack of literature exploring the public health implications of cannabis consumption. One health behavior that may be impacted by increased cannabis use is exercise. The benefits of regular exercise are far-reaching and include the prevention or improvement of some cancers, cardiovascular disease, diabetes, depression, Alzheimer's disease, and memory loss (24). As a reflection of these benefits, the American College of Sports Medicine (ACSM) recommends that adults participate in at least 150 min of moderate- to vigorous-intensity exercise each week (5). Unfortunately, self-report data indicate that fewer than 50% of US adults meet these minimum recommendations (6). These low rates of exercise participation are indicative of a significant and urgent health concern. Given popular stereotypes that cannabis use is associated with a lack of motivation and, indeed, extreme sedentary behavior (c.f., “couch lock”), increased cannabis use could worsen the sedentary lifestyle epidemic that the US is currently facing. On the other hand, cannabis use is banned by the World Anti-Doping Agency because of its potential to improve sports performance, and numerous reports in the popular press suggest that endurance athletes utilize cannabis in their training [e.g., Dreier (7)]. Such conflicting ideas about the relationship between cannabis use and physical activity necessitate further investigation into how cannabis use may affect factors associated with regular physical activity participation.

        The sparse empirical literature base that speaks to the association between cannabis and health emphasizes potential negative and harmful effects associated with use, such as psychosis, impaired driving, and sleep disturbances (810). There is also an established relationship between cannabis use and increased caloric intake (11), which is especially worrisome given the current obesity epidemic; the Centers for Disease Control and Prevention reported in 2017 that nearly 40% of the US population is obese (12). However, recent results from representative national surveys suggest a lower prevalence of obesity in cannabis users than in non-users (13). Further, cross-sectional data from the National Center for Health Statistics indicate positive correlations with cannabis use and measures of metabolic health, such as lower levels of fasting insulin, smaller waist circumference, and reduced prevalence of type II diabetes (14). There is also evidence to suggest that cannabis use is associated with a greater likelihood of meeting the aforementioned exercise guidelines (15), possibly due to positive influences on motivation or reductions in inflammation and pain during and after exercise (16).

        Common barriers that prevent individuals from the initiation or continuation of a regular exercise regimen include (1) improper recovery after exercise (17), (2) lack of motivation (18), and (3) low enjoyment of exercise (19). Cannabis might interact with these barriers in contradictory ways, both positively (e.g., by promoting recovery from or enjoyment of exercise) and negatively (e.g., through decreases in motivation). Gillman et al. (16) address this notion in a review paper commenting on the biological and neurocognitive mechanisms by which cannabis use might impact three potential areas of influence: the effect of cannabis on exercise performance, motivation for exercise, and recovery from exercise. For example, Gillman et al. (16) report that few empirical studies have examined the relationship between cannabis use and exercise performance, and those that have are limited in their external validity due to the use of uncommon forms of cannabis for consumption (e.g., cannabis cigarettes containing unusually low-THC strains). Further, while anecdotal evidence suggests that cannabis reduces motivation for exercise, several neurobiological mechanisms connected to the endocannabinoid system argue against this; rather, there is evidence to suggest that cannabis may have beneficial effects on exercise motivation (16). Finally, while there is evidence that cannabis reduces pain and inflammation in humans (20), other research suggests the use of anti-inflammatory agents, such as cannabinoids, might actually interfere with proper recovery from exercise (16). These limitations and inconsistencies point to a clear need for additional investigations of the effects of cannabis use on health behaviors generally and on exercise in particular (16). Such research is particularly pressing in states with full legal cannabis access, as cannabis use is on the rise in these states and may include broader populations than have been represented in research conducted when cannabis use was an illegal behavior (21).

        The present study aimed to address research questions set out by Gillman et al.'s review, and is the first to collect empirical data on attitudes and behaviors regarding cannabis use and exercise among current cannabis users living in states with full legal access. In particular, we were interested in examining differences between users who consume cannabis shortly before or after exercise (co-use), compared to those who do not. Building on Gillman et al. (16), we were also interested in attitudes regarding the impact of cannabis use before or after exercise on exercise performance, enjoyment, motivation, and recovery. Data were gathered using a web-based survey advertised to users in states with legal recreational cannabis. Since endorsement of the use of cannabis concurrent with exercise inherently increases the likelihood of exercise engagement (i.e., a cannabis user who does not exercise cannot use cannabis concurrent with exercise), we hypothesized that co-users would report more exercise behavior than non-co-users. Based on data supporting the anti-inflammatory and analgesic effects of cannabis (16), we hypothesized that users of cannabis concurrent with exercise would report that it aided in recovery. Finally, given conflicting findings regarding performance and motivation, and little to no data on enjoyment, we considered tests of these associations to be exploratory.

        Methods

        Procedures

        A voluntary, anonymous online “Cannabis and Health” survey was advertised on Facebook and targeted individuals aged 21 and older living in California, Colorado, Nevada, Oregon, and Washington and who “liked” pages related to cannabis use (e.g., Cannabis Culture Magazine). In Colorado, the survey was also advertised through medical cannabis card registration clinics and dispensaries in the Boulder-Denver area. The survey was hosted on Qualtrics.com and data were collected from January 2017 to July 2018. Survey details are described in another recent publication (22). Participants were asked demographic questions, along with health, exercise, and substance use questions. They were free to skip questions, other than acknowledgment of consent and that they were 21 years of age or older. Inclusion criteria for the current study were as follows: (1) reported living in a state with legal recreational cannabis, and (2) responded to the cannabis and exercise questions (details below).

        In the initial iteration of the survey, we asked, “Do you ever use cannabis within 1 hour before and/or 4 hours after you engage in exercise?” This version was completed by 260 (43.0%) of the present study participants. Subsequently, in an effort to delineate those who use cannabis either before or after exercise, the survey was altered and the remaining participants (n = 345; 57.0% of present study) were asked (1) “Do you ever use cannabis within 1 hour before you engage in exercise?” and (2) “Do you ever use cannabis within 4 hours after you engage in exercise?” Participants who answered “yes” to the single question in the first version, or “yes” to either question in the latter version, were categorized as individuals who use cannabis concurrent with exercise for the full-sample analyses.

        Participants who endorsed cannabis use concurrent with exercise were given the following instructions. “The following statements are examples of why you might use cannabis before or after exercise. Please indicate how much you agree with each statement.” They were presented with cannabis-exercise attitude statements (listed below) and asked to indicate their opinion of each on a 7-point likert scale, with the anchors of 1 = “strongly disagree,” 4 = “neither agree nor disagree,” and 7 = “strongly agree.” Statements started with “I believe that” and ended with (1). cannabis enhances my exercise performance; (2). cannabis increases my enjoyment of exercise; (3). I am more motivated to engage in exercise when I use cannabis; (4). cannabis makes it easier to recover from my exercise experience (e.g., reduces inflammation, joint pain, etc.).

        Analyses

        RStudio software was utilized in all analyses. We first computed basic demographic information to describe the study sample, and calculated frequencies of concurrent exercise-cannabis use endorsement in the study. Group differences between those who endorsed cannabis use concurrent with exercise and those who did not were examined with χ2 tests or t-tests as appropriate, for age, gender, ethnicity, body mass index (BMI), state of residency, and frequency of cannabis use. Next, we used t-tests to examine differences between co-using and non-co-using groups on minutes of aerobic and anaerobic exercise per week. When group differences arose, we verified that they were not explained by demographic differences, by including demographic variables that were different between groups as covariates in linear regression models.

        Next, we used two methods to examine cannabis-exercise attitudes among participants who endorsed co-use. First we examined attitudes numerically, by averaging scores for each of the 4 attitudes. We did this in the full co-using sample, and then examined whether average attitudes differed by type of co-use endorsement (cannabis use only before, only after, or both before and after) using between-subjects ANOVAs. This temporal specificity was only available in the 2-question version of the study, so participants from the 1-question version were included in the model as one group, and those from the 2-question version were grouped by type of co-use endorsement. Second, in the full sample of concurrent users, we categorized interpretations of these attitudes by percentage of participants who agreed or disagreed with each statement. A rating between 1 and 3 was categorized as “disagree,” 4 as “neutral,” and 5–7 as “agree.”

        Results

        Study Demographics

        Among the 620 participants that completed either version of the survey and reported residency in a state with legal cannabis, 605 respondents provided answers to the cannabis-exercise questions and were included in the present study. Mean age was 37.5 (SD = 15.7; min = 21; max = 78), and 281 (46.6%) were female. State of residency reports were: 419 (69.3%) in Colorado, 99 (16.4%) in California, 38 (6.3%) in Oregon, 36 (6.0%) in Washington, and 13 (2.1%) in Nevada. The majority (78.3%) of participants were white non-Hispanic, followed by 10.6% Hispanic, 4.0% Native American, 3.8% black or African American, 1.5% Asian, 0.05% Pacific Islander, and 1.3% declined to answer.

        Cannabis Use Before/After Exercise

        In the full sample, 494 participants (81.7%) endorsed using cannabis before and/or after exercise and 111 (18.3%) did not. Among the sample from the first version of the survey, who answered the single cannabis-exercise question (n = 260), 79.6% endorsed using cannabis before and/or after exercise (n = 207), and 20.4% reported that they did not (n = 53). Among the 345 participants in the 2-question sample, 287 (83.3%) endorsed at least one of the two cannabis-exercise questions. Specifically, 237 (68.9%) endorsed using cannabis within 1 h before exercise, while 282 (82.0%) endorsed using cannabis within 4 h after exercise, and 58 (16.8%) reported that they did not use cannabis within 1 h before nor within 4 h after engaging in exercise. Interestingly, 232 of the 345 2-question sample participants endorsed using cannabis both before and after exercise (67.2%), while 50 (14.5%) endorsed only using after exercise, and only 5 (1.5%) endorsed only using before exercise. Thus, most cannabis users who use cannabis concurrent with exercise report doing so both before and after exercise.

        Demographic and Lifestyle Differences Between Co-users and Non-co-users

        Bivariate relationships suggested that participants who used cannabis with exercise were younger, more likely to be male, and of lower BMI than those who did not use cannabis with exercise. Average age of participants who used cannabis with exercise was 36.3 (SD = 14.9), while the average age of cannabis users who did not was 43.1 (SD = 18.0; p < 0.0005; d = −0.39). Females comprised only 42.8% of participants who endorsed using cannabis with exercise, compared to 63.1% of those who did not p < 0.0005). Average reported BMI of co-using participants was 25.6 (SD = 5.61), while the average was 27.0 (SD = 6.0; p < 0.05; d = −0.24) among those who did not use cannabis with exercise. However, these group differences in reported BMI were not present after age and gender, which were different between co-users and non-co-users, were accounted for. Participant race/ethnicity and state of residency did not differ between exercise groups.

        Co-users endorsed using cannabis flower 5.5 days per week on average (SD = 2.5; min = 0; max = 7), while non-co-users endorsed using 3.2 days (SD = 3.1; min = 0; max = 7; p < 0.0001; d = 0.76). Co-users endorsed using high-potency cannabis concentrate 2.5 days per week on average (SD = 2.9; min = 0; max = 7), while non-co-users endorsed using 0.6 days (SD = 1.6; min = 0; max = 7; p < 0.0001; d = 1.0). Co-users endorsed using cannabis edibles 1.3 days per week on average (SD = 2.0; min = 0; max = 7), while non-co-users endorsed using 1.6 days (SD = 2.4; min = 0; max = 7; ns). Even after controlling for age and gender, co-users used cannabis flower on 2.4 more days (p < 0.0001) and cannabis concentrates 1.8 more days (p < 0.0001) than non-co-users on average.

        Differences in Exercise Behaviors Between Co-users and Non-co-users

        Co-using participants reported 159.7 min per week of aerobic exercise on average (SD = 154.3; min = 0; max = 600), while non-co-users reported an average of 103.5 min (SD = 113.6; min = 0; max = 510; p < 0.0001; d = 0.45). Using linear regression to control for potential demographic confounds of age and gender, use of cannabis with exercise was still associated with 43.4 more min of weekly aerobic exercise on average (p < 0.01). Consistent with this finding, 40.1% of cannabis users who used with exercise met or exceeded American College of Sports Medicine's recommendations of a minimum of 150 min of aerobic exercise per week (5), compared to only 28.7% of cannabis users who did not endorse using with exercise (p = 0.036). This discrepancy was not limited to aerobic activity. Cannabis users who used cannabis during exercise also reported an average of 37.4 more minutes of anaerobic exercise (mean = 101.6; SD = 129.1; min = 0; max = 600) than cannabis users who did not use during exercise (mean = 64.2; SD = 104.3; min = 0; max = 600; p < 0.005; d = 0.33). After controlling for the demographic variables that were different between groups (age and gender), cannabis use during exercise was still associated with 30.2 more minutes of reported anaerobic exercise (p = 0.033).

        Attitudes About Cannabis Use Before/After Exercise

        Mean scores on the 1–7 scales for each cannabis-exercise attitude statement among all participants who endorsed co-use were as follows: performance was 4.4 (SD = 1.6; median = 4), enjoyment was 5.3 (SD = 1.6; median = 6), motivation was 4.7 (SD = 1.8; median = 5), and recovery was 5.7 (SD = 1.5; median = 6). With a score of 4 equating to neither agreement nor disagreement, and 7 equating to strong agreement, results indicate that average attitudes, particularly toward enjoyment and recovery, were above neutral when the full co-using sample was combined (Table 1). Of note, more respondents endorsed strong agreement than strong disagreement with the attitude statements (i.e., there were more answers of 6 and 7 than 1 and 2). As such, the median results may represent participant attitudes better than the means and standard deviations. To add nuance to these attitudes, we wanted to examine whether they differed across participants who endorsed cannabis use only before, only after, or both before and after exercise. This level of detail was only available in the 2-question version of the study, so participants from the 1-question version were treated as one group. Due to the low number of survey participants who endorsed cannabis use only before exercise in the second version of the survey (n = 5), they were not included in the ANOVA models. Thus, the 3 groups in the model were: those in the second survey who endorsed cannabis use both before and after exercise, those in the second survey who endorsed cannabis use only after exercise, and those in the first version of the survey who endorsed our single-question regarding cannabis use before or after exercise. Average scores for each attitude statement by group are detailed in Table 2. We found differences in subjective experience of those who reported cannabis use only after exercise, compared to those who used both before and after, and those who participated in the combined single-question survey version (p < 0.0001 for all attitudes). This difference was most prominent for enjoyment, motivation, and performance.

        TABLE 1
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        Table 1. Attitudes on how use of cannabis with exercise impacts exercise performance, enjoyment, motivation, and recovery, among all participants who endorsed co-use (N = 494).

        TABLE 2
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        Table 2. Attitudes on how use of cannabis with exercise impacts exercise performance, enjoyment, motivation, and recovery, among participants who endorsed co-use.

        In order to characterize these attitudes more broadly in all participants who endorsed use before and/or after exercise, we transformed these numeric ratings into categories, grouping all ratings below 4 (“neither agree nor disagree”) as “disagree,” and all ratings above 4 as “agree.” Figure 1 provides a visual representation of these attitudes data. Among participants who endorsed using cannabis before and/or after exercise (n = 494), the majority (70.7%) agreed or agreed strongly that cannabis increases enjoyment of exercise, 19.3% were neutral, and 10.0% disagreed or disagreed strongly. The majority (77.6%) also agreed or agreed strongly that cannabis enhances recovery from exercise, while 16.3% were neutral and 6.1% disagreed or disagreed strongly. In contrast, just over half (51.8%) agreed or agreed strongly that cannabis increases motivation to exercise, 26.5% were neutral, and 21.6% disagreed or disagreed strongly. Finally, a minority (37.5%) agreed or strongly agreed that cannabis enhances exercise performance, while almost half (46.0%) were neutral and 16.5% disagreed or disagreed strongly.

        FIGURE 1
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        Figure 1. Percentage of co-using participants who agreed, disagreed, or felt neutral toward whether use of cannabis shortly before and/or after exercise enhanced exercise performance, enjoyment, motivation, and recovery.

        Discussion

        The current study aimed to characterize differences between adult cannabis users who consume cannabis shortly before and/or after exercising and those who do not, in the context of legal cannabis markets in the United States. Combining across survey versions of cannabis users, we found that the majority of our sample did endorse using cannabis concurrently with exercise. These participants were younger on average, and included a greater proportion of males than those who do not (both p < 0.0005). In line with our hypotheses, they also reported more minutes of aerobic and anaerobic exercise per week (p < 0.01 and p < 0.05, respectively), even after accounting for potential demographic confounds of age and gender. Concurrent users reported consuming cannabis flower and concentrates more often than the non-co-using group (both p < 0.0001, even after controlling for age and gender), but edible use did not differ between groups. Reasons for these correlations can only be speculated upon. It may be that more frequent cannabis users are more likely to engage in co-use simply by virtue of them using so often, rather than reasons related to exercise performance, enjoyment, motivation, or recovery.

        Additionally, the present study sought to take initial steps in understanding possible mechanisms through which cannabis could influence exercise behavior, by examining attitudes toward how cannabis co-use influences the exercise experience. We found that the majority of participants who endorsed using cannabis concurrently with exercise reported that doing so at least somewhat enhances recovery from and enjoyment of exercise, while approximately half reported that it at least somewhat increases motivation, and a minority reported that it enhances performance. These findings supported our hypothesis that co-users may be co-using because they believe it contributes to recovery after exercise. The findings also suggest that co-use may facilitate enjoyment of exercise, and (for a subset of co-users) motivation to exercise. Given that these are recognized barriers to exercise (1719), it is possible that cannabis might actually serve as a benefit to exercise engagement. Finally, the attitudes toward co-use and performance in our participants seem to concur with studies suggesting that cannabis use does not enhance exercise performance for most users (16).

        To our knowledge, this is the first study to survey attitudes and behavior regarding the use of cannabis before and after exercise, and to examine differences between cannabis users who engage in co-use, compared to those who do not. Given both the spreading legalization of cannabis and the low rates of physical activity in the US, it behooves public health officials to understand the potential effects—both beneficial and harmful—of cannabis use on exercise behaviors (16). Cannabis use has become more common in the past decade, especially among adults in states with legal recreational cannabis (21). As legal risks associated with cannabis use decrease, it is plausible that a broader range of individuals will be initiating use. Thus, the present study's focus on legal market populations is timely, and results may help to anticipate the future landscape of other states, as legalization progresses.

        Our results suggest that prior findings of cannabis users being more likely to meet official exercise recommendations (15) may be at least partly associated with perceived impacts of cannabis co-use on enjoyment, reductions in pain and inflammation during and after exercise, and to a lesser extent motivation. Furthermore, participants who use cannabis before and/or after exercise reported that they exercised more, and had positive attitudes about co-use on exercise, which implies cannabis may be a useful tool for exercise among some users. In other words, sedentary cannabis users, particularly those who attribute low physical activity to concerns about recovery, motivation, or enjoyment, may benefit from co-use, provided that they select low-risk exercise options that do not compromise safety during intoxication. However, since the present study did not query potential negative consequences of co-use, any recommendations are premature. For instance, the 16.5% of co-users who reportedly disagreed that co-use enhanced performance may exercise at a lower intensity when they use cannabis shortly beforehand. Similarly, the 6.1% who disagreed that co-use aided in recovery may have experienced injury from exercising while intoxicated. Clearly, more nuanced investigation is needed. Given the diversity of cannabis users in legal states (22), co-use may have a net-positive impact on some, and a net-negative impact for others. Potency and amount of cannabis used, type and context of exercise, and individual health status likely impact whether co-use is a safe and beneficial option.

        Limitations of the current study include its cross-sectional, anonymous, and self-report nature, as well as recruitment issues, particularly that of cannabis users without a non-using comparison group. It is possible that recruitment through social media captured respondents who are invested in promoting cannabis, leading to results that are skewed favorably toward exercise. However, it is also possible that recruitment through medical cannabis card registration clinics might have captured respondents who are less physically able, thus leading to results skewed against exercise. It is also critical to recognize that there is substantial overlap between states that have legalized cannabis and states that have higher levels of physical activity. For whatever historical, political, or economic reasons, it is the case that states with legal access to cannabis are, without exception, more physically active than the national average (23). Without a non-using comparison group, we are unable to rule out potential selection bias; that is, it might be that non-users living in such highly active states are even more active than cannabis users. In addition, our findings about exercise behaviors and attitudes regarding cannabis co-use with exercise may not be representative of states with different cannabis legality and may not translate to future behaviors and attitudes if and when states with lower rates of physical activity legalize cannabis. However, given the positive associations that co-users reportedly experience between cannabis use and exercise enjoyment and recovery, there may indeed even be a stronger correlation between using cannabis with exercise and exercise behaviors in less active states. This will be a fascinating research question as more states move toward legalization. It is important to note that the current study represents a first attempt to elucidate this complex issue, and that there are currently no grounds for suggestion that non-users should initiate cannabis use to increase their physical activity participation.

        As discussed above, future research is needed to refine and expand upon this foundational study. For instance, querying both users and non-users in legal states would clarify the extent to which cannabis use impacts exercise behaviors in these regions. For example, it could be that the non-cannabis users in these highly physically active states are even more active than cannabis users. We are unable to directly test this question with our survey data. Additionally, while the current study illuminates attitudes regarding co-use, it would be useful to explore how often cannabis is used specifically to achieve exercise goals and in what contexts (e.g., specific forms of exercise and during group vs. individual exercise). It is particularly important to explore potential negative outcomes of cannabis co-use with exercise in future research, especially regarding accident or injury as a result of intoxication. Additionally, a longitudinal observational study design could be used to examine how changes in cannabinoid content and product potencies influence exercise behavior. Since we are unable to randomly assign sedentary individuals to use cannabis (or not) and subsequently observe exercise behavior, and because demographic differences can impact exercise engagement, propensity score matching could be used to estimate the effect cannabis legalization has on exercise behavior by equating co-users and non-co-users on influential covariates. Lastly, a useful tool to examine the influence of cannabis on exercise engagement at the population level would be to implement an interrupted time-series study design where exercise behavior is surveyed in a state before and after cannabis legalization.

        In summary, these data suggest that many cannabis users in states with legal cannabis access use in conjunction with exercise, and that most who do so believe it increases enjoyment of, recovery from, and to some extent the motivation to engage in exercise. As these factors positively correlate with exercise behavior (24), using cannabis with exercise may play a beneficial role in the health of cannabis users. Recommendations around cannabis use with exercise are premature until aforementioned research questions have been addressed, including independent verification of self-reported behaviors and negative consequences of co-use.

        Ethics Statement

        This study was carried out in accordance with the recommendations of the University of Colorado Boulder's Institutional Review Board. Informed consent was given by all participants in accordance with the Declaration of Helsinki and all procedures were approved by the University of Colorado Boulder's Institutional Review Board.

        Author Contributions

        KH, LB, SY, and RM contributed to the design and implementation of the research. SY managed and analyzed the data. SY, AB, RM, and LB contributed to the interpretation of the results. SY, RM, and CG wrote the manuscript. SY, AB, CG, and LB edited the manuscript. All authors provided critical feedback and helped shape the manuscript.

        Conflict of Interest Statement

        The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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        Keywords: cannabis, marijuana, exercise, cannabis legalization, health

        Citation: YorkWilliams SL, Gust CJ, Mueller R, Bidwell LC, Hutchison KE, Gillman AS, and Bryan AD (2019) The New Runner's High? Examining Relationships Between Cannabis Use and Exercise Behavior in States With Legalized Cannabis. Front. Public Health 7:99. doi: 10.3389/fpubh.2019.00099

        Received: 14 December 2018; Accepted: 08 April 2019;
        Published: 30 April 2019.

