Master of Public Health Portfolio

The Better Way to Setup a Community Health Coalition.

Maintaining the general health of the community is a process that includes mental, physical, spiritual, and social connections. Building a community health coalition is a straightforward process that requires a clear understanding of the six foundational steps (5W1H) for a community initiative: Why (1), What (2), Where (3), Who (4), When (5) and How (6). The core project should analytically define what the purpose of the coalition is and thereafter identify potential partners.  Click to the to this link for full report: http://wp.cune.org/costandayisabye/files/2017/06/Final-Research-Report.pdf

 

Applied Research Paper

School Outreach for Tobacco Use Prevention

by Costa Ndayisabye, Nzaramba

B.B.A., Independent Institute of Lay Adventists of Kigali Rwanda, 2009

Thesis Submitted in Partial Fulfillment of the Requirements for the

Master’s Degree in Public Health

Concordia University

May 2016

Introduction to the Study

All over the world, public health is continuously experiencing challenges related to tobacco use behaviors among adolescents. Understanding the major causes of these behaviors can give a clue to significantly promote anti-tobacco use campaigns among youth. This research used existing published evidence that focuses on peer relationships and tobacco use in school environments to analyze their correlation and possible prevention strategies.

Problem Statement

It is unquestionably true that tobacco use is still the leading cause of premature deaths in the world. Cigarette smoking damages important numbers of organs in the human body causing both the smoker and people who are exposed to secondhand smoke to be susceptible to diseases. According to the World Health Organization, six million people are killed every year in the world due to tobacco use related illnesses. Half of the people who used tobacco products die from illnesses relating to smoking (WHO, 2015). Research findings indicated that there are a substantial number of smokers who do not experience the common health risks related to tobacco use behaviors (WHO, 2015).

In the United States, 480,000 people die as a result of smoking every year, bringing tobacco use to 1 in 5 of the cause of deaths in the country (CDC, 2015). Many of those who smoke today began smoking when they were young (adolescents). There is a significant prevalence of conventional and non-conventional tobacco use among adolescents. Statistics revealed that 3,800 adolescents smoke their first cigarette every day in the U.S. (CDC, 2015). According to the article “Youth and Tobacco Use” from the Centers for Disease Control and Prevention (2016) if the current smoking prevalence among youth continues 5.6 million of American younger than 18 years old will prematurely die from diseases related to tobacco use, which is equivalent to one of every 13 adolescents.

Although peer relationships are considered to be normal and can sometimes be positive, there is much research that indicated the correlation between peer relationships to the adoption of unhealthy behaviors. According to Forman, “Peer influence is one of the primary contextual factors contributing to adolescent risky behavior” (American Psychological Association, 2015).

Purpose Statement

Understanding the implication of peer relationships in promoting tobacco use prevention campaigns among adolescents in the school environment is the primary goal of this research.

Research Questions and Associated Hypotheses

Question1: Are peer relationships major influential factors of adolescent tobacco use behaviors in school environments?

Null Hypothesis: Peer relationships in school environments are not strong enough to influence adolescent tobacco use behaviors.

Alternative Hypothesis: Peer relationships in school environments are significant catalysts of adolescent behaviors.

Question2: How important are positive peer relationships in promoting tobacco use prevention programs among adolescents in school environments?

Null Hypothesis: Positive peer relationships are not strong strategies to promote tobacco use prevention programs among adolescents in school environments.

Alternative Hypothesis: Positive peer relationships are strong strategies to promote tobacco use prevention programs among adolescents in school environments.

Potential Significance

There is a substantial amount of research that focused on tobacco use behavior among adolescents. Conversely, there are extensive published studies on the impact of social networks on adolescents’ behavior. However, it is important to assess the connectivity of peer relationships among adolescents and the adoption or cessation smoking behavior in school environments. This research therefore, will select the most applicable evidence to systematically answer the above-mentioned questions.