        Edited by:

        Ross Bailie, University of Sydney, Australia

        Reviewed by:

        Marisa Theresa Gilles, Western Australian Center for Rural Health (WACRH), Australia
        Jan Fizzell, New South Wales Department of Health, Australia

        Copyright © 2019 YorkWilliams, Gust, Mueller, Bidwell, Hutchison, Gillman and Bryan. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

        *Correspondence: Sophie L. YorkWilliams, sophie.yorkwilliams@colorado.edu

        2019-04-30T00:00:00Z
         
    • School Climate, Loneliness, and Problematic Online Game Use Among Chinese
             Adolescents: The Moderating Effect of Intentional Self-Regulation
      • School Climate, Loneliness, and Problematic Online Game Use Among Chinese Adolescents: The Moderating Effect of Intentional Self-Regulation

        Chengfu Yu 1,2,3, Wentao Li3, Qiao Liang1, Xuelan Liu3 *, Wei Zhang3, Hong Lu1,2 *, Kai Dou1, Xiaodong Xie4 and Xiong Gan5
        • 1 School of Education, Guangzhou University, Guangzhou, China
        • 2 School of Education, Center for Brain and Cognitive Sciences, Guangzhou University, Guangzhou, China
        • 3 School of Psychology, South China Normal University, Guangzhou, China
        • 4 Human Resources Department, South China Normal University, Guangzhou, China
        • 5 School of Education, Yangtze University, Jingzhou, China

        Evidently, the school climate is important in reducing adolescent problematic online game use (POGU); however, the mechanism accounting for this association remains largely unknown. This study examined whether loneliness mediated the link between school climate and adolescent POGU and whether this mediating process was moderated by adolescent intentional self-regulation. To this end, self-report questionnaires were distributed. Participants were 500 12–17-years-old Chinese adolescents (Mean age = 13.59 years, 50.60% male). After controlling for adolescents' gender, age, family socioeconomic status, and self-esteem, the results showed that the negative association between school climate and adolescent POGU was partially mediated by loneliness. Moreover, this indirect link was stronger for adolescents with low intentional self-regulation than for those with high intentional self-regulation. These findings highlight loneliness as a potential mechanism linking school climate to adolescent POGU and provide guidance for the development of effective interventions for addressing the adverse effects of a negative school climate.

        Introduction

        Over the past two decades, problematic online game use (POGU) as a global public health issue has received increasing research interest (13). POGU, a subtype of problematic Internet use, refers to the uncontrollable, excessive, and compulsive use of online games that causes social and/or emotional problems (4). Individuals with POGU spend more time gaming than planned at the expense of other important activities, causing negative social and academic outcomes. Increasing evidence has consistently confirmed that POGU is associated with a variety of negative outcomes such as poor academic performance, depression, and aggression (3, 5, 6). Specifically, China has one of the highest adolescent POGU prevalence rates in the world raging between 2.2 and 21.5% (1, 7, 8). Therefore, an investigation of the factors that predict POGU is urgently needed to support the development of intervention programs.

        Given that adolescents spend an increasing amount of their time engaged in school-related tasks, the influence of school contexts on adolescent development has received increased attention in the past decade (911). School climate refers to all relationships that affect children's cognitive, social, and psychological development, including adult-adult, adult-student, student-student, family-school, and community-school relationships (9, 12). However, perceptions of specific school climate may vary greatly across individuals.

        According to the stage-environment fit theory (13, 14), optimal development takes place when school contexts adequately satisfy adolescents' increasing psychological needs for autonomy, relatedness, and competence. In this study, we primarily focused on three components of school climate: teacher support, student-student support, and opportunities for autonomy at school. Particularly, teacher support and student-student support may help meet adolescents' relatedness and competence needs. Moreover, teacher autonomy support can help to satisfy students' needs for autonomy, as well as offer students the opportunity to achieve competence and establish positive interactions with teachers and peers (15, 16). There is considerable evidence suggesting that students' perceptions of relatedness and autonomy in the school setting influence adolescents' academic adjustment as well as their physical and socio-emotional well-being (9, 17, 18). By the same token, a mismatch between school climate and the three aforementioned psychological needs can result in problem behaviors such as POGU.

        Research has indicated that adolescents who perceive the school climate as favorable are less likely to develop POGU (10, 11, 19). For instance, Rehbein and Baier (11) found that students' perceptions of favorable school climates were an important protective factor against POGU in a 5-year longitudinal study of 406 students in grades 4–9. Similarly, Yu et al. (19) reported that 7th grade adolescents who perceived opportunities for autonomy at school had a decreased incidence of 9th grade POGU; this association was mediated via increased 8th grade basic psychological needs satisfaction and 9th grade school engagement. These findings highlight the merit of favorable school climate in reducing adolescent POGU.

        Loneliness as a Mediator

        Although the association between school climate and adolescent POGU has been well-established, the mediating and moderating mechanisms underlying this relation are still under-investigated. Loneliness is prevalent in adolescents (20). According to the self-system processes model (21), a favorable school climate helps to reduce the degree of loneliness experienced by adolescents, which in turn reduces the risk of problem behaviors. In other words, loneliness may be an important mediator of the link between school climate and adolescent problem behaviors. When adolescents' socio-emotional needs are not adequately met by contextual factors such as school climate, the feeling of loneliness occurs (22). Moreover, adolescents suffering from loneliness are at elevated risk for POGU (5).

        From one perspective, a school climate that responds to adolescent psychological needs for relatedness, competence, and autonomy, renders adolescents less likely to experience loneliness. Ample research evidence has confirmed the negative association between a favorable school climate and loneliness (2325). For instance, Benner (23) reported that a positive school climate was negatively associated with loneliness. Similarly, Liu et al. (24) and Yu (25) found that junior middle school students who had more favorable school climate perceptions (positive teacher-student support, student-student support, and opportunities for autonomy at school) were less likely to experience loneliness.

        From another perspective, when adolescents experience loneliness, they are more likely to indulge in online games. Growing numbers of studies support the important effect of loneliness in shaping adolescent POGU (5, 6, 26). For instance, Caplan et al. (26) found that loneliness was positively associated with POGU. Similarly, Qin (27) found that loneliness was a risk factor for POGU. In addition, Lemmens et al. (6) reported that loneliness was a significant and powerful predictor of POGU. Moreover, Chen and Fu (5) found that adolescents with POGU scored significantly higher on measures of loneliness than did adolescents without POGU. Taken together, these data led to the following hypothesis:

        Hypothesis 1: Loneliness will mediate the relationship between school climate and adolescent POGU.

        Intentional Self-Regulation as a Moderator

        Despite that a robust relationship between school climate and adolescent POGU has been suggested in previous research, not all adolescents who experience a negative school climate develop POGU; some adolescents still adapt well even though they have negative perceptions of their school climate. Similarly, some adolescents still experience maladjustment even though they perceive their school climate favorably. Such variability in adolescents' responses to the school environment suggests that individual characteristics may play a key role in this observed heterogeneity.

        According to the ecological system theory Bronfenbrenner (28), adolescents' development stems from the interplay between important contexts (such as school climate) and their intrapersonal characteristics. Among the many intrapersonal characteristics influencing adolescents' emotional problems (such as loneliness) and deviant behaviors, intentional self-regulation is an important moderator (2931). Intentional self-regulation refers to one's efficiency in examining his/her abilities and negotiating his/her resources in the context of personal goals in order to attain better functioning and to enhance self-development (32, 33). Consequently, appropriate goals and goal-related strategies for attaining positive individual-context relations should be chosen (34). Thus, people with different levels of intentional self-regulation are influenced by contextual factors differently. More precisely, adolescents with good intentional self-regulation are more inclined to select suitable goals, optimize their own resources, and/or actively search for alternatives when failure happens, in turn increasing adjustment and reducing problem behaviors such as POGU (30, 32).

        The risk-buffering hypothesis proposes that favorable personal characteristics such as intentional self-regulation can weaken the link between environmental stress (such as negative school climate) and problem behaviors (35). Consistent with this hypothesis, Urban et al. (31) found that intentional self-regulation moderated the relationship between neighborhood contexts and adolescent mental health symptoms, such that neighborhood risk factors were associated with increased mental health symptoms including loneliness, depression, and sadness among individuals with lower intentional self-regulation, but not among those with higher intentional self-regulation. This could be because adolescents with higher intentional self-regulation can obtain more coping resources from their neighborhood contexts. Similarly, adolescents with high intentional self-regulation tend to have clear goals and a vision for what they want to achieve, thus they can make good use of school resources and undergo more optimal development (such as less loneliness). Further, when faced with an unfavorable school climate, adolescents with high intentional self-regulation might be better able to focus on their goals and plans, thus reducing their sense of loneliness. Although they may experience setbacks and negative feelings (such as loneliness) when in a disadvantageous school climate, adolescents with excellent intentional self-regulation can adjust better and recover more quickly than those with poorer intentional self-regulation. Therefore, we proposed the following hypothesis:

        Hypothesis 2: Intentional self-regulation will moderate the indirect link between school climate and adolescent POGU. Specifically, the indirect association between school climate and POGU via loneliness will be stronger among adolescents with low-level intentional self-regulation and weaker among adolescents with high-level intentional self-regulation.

        The Present Study

        Grounded in the self-system processes model and the ecological system theory, this study investigated whether loneliness mediates the relation between school climate and adolescent POGU and whether this indirect link is moderated by intentional self-regulation. Figure 1 illustrates the proposed research model.

        FIGURE 1
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        Figure 1. The proposed moderated mediation model. ISR, intentional self-regulation; POGU, problematic online game use.

        Method

        Participants

        The participants in this study were recruited from two junior middle schools in Guangdong province, southern China, through stratified and random cluster sampling. A total of 500 adolescents (50.60% male) ranging in age from 12 to 17 (Meanage = 13.59, SD = 0.65) participated in February 2019. Of those, 207 adolescents came from one school (Urban areas) while 293 came from the other (Rural areas). And Chi-square and t-tests showed that there were no differences between students from urban and rural areas.

        Procedure

        We obtained written informed consent from both participants themselves and their parents before beginning all data collection. The data were collected in classrooms by well-trained psychology graduate students. Before the formal test, data collectors informed participants that participation was voluntary and that any uncomfortable questions need not be answered. Participants were also assured that their responses would be kept strictly confidential and that they would only be used for academic survey research. Adolescents received a pencil for their participation. In addition, our testing material and survey procedures were approved by the ethics in human research committee of School of Education, Guangzhou University, and School of Psychology, South China Normal University.

        Measures

        Data were collected using School Climate Questionnaire, Intentional Self-regulation Questionnaire, Loneliness Scale, POGU Questionnaire, Parent-adolescent Relationship Questionnaire, and Impulsivity Scale.

        School Climate

        Adolescents reported perceived school climate using a 25-item version of a perceived school climate questionnaire (9). This questionnaire demonstrated good reliability and validity in Chinese adolescents (9, 18, 36). It assesses three dimensions: teacher-student support, student-student support, and opportunities for autonomy. Adolescents rated how often the statements applied to them on a 5-point scale ranging from 1 = never to 5 = always. The responses were averaged across the 25 items to form a composite score, with higher scores reflecting higher levels of positive school climate. For this study, the Cronbach's alpha was 0.86, which suggests that this questionnaire had fair internal consistency.

        Intentional Self-Regulation

        Adolescents reported their intentional self-regulation using a 9-item version of the intentional self-regulation questionnaire (29, 36). This questionnaire assesses three dimensions of intentional self-regulation: selection (e.g., “When I think about what I want in life, I commit myself to one or two important goals”), optimization (e.g., “When I want to achieve something difficult, I wait for the right moment and the best opportunity”), and compensation (e.g., “When things aren't going so well, I accept help from others”). Adolescents indicated how true each item was of them on a 5-point scale ranging from 1 = not at all true to 5 = very true. Responses across the nine items were averaged, with higher scores representing higher levels of intentional self-regulation. For this study, the Cronbach's alpha was 0.91, indicating that the scale had good internal consistency.

        Loneliness

        Adolescents reported their loneliness using the UCLA loneliness scale (37). This scale contains 20 items, which assess feelings of social isolation (e.g., “could not find companionship when I wanted it”). Participants rated the extent to which each statement applied to them on a 4-point scale ranging from 1 = not at all to 4 = always. Responses across the 20 items were averaged, with higher scores representing greater loneliness. For this study, the Cronbach's alpha was 0.90, which indicated that the scale had good internal consistency.

        POGU

        POGU was measured using the Chinese version Problematic Online Game Use Questionnaire (19). The instrument has demonstrated good reliability and validity in Chinese adolescent samples (19, 38, 39). Adolescents rated how often each statement (e.g., “Have you spent more time playing online games than was planned?”) was true for them on a 3-point scale: 0 = never, 1 = sometimes, and 2 = yes. The answers were recoded into “never” = 0, “sometimes” = 0.5, and “yes” = 1. This mode of scoring is more accurate because it allows participants who “sometimes” experienced symptoms to be considered (19, 40). The grand total score of the 11 items was calculated, with higher scores representing greater severity of POGU. For this study, the Cronbach's alpha was 0.89, which indicated that the questionnaire had good internal consistency.

        Control Variables

        Given that prior studies shown that adolescents' gender, age, parent-adolescent relationship, and impulsivity were associated with POGU (4042), we include them as control variables in statistical models. Parent-adolescent relationship was assessed using the Chinese version Parent-adolescent Relationship Questionnaire (43), and impulsivity was assessed using the Urgency-Premeditation-Perseverance-Sensation seeking-Positive Urgency (UPPS-P) Scale (44). For this study, father-adolescent relationship, mother-adolescent relationship, and impulsivity all demonstrated excellent internal consistency (Cronbach's α are 0.78, 0.78, and 0.86 respectively).

        Statistical Analyses

        Descriptive statistics were conducted via use of SPSS 25.0. And Mplus 7.1 was utilized to examine mediation and moderation effects by conducting structural equation modeling analysis (45).

        Results

        Prevalence of POGU

        According to the opinions of POGU experts (4, 40), adolescents who exhibited at least 5 of the 11 criteria on the POGU questionnaire were considered to be addict gamers. In the current sample, 5.40% of the participants displayed signs of gaming addiction. This rate is consistent with national Chinese adolescent data (8) and recent literature (19).

        Preliminary Analyses

        The means, standard deviations, and correlation coefficients for all variables of the current study are displayed in Table 1. The results showed that school climate and intentional self-regulation were both negatively related to loneliness and POGU, whereas loneliness was positively related to POGU. These findings suggest that a negative school climate, low intentional self-regulation, and high loneliness all were potential risk factors for POGU, and a negative school climate and low intentional self-regulation were both potential risk factors for loneliness.

        TABLE 1
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        Table 1. Descriptive statistics and correlations for all variables.

        Testing the Moderating Effect of Intentional Self-Regulation on the Direct Link Between School Climate and Adolescent POGU

        The moderated model which was shown in Figure 2 revealed an acceptable fit to the data: χ2/df = 4.29, CFI = 0.91, RMSEA = 0.069. The results demonstrated that the main effects of school climate was significantly associated with POGU (b = −0.66, SE = 0.24, t = −2.77, p < 0.01), however, the main effects of intentional self-regulation (b = −0.24, SE = 0.15, t = −1.64, p > 0.05), and the interactive effect of school climate and intentional self-regulation (b = 0.52, SE = 0.30, t = −1.75, p > 0.05) were non-significantly associated with POGU.

        FIGURE 2
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        Figure 2. Model of the moderating role of intentional self-regulation on the direct relationship between school climate and POGU. ISR, intentional self-regulation; POGU, problematic online game use. Values are unstandardized coefficients and standard error. Paths between gender, age, father-adolescent relationship, mother-adolescent relationship, impulsivity, and each of the variables in the model are not displayed. Of those paths, the following were significant: gender (b = 1.16, SE = 0.16, t = 7.12**), and impulsivity (b = 0.78, SE = 0.23, t = 3.35**) to POGU. **p < 0.01.

        Testing for Mediation Effect of Loneliness

        The mediation model represented in Figure 3 revealed an excellent fit to the data: χ2/df = 2.39, CFI = 0.96, RMSEA = 0.033. The results are displayed in Figure 3. School climate negatively predicted loneliness (b = −0.42, SE = 0.08, t = −5.13, p < 0.01) and negatively predicted POGU (b = −0.49, SE = 0.23, t = −2.12, p < 0.05), and loneliness positively predicted POGU (b = 0.35, SE = 0.12, t = 2.86, p < 0.01). Moreover, bootstrapping analyses indicated that loneliness partially mediated the relation between school climate and adolescent POGU (indirect effect = −0.1482, SE = 0.0676, 95% CI = [−0.3100, −0.0353]).

        FIGURE 3
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        Figure 3. Model of the mediating role of loneliness between school climate and POGU. POGU, problematic online game use. Values are unstandardized coefficients and standard error. Paths between gender, age, father-adolescent relationship, mother-adolescent relationship, impulsivity, and each of the variables in the model are not displayed. Of those paths, the following were significant: impulsivity to loneliness (b = 0.44, SE = 0.08, t = 5.49**); gender (b = 1.16, SE = 0.16, t = 7.19**), and impulsivity (b = 0.74, SE = 0.23, t = 3.29**) to POGU. **p < 0.01.

        Testing for Moderated Mediation

        The moderated mediation model represented in Figure 4 revealed a good fit to the data: χ2/df = 3.16, CFI = 0.92, RMSEA = 0.043. The bias-corrected percentile bootstrap results indicated that the indirect effect of school climate on adolescent POGU through loneliness was moderated by intentional self-regulation. Specifically, intentional self-regulation moderated the association between school climate and loneliness (b = 0.28, SE = 0.11, t = 2.64, p < 0.01). We conducted a simple slopes test, and as depicted in Figure 5, the negative link between school climate and loneliness was much stronger for adolescents with lower intentional self-regulation (1SD below the mean; b = −0.57, SE = 0.12, t = −4.85, p < 0.01) than for adolescents with higher intentional self-regulation (1SD above the mean; b = −0.23, SE = 0.09, t = −2.40, p < 0.05). Moreover, school climate was negatively associated with loneliness (b = −0.40, SE = 0.08, t = −4.73, p < 0.01) and POGU (b = −0.53, SE = 0.24, t = −2.21, p < 0.05). However, the interaction between intentional self-regulation and loneliness in predicting adolescent POGU was no significant (b = −0.03, SE = 0.18, t = −0.15, p > 0.05).

        FIGURE 4
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        Figure 4. Model of the moderating role of intentional self-regulation on the indirect relationship between school climate and POGU. ISR, intentional self-regulation; POGU, problematic online game use. Values are unstandardized coefficients and standard error. Paths between gender, age, father-adolescent relationship, mother-adolescent relationship, impulsivity, and each of the variables in the model are not displayed. Of those paths, the following were significant: impulsivity to loneliness (b = 0.33, SE = 0.08, t = 3.91**); gender (b = 1.16, SE = 0.16, t = 7.15**), and impulsivity (b = 0.69, SE = 0.24, t = 2.89**) to POGU. *p < 0.05, **p < 0.01.

        FIGURE 5
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        Figure 5. Loneliness among adolescents as a function of school climate and intentional self-regulation. ISR, intentional self-regulation.

        Moreover, the indirect link between school climate and POGU via loneliness were significant for adolescents with lower intentional self-regulation (indirect effect = −0.17, SE = 0.07, 95% CI [−0.32, −0.02]) and for those with higher intentional self-regulation (indirect effect = −0.07, SE = 0.04, 95% CI = [−0.13, −0.01]). Adolescents with lower intentional self-regulation were more likely to develop loneliness, which in turn contributed to higher levels of POGU.

        Discussion

        The first goal of this study was to explore the mediating effect of loneliness on the relationship between school climate and adolescent POGU. Consistent with our hypothesis 1, this study found that loneliness significantly mediated the effect of school climate on adolescent POGU. Previous research has demonstrated that the school climate is associated with loneliness (2325) and that the latter is associated with increased risk of POGU (5, 6, 26). We integrated these two links in the current study with a mediation modeling approach. The findings of this study suggest that loneliness is an essential underlying psychosocial process that helps explain why a favorable school climate is linked with less POGU and why a negative school climate is linked with more POGU. When adolescents have positive experiences, perceive more support from their teachers and peers, and report more autonomy, they are less likely to feel lonely, which in turn is associated with less POGU.

        This finding is in line with the self-system processes model (21). It is also congruent with previous research showing that the protective effects of social context on adolescent developmental outcomes (i.e., school climate, social support, family climate) are mediated by psychological processes including loneliness (24, 46, 47). According to self-determination theory (48), contextual factors (i.e., school climate) influence adolescent behaviors (i.e., POGU) through the mediating effects of internal psychology. More concretely, when a school climate cannot satisfy an adolescent's need for autonomy and relatedness, he or she feels lonely and thus seeks an environment through which he/she can meet his/her psychological needs and reduce feelings of loneliness. Online games offer a setting in which people can express themselves in ways that they may not feel comfortable doing in real life, and it can also be a good place for people to make new friends and socialize. Survey research has indicated that players may gain a sense of belonging from an online game and that social communication and relationships are important motivators for engagement in online games (49). In contrast, when a school climate promotes positive emotional student-teacher and student-student bonds, students may not feel lonely at school. Thus, students tend to make efforts to control their behavior so that their actions will be in accordance with social expectations and are therefore less likely to become addicted to online games. Therefore, a positive school climate may be effective in treating loneliness, which may be a promising approach for adolescent POGU prevention and cessation.

        The second goal of this study was to explore the moderating effect of intentional self-regulation on the indirect association between school climate and POGU via loneliness. Consistent with the risk-buffering hypothesis and with our own hypothesis, this study found that intentional self-regulation weakened the link between school climate, loneliness, and POGU through the direct relationship between school climate and loneliness. Specifically, the negative association between school climate and loneliness was stronger among adolescents with low intentional self-regulation, which in turn increased their POGU. This is because adolescents with higher intentional self-regulation tend to have more resources and greater capacity to select appropriate goals, apply and refine relevant means of achieving positive outcomes, and avoid losses (32). This pattern of moderator effects has also been found in the association between environmental factors (i.e., school climate, family environment) and externalizing behaviors. For example, Lin et al. (50) reported that the negative link between school climate and adolescent smoking behavior via deviant peer affiliation was substantially stronger among adolescents with lower intentional self-regulation than among those with higher intentional self-regulation. Similarly, Yuan (51) found that among adolescents with low intentional self-regulation, parental corporal punishment could have increased their deviant peer affiliation, which in turn increased POGU. In contrast, among adolescents with high intentional self-regulation, the relation was not significant. Although these studies have found that intentional self-regulation diminishes the indirect link between environmental factors and adolescent development, they used externalizing behaviors such as deviant peer affiliation as mediating variables rather than loneliness (50, 51). Therefore, this research extended the range of the moderating effect of intentional self-regulation to internalizing behaviors by loneliness.

        This study also examined whether the relationship between loneliness and adolescent POGU was moderated by intentional self-regulation. The findings showed that this moderating effect was non-significant. These findings suggest that intentional self-regulation can help to promote a positive school climate and reduce adolescent loneliness, which in turn can reduce the risk of POGU. However, intentional self-regulation cannot eliminate the risk of adolescent POGU merely due to its effects on loneliness. Even so, this study contributes to the literature by enhancing our understanding of adolescent POGU etiology and suggesting the potential success of improving intentional self-regulation as a personal capability in POGU intervention programs.