Background Literature Review

Search Strategy

Electronic searches from Concordia University of Nebraska Library, MEDLINE, CDC, WHO, DHHS and peer reviews from PubMed, Google Scholar and Cochrane database were reviewed to extract important evidence for this study. This study considered two major primary key words: peer relationships in school environments and tobacco use among adolescents in school environments.

Theoretical Foundation

Ecological Systems Theory

Theoretical understanding on why adolescents adopt smoking behavior is an important process that was considered in this study. Although the American psychologist Urie Bronfenbrenner initially developed the ecological systems theory to broadly understand factors that influence a child from a microsystem to macrosystem levels, the model has been used by public health professionals to theorize the motive behind individuals’ behavior. One idea of the ecological systems theory is that the environment provides significant influences on individuals’ behavior. Microsystem, Mesosytem, Exosystem and Macrosystem are the four important levels of influence that the ecological systems theory uses to understand environmental impact on individual behavior. It should be noted though that, “some environments foster more risk behaviors than the others” (DiClemente, Salazar, & Crosby, 2013). Wiium and Wold (2009) used the ecological systems theory to assess the impact of the ecological factors on impact on adolescent smoking behavior. The study findings stated that leisure factors, school, and family play significant roles in adolescents’ smoking behavior. Therefore, this research indicates that the ecological systems theory is of utmost importance in examining the effect of peer relationships in school environments in order to plan for strategic tobacco use prevention programs (School Outreach in Tobacco Use Prevention).

Literature Review

Other than home, adolescents spend most of their time in school environments. Adolescents view friendship as an integral part of their daily life, and among themselves, they share ideas, jokes, and other influential factors such as doing homework together, smoking, using drugs, etc. According to the report Developmental Milestone published by the Centers for Diseases Control and Prevention (2015), adolescents between ages 15 and17 years old would prefer to spend more time with their peers than with their parents. Many studies have proven that social networks in schools have a significant influence among students. Though tobacco use is still considered as the leading cause of preventable deaths, substantial numbers of adolescents who use both smoke and smokeless tobacco products learn this behavior from their peers. Research titled Tobacco Use Among Middle and High School Students (Appendix 2) published by the CDC indicated that there was no prevalent decrease of tobacco use among middle and high school students in the period of 2008 and 2009 (2010). Environments such as school settings have significant impact on tobacco use among adolescents. Research findings stated that adolescents like to have reciprocal relationships with mutual respect and to grow friendship settings by being “friends’ friends” (Mercken, Snijders, Steglich & Hein de Vries, 2009). The study The Social Context of Adolescent Smoking: A Systems Perspective showed that an adolescent who smoked tended to engage in the same behavior with his or her friends (Lakon, Hipp and Timberlake, 2010). Sharing behavioral ideas is an important characteristic among adolescents. Although there is no scientific proof that shows why adolescent friendship is a determinant of smoking behavior, substantial number of reviews considered in this study indicated that there is a certain level at which peer relationships do, indeed, influence the adoption of smoking behavior among adolescents. Consequently, there is a strong likelihood that a friend of an adolescent who smokes will begin smoking as well. However, while peer relations can be considered as factors in promoting risk behaviors, they can also be a platform to market positive behavioral change.

Research Methods

Approach and Design

This study reviewed the existing research relating to the influence of peer relationships among adolescents in school environments, particularly on tobacco use; consequently, the qualitative method was used to collect significant data to answer the question “How important are positive peer relationships in promoting tobacco use prevention programs among adolescents in school environments?” According to Jeanfreau and Jack (2010), qualitative research is an action that focuses on human life experience through a methodical and interactive approach. It was under this perspective that this research collected data to assess possible answers that will support hypotheses. Some findings used to support the hypothesis: “Peer relationships in school environments are significant catalysts of adolescent behaviors,” were quantitative as they refer to provided statistical representations. The systematic review utilized both retrospective correlational designs to collect data. Retrospective design was used because data were extracted from the already published research. The study design is correlational because it predicts the effectiveness of peer relationships to promote tobacco use prevention among adolescents in school environments.

Exclusion and Inclusion Criteria

Key search words used to select papers of interest were: (a) tobacco use among adolescents, (b) impact of peer relations in school environments, and (c) social network influence in school environments. Using key search words identified in the background literature review, selected research titles, abstracts and full text were reviewed, and all studies that involved the following criteria: (a) studies published in English presenting factors related to peer relationships or tobacco use among middle and high school adolescents between ages 12 and 19 years old, (c) reported a measure of potential factors that discussed the association between adolescents’ networks and tobacco use in school environments. The reason the study limits the students’ age range to those between middle school and high school students is to exclude all articles that did not conform to the research problem and to specifically find articles that would answer the research questions. Moreover, articles published before 2010 were not considered in order to avoid outdated information. Studies that did not reflect issues related to tobacco use among adolescents were also excluded. However, through critical analysis, reports from the CDC and WHO that provided quantitative information about tobacco risks to health and the impact of peer relationships were included.

Papers that were not qualitatively original were excluded from review. The table below (Table 1) shows the inclusion and exclusion criteria used to obtain the most significant reviews for the study.

Table 1

Inclusion and Exclusion Criteria

Inclusion Criteria		Exclusion Criteria
·      English language papers		·      Papers published in other languages
·      Effects of peer relationships among adolescents in schools		·      Effects of parents on adolescents behavior
·      Tobacco use among adolescents aged between ≥12 ≤ 19 years old		·      Adults >19 years old and children who are <12 years old
·      Papers published ≥ 2010		·      All other papers published before 2010

 

Quality Methodological Assessment

Identified studies that fulfilled the above criteria were critically analyzed for quality before final consideration. Sources of information and search database used in this research are provided in the Appendix A. The student performed data assessment follows procedures provided by Bui (2014) whereby identified papers are arranged according to the two key words of this study previously discussed (p. 66).

Data Analysis Plan

This research uses PRISMA flow diagram to describe the included and excluded studies as and were illustrated in Figure 1. The figure provides the initial number of studies identified and final included papers.

Figure 1

Systematic Search Results Flow Diagram of Included and Excluded Studies

Results

Like other unhealthy behaviors, the soaring number of adolescents with tobacco use problems is becoming critical, especially in school environments. Adolescents spend a considerable amount of time in school with the goal of acquiring new skills. However, the school experience introduces children to different aspects of life. When children start their middle school education, they become much more attached to their peers as friendships are formed from shared experiences and/or common interests. Consequently, peer relationships constitute factors that often result in changes in adolescents’ life styles.                                                                   This section will present the correlation between tobacco use behaviors and peer relationships among adolescents in school environments. Furthermore, this section will reveal possible strategies to promote tobacco use prevention in school environments using positive peer relationships will be presented. The researcher endeavored to limit research to adolescents who were in middle school and high school. To ensure a systematic representation of evidence in this section, the researcher categorized and summarized the themes.

Data Collection

Data represented were completed using database searches and Internet-based sources with respect to the inclusion and exclusion criteria. There were 81 papers identified through the systematic literature reviews in this study. The majority of research selected, analyzed, and employed for this project were transversal studies in nature that were conducted within the last five years. After exclusion of the duplicates, 17 papers were removed based on titles and abstracts that did not reflect the research problems. These included studies that did not meet the inclusion criteria. Out of 26 full-text analyzed papers, seven articles were excluded for insufficient information or did not reflect the study’s target population and area. Nineteen papers were, therefore, included in the final review (Figure 2).