        Practical Implications

        The findings of this study have important theoretical and practical implications. Our findings suggest that loneliness is an important mediator in the relation between perceived school climate and POGU. Thus, teachers and parents may prevent adolescent POGU and intervene in this behavior by reducing adolescents' loneliness. Moreover, our findings suggest that the negative link between school climate and adolescent POGU through loneliness is stronger for adolescents with poor intentional self-regulation than for those with high intentional self-regulation. Therefore, it is important to foster more positive perceptions of school climate among adolescents, especially among those with poor intentional self-regulation.

        Limitations

        Several limitations should be noted regarding this study. First, the data were collected using self-report measures; thus, common method biases may have existed. Second, this study only adjusted for the covariates of adolescents' gender, age, parent-adolescent relationship, and impulsivity. Future research should consider other relevant control variables, such as family function and peer context. Third, as the generalization of our results from this small sample of Chinese adolescents was difficult, future research should attempt to recruit larger samples from wider cultural and/or geographical settings for the purpose of clarifying the relationships between the variables in this study.

        Ethics Statement

        Testing material and survey procedures were approved by the ethics in human research committee of School of Education, Guangzhou University, and School of Psychology, South China Normal University.

        Author Contributions

        CY, WL, XL, and WZ designed the work. CY, QL, HL, and WZ collected the data. CY, QL, HL, WL, XL, and WZ analyzed the data results and drafted the manuscript. CY, QL, WZ, HL, KD, XX, XG, WL, and XL revised the manuscript.

        Funding

        This study was supported by Guangzhou University's 2017 Training Program for Young Top-notch Personnels (BJ201725), the National Natural Science Foundation of China (31600901 and 31800938), the 13th Five-Year Plan for the Development of Philosophy and Social Sciences of Guangzhou (2016GZGJ93; 2017GZQN40), the Youth Project of Social Sciences for the Universities Belonged to Guangzhou City (1201630586), the General Project of The Ministry of Education of Humanities and Social Science (18YJA190012), the Natural Science Foundation of Guangdong Province (2018A030313406), the Superiority and Characteristic Subject Group Subsidy Project of Modern Education and Jingchu Culture Research of Yangtze University (2018YSH07).

        Conflict of Interest Statement

        The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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    • Editorial: Global Education of Health Management
      • Editorial: Global Education of Health Management

        • 1 Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC, United States
        • 2 Department of Health Services Administration and Policy, College of Public Health, Temple University, Philadelphia, PA, United States

        Editorial on the Research Topic
        Global Education of Health Management

        The purpose of this special issue is to provide insights about how healthcare executives and managers are educated around the world. As globalization becomes the standard for all industries, healthcare executives must be able to manage effectively with populations, financial arrangements, and technologies that cross geographic boundaries. Education of upcoming students and continuing education of working executives must be broad and encompass a global perspective. Students are increasingly eager to study abroad; our educational programs must include opportunities for students to study in other countries and to have the information in advance that is necessary to make the experience meaningful.

        Throughout the world, health systems are grappling with the need to deliver high value healthcare and high quality services despite rapidly increasing costs. The need for effective management to achieve these ends is well-documented. However, healthcare management education is nascent or non-existent in many countries, especially low and middle-income countries that could benefit most from educating healthcare managers in the art and science of management and leadership. This special issue strives to provide insights that might guide universities in developing healthcare management programs in their respective countries.

        Hahn and Lapetra present an overview of the Global Competency Directory framework that has five main spheres in which healthcare executives should be competent. This framework was developed by the International Hospital Federation's Global Consortium for Healthcare Management (1). Members included associations representing practice, such as the American College of Healthcare Executives. Hahn and Lapetra offer examples of how the framework can be used in various countries, recognizing diversity among nations while creating a basis for shared content and techniques.

        West et al. discuss the role of accrediting organizations in promoting competency-based standards for education. Accrediting bodies such as the Association for the Advancement of Collegiate Schools of Business, the Council on Education for Public Health, and the Commission on Accreditation of Healthcare Management Education are engaged in globalizing accreditation standards. Striving to meet the accrediting standards is an effective strategy in developing healthcare management educational programs.

        Glandon reports on how an association that represents graduate and undergraduate healthcare management training programs can promote sharing across disciplines, geographies, and careers. Regional and local healthcare management associations such as the Association of University Programs in Health Administration (AUPHA), the European Health Management Association (EHMA), and SHAPE (representing Australia and New Zealand) provide forums for universities and faculty to learn from others in developing curricula to provide effective healthcare management education.

        Drilling down from the role of overarching organizations, two articles explain how healthcare management education has evolved within a single country. Tiwari et al. discuss the evolution of healthcare management education in India. Establishing healthcare management education has been a daunting task in a country so large and diverse. Kalang and Thakur describe the current array of educational institutions and programs educating future healthcare executives and speak to the importance of creating curricula that reflect the evolution of the healthcare system. Both articles challenge the match between the health workforce needs of the nation and the workforce that university programs are producing and articulate considerations for adaptions in healthcare management education.

        One of the effective approaches to maximize educational resources across countries is to develop university-to-university partnerships. Two articles provide insights into the details of such partnerships and the benefits provided to each of the partners. Leggat et al. describe a long-standing partnership between universities in China and Australia to train healthcare executives. They emphasize similarities in education despite major differences in the healthcare systems of the two countries.

        Different types of schools such as public health, public administration and health/medical schools as well as business schools, can provide healthcare management education. Sammut and Ngoye discuss a collaborative educational program between the University of Pennsylvania Wharton School in the USA and the Strathmore University School of Business in Kenya. The focus of the partnership has been on the establishment of healthcare management as a concentration in the Master of Business Administration program at Strathmore.

        Counte et al. advocate for health management education to change as health systems evolve. Specifically, they analyze the trends in healthcare financing. Many countries are exploring value-based payment systems designed to increase quality, reduce costs, and improve population health. The authors describe the implications for curriculum revision that recognize the pervasive impact of these new financing mechanisms.

        The majority of articles describe healthcare management programs aimed at graduate students. However, healthcare executive education can start with undergraduate programs and must continue as a life-long commitment. Parviainen et al. report on a national mandate to train mid-career clinicians for management and leadership positions in Finland. Two universities describe their different approaches to fulfilling the mandate. Education of healthcare executives is not only for early careerists, but reaches seasoned managers who seek additional knowledge and clinicians who are tapped to assume management roles. Content, skills, and teaching techniques must be adapted for the experienced student who is being groomed for senior leadership positions.

        Sikipa et al. champion the education not only of healthcare executives but of governing board members. Among the advantages they delineate of having a well-trained governing body are better evaluations of the performance of healthcare executives and more astute fiscal responsibility. The content useful to train governing board leaders is also relevant to those doing direct management, varying more in degree of detail than essential topics.

        Collectively, these articles show the breadth and diversity of healthcare management education. The challenge to the field is to celebrate the breadth but bring cohesion to content that appropriately spans healthcare systems, cultures, health needs, educational systems, and geographies. Understanding the basic landscape of healthcare management education is a place to start international discussion about how to manage ourselves to achieve consistency of high quality, timely education. Worldwide public health depends on the availability of high quality, accessible, affordable, innovative health services, including primary care, hospitals, and health systems. Effective healthcare management education will improve the likelihood of delivering services designed to provide high quality services, reduce costs, and improve the population's health.

        Author Contributions

        Both authors conceived the content of the editorial together. CE wrote the first draft. WA edited and added to the draft. Both agreed on the final version.

        Conflict of Interest Statement

        The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

        References

        1. International Hospital Federation. Leadership Competencies for Healthcare Services Managers. International Hospital Federation (IHF) (2015). Available online at: https:https://www.ihf-fih.org/download_doc_file.php?doc=dfff684f5fd4854ad43566085950b8a8

        Keywords: education of healthcare executives, health management education, health administration education, health management & policy, global health systems

        Citation: Evashwick CJ and Aaronson WE (2019) Editorial: Global Education of Health Management. Front. Public Health 7:103. doi: 10.3389/fpubh.2019.00103

        Received: 28 March 2019; Accepted: 10 April 2019;
        Published: 30 April 2019.

        Edited and reviewed by: Marcia G. Ory, School of Public Health, Texas A&M University, United States

        Copyright © 2019 Evashwick and Aaronson. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

        *Correspondence: Connie J. Evashwick, evashwick@gmail.com

        2019-04-30T00:00:00Z
         
    • Trend and Correlates of Leadership Competencies Among Female Health
             Professionals in Albania
      • Trend and Correlates of Leadership Competencies Among Female Health Professionals in Albania

        Klevis Caushaj1,2, Katarzyna Czabanowska 1,3 *, Enver Roshi4, Herion Muja4 and Genc Burazeri 1,4
        • 1 Department of International Health, School CAPHRI (Care and Public Health Research Institute), Maastricht University, Maastricht, Netherlands
        • 2 Operational Department, American Hospital, Tirana, Albania
        • 3 Faculty of Health Sciences, Institute of Public Health, Jagiellonian University, Krakow, Poland
        • 4 Department of Public Health, Faculty of Medicine, University of Medicine, Tirana, Albania

        Aim: Our aim was to assess the trends and correlates of the leadership competency level of female health professionals in Albania, a transitional country in the Western Balkans, based on a standardized international instrument.

        Methods: Two nationwide cross-sectional studies were conducted in Albania in 2014 (first wave; n = 105 women) and subsequently in 2018 (second wave; n = 121 women). A structured questionnaire was administered to all female participants aiming at self-assessing the current level of leadership competencies and the required (desirable) level of leadership competencies for their current job position. The questionnaire consisted of 52 items pertinent to eight domains. Answers for each item of the instrument ranged from 1 (“minimal competency level”) to 5 (“maximal competency level”). Overall summary scores (range: 52–260) were calculated for both the current and the required leadership competency levels in both survey rounds, based on which the gap in leadership competency level was also computed (required minus current competency level). Binary logistic regression was used to assess the correlates of the gap in leadership competency level among study participants.

        Results: In multivariable-adjusted logistic regression models, there was evidence of a positive association between the gap in leadership competency level and: workplace in urban areas (OR = 3.2, 95%CI = 1.6–6.6); work experience (OR[for 1 year increment] = 1.1, 95%CI = 1.0–1.2); first round of the survey conducted in 2014 (OR = 2.1, 95%CI = 1.0–4.3); and, particularly, a high managerial job position/level (OR = 3.8, 95%CI = 1.6–9.3). Conversely, there was an inverse relationship with the age of women (OR[for 1 year increment] = 0.9, 95%CI = 0.8–1.0).

        Conclusion: Our study provides useful evidence about trends over time and selected correlates of the gap in leadership competencies among female health professionals in Albania. Policymakers and decision-makers in Albania and other countries should be aware of the unmet need for leadership training of female health professionals at all levels.

        Introduction

        Several competency frameworks have been already established aiming at addressing public health leadership and medical leadership competencies in different countries (14). A more recent framework was established by Czabanowska et al. (5), in the context of the Leaders for European Public Health (LEPHIE) Erasmus Multilateral Curriculum Development Project, supported by the European Union Lifelong Learning Programme (5). This framework is recommended for use in all countries of the European Region. In particular, the goal of this newly introduced instrument is to promote a competency-based European public health leadership curriculum and ultimately strengthen the leadership knowledge, abilities, skills, and competencies among public health professionals operating at all levels and in different European countries (5).

        Albania constitutes a transitional country in the Western Balkans, which has been characterized in the past few decades by rapid political and socioeconomic changes which have been linked to negative health outcomes (6, 7). Of note, there has been a significant change in the epidemiological profile of the Albanian population in the past 30 years with a remarkable transition toward non-communicable diseases (NCDs) (8). As a matter of fact, there is a huge increase in the total burden of NCDs in Albania including cardiovascular diseases, cancer, lung and liver diseases, and diabetes (8). However, the current health workforce is not capable of managing properly this multi-factorial and complex burden of disease in Albania (9). Therefore, based on the rapid epidemiologic transition, there is an urgent need to improve and strengthen workforce abilities and competencies including also leadership capacities in order to address the current health challenges of the Albanian population and meet the objectives of the health care reform.

        Importantly, the Albanian health system suffers from a severe shortage of health professional including also the public health workforce. The health personnel per capita ratio has been reported at about 1.2/1,000 for doctors and 3.6/1,000 for midwives/nurses (9). More importantly, human resources in health care services are characterized by an unequal distribution (10). Hence, medical specialists are mainly concentrated in Tirana and in the other large cities of Albania, whereas small districts and especially the remote areas of the country experience a severe shortage of health care personnel and public health professionals. Nonetheless, a main achievement is the establishment of the continuing education system (CES) for health professionals in Albania including physicians, dentists, and pharmacists. The successful completion of the first CES round provided an opportunity to improve this experience and expand the ongoing education also among nurses and midwives (9). Yet, further efforts are envisaged to standardize their professional level, motivation, and distribution according to the skills and competencies in the workplace.

        However, demographic trends and epidemiological profile of the Albanian population require a workforce of health professionals and especially public health practitioners with new knowledge, abilities, skills, and competencies. Besides filling in the gaps in health-care professionals and public health specialists created over the years, an effective human resources strategy should ensure the restoration of authority and dignity of health workers and public health professionals in Albania (9). In particular, efforts should be made for ensuring a proper distribution of the health workforce and public health specialists in all regions of Albania (9) and improving their training and qualification, including also leadership competencies.

        In this framework, the aim of our study was to assess the trends and correlates of the leadership competency level of female health professionals in Albania, a post-communist country in South Eastern Europe, based on a standardized international instrument. We hypothesized a bigger self-perceived gap in leadership competency level among women working in urban areas and/or those promoted in high managerial positions given the higher pressure and demands for high-quality services.

        Materials and Methods

        The current analysis was based on two survey rounds conducted in 2014 (first wave/round) and subsequently in 2018 (second wave/round).

        Both rounds of the survey consisted of cross-sectional studies applying the same methodology for sampling of health professionals and employed the same instrument for data collection (5), which had been already validated in Albania in May 2014 (11), before conducting the first round/wave of the survey.

        The survey conducted in July-December 2014 targeted a nationwide representative sample of 120 female health professionals working at different health institutions all over Albania [primary health care services (n = 40), regional hospitals (n = 40), University Hospital Center “Mother Teresa” (n = 10), Institute of Public Health (n = 10), Regional Directorates of Public Health (n = 10), and Health Insurance Fund (n = 10)]. The sampling frame was made available from each institution. Based on the sampling frame, a random sample of health professionals was drawn from each institution. Of 120 targeted individuals, 105 female health professionals participated in the study (response rate: 88%). Details about the first survey round have been also described elsewhere (12).

        Conversely, the second round of the survey conducted in June-November 2018 targeted a similarly nationwide representative sample of 150 female health professionals working at the same health institutions at both central and local level in Albania [primary health care services (n = 50), regional hospitals (n = 50), University Hospital Center “Mother Teresa” (n = 10), Institute of Public Health (n = 15), Regional Directorates of Public Health (n = 15) and Health Insurance Fund (n = 10)]. Of 150 targeted female health professionals, 29 individuals did not participate (11 women were willing but did not manage to answer, whereas further 18 women refused to participate). Therefore, the study sample in 2018 consisted of 121 female health professionals, with an overall response rate of: 121/150 = 81%.

        In both survey rounds, a structured self-administered questionnaire was applied aiming at self-assessing the current level of leadership competencies and the required (desirable) level of leadership competencies for the actual job position of female health professionals.

        The questionnaire comprised 52 items categorized into the following eight competency domains (subscales) (5), each of which matching one educational session within public health leadership curriculum (5, 13): (i) systems thinking; (ii) political leadership; (iii) collaborative leadership: building and leading interdisciplinary teams; (iv) leadership and communication; (v) leading change; (vi) emotional intelligence and leadership in team-based organizations; (vii) leadership, organizational learning, and development, and; (viii) ethics and professionalism.

        Domains (subscales) of the framework were a result of a systematic review process constituting an important attempt to define, profile, and position public health leadership through an analytically developed, comprehensive and multidisciplinary competency framework (5). As convincingly argued elsewhere (5), domains of this framework promote a collaborative and shared leadership and embrace specific public health leadership attributes such as the ability to identify and engage stakeholders in interdisciplinary projects to improve public health; to ensure that organizational practices are aligned with changes in the public health system and the larger social, political, and economic environment and ability to build alliances, partnerships and coalitions to improve the health of the populations (5).

        Answers for each item of each subscale of the instrument ranged from 1 (“minimal competency level”) to 5 (“maximal competency level”).

        An overall summary score (range: 52–260) and a subscale summary score for each domain were calculated for both, the current level of competencies and the required level of competencies, in each of the two rounds of the survey.

        Furthermore, the gap between the required (desirable) and the current level of leadership competencies was calculated for each participant, as a difference between the summary score of the required (desirable) level and the current level of leadership competencies. In the analysis, the competency gap was dichotomized into: “competency gap” (all positive summary score differences between the required and the current level of leadership competency levels) vs. “no competency gap” (including zero and/or negative scores).

        In addition to the leadership competency tool, the (structured) questionnaire inquired about demographic information (age of female health professionals), place of work (urban areas vs. rural areas), type of diploma, and main degree obtained (which in the analysis was dichotomized into: health sciences [including medicine, public health, nursing, pharmacy, and dentistry] vs. other diploma/degree [including law, economics, social sciences, engineering, or other diplomas/degrees]), years of working experience, training in leadership skills (dichotomized into: yes vs. no), as well as the current job position (which is the analysis was categorized into: high, middle and low managerial position/level).

        In both survey rounds, the internal consistency for the current and the required level of leadership competencies was assessed by use of Cronbach's alpha (14). Conversely, Fisher's exact test (for categorical variables) and Mann-Whitney's test (for numerical variables) were used to compare the distribution of baseline characteristics between female health professionals involved in the two survey rounds. Also, Mann-Whitney test was used to compare the overall scores and the subscale scores of the current and the required level of leadership competencies between females participating in the two waves of the survey. General linear model was used to calculate the crude (unadjusted) mean values and their respective 95% confidence intervals (95%CIs) and p-values for the gap in leadership competencies level (calculated as follows: summary score of the required level minus summary score of the current level) between women included in the two survey rounds (2014 vs. 2018). On the other hand, binary logistic regression was employed to assess the correlates of the gap in leadership competency level (dichotomized into: “competency gap” vs. “no competency gap”) among female participants. Crude (unadjusted) odds ratios (ORs: competency gap vs. no gap) and their respective 95%CIs and p-values were calculated. Subsequently, multivariable-adjusted ORs, 95%CIs and p-values were calculated in logistic regression models controlling simultaneously for all covariates [age of participants (numerical variable), years of working experience (numeric), place of work (urban vs. rural areas), job position (low, middle and high position/level), main degree (health sciences vs. other degrees), training in leadership skills (yes vs. no), and round/wave of the survey (2014 vs. 2018)]. All the logistic regression models met the goodness-of-fit criterion as appraised by the Hosmer and Lemeshow test (15).

        For all statistical tests performed, a p ≤ 0.05 was considered as statistically significant. All statistical analyses were performed by use of the Statistical Package for Social Sciences (SPSS, version 19.0).

        Results

        Mean age of female health professionals included in the first round (conducted in 2014) was higher than in the second round of the survey (in 2018): 44.4 ± 9.9 years vs. 40.8 ± 8.9 years; P < 0.01 (Table 1). About 28% of participants in 2018 were working in rural areas compared with only 14% in 2014 (P = 0.02). About 78% of the women in 2018 had their main degree in health sciences compared with 87% in the first round, a difference which was only borderline statistically significant (P = 0.09). In 2018, mean working experience was 13.2 ± 9.8 years, whereas in 2014 it was 19.0 ± 9.6 years, a difference which was highly statistically significant (P < 0.01). On the other hand, 33% of female health professionals included in the 2018 round had a high managerial job position compared with only 21% of their counterparts involved in the first round conducted in 2014, notwithstanding the lack of statistical significance of this finding (Table 1).

        TABLE 1
        www.frontiersin.org

        Table 1. Baseline characteristics in two nationwide representative samples of female health professionals in Albania, in 2014 and 2018.

        For the year 2014, the internal consistency of the overall scale of the leadership competency instrument (52 items) was Cronbach's alpha = 0.88 for the current competency level and Cronbach's alpha = 0.96 for the required competency level; for the year 2018, these values were alpha = 0.81 and alpha = 0.95, respectively (data not shown in the tables).

        Mean value of the summary score (52 items) for the current level of leadership competencies was significantly lower in 2018 than in 2014 (138 ± 10 vs. 143 ± 12, respectively; P < 0.01) [Table 2–upper panel]. In particular, “political leadership” and next the “collaborative leadership” subscales' scores were significantly lower in the second round (in 2018) compared to the first round (in 2014) of the survey. As for the required (desirable) level of leadership competencies, there was evidence of a bigger difference between the two survey rounds: the overall score was 141 ± 22 in 2018 as opposed to 154 ± 26 in 2014 (P < 0.01). There were significant differences for all subscale summary scores for the required level of leadership competencies between the two survey rounds (all P < 0.02) [Table 2–lower panel].

        TABLE 2
        www.frontiersin.org

        Table 2. Summary score of each domain (subscale) of the “leadership competency instrument” for the current and the required level of competencies in two nationwide representative samples of female health professionals in Albania in 2014 and 2018.

        There was evidence of a bigger gap in the leadership competency level in 2014 (mean value: 10.9; 95%CI = 8.0–13.9) compared with the year 2018 (mean: 2.9, 95%CI = 0.2–5.7) [Table 3]. The gap was the biggest for the “emotional intelligence and leadership in team-based organizations” domain (mean values: 0.2 in the year 2014 vs. −1.4 in the year 2018), followed by the “leadership and communication” subscale (2.7 vs. only 1.3, respectively) and next the “leadership, organizational learning, and development” domain (2.3 vs. 1.2, respectively).

        TABLE 3
        www.frontiersin.org

        Table 3. Gap in leadership competencies (difference in the summary scores between the required and the current level of competencies) among female health professionals in Albania (2014 vs. 2018).

        In crude (unadjusted) logistic regression models (Table 4), significant positive correlates of the gap in leadership competencies among Albanian female health professionals included age, work experience, employment in urban areas, middle, and especially high managerial job position/level and the first survey round (conducted in 2014). In multivariable-adjusted logistic regression models, there was evidence of a positive association between the gap in leadership competency level and: workplace in urban areas (OR = 3.2, 95%CI = 1.6–6.6); work experience (OR[for 1 year increment] = 1.1, 95%CI = 1.0–1.2); first round of the survey conducted in 2014 (OR = 2.1, 95%CI = 1.0–4.3); and a high managerial job position/level (OR = 3.8, 95%CI = 1.6–9.3). On the other hand, upon simultaneous adjustment for all covariates, there was evidence of an inverse relationship with the age of female health professionals (OR[for 1 year increment] = 0.9, 95%CI = 0.8–1.0) (Table 4).

        TABLE 4
        www.frontiersin.org

        Table 4. Correlates of the gap in leadership competencies among female health professionals in Albania.

        Discussion

        Main findings of this study conducted in a rapidly evolving society with tremendous public health challenges include a significant decrease in the leadership competency gap of female health professionals during the past 4 years (i.e., between the first survey round conducted in 2014 and the second round conducted in 2018). Furthermore, irrespective of the survey round/wave, independent positive correlates of the gap in leadership competency levels among female health professionals included their work experience, workplace in urban areas and, particularly, a high managerial job position.

        In both survey rounds, there was evidence of a higher self-perceived level of the required leadership competencies than the current (actual) level of leadership competencies among female health professionals. Yet, the overall gap was considerably higher in the first round compared with the second round of the survey. Furthermore, in the first round of the study, all the eight subscale (domain) scores were significantly higher for the required competency level compared with the actual/current competency level, a finding which was not evident in the second round, where there was noted a negative score in the competency gap for the “leading change” and especially the “emotional intelligence and leadership in team-based organizations” subscales, indicating a “surplus” in the level of competencies for these two domains in the current job position of female health professionals in the year 2018.

        Interestingly, regardless of the survey round, there was evidence of a positive relationship between the leadership competency gap and years of work experience of the Albanian female public health professionals. This may be explained by the fact that more experienced women are promoted to higher positions/levels which nevertheless require additional leadership skills and competencies. On the other hand, upon adjustment for work experience, there was evidence of an inverse association with age of participants indicating that older women perceived a lower gap in the leadership competencies compared with their younger counterparts, a finding which is seemingly intuitive. In addition, regardless of the job position/level, female professionals working in urban areas reported a significantly higher gap in leadership competencies, a finding which is expected given the higher pressure and demands for high-quality services in urban areas, especially in big cities. Surprisingly though, there was no significant association with previous leadership training courses, which points to the need for well-designed and carefully tailored training programs in the near future.

        Czabanowska et al. have convincingly argued that a starting point in this process is to identify the competency capacities of future leaders in relation to population health and well-being and apply the study results to inform education, training, and culture change throughout the workforce (13). From this perspective and based on this valuable guiding principle, we considered that the description of the competencies supports the curriculum design and it can be used as a self-assessment instrument for students and public health professionals at all levels, helping, and supporting them to reflect and identify gaps in their knowledge, skills, abilities, and competencies (5, 12). It has been already pointed out that teaching of leadership is still uncommon in public health training programmes in most countries worldwide, particularly in those countries undergoing intensive public health reforms (16). Therefore, there is clearly an urgent need for a considerable investment in leadership training for public health professionals (17).

        Regarding gender differences in general, the United Nations (UN) have included gender equality and women empowerment as Goal No. 5 in its list of Sustainable Development Goals (SGDs) for the 2030 Agenda (18). In turn, the European Union (EU) Progress Report of 2012 (19) has revealed several existing barriers regarding women leadership including different work conditions, unequal employment opportunities, lack of adequate networking, and unequal access to opportunities in general. While there is no reliable recent information about Albania, the evidence from other former communist countries indicates that women's participation in decision-making is very low, as illustrated in a fairly recent report from Ukraine (20). Furthermore, a pretty recent article indicates women in most countries as remarkably underrepresented in top leading positions an issue which, according to the authors of the report, may constitute a critical limitation toward organizational, societal and cultural progress regarding inclusion and balanced decision-making (21).

        The current analysis may have several limitations including the study design, sampling strategy, and the information obtained. Regarding the possibility of selection bias, in both rounds of the study, a nationwide representative sample of public health professionals was included, which is reassuring. The response rate was very high in the first round of the survey conducted in 2014 (88%), but a bit lower in the second wave conducted in 2018 (81%), which may raise some concerns. As for the instruments of data collection, we employed an internationally standardized instrument (5), which had been previously validated in Albania (11). Also, in both rounds of the survey, the instrument used for the measurement of leadership competencies indicated very good internal consistency for both the required (desirable) and the actual/current leadership competency levels. On the face of it, there is no reason to assume differential reporting in the actual and/or required levels of leadership competencies among female professionals involved in the two rounds of the survey (2014 vs. 2018). Yet, the possibility of information bias cannot be completely excluded in such types of surveys. More importantly, findings pertinent to cross-sectional studies are not assumed to be causal and, therefore, should be carefully interpreted.

        In conclusion, regardless of potential limitations, this analysis provides interesting and important evidence about the trends and selected correlates of the leadership competency level of female health professionals in Albania. It should be noted that the curriculum of undergraduate and/or postgraduate public health programs, as well as continuous professional education programs does not adequately foster leadership skills and competencies for future public health professionals and health workers in Albania (9, 12). Hence, findings from the current analysis should support policymakers and decision-makers in Albania for adapting, regulating and adjusting the public health curricula in accordance with the identified gaps and needs for further training, especially in the area of public health leadership. At a broader level, findings of this analysis should be confirmed and expanded in bigger representative samples of health professionals and public health specialists in different countries of the European region, with the ultimate goal of reinforcing the leadership skills and competencies among public health professionals at all levels of practice.

        Ethics Statement

        This study was carried out in accordance with the recommendations of the University of Medicine, Tirana. The protocol was approved by the Department of Public Health, Faculty of Medicine, University of Medicine, Tirana, Albania.

        Author Contributions

        KC, KaC, and GB contributed to the study conceptualization and design, analysis and interpretation of the data, and writing of the article. ER and HM commented comprehensively on the manuscript. All authors have read and approved the submitted manuscript.

        Conflict of Interest Statement

        The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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        Keywords: Albania, competency level, competency gap, female health professionals, leadership competency, public health leadership, Western Balkans, women

        Citation: Caushaj K, Czabanowska K, Roshi E, Muja H and Burazeri G (2019) Trend and Correlates of Leadership Competencies Among Female Health Professionals in Albania. Front. Public Health 7:109. doi: 10.3389/fpubh.2019.00109

        Received: 04 February 2019; Accepted: 12 April 2019;
        Published: 30 April 2019.

        Edited by:

        Vesna Bjegovic-Mikanovic, University of Belgrade, Serbia

        Reviewed by:

        Emmanuel D. Jadhav, Ferris State University, United States
        Woohyun Yoo, Incheon National University, South Korea

        Copyright © 2019 Caushaj, Czabanowska, Roshi, Muja and Burazeri. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

        *Correspondence: Katarzyna Czabanowska, kasia.czabanowska@maastrichtuniversity.nl

        2019-04-30T00:00:00Z
         
    • Integrative Learning in US Undergraduate Public Health Education: A Review
             of Student Perceptions of Effective High-Impact Educational Practices at
             Georgia State University
      • Integrative Learning in US Undergraduate Public Health Education: A Review of Student Perceptions of Effective High-Impact Educational Practices at Georgia State University

        Elizabeth Armstrong-Mensah 1 *, Kim Ramsey-White 1 and Ernest Alema-Mensah2
        • 1 Department of Health Policy and Behavioral Science, Georgia State University, Atlanta, GA, United States
        • 2 Morehouse School of Medicine, Atlanta, GA, United States

        In 2003, the United States (US) Institute of Medicine of the National Academies recommended that all undergraduate students have access to an education in public health to assist with diversifying the public health workforce and ensuring an educated citizenry on public health issues. In line with this recommendation, and that of the Consensus Conference on Undergraduate Public Health Education, Georgia State University established a Bachelor of Science in Public Health (BSPH) program in 2016, with the mission of advancing health through leadership, scholarship, research, and service, to better the human condition and to promote the common good, especially for urban communities in the US and for global populations. Using integrative approaches that encourage student empowerment, self-development, integrative thinking, and reflective learning, the Georgia State University BSPH program currently offers a range of generalist introductory public health courses to over 400 students. This review seeks to examine student perceptions of integrative practices utilized by Georgia State University faculty in the BSPH program and to investigate the extent to which student perceive these integrative educational practices as preparing them to use insights gained in the classroom and from the field, to question, modify, connect, and integrate material learned in the academic setting, to real-life public health challenges. It also seeks to identify which of the integrative educational practices have the highest impact of helping students integrate the knowledge and skills gained to public health issues.

        Introduction

        Georgia State University is an urban public research institution located in Atlanta, Georgia. Established in 1913, the university has seven campuses throughout metro Atlanta with over 51,000 students of diverse backgrounds, enrolled in over 250 degree programs in 100 fields of study, including public health (1). In June 2016, The Council on Education for Public Health (CEPH) Board of Councilors accredited the School of Public Health (SPH) at Georgia State University. Georgia State University's SPH began as a Master of Public Health (MPH) program, accredited by CEPH since 2007—making it the first public university in Atlanta to gain that distinction (1). In 2016, a Bachelor's of Science in Public Health (BSPH) program was created within the SPH, with an emphasis on urban and global public health. The new BSPH program leverages the existing interdisciplinary make-up of Georgia State University's School of Public Health. The BSPH program seeks to prepare students for course work across public health disciplines, and to equip graduates with cross-professional competencies for public health jobs with urban, and global public health organizations. The SPH does this by utilizing integrative learning approaches that encourage student empowerment and self-development, and by equipping students with the requisite knowledge and skills to be integrative thinkers, critical and analytical problem solvers, and reflective learners. The establishment of the BSPH program supports Goal 3 of the Georgia State University Strategic Plan, as well as the recommendation of the Institute of Medicine (IOM) that, “all undergraduates should have access to education in public health” (2). The establishment of the BSPH program is also consistent with the IOM's call for expansion of undergraduate public health education to address two priority needs; (1) a serious disparity between the number of graduates produced by schools of public health and the number of workers needed (i.e., a workforce shortage), and (2) the need for a large, well-educated public health workforce that is able to respond effectively to emerging trends that impact population health, such as globalization, urbanization, population aging, health disparities, and alterations to the US health care system (3).

        This review seeks to examine student perceptions of the high-impact educational practices (HIPs) utilized by Georgia State University faculty in the BSPH program, and the extent to which students see these HIPs as preparing them to use insights gained in the classroom and from the field, to question, modify, connect, and integrate academic material to real-life public health challenges. It also seeks to examine HIPs that have the greatest impact.

        HIPs and Student Learning

        Students pursue a college education for several reasons, prime among them being the need for financial well-being and the ability to engage in leisure activities (4). As colleges and universities prepare students for their future careers, and work toward attracting the next set of potential students, they are faced with identifying educational practices that will prepare students for a dynamic and competitive workforce (5). These institutions are also faced with the question of whether their undergraduate students are academically engaged and learning enough in college, and whether their students are being taught foundational skills effectively (6).

        Several studies have established a significant association between good educational practices and student college outcomes. Chickering and Gamsons assert that contact between students and faculty, reciprocity and cooperation among students, active learning, and prompt feedback are practices that can aid this process (7). These practices have been vetted, and found to positively influence undergraduate student learning and growth (8, 9) put together, these practices comprise high impact learning practices.

        HIPs have been found to contribute to student increased academic engagement, knowledge, resolve, and general academic success (10). These educational practices afford students the opportunity to participate in activities beyond the classroom over a period of time, resulting in learning and personal development (11). HIPs not only enable students to apply what they have learned, or make meaning of their learning, they also contribute to metacognitive gains by students (12). In his article on HIPs, Kuh lists writing intensive courses, collaborative assignments and projects, undergraduate research, service learning, community-based learning, and <underline >diversity/global learning as practices that help to increase student retention and learning (13). According to Kuh, the implementation of HIPs among other things, has the tendency to increase student interaction with faculty and their peers on course work, and to induce reflection on course material and integrated learning (14). Engaging students in activities that focus on “learning by doing” has the tendency to make classroom learning real and relevant through the application of new knowledge to real life settings (15). Kinzie (16) noted that faculty engagement of students in projects in and outside the class increases student learning. Indeed project-based learning integrates knowing and doing. Through this effort, students not only learn elements of the core curriculum, but also apply what they know to solve authentic problems and produce results that matter (16). Students exposed to good educational practices tend to obtain better grades, and have increased cognitive, emotional, and personal growth. They also tend to be more satisfied with their college experience (17).

        Materials and Methods

        Setting and Population

        The BSPH program has over 400 racially and economically diverse students enrolled in the public health major, and caters to both traditional and non-traditional students. The program is a 4-year degree that places special emphasis on urban and global health issues, and has a curriculum that focuses on elements of life and biological sciences, social sciences, and the humanities. The goal of the program is to provide students with an interdisciplinary understanding of public health, using a broad spectrum of approaches and course work. Students enrolled in the program acquire knowledge and skills needed for graduate school, and for careers in a wide range of public health and interdisciplinary professions.

        Sampling and Data Collection

        We used a cross-sectional convenience sample of current and graduated BSPH students to assess student perceptions of the extent to which six HIPs implemented by Georgia State University's BSPH program faculty, impact undergraduate student cumulative learning, academic success, and career outcomes. Undergraduate course work and assignments, service learning/community-based learning, collaborative projects, study abroad, undergraduate research, and signature experience were the HIPs examined.

        Students in the BSPH program were informed about the study and its purpose, through faculty announcements, emails, the BSPH general learning management system (iCollege), and were invited to take the survey. Completed survey questionnaires were collected on a daily basis using Qualtrics. All students associated with the program were given an equal opportunity to participate in the study.

        To assess the impact of BSPH HIPs, data was collected on the amount of time students purposely devoted to course work and assignments, the extent of student interaction with peers and faculty on course work, and student opportunities to receive guidance and on-going feedback from faculty on their course work and assignments. Data was also collected on student's confidence in their ability to apply public health knowledge situations both in and outside the classroom.

        The study was exempt from the Georgia State University IRB review process because, it was conducted in an established or commonly accepted educational setting that specifically involved normal educational practices that did not adversely affect students' opportunity to learn required educational content. The study was further exempt from IRB approval because it sought to research the effectiveness of or the comparison among instructional techniques, curricula, or classroom management methods.

        Variables and Measurement

        The HIPs survey comprised a 23-item questionnaire containing closed-ended questions on a six-point Likert scale ranging from “strongly disagree” to “strongly agree.” The questionnaire was pilot-tested with randomly selected BSPH students for accuracy and consistency of measures. The questions assessed HIPs on six domains; (1) undergraduate course work and assignments, (2) service learning/community-based learning, (3) collaborative projects, (4) study abroad, (5) undergraduate research, and (6) signature experience. The survey questionnaire also asked for demographic and academic information.

        The demographic and academic variables of the survey included academic status ranging from recent graduate to freshman, and the sex of students. The undergraduate course work and assignments variable focused on the amount of out of class time students devoted to course work and assignments, the availability of faculty to provide continuous feedback on course work and assignments, and student confidence in their ability to apply course material to real-life public health situations both in and outside the classroom. The service learning and community-based learning variable focused on career and occupational skills development, preparation for professional employment, and the application of classroom knowledge to service and community-based learning activities. The collaborative projects variable focused on working with peers, enhanced understanding of course material, and integrating and merging of knowledge from other courses with team members to produce a high quality academic product. The study abroad variable focused on decisions for postgraduate education and the acquisition of additional skills for a future career. The undergraduate research variable focused on student ability to research public health issues and their ability to present at conferences, and the final variable, signature experience, focused on the ability of students to create faculty reviewed academic products that were pertinent to their experience.

        Statistical Analysis

        The data collected in Qualtrics were cleaned and exported to SPSS for analysis. Univariate analysis was conducted to summarize and describe data. Missing data were excluded from calculations. Univariate, bivariate, and multivariate data analyses were conducted using SAS 9.4 and Stata 11. Univariate analysis was conducted to obtain descriptive statistics for the six HIPs domains, sex, and educational status. Bivariate data analysis was conducted to determine the relationship between academic status, sex, and the six domains. At the multivariate level, we conducted an ordinal logistic regression to determine whether there was a relationship between academic status and the six HIPs domains and adjusted for sex. The 95% confidence interval was used to provide an estimated range of values for each of the HIPs variables measured.

        Results

        Univariate Statistics

        Demographic and Academic Status

        All 436 students currently enrolled in the BSPH program and the 19 students who have graduated from the program were invited to participate in the survey. One hundred and five students currently enrolled in the program and nine students who have graduated from the program, completed the survey. The majority of students (93.8%) are still enrolled in the program, and 88% of the respondents self-identified as female. Table 1 shows the academic level of the students who participated in the survey and Table 2 shows the number of students who responded to each of the HIPs domains by academic level.

        TABLE 1
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        Table 1. Academic level of students who participated in the survey.

        TABLE 2
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        Table 2. Number of students who responded to each of the high impact learning practices domain questions by academic level.

        Undergraduate Course Work and Assignments

        Regarding undergraduate course work and assignments, 58% of students said they devoted a minimum of 3 h per day to their course work and assignments, 52% said they met with BSPH faculty outside of class for guidance on course work and assignments, and 66% said that they received feedback from BSPH faculty on their course work and assignments. Over half of the students surveyed (58%) said that they were confident that they could apply material from various courses offered by the program to public health issues both in and outside the classroom. Undergraduate BSPH courses include Health Equity and Disparities and Introduction to Public Health.

        Service Learning/Community-Based Learning

        Forty-eight percentage of students in the BSPH program said service learning and community-based learning was an important part of their BSPH experience, and 49% said the experience helped them to develop career and occupational skills. Fifty-two percentage of students indicated that they were able to apply their classroom knowledge to the service and community-based activities they engaged in. Fifty-six and 54% of students, respectively, said that their participation in service and community-based activities gave them a sense of personal achievement and prepared them for professional employment opportunities. Forty-seven percentage of the students surveyed disclosed that they were able to integrate their classroom work into their service and community-based activities.

        Collaborative Projects

        On the issue of collaborative projects, 45% of students stated that working with peers was an important part of their BSPH experience, while 8% did not think so. Forty percentage of students stated that collaborative projects helped them to better understand course material. Less than half of the students surveyed (40%) said group projects inspired them to do their best on assignments, and 42% of students indicated that group projects allowed them to integrate the ideas and knowledge they acquired from various program courses, with that of their peers to create good academic products (papers, projects, and presentations).

        Study Abroad

        A little more than a third (36%) of students reported that their study abroad experience motivated them to consider pursuing graduate studies, and allowed them to acquire additional skill sets for their future careers. Less than half (39%) of the students neither agreed nor disagreed that it influenced their decision to enter the public health workforce or pursue graduate education.

        Undergraduate Research

        Undergraduate research is one of the most requested opportunities from the student body. Forty-two percentage of the respondents took a course that required them to do some research. As a result, 43% of these students were able to use their research skills to develop oral and poster presentations delivered both on and off Georgia State University's campus.

        Signature Experience

        Given that the BSPH program is only in its third year of development, and the signature experience courses are taken when the predominance of the major coursework is completed, most of the respondents in the program have not taken the signature experience course yet. Of those who have, 42% stated that they were able to integrate and apply what they had learned in the classroom to their signature experience, and 42% said that enrolling in the course exposed them to experiences they would otherwise not have gained in the classroom. Forty-two percentage of students who took the signature experience course indicated that, with guidance from faculty members, they were able to produce good final academic products.

        Bivariate and Multivariate Analysis

        We conducted bivariate analysis for sex, academic status (including BSPH graduates, seniors and juniors) by all the six HIPs domains. We found no statistically significant relationship between sex and the six HIPs domains, but we found statistically significant relationships between BSPH graduates and juniors for collaborative projects (p = 0.0357) and signature experience (p = 0.0085) with regards to the question, I am/was able to apply what I learned in the classroom to my signature experience. When it came to BSPH graduates and seniors, we also found statistically significant relationships for collaborative projects (p = 0.0456) regarding the question, Working on group projects collaboratively helps/helped me to integrate my ideas with those of others in the group to produce a good product; for study abroad (p = 0.0331) with regards to the question, Participating in the BSPH study abroad program allowed me to acquire additional skill sets for my future career and signature experience; and for signature experience (p = 0.0379) in relation to the question, I was able to apply my undergraduate research skills by presenting at a conference. Concerning seniors and juniors, we found statistically significant relationships for undergraduate course work and assignments (p = 0.0065) regarding the question, Faculty in the BSPH program provide/provided feedback on my coursework and assignments; for service learning/community-based learning (p = 0.0464) with respect to the questions The BSPH service-learning experience will help/helped with the development of career/occupational skills and I am/was able to apply classroom knowledge to my service learning activities; and for collaborative projects (p = 0.0324) concerning the questions, Collaborative group projects helps /have helped me to better understand course material and “Working collaboratively on group projects inspires /inspired me to do my best in an assignment., undergraduate research. Concerning seniors and juniors, we also found statistically significant relationships for undergraduate research (p = 0.0224) regarding the question, I participated/was able to participate in undergraduate research opportunities as a requirement of a class that I took in the BSPH program; and for signature experience (p = 0.0448) in relation to the question, The BSPH signature experience caused me to produce a final product that was evaluated by a faculty member.

        To examine the relationship between student educational levels in the BSPH program and the six HIPs domains, we performed multivariate analysis and adjusted for sex (using Stata 11).

        Table 3 shows the overall outcomes from the ordinal logistic regression model for each of the six HIPs domains. Statistically significant relationships were found between all of the HIP domains and student academic level. Service learning/community-based learning had the strongest impact in our ordinal logistic model with an odds ratio of 7.117. This domain had more than seven times impact, compared with the other domains, which were all protective (having odds ratios <1). It is therefore likely that more students benefitted from the service learning/community-based learning than the other HIPs domains.

        TABLE 3
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        Table 3. Ordinal logistic regression model of respondents' domain by educational levels—adjusting for sex.

        Discussion

        Results from the study provide baseline data of the effectiveness of HIPs utilized by the BSPH faculty to educate and prepare students for real-life public health challenges. The results also indicate that students perceive the HIPs implemented in the program as effective in impacting their learning and preparing them for real-life public health challenges.

        Undergraduate Course Work and Assignments

        Our study revealed that most students in the BSPH program (58%) devote more than 3 h per week per semester on undergraduate course work and assignments. This is consistent with the National Survey of Student Engagement's (NSSE) findings, that the average student spends about 17 h per week on course work including homework, reading, and assignments. For the majority of students responding to the survey, interaction with faculty outside classes provided additional guidance on how to do their coursework and assignments. Previous research indicates that student-faculty interactions can have several positive influences. Indeed, Pascarella and Terenzini found that student-faculty interaction generally have a positive influence on the cognitive growth and development of college students (9). They also found that student-faculty interaction is positively related to students' academic achievement and that the frequency of contact is related to students' positive learning outcomes (9).

        Service Learning/Community-Based Projects

        Service learning affords students the opportunity to apply knowledge gained in the classroom to practical community-based projects. It also allows students to make real-life connections between what they learn in the classroom and what actually happens in practice. Close to half (48%) of the students who responded to our survey found service learning/community-based learning to be beneficial. This statistic is modest and may be because of the infancy of the BSPH program and the fact that not many students are at a point where they can engage in the practice. We found that participating in service learning activities was a catalyst to student development of skills for future employment, increased personal insight, cognitive and social development, and created a sense of personal and academic achievement. This is consistent with earlier research findings by Austin et al. (18), Yoiro et al. (19), and Conway et al. (20).

        Collaborative Undergraduate Projects

        The goal of collaborative undergraduate projects is to help students learn to work and solve problems in the company of others, and to sharpen their understanding by listening seriously to the insights of others, especially those with different backgrounds and life experiences. Unfortunately, not as many BSPH students (40%) found this HIP to be helpful in increasing their understanding of course material. These results are consistent with the findings of a previous study conducted by Premo et al. which found that, collaborative projects by themselves are not enough to promote increased student achievement (21). Group projects sometimes end up becoming a source of friction between students. At their best, collaborative projects foster productive team and idea sharing among future professionals, while at their worst, team projects force high-achieving students to compensate for those less willing to put in the effort. It may be because of the latter reason that this HIP was not as popular with BSPH students who responded to our survey (22).

        Study Abroad

        Brazil, The Dominican Republic, China, India, and Uganda are the five countries where students in the BSPH program have had the opportunity to visit and explore different cultures, worldviews, and life experiences. Led by full-time faculty from the SPH, as well as faculty from geosciences, criminal justice and communications, students who took the survey indicated that studying abroad enabled them to acquire additional skills sets such as critical thinking, problem solving, communication, leadership, professionalism, and intercultural fluency that they need for their future careers. These competencies are consistent with the National Association of College and Employers (NACE) key career competencies (23). All BSPH programs are designed to prepare students to be informed and exposed to public health issues from an urban and global perspective. Through mentoring, a challenging overseas academic program, and hands on experiential activities, students are positioned to gain invaluable knowledge and skills that augment their academic preparation. Consistent with Sanchez's (24) previous research finding, we found that the study abroad experience by itself is an example of several HIPs wrapped into one academic experience that lasts for a lifetime, transforms student intellectual perspectives and personal growth, and causes students to rethink their majors and incorporate further studies abroad into their academic schedules (24).