Figure 2. Studies Inclusion Process for Systematic Review 

 Data Analysis

Most of the evidence included in this study is cross-sectional in nature. The author selected studies based on the data they contained. With respect to the study questions and the hypotheses for this project and in order to minimize potential bias, the systematic review assessed papers published between January 2010 and February 2016 with targeted populations that are equal to twelve years old and not over nineteen years old. The concise description of included studies, their designs, interventions, populations of interest and primary outcomes are depicted in Table 2 and Table 3 as they relate to the influence of peer relationships among adolescents and tobacco use among adolescents respectively.

Table 1 briefly describes studies included that focused primarily on the effect of peer relationships in school environments and respects all the inclusion criteria of this project. Table 2 briefly presents the analysis of studies included with a main focus of “Tobacco Use Behaviors” among the adolescents. The inclusion criteria presented in the methods section of this study was highly considered.

 

Authors	Setting	Study Design	Population and Number (if defined)	Intervention	Primary Outcomes	Score
Karakos (2014)	School based analysis	Qualitative interview	High school staff members	Role of peers among adolescents in high schools	Presence of both positive peer support and negative peer influence Added a space here	8
Prinstein et al. (2011)	School based analysis	Qualitative interview	43 white adolescents, 11th grade	Susceptibility to peer influence	Normal distributed variable	8
Jeon & Goodson (2015)		Matrix methods: Systematic review	Adolescents	Friendship networks and health risk behaviors	Understanding risky behaviors can be useful to promote health programs	7
Tucker et al. (2014)	School based	Longitudinal study review	Adolescents in 11th and 12th grades	Peer influence and marijuana use	Peer influence on youth acts in different ways	6
Marks et al. (2015)	School based	Cross sectional study	310 students, aged 11-13 years	Friendship network characteristics are associated with physical activity and sedentary behavior in early adolescence	Friendships are associated with behaviors	6
Sussman & Grigsby (2014)	School based	A systematic, exhaustive literature search	Students	Alcohol, tobacco, and other drug misuse prevention and cessation programming for alternative high school youth	Successful efforts have focused on instruction in motivation enhancement, life coping skills, and decision-making.	7

Table 1: Characteristics of Included Studies: Peer Relationships’ Influences

 

Authors	Setting	Study Design	Population	Intervention	Primary Outcomes	Score
Morton and Farhat (2010)	Home and schools	Systematic review	Adolescents	Peer group influences and substance abuse	Adolescents with friends who smoke are likely to smoke	8
Green et al. (2013)	In-home survey	Longitudinal survey	Adolescents in 11th and 12th grades (20,745)	Adolescent smoking behavior	Smoking status might be derived from social network	7
CDC (2013)	School based	Cross-sectional	(24,658) Middle school students (6th & 8th grades)	Tobacco product used in middle schools and high schools	Ethnicity is a major determinant in smoking behavior	7
Cho, J., Shin, E. & Moon, SS. (2011)	Community	Hierarchical logistic regression analysis	4,341 Students	Electronic cigarette smoking among adolescents	Results were statistically significant predictors of e-cigarette experience	8
Thomas et al. (2013)	School based	Systematic review	428,293 students, aged 5-18 years old in 134 studies	Smoking intervention programs in schools	None of the studies showed the effectiveness of the program	6
Brinn et al. (2012)		Cochrane Review	Youth	Media and smoking cessation	No significant proof for media effect on smoking cessation	6
					Table continues

Table 2: Characteristics of Included Studies: Tobacco Use

 

Thomas et al. (2015)	School and community based	Randomized controlled trials	Adolescents	Family based smoking prevention among children	Family based intervention has positive effect on smoking prevention among children	7
Wakefiled et al. (2014)		Systematic review	Youth	Role of media and youth smoking behaviors	High quality evidence shows the effects of smoking behavior among youth	6
Stanton & Grimshaw (2013)	Community based	Review of randomized controlled trials	Teenagers	Tobacco cessation intervention	No specific intervention strategies on tobacco cessation among teenagers	6
Khrosravi et al. (2015)	School based	Cross-sectional study	450 males high school students	Smoking factors among youth in Iran	High prevalence of smoking behaviors	6
Warren et al. (2015)	School based	Systematic Reviews	513, 909 students	Disparity smoking effects among students from rural and urban schools	Consistent and fair differences of smoking behaviors between rural and urban students	7
McIsaac et al. (2016)	School based	Scoping review	Youth	Support system level of health promotion in schools (HPS)	Existing policies are challenges for HPS	6
Sarin et al. (2014)	School based	Cross-sectional anonymous survey	Adolescents	E-cigarette use among middle schools and high schools students	E-cigarette use among adolescents and establishment of policies to limit access are imperatively needed.	6

Fifteen of the nineteen studies included for the final review were conducted in the United States while the four other papers were conducted in South Korea, Iran, Senegal and Australia. The majority of the studies involved children who are in the adolescent age range. While others included children from the ages of five to nineteen. Four studies discussed both peer influence and tobacco use behaviors only among adolescents. They analyzed the correlation between peer influence and the adoption of tobacco use behaviors. Three studies examined the effect of peer relationships, nine discussed tobacco use behaviors and three focused on tobacco prevention. It is important to note that all studies had school environments as their primary area of interest.

Quality Assessment

To minimize potential risks of bias, quality of evidence was also assessed using the traditional Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework (Table 4) that justified the scoring method used in Table 3. Nine papers were considered to contain sufficiently high quality, significant data to answer the research problem (n=9, score=2). Five papers were considered to be of moderate quality with reasonable data (n=5, score=3) while five papers reflected low quality with one or two sections including significant information for the study (n=5, score=1). In all studies (n=19) included in the final review, the author did not find papers with a very low quality grade.

Table 3: Included studies rating using GRADE framework

Measure	Justification
High Quality (9)	Very confident that papers contained relevant information for the study
Moderate Quality (5)	Moderately confident that papers contained relevant information for the study
Low Quality (5)	Mixed findings. Confidence is limited in some part of the papers. Only a few sections of the papers provided important information for the study
Very Low Quality (0)	N/A

Even though the nineteen papers which were found to have significant elements needed by the author for this project, consideration may be given to some peer reviews or papers with relevant information for the study and may possibly be published during the compilation of this systematic review. For example, “Tobacco Use Trend Among the Adolescents in the U.S.” which was published in March 2016 would, therefore, be included in the data collection of the result sections.

The nineteen papers considered in this systematic review provided cases with different findings regarding peer relationships and adolescents’ behaviors particularly in the context of tobacco use. The most significant findings are represented in Figure 3. The first column represents studies that pointed to the effect of peer relationships on adolescents’ smoking behaviors whereas the second column specifies authors with different findings.

Figure 3: Findings with similar and different line of findings

Similar	Different
·       Adolescent with friend who smokes is likely to smoke (Mortona & Farhat 2010). ·       Adolescents’ friendship promotes both negative and positive behavior (Karakos, 2014) ·       Friendship is associated with behavior (Marks et al.2015) ·       Smoking behavior might derive from social network (Green et al. 2013)	·       Ethnicity plays a big role in smoking behavior (CDC, 2013). ·       Geographic area is the cause of smoking behavior (Warren et al. 2015)

Discussion

The study “School Outreach for Tobacco Use Prevention” is a systematic review, which was developed to determine if there is a possible correlation between peer relationships and adolescent smoking behaviors in school environments. Furthermore, the author sought to reveal whether or not peer relationships among adolescents could be used as a channel to promote tobacco cessation programs in school environments.

The use of systematic review in this study addressed significant limitations by comparing the evidence from various prior literature regarding the effect of peer relationships in on tobacco use among adolescents.

Because tobacco use behavior is becoming increasingly common among adolescents, understanding the major causes of this health risk behavior is essential in order to craft appropriate intervention programs.