        Undergraduate Research

        Even though the number of students who indicated that they were able to participate in undergraduate research was <50% of those who responded, 43% reported that their understanding of how to conduct research, increased their ability to write papers and to present at conferences, both on and off campus. This is consistent with Lopatto's (25) findings on undergraduate research and HIPs. He found that the undergraduate research experience affected student career plans and sometimes helped them to fine-tune their career plans (25). We found evidence of a connection between undergraduate research experiences, and personal academic growth and confidence in foundational research methods, and increased interest in graduate education and preparation for the labor force. Lin et al. in a previous study confirm that working with faculty is an important component of a successful undergraduate research experience (26).

        There is no other extracurricular activity that undergraduate students at Georgia State University request more, than doing research with faculty. Students focused on continuing their education beyond the baccalaureate degree, know that learning how to conduct public health research with experienced faculty can enhance their graduate school applications considerably. Thus, in the 3 years that the BSPH program has been in operation, opportunities for students to participate in undergraduate research has continued to increase. In the spring of 2017, just one semester after the program was inaugurated, a faculty member agreed to work with two undergraduate students on a funded research project to examine the impact of mindfulness on tobacco cessation in low-income communities. Since that spring, in each semester, additional faculty have worked with more and more undergraduate students in the program. As of the fall 2018 semester, four faculty members are working with more than 10 students on research projects related to health policy, water quality, nano-particles, and health promotion and behavior. Additionally, the lead author of this paper has started a research club to work with students to develop manuscripts based on primary and secondary data analysis and the systematic reviews of the literature. Within a week of the faculty member announcing the launching of the club, over 20 students had signed up.

        Signature Experience

        All students at Georgia State University are encouraged to complete at least one signature experience. Utilizing experiential strategies, signature experience courses give students the opportunity to apply course content to real-life situations. While signature experience courses are highly encouraged across the university, they are not a required course in any program of study except in the BSPH program. In this program, students entering their senior year of study register for PH 4991 (Signature Experience 1–Prospectus) and PH 4992 (Signature Experience–Capstone). Both courses are offered every semester in a 7-week mini-mester, so both courses can be taken in one semester. This increases the odds for students to progress to graduation in any given semester. The prospectus course (4991) is the first of a two-course sequence required to meet the area H requirements of the BSPH program of study. Students have the opportunity to integrate, synthesize and apply their public health knowledge through cumulative and experiential activities. In this course, students complete a variety of projects, and written assignments designed to assess student acquisition of the required public health competencies covered within the public health major. Mastery of these competencies is required to receive the BSPH degree.

        Forty-two percentage of students indicated that participation in the signature experience course exposed them to things that typically do not occur in a traditional classroom, and that they were able to integrate what they learned in the classroom into the course, and were able to produce quality, culminating artifacts that were evaluated by their faculty. This finding is consistent with that of Fitzpatrick et al. (27) who assessed undergraduate public health capstone courses in 2016. In their study, they found that capstone projects caused students to integrate what they had learned from various courses, into their capstone experience and that, their success was most evident in their ability to transform draft literature reviews into a final product (27).

        Limitations

        While the results from the assessment are promising, it would have been good to have more BSPH graduates complete the survey. To address this challenge, faculty will ensure to create awareness among BSPH students of the importance of participating in such surveys in the future.

        Conclusion

        The study assessed six HIPs utilized by Georgia State University BSPH faculty and the extent to which integrative educational practices prepare students for the labor force and for further education. It also sought to identify integrative educational practices that have the highest impact of helping students integrate knowledge and skills gained in the classroom to public health issues. Results from the study provide invaluable baseline data for the assessment of future integrative educational HIPs utilized by Georgia State University faculty in the BSPH program.

        Author Contributions

        EAr-M and KR-W wrote the draft manuscript, finalized, and edited the final manuscript. EAl-M performed the statistical analysis. All authors reviewed and approved the final manuscript.

        Conflict of Interest Statement

        The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

        Acknowledgments

        We thank Mrs. Souvann St. John-Brown for her assistance with data collection and survey follow-up activities. We also thank faculty in the BSPH program at Georgia State University who, continue to work with and inspire the students in our program and for their help with announcing the survey and encouraging students to participate.

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        Keywords: integrative learning, high impact educational practices, undergraduate course work and assignments, service learning/community-based learning, collaborative projects, study abroad, undergraduate research, signature experience

        Citation: Armstrong-Mensah E, Ramsey-White K and Alema-Mensah E (2019) Integrative Learning in US Undergraduate Public Health Education: A Review of Student Perceptions of Effective High-Impact Educational Practices at Georgia State University. Front. Public Health 7:101. doi: 10.3389/fpubh.2019.00101

        Received: 20 November 2018; Accepted: 08 April 2019;
        Published: 30 April 2019.

        Edited by:

        Andrew Harver, University of North Carolina at Charlotte, United States

        Reviewed by:

        Darcell P. Scharff, Saint Louis University, United States
        Edward J. Trapido, Louisiana State University, United States

        Copyright © 2019 Armstrong-Mensah, Ramsey-White and Alema-Mensah. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

        *Correspondence: Elizabeth Armstrong-Mensah, earmstrongmensah@gsu.edu

        2019-04-30T00:00:00Z
         
    • Cue-Reminders to Prevent Health-Risk Behaviors: A Systematic Review
      • Cue-Reminders to Prevent Health-Risk Behaviors: A Systematic Review

        Lonneke van Leeuwen1, Simone Onrust1, Bas van den Putte1,2, Marloes Kleinjan1,3 *, Lex Lemmers1, Rutger C. M. E. Engels4 and Roel C. J. Hermans 5,6
        • 1 Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, Netherlands
        • 2 Amsterdam School of Communication Research, University of Amsterdam, Amsterdam, Netherlands
        • 3 Department of Interdisciplinary Social Sciences, Utrecht University, Utrecht, Netherlands
        • 4 Erasmus School of Social and Behavioural Sciences, Erasmus University, Rotterdam, Netherlands
        • 5 Behavioural Science Institute, Radboud University, Nijmegen, Netherlands
        • 6 Department of Health Promotion, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands

        Introduction: It has been proposed that the use of cue-reminders may increase the effectiveness of interventions that aim to prevent health-risk behaviors (i.e., having unsafe sex, unhealthy dietary intake, lack of physical activity, and substance use). The aim of this systematic review was to explore whether there is evidence supporting this proposition, and to explore how cue-reminders are applied in health-risk behavior interventions to date.

        Method: We systemically reviewed (non-) randomized trials that examine differences in health-risk behaviors between an experimental group receiving an intervention with exposure to a cue-reminder and a control group receiving the intervention without such cue.

        Results: Six studies were eligible for inclusion. The studies differed in sample and research design, and how the cue-reminder was applied. One study demonstrated a positive and small effect, and one study found a negative medium effect of the cue-reminder. In the remaining studies, the effect sizes were positive but non-significant.

        Discussion: It is unclear whether complementing health-risk behavior interventions with cue-reminders increases the effectiveness of these interventions. Further investigation and experimentation into the efficiency and effectiveness of cue-reminders is needed before health-risk behavior interventions are complemented with cue-reminders.

        In Western society, the most prominent contributors to mortality and morbidity can be linked to health-risk behaviors, such as having unsafe sex, unhealthy dietary intake, lack of physical activity, and substance use (1). Consequently, many health-promoting organizations develop and implement interventions to prevent or reduce these health-risk behaviors. Despite the aim of these interventions to help people maintain and improve their health, evidence indicates that post-intervention changes are difficult to sustain (2). Merely through the passing of time, intervention recipients tend to forget what was learned during interventions (3) and easily return to their initial behavior(s) once they face the tempting daily life situations in which they used to enact these health-risk behaviors (2).

        To increase the effectiveness of health-risk behavior interventions (hereafter: interventions), it is proposed that offering intervention recipients a cue-reminder may be an effective strategy (2, 4). Cue-reminders are grouped in the “associations” category of the Behavior Change Taxonomy (5). A cue-reminder is an object that is aimed to increase the salience of an intervention message at the time and place where normally the health-risk behavior would occur. The cue-reminder is introduced during a learning situation (the intervention), thereby aiming to create an association between the cue-reminder and the learning situation (3). Observing this cue-reminder in potentially risk behavior-inducing contexts may facilitate the reactivation and retrieval of relevant memories associated with intervention (3), such as the experience of having received the intervention or the specific health information received during the intervention. Further, cue-reminders may serve as a reminder of intentions, thereby supporting intervention recipients in turning their intentions into behaviors (6). Lastly, cue-reminders may help to inhibit social reactive processes that could negatively influence recipients' behaviors, such as conforming to pro-alcohol social norms (7, 8). It has been found that inhibitory cues, when made salient, impede impulsive behaviors, and counteract seducing or appealing cues or pressures present in that specific situation (4, 9). Thus, to summarize, cue-reminders may help to increase the salience of a risk-behavior inducing situation and reinforce actions needed to avoid this situation and adapt one's behavior accordingly to the intervention goal. An example of a cue-reminder in a health-risk behavior intervention is a bracelet worn by intervention recipients, as a reminder of the dangers of unsafe sex and to encourage condom use during intercourse (4).

        Although complementing interventions with cue-reminders may be intuitively appealing, little is known about the effectiveness of cue-reminders in the context of health-risk behaviors (i.e., having unsafe sex, unhealthy dietary intake, lack of physical activity, and substance use), and how cue-reminders are best be applied. Therefore, the first objective of this systematic review is to explore whether there is evidence supporting the proposition that complementing health-risk behavior interventions with cue-reminders increases the effectiveness of such interventions. The second objective is to explore how cue-reminders are applied, because this may inform risk-behavior preventing organizations who are planning to complement their interventions with cue-reminders. To reach these objectives, we systematically review (non-) randomized trials that examine differences in health-risk behaviors between an experimental group receiving an intervention with exposure to a cue-reminder and a control group receiving the intervention without such cue.

        Methods

        This systematic review was prepared in accordance with the PRISMA statement for the reporting of systematic reviews (10). A review protocol was established in preparation of this systematic review (not registered).

        Selection of Studies

        Eligibility Criteria

        There were six inclusion criteria. First, eligible studies should be randomized controlled trials or non-randomized controlled trials. Second, the experimental condition should involve exposure to an intervention followed by exposure to a cue-reminder. The control/comparison condition should consist of exposure to the same intervention but without exposure to the cue-reminder. We conceptualized cue-reminders as objects that provide reminder cues or subtle stimuli to intervention recipients with the aim to activate and retrieve intervention-related memories. Therefore, studies that did not involve an object as a reminder were to be excluded. Third, eligible studies should assess the impact of interventions on behavioral outcomes related to one or more of the following health-risk behaviors: having unsafe sex, unhealthy dietary intake, lack of physical activity, and substance use (i.e., tobacco, alcohol, illicit drugs). Fourth, eligible studies should report results about the added effect of a cue-reminder on behavioral outcomes or data from which this added effect can be calculated. Fifth, eligible studies should be written in English. Sixth, study subjects should be human.

        Search Strategy

        Four electronic databases (PsycInfo, PubMed, CINAHL, and EMBASE) were searched for eligible studies (search date: July 10th 2017). The search strategy is described in Table 1. No restrictions were imposed on studies' publishing dates or sample characteristics. Studies listed in these databases were retrieved by using combinations of thesaurus terms, key words, and text words in titles and abstracts. These terms and words refer to health-risk behaviors, cue-reminders, and interventions. In total 2,101 records were retrieved: 389 records were retrieved by the search in PsycInfo, 579 by PubMed, 197 by CINAHL, and 936 by EMBASE. All records were combined in Reference Manager Version 12 (Thomson Reuters, Philadelphia, PA, USA). Removal of duplicates resulted in 1,397 unique records. In addition, the reference lists of eligible studies were hand searched to identify additional eligible studies, as well as the studies that cited eligible studies. This resulted in the identification of 17 additional potential eligible studies.

        TABLE 1
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        Table 1. Applied search strategy.

        Potential eligible but unpublished studies were searched by a variety of strategies. First, the authors shared an online request for unpublished studies through email and (professional) networking accounts amongst peer researchers and health promoters. Second, authors from eligible studies as well as authors who cited eligible studies were contacted by email with this request. Third, a request for unpublished studies was posted on the forum of the Society for Personality and Social Psychology. Nine researchers responded with suggestions for unpublished and potentially eligible studies, resulting in the identification of six additional potentially eligible studies. In total, the search strategy for this systematic review yielded 1,420 potentially eligible records.

        The titles and/or abstracts of the 1,420 identified records were then screened by two researchers (by LL/RCJH and LvL) to assess whether the studies met the inclusion criteria. In cases of disagreement, titles or abstracts were discussed until consensus about potential eligibility was achieved. Based on this screening, 1,405 records were excluded. The majority of records were excluded because the studies did not investigate cue-reminders but focused on associative, situational, or environmental cues, such as images of alcoholic drinks or food. Thus, these studies focused on cue-reactivity in health-risk behavior rather than on the use of cue-reminders to prevent those behaviors. Also, in many studies, the abstract showed that more differences existed between the experimental and control conditions than the presence/absence of cue-reminders only. For example, there were studies in which the experimental group received an intervention including a cue-reminder, but in which the control group received no intervention at all. Next, the full-text articles of the remaining 15 records were retrieved and screened against the inclusion criteria (by LvL and RCJH). In the case of disagreement, studies were discussed until consensus about eligibility was achieved. The full-text screening resulted in the exclusion of another nine articles for three reasons. Firstly, the full-text versions showed that the reminder was not an object but, for example, a text message. Secondly, the full-text versions indicated more differences between the experimental and control conditions than the presence/absence of cue-reminders alone. Thirdly, full-text versions indicated that the focus of the reminder was not on one of the four health-risk behaviors selected for this review. The remaining six studies were included (see Figure 1 for the overview of screening and selection procedures).

        FIGURE 1
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        Figure 1. Overview of screening and selection procedures.

        Data Extraction and Risk of Bias

        The following data were extracted from each study: outcome measure(s), sample size, participants' mean age, sample size per condition, number and timing of measurements, information about the content of the intervention, and information about the design and implementation of the cue-reminder. To assess the risk of bias of included studies, two researchers (SO and LvL) independently completed the risk of bias assessment tool of The Cochrane Collaboration (11). After completion, the researchers discussed any disagreement until consensus was achieved. The results of the risk of bias assessment were used to describe the overall risk of bias across the included studies.

        Data Analysis

        Effect sizes were calculated for each comparison of the impact of an intervention plus cue-reminder condition vs. an intervention only condition. The calculated effect sizes were standardized mean differences (Cohen's d).

        Effect sizes per outcome per study were calculated with the software program Comprehensive Meta-Analysis (CMA; version 2.0; Biostat, Englewood, New Jersey). For the calculation of effect sizes for which no procedures were available in CMA, an online effect size calculator was used (12). In cases where multiple outcome measures were used to assess the same behavior, for example quantity and frequency of alcohol consumption, the effects sizes per outcome measure were pooled to yield a single effect size. Positive effect sizes indicate a positive added effect of the cue-reminder, such that participants in the intervention plus cue-reminder condition showed less health-risk behavior than participants in the intervention only condition. Following Lipsey (13), Cohen's ds of < 0.32 can be considered as small effect sizes, between 0.32 and 0.55 as medium effect sizes, and larger than 0.55 as large effects sizes.

        Results

        Overview

        Detailed information of each included study is shown in Table 2. Of the six studies, four studies focused on substance use (alcohol consumption) (14, 1618), one study focused on unhealthy dietary intake (i.e., candy consumption) (15), and one study focused on unsafe sex (4). The cue-reminders that complemented the interventions were a bracelet (4, 17), a bracelet or a self-selected cue (14), a monkey puppet (15), and drink coasters (16, 18).

        TABLE 2
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        Table 2. Descriptive information and effect sizes of the included studies.

        In all studies participants were randomized to an experimental group receiving an intervention including a cue-reminder or a control condition receiving the intervention only. One study had a pretest–posttest design (14), whereas the other studies had a posttest only design. In three studies, participants were exposed to the cue-reminder in a test session after the intervention (15, 16, 18), whereas in the other three studies, exposure to the cue-reminder took place in participants' daily lives (4, 14, 17).

        All studies included participants of both sexes. Three studies included more females than males in their design (4, 16, 18), one study included more males than females (15), and two studies included an almost equal number of both males and females (14, 17). In terms of sample age, one study included 8 year-old participants (15), four studies included participants with a mean age of ~20 years (4, 1618), and one study included participants with a mean age of 37 years (14). The majority of studies sampled highly educated participants (4, 14, 16, 18). One study did not report participants' educational level (17) and one study focused exclusively on children in elementary school (15). Finally, four studies included between 100 and 200 participants in their design (4, 15, 16, 18), whereas two studies included a substantial larger number of participants with 1,412 and 2,634 participants, respectively (14, 17).

        Systematic Review

        In addition to variation in participants' characteristics, we observed a variation in how the cue-reminders were applied in the included studies. First, the studies differed in whether or not the aim of the cue-reminder was made explicit to intervention recipients. Second, the studies differed in the duration to which intervention recipients were exposed to the cue-reminder.

        Explicitness of Cue-Reminder Aims

        In three studies, participants were explicitly told that the aim of the cue-reminder was to remind them of intervention-related information (4, 14, 17). Thereby, the interventionists attempted to create an explicit association between the cue-reminder and the intervention message. In the study of Dal Cin et al. (4), participants were given a bracelet and were explicitly told to think about the dangers of unsafe sex whenever they looked at the bracelet. Likewise, Lange et al. (17) asked designated drivers to wear a bracelet with the words “designated driver” printed on it. Their goal was to increase the activation and accessibility of the designated driver concept in memory for those who reported being the designated driver. Finally, in the study of van Lettow et al. (14) participants were offered a bracelet or asked to self-select an object of frequent use and were instructed to think of their alcohol consumption-related action plans whenever they looked at their bracelet or self-selected object.

        In contrast, in the other three studies (15, 16, 18), participants were not specifically told about the presence of a cue-reminder nor about the aim of the cue-reminder. Thereby, no explicit association was attempted between the cue-reminder and the intervention message. In Bevelander et al. study (15) children in the control condition received a short interactive lesson featuring photos, video clips, and real-life situations, and were taught about social modeling effects on their food intake. In the experimental condition, the experimenter introduced a monkey puppet at the start of the intervention and used this puppet to explain social modeling and communicate the prevention message. In a subsequent test session, the monkey-puppet was merely present. Kleinjan et al. (16) and Hermans et al. (18) also did not explicitly instruct participants about the cue-reminders. In both studies the cue-reminder was a visual symbol (“The Power Button”) that was embedded in an educational prevention film. The aim of the film was to educate participants about environmental pressure and alcohol use. This symbol was also printed on the drink coasters that were present in a subsequent test session in a bar. By doing so, the authors hoped that the cue-reminder would implicitly trigger the recall of the intervention message.

        Duration of Exposure to the Cue-Reminder

        Included studies also differed in the extent to which participants were exposed to the cue-reminder after the intervention. In four studies, participants were exposed to the cue-reminder for a relatively short period of time. Bevelander et al. (15) exposed children to the cue-reminder (i.e., the monkey puppet) during a 10-min test session in which they were allowed to eat candy. Hermans et al. (18) and Kleinjan et al. (16) exposed their participants to their cue-reminder for 30 and 45 min, respectively. Finally, Lange et al. (17) asked designated drivers to wear the bracelet for a couple of hours until their return of their night out. In two studies, however, participants were exposed to the cue-reminder for a relatively longer period of time. In the study of van Lettow et al. (14) participants were requested to use the cue-reminder for 1 month, whereas Dal Cin et al. (4) asked their participants to wear the bracelet at all times until the post-intervention measurement 5–7 weeks later.

        Effect Sizes

        Table 2 presents the effect sizes of the cue-reminders per study. Because no data on the long-term effects of cue-reminders on health-risk behaviors were available, we only present the effect sizes of the cue-reminders on the behavioral outcome(s) measured directly after the exposure period. From the six studies, only one study demonstrated a positive and significant small effect (14). Specifically, this study demonstrated that the intervention with cue-reminder was more effective in reducing alcohol consumption than the intervention only. In another study, a negative and significant effect size was found (18). In the group receiving the intervention with cue-reminder, alcohol consumption was higher as compared to the group receiving the intervention alone. In the remaining four studies, the effect sizes were positive but not significant.

        Risk of Bias

        Of the seven assessment items, the number of items judged as unclear risk of bias per ranged from 0 to 3 per study (M = 2.33, SD = 1.21). The number of items judged as low risk of bias ranged from 2 to 5 per study (M = 3.33, SD = 1.03). The number of items judged as high risk of bias ranged from 0 to 3 per study (M = 1.33, SD = 1.03). In four studies high risk of bias was expected due to blinding of outcome assessment. Two studies relied on participants' self-reports of health-risk behavior, along with participants' awareness of exposure to a cue-reminder (4, 14). Two other studies used more objective outcome assessment methods, but the assessors were not blinded for condition (16, 18). In all but one study (14), risk of bias in relation to random sequence generation and allocation concealment was not reported and therefore judged as unclear risk of bias.

        Discussion

        The aim of this systematic review was to explore whether there is evidence supporting the proposition that cue-reminders increase the effectiveness of health-risk behavior interventions. Therefore, we examined the added effect of complementing interventions with cue-reminders. In addition, we explored how cue-reminders are applied in health-risk behavior interventions to date.

        Six studies were included in this systematic review. Four studies focused on the reduction of alcohol consumption, one study focused on prevention of unhealthy dietary intake, and one study focused on prevention of unsafe sex. Two studies demonstrated significant but contrasting effects of the cue-reminder on participants' health-risk behavior, as measured directly after exposure to the cue-reminder. One study (14) demonstrated a positive, small effect of the cue-reminder: exposure to the cue-reminder was significantly and positively associated with reduced alcohol consumption. In contrast, another study (18) demonstrated a negative, medium effect of the cue-reminder: exposure to the cue-reminder increased participants' alcohol consumption. In the remaining four studies, the effect sizes were positive but not significant. Thus, evidence in support of the proposition that cue-reminders increase the effectiveness of health risk-behavior interventions was found in one study.

        A qualitative examination of the included studies revealed that the studies differ on multiple aspects: (1) characteristics of the study sample, (2) whether the design was a pretest—posttest design vs. posttest only design, (3) whether exposure to the cue-reminder took place in participants' daily lives vs. during a test session, (4) whether participants were explicitly instructed about the aim of the cue-reminder during the intervention, and (5) the extent to which participants were exposed to the cue-reminder after the intervention. Although these differences increase our understanding of the potential ways cue-reminders can be applied, these differences complicate the comparability of the studies and thus the identification of the specific factor(s) responsible for the varying findings related to cue-reminder effectiveness.