Besides spending time at home, the majority of adolescents spend a substantial amount of time in school environments. The main purpose of education is to provide vital learning resources to build students’ academic development, physical and mental health statuses. However, when at school, adolescents tend to broaden the academic development purpose to include friendship creation, which encompasses different types of behaviors. While the majority of the studies focus on academic, physical and mental development, the author of this study concentrates his attention on behavioral factors that are derived from peer relationships in school environments, particularly on tobacco use among adolescents. Therefore, school environments are very conducive to understanding the relationship between adolescent friendships and tobacco use behaviors. To deeply understand adolescent behaviors in school environments, the author analytically reviewed various papers that addressed the issue.

Data Interpretation

To better interpret the results in this study, the author categorized the findings into three subjects: (a) “peer relationships among adolescents,” (b) “tobacco use behavior among adolescents,” (c) the correlation of the previously two mentioned categories.

Peer Relationships

The setting of socialization provides opportunities for group interaction. Simply stated, creating friendships is a natural structure for social interaction. Friendship formation varies depending on age, sex, culture, and religion and people adhere to a social group that is compatible with their personal interests. Places such as home, school, church, and the workplace are settings that play a significant role in accommodating social groups. One study found that people from different demographic settings were often influenced by friendships that were consistent with what their peers offered (Morton & Farhat, 2010).

This particular study focused on social networks that involved adolescents, especially in school environments. During the period of adolescence, an individual typically experiences physical changes that are distinctive according to mental and social developmental norms of the specific age group. Peer relationships constitute one of the most important influences on life styles during adolescence. Adolescents tend to have less connection with their parents than they did in their younger years; rather, they are likely to find those who are the same age as them at school to be more important than their parents. The friendships created in school environments open the window to adolescents for both positive and negative behaviors. It is essential to an adolescent to have peer with whom he or she can share ideas and create companionship. According to the article Friendships — Helping Your Child Through Early Adolescence published by the U.S. Department of Education, friendships are important to teenagers’ development. Adolescents who are unsuccessful in making friendships can struggle with “self-esteem” issues and even perform poorly in school (2013). The same article indicated that adolescents consider friendships as a crucial sign of who they are and which direction of life they are taking (U.S.DE, 2013).

In a study conducted by Karakos (2014) regarding the role of peers among adolescents, peer relationships have both positive influences, which were considered as “peer support,” and negative influences. Positive behaviors derive from adolescents’ friendships help adolescents to build confidence and to provide support to themselves in times of stress. Negative behaviors obtained during youth are common and sometimes pose risks to adolescents’ lives, which could lead to problems such as delinquency, health issues and less interest in school. Supporting Karakos findings, two of the papers reviewed in this study indicated that peer relationships had have more influence on adolescents’ behaviors while four papers mentioned that adolescents’ peer relationships are significant to understand risky behaviors. Morton and Farhat (2010) pointed out that the chance of juveniles being susceptible to peer influences is greater, especially in school environments.

Tobacco Use Behavior

Tobacco use is still the leading cause of preventable deaths in the United States. A report from the CDC indicated that 16 million Americans suffer from diseases derived from tobacco use whereby 480,000 deaths occurred every year as result of smoking behavior (CDC, 2016). Smoking is found to be responsible for lung diseases, diabetes, chronic obstructive pulmonary disease (COPD), cancer, stroke, heart disease, and it also increases the risk for tuberculosis (CDC, 2016).

Adolescents constitute the first generation of smoking groups. Research has shown that nearly 90% of individuals who smoke for the first time are adolescents who are 18 years or younger (Park, S., 2011). With that said, tobacco use behavior among adolescents is regarded as an evolving trend that is causing significant challenges to public health. In 2014 a soaring number of adolescents who smoke was recorded, the highest ever in history (U.S.DHHS, 2016). In the United States for example, a report indicated that every day 3,200 people aged 18 years old or younger smoke their first cigarette, which is equivalent to 1,152,000 per year (CDC, 2016). Adolescents who use tobacco experience early health consequences that interfere with the body system and are likely to develop a dysfunction of the peripheral airway and experience a decrease of the forced expiratory in seconds (FEV1) (Park, S., 2011).