        Future research may therefore manipulate specific factors that are expected to influence cue-reminder effectiveness. It is possible, for instance, that providing an explicit instruction about the cue-reminder may contribute to the effectiveness of the cue-reminder. When the aim of the cue-reminder is made explicit, the likelihood that intervention recipients associate the cue-reminder with the intervention message may be higher than when the aim is not made explicit. As a consequence, observing the cue-reminder may lead to a better retrieval of relevant health information associated with the intervention. Further, one may better remember one's healthy intentions. Also, when intervention recipients are instructed to expose themselves to the cue-reminder, it is possible that this might to lead higher commitment to the intervention aims. That is, by making such a commitment, it is possible that they feel more pressure to behave consistent with the intervention message and are more likely to reach the behavior goals that are linked to the intervention (19). To increase our understanding of the effectiveness of cue-reminders as well as whether explicit instructions contribute to its effectiveness, future studies might compare the effects of an experimental condition that includes a cue-reminder and gives explicit instructions about the cue-reminder aims with an experimental condition in which the cue reminder is not made explicit or in which no cue reminder is present at all. Similarly, it may be expected that exposure duration could affect cue-reminder effectiveness. That is, longer exposure periods may provide more opportunities for recipients to retrieve relevant health information and act upon their positive intentions, resulting in stronger behavior change effects. On the other hand, longer exposure periods may be less impactful because of reduced sensitivity to the cue-reminder due to its longer presence. To elucidate whether and how the length of exposure period influences the ability of cue-reminders to increase intervention effectiveness, future studies may involve multiple cue-reminder conditions, varying in the duration of exposure to the cue-reminder after the intervention.

        The studies included in this systematic review describe potential psychological mechanisms that may be involved in cue-reminder effectiveness, but these are yet to be explored. For example, multiple studies recognize that health-risk behaviors are automatic or impulsive, triggered by contextual cues, such as observing or feeling pressure from peers who are drinking alcohol or eating candy (1416). The salience of the cue-reminder in such risk-behavior inducing contexts may then serve as an inhibiting cue, disrupting the health-risk behavior. This disruption may be due to enhanced awareness or increased activation and accessibility of the intervention message in memory of the intervention message (14, 16, 17) or the recall of one's personal goals (14). Dal Cin et al. (4) adds that cue-reminders are expected to increase the personal relevance of intervention messages. While participating in an intervention, recipients may not see the importance of the intervention message for their own lives. Cue-reminders may increase the salience of the message at the time and place the behavior is occurring, making the message more personally relevant. To gain insight into how cue-reminders may increase the effectiveness of health-risk behavior interventions, a suggestion for future research is to focus on the psychological processes that may be involved in cue-reminder effectiveness.

        Strengths and Limitations

        The present systematic review is the first systematic evaluation of the added effect of cue-reminders in health-risk behavior interventions, which can be considered a strength. Nonetheless, this review is also subject to limitations. Firstly, despite a broad search strategy for both published and unpublished studies and the retrieval of many potentially relevant records, only six studies matched the inclusion criteria. Although the effectiveness of health-risk behavior interventions with cue-reminders was explored in multiple studies, many studies involved an experimental group which received an intervention including a cue-reminder and a control receiving no intervention. With such a study design, the independent effect of the cue-reminder cannot be established. Secondly, given the limited number of studies and heterogeneity across studies, we were not able to perform a meta-analysis to quantitatively explore whether cue-reminders increase the effectiveness of health-risk behavior interventions. A meta-analysis of few studies is only informative if the studies are highly similar (20), which was not the case with the studies included in this review. To provide as much insight as possible into whether complementing interventions with cue-reminders increases the effectiveness of these interventions, we therefore reported the effect sizes and their confidence intervals for each individual study [cf., (20)]. Thirdly, all included studies assessed only the immediate effects of exposure to cue-reminders on the health-risk behavior of interest. Therefore, our exploration of whether cue-reminders increase intervention effectiveness is also limited to short-term effectiveness. To acquire more insight into the potential long-term effects, future studies should include a follow-up measurement.

        Practical Implications

        The results of the present systematic review are of value for intervention developers who are planning to complement their health-risk behavior interventions with cue-reminders. The varying and contrasting effect sizes show that effectively complementing interventions with cue-reminders may be a challenge. Although cue-reminders may be perceived as a simple add-on intervention component to increase intervention effectiveness, this review shows that intervention developers have multiple points to consider.

        Conclusion

        To date, only six studies have been performed to investigate whether adding cue-reminders to interventions increases the effectiveness of health-risk behavior interventions. Because of the heterogeneity across the studies in terms of sample, research design, and how the cue-reminder is applied, it remains largely unclear whether and how cue-reminders increase the effectiveness of health-risk behavior interventions. Nevertheless, this systematic review provides a valuable insight into which practical issues have to be considered by intervention developers who are planning to complement their health-risk behavior interventions with cue-reminders.

        Data Availability

        The datasets generated for this study are available on request to the corresponding author.

        Author Contributions

        LvL, MK, and RH were involved with conceptualization of the research, data interpretation, and writing up the manuscript. BvdP was involved with conceptualization of the research and data interpretation. LvL and SO were involved with analyses and data interpretation. LvL, SO, BvdP, LL, RCME, MK, and RCJH contributed to manuscript revision, read, and approved the submitted version.

        Funding

        This work was supported by the Dutch Health Research Council (ZonMw) [grant number 200130011].

        Conflict of Interest Statement

        The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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        Keywords: cue-reminder, reminder cue, health promotion, health-risk behaviors, intervention programs

        Citation: van Leeuwen L, Onrust S, van den Putte B, Kleinjan M, Lemmers L, Engels RCME and Hermans RCJ (2019) Cue-Reminders to Prevent Health-Risk Behaviors: A Systematic Review. Front. Public Health 7:97. doi: 10.3389/fpubh.2019.00097

        Received: 15 February 2019; Accepted: 05 April 2019;
        Published: 30 April 2019.

        Edited by:

        Allen C. Meadors, Independent Researcher, West End, NC, United States

        Reviewed by:

        Warren G. McDonald, Methodist University, United States
        Timothy Lynn Taylor, Independent Researcher, Wellton, AZ, United States

        Copyright © 2019 van Leeuwen, Onrust, van den Putte, Kleinjan, Lemmers, Engels and Hermans. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

        *Correspondence: Marloes Kleinjan, m.kleinjan1@uu.nl

        2019-04-30T00:00:00Z
         
    • Integrative Approaches to the Undergraduate Public Health Major
             Curriculum: Strengths, Challenges, and Examples
      • Integrative Approaches to the Undergraduate Public Health Major Curriculum: Strengths, Challenges, and Examples

        • 1 Department of Health, Behavior and Society, College of Public Health, University of Kentucky, Lexington, KY, United States
        • 2 Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States

        Many “first generation” undergraduate public health degree programs were designed based on “siloed” course structures centered around subunits in the discipline (e.g., Introduction to Epidemiology, Introduction to Environmental Health) that may be meaningful primarily to experts in the field. An alternative to the siloed approach is an integrative curricular design, in which courses are designed around meaningful thematic units (e.g., explaining public health problems, asking and answering scientific questions in public health), with an emphasis on drawing connections between knowledge from different but complementary disciplinary areas as a means to improve student learning and retention. The integrative approach shifts the curriculum conversation to capitalize on the interdisciplinary roots of the public health profession. This approach is consistent with the learning outcome recommendations in the Framing the Future Task Force report and in the CEPH requirements for the undergraduate public health major. We explore integrative approaches to developing curricular models for undergraduate public health programs and discuss both pedagogical and career preparation arguments supporting an integrative curriculum approach. These include facilitating the often-challenging task for students of seeing how concepts interrelate, making transparent how “basic” knowledge in the discipline relates to “real world” applications of the content, and better mirroring how professionals in the discipline actually use knowledge in practice. Finally, we review examples of core concepts and features in an integrative curriculum approach to the undergraduate public health major as an effective educational program with high-quality, learner-centered educational experiences.

        Introduction

        The goal of any undergraduate curriculum, including public health, we would argue, is to accomplish two objectives. First, it should teach students the “habits of thought” that characterize the discipline—how do public health professionals think about problems, analyze them, and go about solving them? Second, it should equip students with the essential skills necessary to function as entry-level public health professionals [for discussion of these two goals and their possible rapprochement see (1)].

        As a way of considering what is involved in meeting these two goals, consider a classic problem in public health education—the “potato salad” problem (2). A group of people goes on a picnic and they eat several foods, including potato salad. Later, some of them get sick (and, in true public health fashion, some of them do not). They provide some data on what foods they ate at the picnic, and the task for our budding public health professional is to decide whether they got sick because they ate the potato salad. As it has been traditionally done in class, this is epidemiology content pure and simple—students craft out a table calculating the disease rate for those who ate the potato salad relative to those who did not and, if they want to get really fancy, compare that to the disease rate for people who ate other foods vs. those who did not. A few simple calculations later and, voilà, the potato salad is identified as the cause of the sickness and students have a piece of knowledge on how to use an epidemiological principle to answer a public health question.

        As a class example to teach and test a piece of knowledge from epidemiology, this works well as is. But going back to the articulated goals for a public health curriculum, we need to consider phenomena as they would occur in the “real world.” In the real world of public health, the problem that would present itself to a member of the public health workforce wouldn't be friends on a picnic, it would be multiple people in the community buying vats of potato salad at the grocery store's deli counter to serve at their picnics and a set of ambiguous, incomplete case reports trickling in from around the community and needing to be assembled into a coherent whole. Also, in the real world a data table wouldn't magically appear from which students could calculate disease rates. The public health worker would have to use community engagement skills to go out, collect relevant data, assemble information from people's memory, and overcome community suspicions. Then, the data analytic skills above would surface. Even then, though, the real world work wouldn't be done. The public health worker would have to consult with a legal team to decide what steps could be taken to address the situation within the bounds of the city or county health department's authority. Health communications work would then need to come into play to develop the optimal strategy for getting the information disseminated to the public in a way that not only informs but also leads to needed action. The contrast between the class example and the real world is telling. Real world public health requires the integration of knowledge and skills from across the spectrum of traditional public health disciplines in order to understand and address the problem. It also requires a more complex set of thinking and analytic skills than simply the calculation of an odds ratio from a 2 × 2 table.

        The primary question for public health education, and the question we seek to address in this paper is: how do we best define and develop undergraduate public health education programming in a way that allows us to simultaneously meet two critical goals—to both best educate students to understand and analyze the complexities involved and to ensure that students leave our programs with skills that allow them to do things to address these complex problems when they engage in the “real world” work of public health practice? This real world of public health involves the kinds of complexities in the examples above, and such complexities are growing over time as we shift toward a public health paradigm that explicitly addresses social determinants (3), pushes for an approach of health in all policies (4), and shifts focus toward one health (5) and other explicitly interdisciplinary, multilevel approaches. In doing so, we ask a key question at the level of the curriculum for the undergraduate public health major—what high impact, learner-center practices and approaches should be used in developing and implementing a curriculum in order to maximize student learning and student outcomes?

        In this paper, we make the argument that achieving the goals of undergraduate education within the interdisciplinary context of public health is best done by designing curricula using an intentional, integrative approach. We begin by discussing what is meant by an integrative approach. We then advance arguments for the effectiveness of an integrative approach within the context of the goals of undergraduate education and why we would characterize it as a high impact approach to the undergraduate public health curriculum. Finally, we describe an exemplar of an undergraduate public health (UGPH) curriculum developed using principles of integrative curriculum design.

        What is an Integrative Curriculum Model?

        To develop an integrative Bachelor of Science in Public Health (BSPH) curriculum, one's team must first examine existing definitions. Jacobs defines interdisciplinary learning as “a knowledge view and curriculum approach that consciously applies methodology and language from more than one discipline to examine a central theme, issue, problem, topic, or experience” [(6), p. 8]. Public health curriculum developers must also recognize the discipline field as a “specific body of teachable knowledge with its own background of education, training, procedures, methods, and content areas” [(6), p. 7].

        The key feature of an integrative curriculum model is taking a conscious approach to integrating in coursework and drawing explicit educational connections between pieces of knowledge from particular separate disciplinary backgrounds (7). Thus, one does not define the curriculum in terms of a set of courses that individually cover particular disciplinary domains, but rather defines in terms of common questions, problems, ideas, skills or other meaningful thematic units built from the connections drawn as described above. Consequently, integrative curricula can have a variety of definitions [for examples see (8, 9)]. A common approach in medical education has been to replace separate and distinct “disciplinary” courses in the first 2 years of the curriculum with interdisciplinary courses organized around organ systems (10). In our UGPH program, the organization of a curriculum around meaningful thematic units was designed with both attention to what thematic organization best meets student learning objectives and best captures the “real world” uses of the curriculum material.

        Why an Integrative Curriculum Approach?

        With the definition of an integrative curriculum model in mind, we now turn to a brief discussion of why a unit or department would want to consider an integrative approach to developing an undergraduate public health curriculum and the advantages that it may have over the more traditional, siloed approach. Why would one design or redesign an undergraduate public health curriculum from an integrative standpoint?

        What Are the Goals of an Undergraduate Curriculum?

        Central to our arguments about the advantages of an integrative approach relative to the traditional, siloed model is a set of basic assumptions about the desired outcomes of an undergraduate degree in public health. We assume that any undergraduate public health program has as its goal meeting at least four key outcomes.

        First, we want to develop and implement a curriculum that prepares undergraduate students with the knowledge, skills, and values necessary to enter the public health workforce (broadly defined) ready to successfully begin their careers or further their education and contribute to addressing the public health needs of the population from their first jobs and continuing through the remainder of their careers (11, 12).

        Second, we want to offer a curriculum that introduces students to how public health thinks about the world, the ideas and lenses through which one takes a public health perspective in explaining and preparing to change and improve the world, that provides reasoning and problem-solving skills and that introduces students to the values and underlying principles that inform the public health perspective (1). Although programs and curricula can vary in the relative weighting they place on goals one and two (13) both are, we would argue, necessary for a high-quality curricular approach.

        Third, for undergraduate programs situated within schools or programs of public health or for those that have pursued standalone baccalaureate program status from the Council on Education in Public Health, a key goal is to ensure that the curriculum allows full satisfaction of the required learning outcomes for an accredited undergraduate degree in public health. The accreditation requirements for schools and programs offering the undergraduate degree articulate both content knowledge (e.g., “the socioeconomic, behavioral, biological, environmental, and other factors that impact human health and contribute to health disparities”) and demonstrable skills (e.g., “the ability to locate, use, evaluate and synthesize public health information”) that must be addressed in the curriculum (14).

        The preceding goals don't occur unless we achieve a fourth, final goal—a goal of undergraduate education (and truthfully, all higher education), is to produce student learning and especially to produce high-quality learning that a student retains over a period of time—in other words, although the task we undertake in our classrooms is providing instruction, the ultimate goal in our courses and overall programs is to produce learning in our students (15, 16). Although this seems like a statement of the blindingly obvious, it needs to be explicitly stated because designing the curriculum in a way that best produces long-term learning needs to be an explicit goal when one engages in curriculum design.

        How and Why Does an Integrative Curriculum Help With Meeting These Goals?

        So, from the viewpoint of these four goals for undergraduate education, why is an integrative curriculum approach potentially a better bet than the traditional, siloed approach? Let's consider potential integrative curriculum advantages from the vantage point of the four goals of undergraduate education outlined above.

        The Nature of the Field of Public Health

        For the first goal, preparing students for the workforce, the core argument for the integrative curriculum approach is that the work that is done in public health is inherently integrated. Very few of the tasks a public health professional undertakes in her daily life, and virtually none of the problems that public health professionals tackle, neatly fit into a single one of the silos defining the traditional curriculum approach.

        The potato salad example above illustrates this point nicely. Identifying, developing plans to address, intervening to address, and evaluating whether the intervention was effective involves knowledge and skills that span multiple knowledge domains within public health. Virtually every public health example is similar. A group of residents from a particular neighborhood are concerned about what they perceive as high rates of respiratory problems in their children. Is something going on and if so, how is the local health department going to respond? Even answering the “is there a disease cluster?” in this community question involves the combined knowledge set of epidemiology and biostatistics, and the skills to gather the requisite exposure information from community members and health outcome knowledge requires skills from both community health and health services perspectives. We're only one step into fully addressing the problem and already addressing it involves skills in four of the traditional knowledge domains of public health.

        We leave it to the reader to conduct additional thought experiments here if additional illustrations are needed. Suffice it to say that we take as a given that “real world” public health work has an inherent and inescapable requirement for integrated knowledge and skills across public health disciplines. We also take it as a given that as the public health challenges faced by the population shift over time, the need for integrated knowledge and skills will only grow. Emerging perspectives shaping the field all require more integrated knowledge and skills than did John Snow's work with the Broad Street Pump in 1854 (17) (and we would argue that there was some integrated knowledge at work even there).

        A core principle in education and curriculum design is that one provides a learner with mastery of a set of program-level learning outcomes by providing instruction, practice, and the ability to demonstrate mastery of the types of skills that the learner will need to perform to be successful moving forward. To that end, if the reader buys our argument that the “real world” skills our undergraduate public health students will be expected to perform are integrated skills, then the work we do in our classrooms must be to teach and allow the opportunity to master those skills. If we teach a series of siloed courses in which students learn and practice skills in epidemiology in an epidemiology course and skills in biostatistics in a biostatistics course and so on, when and where do they get the opportunity to practice the integration of those skills?

        In a siloed curriculum model, the student is most often left to master the integration of skills on her or his own. This approach rests on two rather tenuous assumptions–that the student should master them and that the student can master them. The should part comes down to a belief about educational philosophy. While we hope that the reader will be convinced by the end of this paper that students should not be left to master integration of siloed content knowledge on their own, that has to be a judgment made by the curriculum designers.

        The question of whether students can master siloed knowledge integration on their own is an evidence-based question. The predominance of evidence suggests that the answer to this question is more often than not no. Evidence on retention of knowledge and ability to integrate skills across domains shows that often students are unable to integrate unaided (18, 19). Although integrating information and applying it to novel situations is a key educational outcome, students often do not integrate and extend application successfully on their own [e.g., (19)]. In fact, some attempts to accomplish integration by maintaining siloed courses but using common themes and topics to draw connections have found that students didn't even notice the integrated material until it was explicitly pointed out by faculty members.

        The Nature of Student Learning

        As discussed above, the central goal of education is not teaching a particular set of content; it is creating student learning, particularly learning that is long-lasting and able to be effectively retrieved and used when needed in a student's post-collegiate life and work (15, 16). Curriculum designs focused on ideas, themes, and answering public health questions can be more effective than designs focused on delivering information and leaving it to students to integrate (16, 20, 21). As such, improved learning outcomes and improved student motivation are core arguments for the integrative approach (2224).

        Public health is an evidence-based discipline–we (rightly) ask about the evidence base for interventions and policy approaches to address public health problems, we recognize assessment and evaluation as core functions of public health, and at all levels of the curriculum, we take as a core goal providing students the skills to assess, interpret, and evaluate the evidence for an approach. It behooves us, then, to apply evidence-based practices to the design of our curricula and courses. There are a variety of articulations of these best practices [e.g., (25)] and, notably, siloed curriculum approaches are not among them. Indeed, an overview of teaching best practices for long-term learning argued that “…it would be difficult to design an educational model that is more at odds with current research on human cognition than the one that is used in most colleges and universities” [(25), p. 4]. Within the context of these best practices, integrative learning is frequently cited as a high-quality educational practice and as a means of producing high-quality, long-lasting learning. Integrating allows focus on the “big ideas”—often cited as a best practice in curriculum design (16). The American Association of Colleges and Universities (AACU) has argued that the ability to integrate and synthesize knowledge is one of the four essential outcomes of an undergraduate educational experience (26).

        Accomplishing integrative learning involves several shifts—from “surface level” taking in of facts to “deeper level” thinking about connections across time and across contexts (27), from thinking about disciplinary and course contexts as isolated from one another to thinking about the webs of connection that tie things together to solve “real world” issues (19).

        Unfortunately, typical undergraduate students are unlikely to learn very real and necessary connections on their own. There are two types of integration involved—first, students may not see how concepts from one course/discipline/module connect to related concepts from another course/discipline/module (typically termed horizontal integration). Second, students may not see how “basic” or “conceptual” material concepts relate to applications and professional lives (vertical integration) (10). Noticing, appreciating, and accomplishing integration is often one of the most challenging cognitive tasks we ask students to undertake. By making explicit the connections between ideas, and indeed framing the curriculum around those connections, the integrative curriculum approach addresses directly the difficult cognitive task that, in more traditional siloed approaches, is left to students to accomplish on their own.

        In addition to the direct cognitive task of integrating knowledge, a second learning-based argument for the integrative approach is that learning is only effective if it is long-term learning that can be retrieved and used in the future. In terms of teaching and learning best practices, the argument has been made that “We need to provide an education that lasts a lifetime, which means thinking beyond the end of the semester, and let the learning principles for long-term retention and flexible recall guide our teaching practices” [(25), p. 4].

        In the context of long-term retention and retrieval of information, some key principles of human memory and how humans learn highlight advantages of the integrative approach. In order to be remembered, retrieved, and used, delivered course content has to be tied to other, pre-existing memory structures (28). An item in isolation is much less likely to be effectively learned and remembered than one that is tied to pre-existing knowledge. Organization and association of information in memory is key to long term retention and undemanding. It aids initial understanding by contextualizing the information in light of other information, but also aids the likelihood of long-term recall (29, 30). Full mastery of learning content involves multiple steps—acquiring skills/knowledge; integrating the individual skills and knowledge with others; and then applying those skills and knowledge appropriately to address and understand problems, including extending the domains for that application past the specific domain in which the skill was acquired (18).

        Finally, not only can integrative curriculum designs aid students in seeing and understanding critical interconnections between content domains and in learning course material in ways conducive to long-term information retrieval, such design also aids in developing critical higher-order thinking and reasoning skills. One example of this is creative generation of new ideas. One conceptual approaching and fostering creativity is a “Janusian approach” in which creative thinking involves creating connection between ideas that might otherwise not seem connected at all (31). To the extent that we want our students to be both creative thinkers and problem solvers, arguably a core professional skill for public health where problem solving and intervention development involves working within systems and with multiple constraints to solve health problems that may not have existed when the student was in college, developing the ability to see connections between seemingly disparate ideas is critical. As discussed above, most students are unlikely to see or form such connections on their own and therefore a goal of education has to be teaching those connections as a core, concrete skill to be introduced practiced, and mastered in the course of the undergraduate program (7).

        As another thinking skills domain, consider the need to take ideas and skills developed in the classroom and apply those skills to solving a problem that may be in a novel domain. Such an ability to transfer across domains is not inherent or automatic and therefore must be learned, and curriculum design needs to take this necessary learning into account. We know that repeated practice with different applications and different spheres is advantageous—organizing around the skill/topic may help (32). In fact, some have even argued that course content should be framed by laypeople because laypeople tend to think about things in terms of actual problems to be solved whereas professors tend to focus on subject matter (33).

        For all of these student learning-focused reasons, we argue that an integrative curriculum approach offers advantages in engaging student learning. We are not the only ones to support this strategy. Many curriculum reform efforts advocate for integrative learning as a core feature of high-quality educational programs across various disciplines? (20, 34, 35). The AACU argues for creating “intentional learners” and defines that, among other things, “Intentional learners are integrative thinkers who can see connections in seemingly disparate information and draw on a wide range of knowledge to make decisions. They adapt the skills learned in one situation to problems encountered in another” [(36), p. 21].

        In the context of undergraduate degree programs in public health, where there are accreditation requirements specified by the Council on Education in Public Health, one can also consider the learning advantages of the integrative curriculum approach from the perspective of meeting accreditation requirements. Although the CEPH accreditation requirements (14) do not specify any particular curricular approach, we would argue that they do implicitly articulate a vision for undergraduate public health education that has integrative themes woven throughout. Themes like multilevel, social-ecological approaches to understanding and addressing problems, systems thinking, and synthesis of information are all inherently integrative. Moreover, regardless of the curricular approach taken to address the knowledge and skill domains specified by CEPH, one must demonstrate student learning and outcomes relevant to those domains. To that extent, the articulated advantages of the integrative approach for student learning are also advantageous for satisfying the accreditation requirements of ensuring student learning of what is inherently an integrative, interdisciplinary field of study.

        Curriculum Synergies

        As a final argument for the advantages of an integrative undergraduate public health curriculum, our experience of developing the integrative curriculum approach described in detail below is that there were interesting, unexpected synergies that occurred when considering the curriculum from an integrative perspective. The first of those synergies is that we discovered there were some topics that don't have a natural “home” in any of the siloed, disciplinary courses typical of non-integrated curricula but that emerge and fit quite nicely in an integrative approach. For example, our integrative curriculum includes a course on public health intervention approaches that uses the social-ecological model as an organizing framework. When developing content for the course, we realized that food fortification was an ideal public health strategy to talk about as a basic biological intervention in the ecological framework. We then realized that food fortification wouldn't likely come up naturally in any of the coverage of intervention approaches in a siloed model—health education and individual interventions would be covered in health behavior, policy approaches would be addressed in a health systems/services course, and screening would be covered in epidemiology, but food fortification wouldn't fit neatly into any of the necessary disciplinary “bins” and therefore likely wouldn't be covered.

        In addition, the integrative approach allows for efficiencies in coverage of key concepts that are more challenging to achieve in a siloed approach. Consider the issue of different models for explaining public health problems. We use the epidemiologic triad to explain infectious disease transmission, the exposure pathways model to describe human exposure to environmental pollutants, and the social-ecological model to describe the complex causation of chronic disease risk (and other public health outcomes). Understanding each of the models involves being able to think about multiple constructs as causes or influences, characterizing and understanding the interrelations between the multiple constructs, and understanding the different ways in which constructs can intersect and interact to determine outcomes.

        In a siloed approach, where the epidemiologic triad would be covered in an epidemiology course, the social-ecological model in a health behavior course, and the exposure pathways model in an environmental health course, the relevant tasks of understanding multiple causes would have to be taught each time. In an integrative curriculum model, though, one can organize an undergraduate course around ways of understanding and explaining public health problems, teach the basic logic of multiple causes early on in the semester, and then introduce all three models in turn and use teaching and applying them as a way to provide repetition and practice across novel contexts as each model is learned and the principles of multiple causation observed and used repeatedly.

        An Example Integrative Curriculum Approach

        At the University at Buffalo's School of Public Health and Health Professions, the UGPH program began in Fall 2017 as the first ever BSPH program in the School. Incoming freshmen began direct admission in Fall 2018. From its inception, the UGPH curriculum is designed with five key elements: (1) major building blocks, (2) introductory coursework, (3) upper-level coursework, (4) electives, and (5) one capstone course. The major building block courses entail 11 credit hours in the College of Arts and Sciences and include coursework in chemistry, political science, and statistics as well as 4 credit hours in the School of Medicine for a human physiology course. At the introductory level, students take two required lower division courses, with 200–300 students typically in each course. These courses expose them to a broad overview of the discipline and include basic principles of population health, with an integration of both historical and contemporary public health problems as a method to improve public health via the explicit integration of both content knowledge and approaches from all five core areas. At the upper division level, students take 16 credits over five courses, each currently capped at 75 students. Each integrate core curriculum content in a reflective manner, where students are challenged to assimilate the subject matter using deliberate teaching and evaluation criteria. At the upper division level, students complete nine credits of upper-level electives from a growing menu of options (e.g., Public Health Nutrition, Social Determinants of Health). Finally, a four-credit capstone experience offers students the opportunity to synthesize and apply the knowledge and skills developed in previous coursework and out-of-classroom experiences in a holistic way. The capstone is capped at 30 students with the first cohort of BSPH graduates in Spring 2019. We envision several flavors of the capstone including but not limited to an independent research project, a study abroad experience, and a public health internship at a partnering public health agency (see Tables 1, 2). The program currently has approximately 280 students enrolled.

        TABLE 1
        www.frontiersin.org

        Table 1. Linkages between critical components elements, domains, and courses in the Undergraduate Public Health Major at the University at Buffalo.

        TABLE 2
        www.frontiersin.org

        Table 2. Undergraduate public health courses at the University at Buffalo.

        BSPH Curriculum—Distinctive Design Features

        There are several advantages of using an integrative curriculum approach to the design and implementation of a BSPH program. First, the deliberate, distinctive design features of our UGPH curriculum allow for the careful and thoughtful integration of the five core public health areas in each and every one of the core courses throughout the curriculum, allowing for the high impact delivery of integrative learning experiences throughout the students' time in the major (36). In particular, students are presented with various opportunities for both breadth of exposure to core public content and ways of thinking and depth in a focus area of interest. The inclusion of a flexible capstone course allow synthesis and integration based on student experiences (e.g., undergraduate research, study abroad, internship), incorporating Kuh's capstone experiences as a high impact practice (37). Second, the leveraging of general education provides disciplinary foundations for public health learning at lower levels of the required curriculum. In designing the core courses, we identified general education offerings that provided important background knowledge relevant to each course and made those general education offerings pre-requisites to the public health core. For example, a human physiology general education course is a pre-requisite for the core course addressing biological, psychosocial, and environmental mechanisms of health and disease and a political science introductory course is a pre-requisite for the course on public health systems and policies. This leveraging of general education not only makes the curriculum stronger, but also illustrates for students the integration of core knowledge from multiple disciplines into the public health approach to addressing and understanding health. The University at Buffalo's core general education curriculum explicitly incorporates several high impact practices into its design, including first year experiences, use of portfolios, capstone experiences at the end of the general education sequence, common intellectual experiences, and diversity/global learning (37). Third, the curriculum design allows for two primary options for student learning experiences: many students will assume a “stand alone” baccalaureate experience and others may opt for a seamless transition into a BSPH + MPH without unnecessary duplication for master's level coursework (in either a 3+2 or 4+2 track). The curriculum development and implementation plans were explicitly informed by and responsive to Framing the Future. The content coverage takes a thoughtful approach to integrate the course content, allowing students to make often implicit connections between courses explicit. Importantly, the UGPH curriculum successfully incorporates Critical Component Elements (see Table 1) from ASPPH's Framing the Future project (38, 39).

        BSPH Course Examples

        To highlight samples of what an integrative approach to curriculum development and implementation looks like, we present two course examples in our BSPH program: PUB 315: Asking and Answering Scientific Questions in Public Health and PUB 320: Models and Mechanisms for Understanding Public Health.

        In PUB 315, students engage in an overview of scientific methodology and evidence-based practice in public health where they learn about the epidemiological research methods used to collect data and the biostatistical methods used to evaluate that data in public health research and practice. They begin the course by learning about the importance of evidence-based practice for public health with an overview of the research process and the development of research questions. Students examine the types of empirical questions addressed in the discipline and the links between the types of questions and appropriate methods to collect, manage, and analyze public health data. These learning synergies provide students the opportunity to deliberately engage in understanding the interrelation between not only key public health concepts but also draw connections between conceptual commonalities in all five core areas of the discipline.

        In PUB 320, students engage in course material to learn about how we understand and explain the causes of public health problems. Using active learning techniques, students gain an understanding of the complex causal mechanisms of different types of public health problems, including infectious diseases, chronic diseases, and environmental health hazards. These active learning strategies include working in groups to develop and apply multilevel explanations of public health problems and to develop knowledge through activities designed to compare and contrast the ways in which different models in public health reflect systems thinking principles. By first learning how to apply basic principles of model building to analyze and explain public health problems, they then explore the importance of identifying and understanding the relationship between and among causes within complex systems using various levels of the social ecological model and the epidemiologic triad. Using experiential learning strategies, students gain skills in describing and explaining factors that influence health-related behaviors using public health theories and environmental models. For example, students work to create the textbook through for the course, curating, and writing about core content knowledge in a way that involves experiential engagement in knowledge creation (40). Finally, students explore fundamental causes and use model applications to reduce health disparities at a population level using principles in the five core areas of public health.

        Conclusion

        Integrative learning is an educational practice intended to produce high-quality, long-lasting learning experiences. Consistent with CEPH requirements for the undergraduate public health major and learning outcome recommendations in the Framing the Future Task Force report, an integrative approach to curriculum design and implementation derives from the interdisciplinary roots of the public health profession and the key notion that public health work is fundamentally integrated in nature. From a curriculum design perspective, it is critical to develop an educational program at the bachelor's level that helps students establish knowledge, problem-solving, and critical thinking skills for understanding and analyzing the complexities involved in public health phenomena as well as fostering proficiencies to effectively respond to these complex problems in the “real world” work of public health practice. These competencies focus on the utilization of interdisciplinary, multi-level approaches. An integrative curriculum for undergraduate public health students prepares them to enter the public health workforce with thoughtful, deliberate synthesis of key principles in our field and provides them with disciplinary foundations for their future careers as public health practitioners and researchers.

        Author Contributions

        MK contributed to the conceptualization and design of the manuscript. MK and SP co-wrote the first draft of the manuscript. Each author contributed to manuscript revision, read, and approved the submitted version.

        Conflict of Interest Statement

        The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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    • The Impact of an Educational Video on Clinical Trial Enrollment and
             Knowledge in Ethnic Minorities: A Randomized Control Trial
      • The Impact of an Educational Video on Clinical Trial Enrollment and Knowledge in Ethnic Minorities: A Randomized Control Trial

        Jeannine S. Skinner1 , Alecia M. Fair 2, Alexis S. Holman3, Alaina P. Boyer4 and Consuelo H. Wilkins 2,5 *
        • 1 Interdisciplinary Gerontology Program, Department of Psychological Sciences, University of North Carolina at Charlotte, Charlotte, NC, United States
        • 2 Meharry-Vanderbilt Alliance, Vanderbilt University Medical Center, Nashville, TN, United States
        • 3 Sarah Cannon Research Institute, Sarah Cannon, Nashville, TN, United States
        • 4 National Health Care for the Homeless Council, Nashville, TN, United States
        • 5 Department of Medicine, Meharry Medical College, Nashville, TN, United States

        Introduction: Innovative methods to increase awareness about clinical trials and address barriers associated with low participation among racial/ethnic minorities are desperately needed. African Americans comprise 5% of all clinical trial participants, and Hispanics make up 1%. Use of multimedia educational material has shown promise as an effective strategy to increase minority clinical trial enrollment. However, this approach has not been broadly implemented. We tested the effect of a video educational program on clinical trial knowledge and enrollment in a sample of oncology outpatients.

        Methods: A randomized controlled trial was conducted with 63 oncology patients without previous history of clinical trial participation. Participants were randomly assigned to the intervention, to watch a clinical trial educational video in the office, or to the control group which did not receive in-office education. The Clinical Trial Knowledge survey was administered before the intervention and 1 week after the intervention. Participation in clinical trials was assessed 1-year post study participation. Results for white participants and ethnic minorities were compared. Ethnicity was self-reported through the electronic health record and confirmed by self-reporting on questionnaire.

        Results: Sixty-three participants were recruited in this study. At 1-year follow-up, 3 participants enrolled in clinical trials in the study group which had received office-based video intervention and 2 participants enrolled in the control group (Z = 0.39, p = 0.69). These results were not statistically significant. Impact of the intervention by ethnicity could not be assessed due to low total clinical trial enrollment. The video intervention did not change knowledge, attitudes, or barriers as measured by the Clinical Trial Knowledge Survey. Minority participants did report significantly more negative beliefs and barriers to participation than white participants.

        Conclusions: Increasing awareness and knowledge about clinical trials in underrepresented communities is an important step to providing opportunities for participation. Future studies should focus on how to address the negative expectations of clinical trials and the greater information needs in minority populations. Tailored or personalized messaging may address negative perceptions of clinical trial participation.

        Introduction

        Clinical trial participation is low especially among racial/ethnic minorities. Studies show African Americans comprise 5% of all clinical trial participants, and Hispanics make up 1% (1). Only 3–5% of cancer patients enroll in clinical trials, with racial/ethnic minorities making up a small fraction of enrollees (2, 3). Cancer incidence rates are typically lower among racial/ethnic minorities than non-Hispanic Whites, yet, minorities have a higher risk of mortality and shorter survival than non-Hispanic Whites (4, 5). For this reason, minority participation in clinical trials has important implications for improving health equity and addressing ethnoracial health disparities (6).

        Limited awareness and knowledge about clinical trials (7, 8) are key personal factors that impede a prospective participant's ability to decide on whether he/she would like to participate in a clinical trial (8). Studies show clinical trial awareness and knowledge is associated with sociodemographic and economic factors, such that younger individuals, Whites and persons of higher socioeconomic status (9) have greater clinical trial awareness and knowledge, and are more likely to participate in clinical trial than persons who do not fit this sociodemographic profile. As such, initiatives focused on clinical trial education (10) and increasing health and scientific literacy among minorities (11) may be particularly effective in reducing barriers to clinical trial participation in these groups. Video-based education may be especially effective in increasing knowledge about research (12), improving attitudes toward research (13), and increasing enrollment in research studies (1) among hard-to-reach populations. Clinical research education provided through multimedia may also be favored among those with limited health and scientific literacy (14, 15).

        We undertook a study to (a) describe the utility of a clinical trial educational video in a diverse oncology patient population, and (b) examine the preliminary effect of an office-based clinical trial education video intervention on clinical trial knowledge, perceived barriers, and clinical trial enrollment. We also explored differences in clinical trial knowledge and barriers to participants between minority participants and White participants. The feasibility of implementing this intervention in a clinic setting was conducted using the Stages of Implementation Completion (SIC) measure (16). Findings from this study will add to the existing literature on effective strategies to increase minority group participation in clinical trial research.

        Materials and Methods

        Study Design

        A randomized control trial design was conducted to determine preliminary effects of a clinical trial education video on clinical knowledge, perceptions of barriers to participating in clinical studies, willingness to participate in clinical trials and clinical trial enrollment. The Vanderbilt University Medical Center Institutional Review Board approved this study.

        Participants and Setting

        A power size calculation (power of 0.80, a 0.05 significance level) based on a previous study (17) with similar goals and methodology indicated a sample size of 40 (20 for each group) would provide confidence that the resulting effect size represents that which would be expected in a fully powered study. We sought to include in our sample a matched proportion of participants of racial/ethnic minorities. Inclusion criteria were a diagnosis of malignancy, age of 18 years or older, English proficiency, and no previous history of clinical trial participation. Prospective participants were recruited from urology, hematology and breast specialty clinics of Vanderbilt Ingram Cancer Center (VICC).

        Intervention

        Participants were randomized to the intervention (in-office video viewing group) or control, (DVD to take home, usual care group) using the web-based program Research Randomizer (4.0). Both groups received a clinical trial educational booklet and a copy of the DVD video on cancer clinical trials. The booklet provided a definition of clinical trial, descriptions of different types of clinical trials, and potential benefits and risks associated with participating in clinical trials. The video depicted oncology patient advocates sharing personal stories of participation in clinical trials and interviews with oncologists discussing the importance of cancer clinical trials. The video was created by the Vanderbilt-Ingram Cancer Center Office of Patient and Community Education and is distributed as an educational resource to new oncology patients. Using a tablet computer and headphones, the intervention (video viewing) group viewed the video while in the clinic. The control group was provided a copy of the booklet and video and given no further instruction.

        Measures

        After randomization, all participants were asked to complete a pre-survey prior to receiving the educational resource intervention. A post-survey was conducted by phone 1 week later. A participant flow diagram is provided in Figure 1. The 22-item Clinical Trial Knowledge survey was used to assess participants' awareness about clinical trial research (18). Survey items span 5 independent subscales [positive beliefs (4-items), safety (4-items), information needs (4-items), negative expectations (6-items), and patient involvement (4-items)] and are measured on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Perceived barriers to participation in clinical trials were assessed with 8-items on a 3-point scale ranging from 1 (this is not a reason for me), 2 (this is a minor reason for me), and 3 (this is a major reason for me) (unpublished observations, Patient-Centered Clinical Research Network, 2014). Participants were provided a list of reasons he/she may not want to participate in medical research studies and asked to indicate their feelings. Clinical trial knowledge and barriers to participation survey questions are provided in Supplementary Material. Enrollment in clinical trials was assessed 1-year post follow-up visit by review of VICC clinical trial participation electronic record. Study feasibility was measured using the Stages of Implementation Completion (SIC) measure an 8-stage, validated tool, measuring the implementation process across three phases (pre-implementation, implementation, and sustainability) (16).

        FIGURE 1
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        Figure 1. Participant flow.

        Procedures

        Potential participants were identified using Subject Locator, a recruitment tool to identify potential research participants based on discrete study inclusion/exclusion criteria available in Vanderbilt University Medical Center clinical systems. Study participant recruitment was streamlined by pre-screening patients from a list of upcoming appointments at the Vanderbilt Ingram Cancer Center. The resulting subset of clinic patients matched our study criteria and followed recruitment work flow.

        To ensure sufficient representation of racial/ethnic minorities, the prospective participant pool was oversampled for racial/ethnic minorities at a ratio of 2:1. Prospective participants received a recruitment letter by mail and a follow-up phone call to determine interests and confirm eligibility for study participation. Study appointments were scheduled before or after the patient's next clinic visit. Once study appointments were scheduled, staff randomly assigned participants to the intervention or control condition.

        All participants completed the pre-survey using android-based tablet computers equipped with Talking Survey™ software. Talking Survey™ 1 is an integrated patient surveying and healthcare education system. Key features include multilingual abilities, voice-over question administration, voice response option, and audio-to-text transcription. Participant data was automatically transmitted to the secure Research Electronic Data Capture (REDCap) database (19). Voice-over survey administration and touch screen response were used. After completing the pre-survey, participants in the video-viewing group watched the 10-min clinical trial education video. Participants in the control group were provided with the educational booklet and a DVD copy of the video after completing the survey. One week after completing the pre-survey, all participants completed the post-survey via a phone call. Approximately 1-year after participating in the study, participant's VICC clinical trial record system was queried to determine whether the participant enrolled in a VICC-affiliated clinical trial study. Participants received $50.00 after completing the post-survey.

        Statistical Analyses

        Results are reported using standard descriptive statistics. A mixed ANOVA was performed to assess the impact of the two interventions in the scores of the survey before and after the intervention. Race was converted into a dichotomous variable (whites/minorities) and included into the model as a covariate to assess its effects. Change scores from pre-survey to post-survey were calculated for each dependent variable and these values were used in the analyses. A series of one-way between-group analyses of variance were conducted to determine the impact of the experimental video vs. control on dependent variables. Between-group differences in clinical trial enrollment at 1-year post follow-up were analyzed using chi-square analysis. Significance was set at 0.05 level. Data was analyzed using Statistical Package for Social Sciences (version 23).

        Results

        Participants

        Sixty-three participants were recruited. Baseline demographic characteristics are provided in Table 1. The intervention group and control group did not differ in age, gender makeup, level of education, or household income (p > 0.05). Hispanics were present in the video group but not the control group (p = 0.04). The majority of participants (53.2%) reported not reviewing either the educational booklet or video at home. There were no differences (Z = 0.39, p = 0.69) in the proportion of subjects who enrolled in a clinical trial after the video intervention (n = 3) and the control intervention (n = 2) (Table 2). This result could not be compared for minorities and whites due to low total clinical trial enrollment at the end of the study. We also studied the results of the survey by ethnic group to assess differences in clinical trial knowledge. Between groups analysis showed that the intervention did not have a significant impact on any of the domains assessed by the Clinical Trial Knowledge Survey or barriers to participation survey (Table 2). Within groups analysis did not demonstrate significant differences in baseline survey scores for the intervention and control groups. Within groups, minority participants were significantly more likely to harbor negative expectations of clinical trials (F = 23.21) and report higher barriers to participation (F = 7.97) irrespective of randomization arm (Figure 2 and Table 2).

        TABLE 1
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        Table 1. Baseline demographic characteristics for the total study population, intervention group, and control group.

        TABLE 2
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        Table 2. Pre- and post-survey results and mixed ANOVA analysis.

        FIGURE 2
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        Figure 2. Pre and post intervention mean values of barriers to participation and negative expectations for each group of intervention by ethnicity.

        Discussion

        In this study we describe the utility of multimedia clinical trial educational resources and investigate the preliminary effect of a video educational program on clinical trial knowledge and subsequent enrollment in clinical trials in a diverse sample of oncology outpatients.

        Our pilot randomized controlled trial revealed a null effect of video intervention on clinical trial knowledge or subsequent enrollment in clinical trials. In the control group, nearly half of participants reported not reading the educational booklet or watching the video provided to them, and only 19% in the video group reported reading the education booklet. These findings put into question the usefulness of multimedia technology as a method of health education and recruitment into clinical trials. Moreover, the study found that, within the randomization arms, minority participants were more likely to experience negative expectations of clinical trials and perceived more barriers to clinical trial participation than white participants which were not sufficiently addressed by the in-office video presentation. These findings align with prior work documenting minority group concerns about participation in clinical research, including clinical trials (1, 2022).

        These study findings suggest that alternative forms of communication be used to improve clinical trial knowledge and address barriers to participation which disproportionately affect minority groups (23). Some evidence suggests African Americans and Whites differ in their perceptions of effective communication channels for clinical trial information such that African Americans prefer to receive easy-to-understand clinical trial information through faith-based organizations and other in-person community-based channels, while Whites prefer to receive clinical trial information from doctors and print media (22). African Americans also express a preference for peer concordance representation in cancer information advertisements (24). Visual representation of extended family networks in cancer clinical trial educational videos provided to Hispanic cancer patients received greater clinical trial uptake, as it highlights cultural aspects of family input in patient decision-making central to Hispanic/Latino culture (20).

        This study has several limitations. First, our sample size calculation based on previous studies

        With similar goals and methodology indicated a sample size of 40, despite recruiting a total of 63 participants for this study. We did not account for stratification by ethnicity in our calculation of the sample size. This makes our results underpowered and hinders our ability to generalize findings, as studies with larger sample sizes are needed to confirm our results. Further studies should also apply stratified randomization and an adjusted sample size calculation to control for minority oversampling. Our results should be interpreted with caution as our study did not stratify randomization nor adjusted the sample size calculation by ethnicity.

        To address the concerns about the combined analysis of the groups, we conducted between and within group analysis using ANOVA methods. Second, when assessing clinical trial enrollment 1-year post study participation, we did not query whether participants were asked to participate. It is possible some participants were never asked to participate in a clinical trial during the follow-up period. Despite these limitations, this study is unique in that it is one of the first to administer an interactive, tablet-based clinical trial educational video and survey in a clinic setting to a diverse patient population. Our use of interactive technology helps to circumvent research participation barriers related to lack of awareness about clinical trials, low literacy, and accessibility (25). Other strengths of our study include its RCT design and 50% minority group representation in the study population.

        Interpersonal trust within the clinical relationship and medical establishment has been shown to be a significant factor in enhancing minority participation in clinical trials (2628). A recent systematic review on barriers and facilitators to minority research participation recognized mistrust as a barrier to clinical trial participation (29). Despite expressions of mistrust, minority groups were willing to participate in clinical trials for altruistic reasons benefitting their family and community. Facilitators to clinical trial participation were illustrated as adapting culturally congruent practices such as addressing gaps in knowledge about research among a particular minority group (30, 31) translating study materials into appropriate languages and involvement of culturally and linguistically competent research staff (29, 3235).

        This study provides a guiding framework for future efforts to most effectively address and educate diverse patient populations about clinical trials for increased diversity in clinical research.

        Ethics Statement

        This study was carried out in accordance with the recommendations of the Vanderbilt University Institutional Review Board, Behavioral Sciences Committee, a sub-committee of the Institutional Review Board with written consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Vanderbilt University Institutional Review Board, Behavioral Sciences Committee, a sub-committee of the Institutional Review Board.

        Author Contributions

        CW is the principal investigator of the study who designed the study and coordinated all aspects of the research including all steps of the manuscript preparation. She is responsible for the study concept, design, writing, reviewing, editing and approving the manuscript in its final form. JS and AH contributed in the study design and data collection. JS, AF, and AB contributed to the analysis and interpretation of data, drafting the work, writing the manuscript and reviewed and approved the manuscript. All authors read and approved the final manuscript.

        Conflict of Interest Statement

        The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

        Acknowledgments

        Trial Registration: https://clinicaltrials.gov/ NCT02600533 registered 20 November 2015. Vanderbilt-Ingram Cancer Center and Cancer Center Support Grant (P30 CA068485), Research Electronic Database Capture (REDCap) and Subject Locator (UL1 TR000445) provided support for this research from NCATS/NIH. Thank you to the Vanderbilt University Information Technology Department, Vanderbilt University Research Informatics Core departments, Talking Survey™LLC, Middle Tennessee State University and the Tennessee Cancer Coalition Student Internship Program.

        Supplementary Material

        The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2019.00104/full#supplementary-material

        Footnote

        1. ^ Talking Survey LLC: Talking Survey. Available online at: www.talkingsurvey.com.

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    • Universal Health Coverage and Facilitation of Equitable Access to Care in
             Africa
      • Universal Health Coverage and Facilitation of Equitable Access to Care in Africa

        N'doh Ashken Sanogo 1, Arone Wondwossen Fantaye1 and Sanni Yaya 2 *
        • 1 Interdisciplinary School of Health Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
        • 2 School of International Development and Global Studies, Faculty of Social Sciences, University of Ottawa, Ottawa, ON, Canada

        Background: Universal Health Coverage (UHC) is achieved in a health system when all residents of a country are able to obtain access to adequate healthcare and financial protection. Achieving this goal requires adequate healthcare and healthcare financing systems that ensure financial access to adequate care. In Africa, accessibility and coverage of essential health services are very low. Many African countries have therefore initiated reforms of their health systems to achieve universal health coverage and are advanced in this goal. The aim of this paper is to examine the effects of UHC on equitable access to care in Africa.

        Methods: A systematic review guided by the Cochrane Handbook was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria (PRISMA). Studies were eligible for inclusion if 1- they clearly mention studying the effect of UHC on equitable access to care, and 2- they mention facilitating factors and barriers to access to care for vulnerable populations. To be included, studies had to be in English or French. In accordance with PRISMA guidelines, our systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on April 24, 2018 (registration number CRD42018092793).

        Results: In all 271 citations reviewed, 12 studies were eligible for inclusion. Although universal health coverage seems to increase the use of health services, shortages in human resources and medical supplies, socio-cultural barriers, physical inaccessibility, lack of education and information, decision-making power, and gender-based autonomy, prenatal visits, previous experiences, and fear of cesarean delivery were still found to deter access to, and use of, health services.

        Discussion: Barriers to greater effectiveness of the UHC correspond to various non-financial barriers. There are no specific recommendations for these kinds of barriers. Generally, it is important for each country to research and identify contextual uncertainties in each of the communities of the territory. Afterwards, it will be necessary to put in place adapted strategies to correct these uncertainties, and thus to work toward a more efficient system of UHC, resulting in positive impacts on health outcomes.

        Introduction

        Set in 2015, the UN sustainable development goals (SDGs) present an opportunity for the international community to continue its commitment to improve health, which is a central component of development. Achieving universal health coverage (UHC), which refers to access to quality health-care services coverage and financial risk protection for all residents, is a key health target (SDG 3.8) in the SDGs (1). UHC is a significant objective for equitable and sustainable health outcomes worldwide and thereby a key path to promote progress toward other health-related SDG targets (1). Unfortunately, access to quality health services continues to be a problem for most people in the developing world (2). About 400 million people do not have access to basic quality health services globally, and among people living in low and middle-income countries, 6% experience extreme poverty as a result of payment for health services (2). In Africa, accessibility and coverage of essential health services are especially low. In fact, only 43% of pregnant women attended the four recommended prenatal visits compared to the global average of 55% as of 2014 (3, 4). Only 49% of births are attended by skilled health personnel compared to the global average of 70% (3, 4). Relative to financial risk protection, direct payments have been identified as a major cause of this situation across the continent, with several studies showing that direct payments of care provide limited access to care for the underprivileged and women (57).

        In order to achieve UHC, adequate provision of healthcare as well as healthcare financing systems that ensure access to adequate care regardless of ability to pay were identified as significant needs (8). In 2005, the World Health Assembly of the WHO advocated to member states to aim for UHC and access to promotive, preventive, curative, rehabilitative, and palliative health interventions on the foundation of equity (3, 9). The path advocated by the WHO to achieve this UHC included prepayment of health care by significantly reducing direct payments and user fees (10, 11). Such an objective was believed to be achieved by a broader and more equitable tax system, a compulsory health insurance, or both (10). Today, the progress toward achieving SDG target 3.8 on UHC by 2030 is monitored through two major indicators: the coverage of essential health services, such as curative care and health promotion; the proportion of households with large expenditures on health from total income (12).

        The WHO has identified health system strengthening, which refers to the improvement of a system's performance, as a major means to progress toward UHC (1). A functional health system is one that is organized around stakeholders associated with improving, maintaining, or restoring the health of their populations. Health system strengthening and UHC are interlinked with other goals and contribute to SDGs in numerous ways: reducing poverty (SDG1); equitable health outcomes and wellbeing and promoting global public health security (SDG3); improving the quality of education (SDG4); promoting gender equality (SDG 5); developing inclusive economic growth and decent jobs; and promoting inclusive societies (1). For progress of UHC and to ensure equitable access to UHC, the ability of services to reach all populations (population coverage), the availability of services that can be provided (service availability), and the extent to which individuals are protected from the financial consequences of accessing and receiving healthcare must be tracked, measured and tackled worldwide (13).

        Since the early 2000s, many African countries began initiating reforms of their health systems to achieve universal health coverage and are still working toward this goal today. However, implementing UHC has been riddled with various challenges across the continent and there are uncertainties as to whether supposed UHC in African countries has been able to provide equitable access to healthcare for its populations, especially in deprived communities. As a result, the aim of this systematic review is to examine the effects of UHC in facilitating equitable access to care in Africa amongst underprivileged individuals and communities. For the purpose of a research inquiry with a specific scope, the review focuses on vulnerable populations, which are the most excluded individuals and groups from access to, and use of, health services. This will help inform whether and in which contexts UHC programs have been successful in increasing equitable access to care, as well as to provide guidance for future evidence-based healthcare reforms. To the best of our knowledge, no systematic reviews of the effect of UHC in facilitating equitable access to care in Africa currently exist.

        Methods

        A systematic review guided in part by the Cochrane Handbook was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria (PRISMA) (14, 15). In accordance with PRISMA guidelines, our systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on April 24, 2018 (registration number CRD42018092793).

        Search Strategy

        The research strategy protocol was developed in collaboration with a university Health Sciences Librarian to refine our queries and characterize them in terms of the elements [Population, Intervention, Comparison, and Outcomes (PICO)] used for the questions even if all these elements have not been used in the formal research strategy.

        Search terms designed for Medline (see Appendix 1) and other databases included the following terms, namely: universal health coverage, health services accessibility, health equity, Africa. The following databases were searched without language restriction: MEDLINE, EMBASE, CINAHL, Global Health, and the Gray Literature. The PROSPERO registry was also searched for ongoing or recently completed pertinent systematic reviews. Reference lists of qualifying studies were also scanned. Citations published since the commitment of the WHO member countries in 2005 to reach Universal Health Coverage were searched (from 2005 to March 6, 2018).

        Selection Process

        Studies were eligible for inclusion if 1- they clearly mention studying the effect of UHC on equitable access to care, and 2- they mention facilitating factors and barriers to access to care for vulnerable and underprivileged populations (the needy). To be included, studies had to be in English or French (Table 1).

        TABLE 1
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        Table 1. Systematic review inclusion and exclusion criteria.

        After identification of studies, duplicates were removed using standard software (Endnote 7). Two independent reviewers conducted two levels of screening after exporting references from ENDNOTE 7 to Covidence. Level one screening, using citation titles and abstracts, was to determine study relevance to the overall objective of the systematic review (Table 1). Level two screening of full text was to determine if citations met inclusion criteria. The two reviewers independently extracted data with disagreement resolved through discussion.

        Study findings were extracted using a data extraction form that was initially pilot tested on three randomly selected included studies before its actual use. The two reviewers used the form to extract data independently.

        Method of Synthesis

        The method of synthesis used for this review is a narrative synthesis as guided by Popay et al. (16). The method is ideal and renowned for synthesizing evidence from a range of diverse sources, including quantitative, qualitative and mixed-methods primary research. The tool used to synthesize findings is a textual narrative description, which enables a simple and structured manner for describing and summarizing primary research data (Popay).

        Comprehensiveness of Reporting

        All included studies were appraised by both reviewers using the Critical Appraisal Skills Program (CASP) tool (17). The CASP tool has different tools for different study types (qualitative, quantitative, reviews, RCTs, etc.), so we used the appropriate tool depending on the study appraised. The appraisal tool included for each type of study between 10 and 12 questions and each question included options “Yes,” “No,” or “Cannot tell.” We considered that “Yes,” meant that the study included the subject of the evaluation of the question, and “No” and “Cannot tell” meant that the study did not include the subject of evaluation of the question. At the end of the evaluation of each of the 12 included studies, we gave a score. For example, if the study had 6 “Yes” and 4 “No—Cannot tell,” we gave it the score of 6/10 (60%). The two reviewers tested each study independently with the CASP guidelines regarding their design. Disagreements were resolved by consensus. Studies were considered high quality if they scored 80% or above of CASP criteria, medium quality if they scored 60–79.9% of CASP criteria, and low quality if they scored < 60% of CASP criteria.

        Data Analysis

        The data were synthesized by classifying different study types. Due to heterogeneity across study outcomes, data were analyzed descriptively. Study comparisons were grouped to answer research questions, and findings were synthesized based on outcomes. Characteristics of included studies were analyzed descriptively, and results were presented in a narrative format recommended by PRISMA and Popay et al. (16).

        Results

        Of the 271 citations reviewed, 12 studies published in 12 papers were eligible for inclusion (Figure 1). In terms of exclusions, duplicates were removed (n = 96), titles and abstracts not matching criteria (n = 159), and full texts that did not meet the inclusion criteria (n = 4) (see Appendix 2)

        FIGURE 1
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        Figure 1. Flow diagram of study selection process.

        The 12 studies were published between 2005 and 2018, with most published in 2017. Studies were conducted in: Ghana (n = 6), Kenya (n = 2), Malawi (n = 1), Madagascar (n = 1), Burkina Faso (n = 1), and Rwanda (n = 1) (see Table 2).

        TABLE 2
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        Table 2. Characteristics of included studies.

        Quality Appraisal

        The checklists cover the appropriateness of the research design, ethical considerations and standard conceptions for assessing risk of bias and overall quality. Quality assessment helped gather the relative strengths and weaknesses of the body of evidence.

        The 12 included studies (6 mixed methods studies, 5 quantitative approach and 1 qualitative approach) demonstrated that their research designs and recruitment strategy were appropriate for addressing the aims of their research. Ethical issues were taken into consideration in only 5 out of the 12 included studies, with the rest not clearly demonstrating the maintenance of ethical standards or indicating ethical approval from committee. Although the 12 studies had a sufficiently rigorous data analysis process and a clear statement of findings, using multiple strategies to establish credibility, 4 of them did not discuss potential bias and limitation. No study was excluded due to assessment of conduct (validity and robustness), assessment of reporting (transparency) or assessment of content and utility of findings. The average overall quality is 8.3/10, which suggests the sum quality of the included studies for this review is high. Studies were not excluded or weighted based on the quality of the assessment; instead, the quality is used to inform data interpretation and ultimately determine the credibility of review findings and conclusions.

        Synthesis

        As measured by health system reported service use, the use of health services by the poorest of the population increases equitable access to care in Africa, and this makes universal health coverage effective (19, 21, 22, 24, 26).

        Rwanda is the most advanced country in Africa regarding universal coverage. The country has achieved 96.15% coverage in health insurance, with 1.07 patient health center visits per year as compared to 1 visit recommended by WHO (24). In addition, equity is demonstrated with 24.8% of the subsidized indigents vs. 24.1% living in extreme poverty, and they have access to quality services that meet WHO standards (24). Life expectancy increased from 49.74 years in 2001 to 68.21 in 2017.

        In Madagascar, exemption from payment of health care in rural areas has led to an increase in the use of health services (22). In fact, less than one-third of people in need of care consulted in the past; but once the fees were removed, the use increased by 65% for all patients, 52% for children under five and more than 25% for maternity visits for an average direct cost of US $ 0.60 per patient (22). In Ghana, the government health insurance scheme increased the proportion of pregnancies with at least four antenatal visits by 7 points, with a significant effect on assisted deliveries by 10 points during the first year of operation (2, 19).

        Although universal health coverage seems to have an effect on increasing the use of health services, some imperfections remain. One of these factors is the shortage and inequitable distribution of health professionals (20, 21, 23). In fact, achieving universal health coverage involves distributing resources, especially human capital for health, to match population needs. In Malawi, the shortage of health care providers and materials combined with various factors including late bill payments and lack of transparency have greatly affected their system's performance (21). Moreover, between 1990 and 2009, Ghana witnessed a rapid increase in its supply of professional health workers: 185% more midwives, 260% more nurses and 1300% more physicians (8, 20). Approximately 14,000 additional professional health workers were trained and employed, a number representing four times the increase in population growth (240 vs. 59%) over the same period (20). A strategic plan for the equitable distribution of health professionals in Ghana was set up to improve the decentralization of human capital for health across the country (20). In Rwanda, the situation is similar; equity in the distribution of health professionals throughout the national territory is respected (24). However, in Ghana, a study shows that key areas of misalignment between the operations of the national health insurance and that of primary health care was the delays in reimbursements of claims for services provided by health care provider; which serves as a demotivation for service providers (9).

        The higher the health insurance coverage rate for the underprivileged, the more that people have access to it, displaying equity and social justice. In Madagascar, free reproductive health care has increased the use of services, including greater access to these services for the needy and thereby socially inclusive (22). In Rwanda, social justice exists to the extent that poor people and people living in extreme poverty have access to primary health services (as well as the more advantaged social classes) according to WHO standards (24). The Ghanaian health insurance has significantly increased access to prenatal care, and deliveries in health facilities for the most disadvantaged classes (19). However, although health insurance coverage increases the access of all social classes to primary health services by significantly reducing the financial contribution of users, the quality of its services (services capacity) still poses a problem in the majority of cases (20, 21, 23). There are governance issues of health systems. For instance, in Malawi, the lack of health professionals and their unequal distribution throughout the country, the stock-outs of medicines and health care equipment, as well as the late payment of rebate payments to health professionals, lead to a poor takeover of patients and demotivation of health professionals (21). In this case, even if the populations have access, the poor quality of the services will lead to a lack of confidence of the patients and a decrease of the use of the primary health services. Equity will not be respected because the wealthiest will go to private clinics or out of their country and the poor will be left to their own fate. As mentioned earlier, Ghana and Rwanda are success stories in this area as they have a strategic plan for the governance of their health systems according to WHO standards (20, 24).

        Finally, aside from financial risk coverage and quality of care, other factors are important to consider in order to ensure equity and performance of health systems (22). This includes ethnicity, religion, physical accessibility, decision-making, gender and autonomy, information and education. These non-financial factors pose considerable barriers to access because they are mostly sociocultural. In fact, they vary considerably not only between countries but also between different communities (23, 25). For instance, in Burkina Faso, factors such as age, distance from the household to the primary health center, prenatal visits, previous experience of giving birth at home, negative experiences with health centers, fear of cesarean delivery, and lack of transport, were key predictors of home births (23). To face this situation from an equity perspective, communities with the lowest utilization levels should be prioritized and the access barriers specific to that community identified.

        Discussion

        This systematic review set out to examine the influence of UHC on equitable access to healthcare. Study findings indicated that the UHC through the coverage of indigents by the health insurance increased the access to the primary health services but that the quality was not necessarily at the rendezvous. Access to quality care is the foundation of a health system's performance. Equity is respected only if both conditions are met. Indeed, the lack of health professionals and their unequal distribution throughout the country, the stock-outs of medicines and health care equipment, as well as the late payment of rebate payments to health professionals, led to a poor takeover of patients and demotivation of health professionals. Health system governance is the key element and some African countries such as Ghana and Rwanda are success stories in this area as they have a strategic plan for the governance of their health systems according to WHO standards. In addition, other barriers such as ethnicity, religion, physical accessibility (distance from the household to the primary health center), decision-making, gender and autonomy, information and education, age, prenatal visits, previous experience of giving birth at home, negative experiences with health centers, fear of cesarean delivery, and lack of transport impede the utilization of health services and therefore equity.

        The first element of equity that is access to health care (the second element being the quality of care) is not respected for different reasons beyond the UHC. Indeed, a systematic review published in 2017 on access barriers to obstetric care at health facilities in sub-Saharan Africa shows that access to obstetric care is riddled by several demand-side barriers including household income, non-availability of means of transportation, indirect transport costs, lack of information on health care services and providers, stigmatization, women's self-esteem, lack of birth preparation, cultural beliefs, and ignorance about required obstetric health services (27). The review also identified supply side barriers, including cost of services, physical distance to health facilities, long waiting times, poor staff knowledge and skill, poor referral practices and poor staff interpersonal relationships (27). Another systematic review analyzing non-financial barriers to access to health services in Ghana, Bangladesh, Vietnam and Rwanda presented perceptions of the condition, home management and local treatment, the influence of family and community, lack of autonomy and agency to act, physical accessibility, and health facility and biomedical barriers are deterrents to access to maternal, neonatal and child health services (28). Non-financial barriers have different expressions and weight depending on context and constitute significant constraints to the equitable access of the full range of health services included under UHC policies.

        Studies from developed countries found that despite systems of universal coverage, there was greater inequity, in terms of wait times and receiving of services, for programs deemed non-urgent, elective or for which there will minimal defined treatment protocols (29).

        In both developing and developed countries, inequity arose through disparities in quality of care and accessibility of specialized facility-based services. The type of health facilities being accessed varied by different socioeconomic groups. The privileged received most care services in provincial or general hospitals and private clinics, while the underprivileged tended to receive care from the lowest level providers, health centers (29). The underprivileged also had less options regarding providers, receive poor referrals and thereby a restricted set of benefits. This is consistent with findings amongst the underprivileged in the included studies of this review.

        The relationship between UHC and equity is evident to the extent that it allows for an increase in health care coverage and health outcomes, but it depends on the availability, accessibility, and capacity of health workers to deliver quality people-centered integrated care. It is therefore important to focus on the primary health care workforce because this is the most cost-effective way to ensure access to primary health care for all (30). To this, the addition of barriers of access to care and good governance of the health system should allow equity in access to quality health care and thus the achievement of the UHC and consequently the SDG 3.

        In December 2018, the WHO Health Workforce Director stated: “Health Workers bring us closer each day to achieving UHC. Their rights must be protected in the Health For All movement” (31). In fact, health systems can only function with health workers; improving health service coverage and realizing the right to the enjoyment of the highest attainable standard of health is dependent on their availability, accessibility, acceptability and quality (31, 32). African countries need to have a regional road map that defines actions for scaling up health workforce capacity. Currently, of the 46 countries in the Region, 36 have critical shortage of Human Resources for Health (HRH), 8 with only about 0.8 physicians, nurses and midwives per 1,000 population while the minimum acceptable density threshold is 2.3 per 1,000 population (32). When all categories of health worker are included, the shortfall is estimated at 1.4 million (32). The projected shortage of health worker for the African region will be 18 million by 2030. The reasons of this shortage of health workers are: migration of qualified health workers; inadequate remuneration and incentives; maldistribution of the available health workers significant disparities between rural and urban areas, with shortages in the rural areas (32). Over 90% of pharmacists and dentists practice in urban areas. The situation is the same for medical specialists (86%), general physicians (63%), and nurses and midwives (51%) serve mainly in urban areas; underinvestment in the production of sufficient health workers; inadequate capacity of HRH departments to carry out the main HRH functions; and low implementation of most of the existing plans are identified as the main causes of the present situation that constitutes a key impediment to meeting the needs for health care delivery for all.

        It is important for each country to research and identify these uncertainties in each community of the territory. In addition, there is a pressing need for further research on how these specific barriers interrelate and what their role and contribution is to accessing healthcare across different at-risk groups. Then, it will be necessary to put in place adapted strategies to fix these issues, and thus to aspire to increase the efficiency of UHC, which will result in a positive impact on health outcomes. This involves important political decisions. As a first step, African countries should have increased their health budget to reach the 15% provided for in the Abuja Declaration (33). Furthermore, it is important to improve the efficient use of scarce financial resources by enhancing value for money in health. In this regard, it is important for countries to continue to engage in policy dialogue to improve the efficiency and inclusiveness of service delivery, building on on-going operations and gains of the Value for Money Program. Mainstreaming the value for money agenda in all its health operations and contemplating similar action in education is necessary (34). The private sector through public-private partnership could be involved to address quality, efficiency, and financing issues in the health infrastructure and service delivery (34).

        Limitations

        There are limited studies on UHC in Africa' only 271 studies on the effects of UHC on equitable access to care were found through the databases. The review has only included 12 studies, which can be seen as low for this topic. However, the term UHC is new and many countries in the continent are still in the early stages. It is an emerging goal in most African countries and therefore still at the implementation stage. A major reason for the low amount of studies was because the authors sought studies that mentioned the term UHC, since using other terms, such as health insurance, would have complicated the analysis as there are several types of health insurance. The other major reason was the focus on underprivileged populations, which was justified in this review as underprivileged populations experience inequity to the largest extent. Additionally, many of these included studies were conducted in Ghana (6). As a result of these limitations, the results of this review cannot be feasibly generalized throughout the continent. The textual narrative synthesis method also has limitations. It is a relatively young method of evidence synthesis, with limited guidance on the conduct of the synthesis. As a result, complete transparency is an inherent limitation of the method. Implementation of tools and techniques to report findings relied on the authors' discretion of best practice, making it difficult for audiences to scrutinize authors' judgements and decisions. Nevertheless, the findings of this review are innovative, and the review is the first to help synthesize evidence on UHC and equitable access in Africa amongst underprivileged populations.

        Conclusion

        Universal health coverage and SDG 3.8 cannot be adequately achieved without equitable access to quality care by all citizens, including those who are underprivileged. African countries need well-functioning health systems and governance with sufficient and equitable distribution of health professionals who are adequately trained and skilled to provide quality care to patients. A system to control medicines and prevent material shortages and a strong regulation of the financial system for rebate payments to health professionals is also recommended. Through the increase of coverage by health insurance schemes, there can be improvements in access to care and thereby positive health outcomes in African populations. These requirements will need budget allocation to health from African governments. Lastly, as developing countries attempt to fully implement UHC for all residents, further research is required to assess the underlying changes in equity.

        Author Contributions

        NAS and SY conceived of the study and participated in its design and coordination. NAS, AWF, and SY drafted the manuscript. Each author critically reviewed the manuscript for its intellectual content. All authors read and approved the final manuscript.

        Conflict of Interest Statement

        The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

        Supplementary Material

        The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2019.00102/full#supplementary-material

        Abbreviations

        PICO, Population, Intervention, Comparison and Outcomes; UHC, Universal Health Coverage; WHO, World Health Organization; HRH, Human Resources for Health.

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