Smoking behavior is a learned process that adolescents acquire gradually. Adolescents who use tobacco products tend to use them over and over. The frequency of smoking behavior increases with the length of the smoking period. According to Park (2011), cigarettes were categorized as one of the most addictive products available to consumers. Considering the growing number of adolescents who use tobacco products, it is important to understand the root cause of this health risk to plan for precautionary measures.

Peer Relationships and Tobacco

Peer relationships are among the most influential social factors associated with tobacco use among adolescents (Morton & Farhat, 2010). Papers included in this research in one way or the other indicated that adolescents smoking behavior is linked to social network motives. Out of the 19 papers reviewed for the purpose of this study, the author found 13 papers indicating that the role of peer relationships represent a significant influence to risk behaviors including tobacco use among adolescents. Chan and Goodson (2015) stated that adolescents with direct relationships have cohesive behaviors (Figure 4, A-B).

Figure 4: Cohesion and structural equivalence of peer relationships

 

 

Adapted from Peer, J. article published by Chan and Goodson (2015).

Figure 4, Part 1 Cohesion represents the diagrams of cohesion and structural equivalence in a network. The significance derived from A and B indicates that there is a strong relationship explaining the existence of cohesion between two teenagers with a direct friendship; conversely, A-B and A-D seem to have indirect relationships indicating the absence of cohesion that might lead to friendships’ influence. Part 2 represents B-C and C-D to be structurally equivalent because adolescents have the same interests, in which case relationships are likely to influence behaviors.

According to Green et al (2012), numerous studies have proven that peer relationships have a significant influence on adolescent smoking behavior. The authors added that adolescents whose peers place a high value on using tobacco products would ultimately tend to emulate the same values for like behavior. The stronger the friendship, the more it builds trust among peers on different behaviors offered mutually. A one-year longitudinal data gathering from the National Longitudinal Study of Adolescent Health Tucker et al (2014) indicated that adolescents might feel comfortable in offering illegal substances to their friends or in trying whatever is offered to them by their friends in order to credit their friendships.

Theoretical Interpretation

Studies included in this research did not fully explain the correlation between the influence of peer relationships and tobacco use behavior among adolescents. However, theories indicated that adolescents learn different behaviors including smoking from their peers. Green et al. (2012) presented strong theories that connected peer relationships to adolescent behavior.

Conclusion

Despite of policies in place to restrict smoking in public areas, tobacco remains legal in many countries albeit its incessant hazard to consumers’ health. The use of multiple tobacco products today is predominant among adolescents. This research, therefore, endeavors to analyze possible channels used by youth to adopt tobacco use behavior and identify potential strategies to eradicate smoking habits among adolescents. However, limitations were encountered in this study, which is why the researcher provided recommendations to obtain more evidence that will more clearly determine the major cause of tobacco use among youth and potential prevention strategies.

Limitations

This project has a number of limitations derived from included studies. Based on the Traditional Grading of Recommendations Assessment, Development and Evaluation (GRADE), the author has concluded that five out of the 19 included studies were of low quality due to limited data they contained. Conversely, six studies were inferior in providing significant evidence as they were conducted outside of school environments.

For example, the survey conducted by Tucker et al. (2013) was an in-home based study, which did not discuss important information on adolescent behaviors that might occur in school environments.

When searching for research to include in this study, the author obtained a substantial number of articles that discuss either tobacco use behavior among adolescents or the effects of peer relationships on adolescent behavior. With that being said, most of the studies did not directly discuss the relationship between the two dependent variables of this study (peer relationships and tobacco use behavior), which in turn, led to inadequate findings to support the study’s goal to determine potential correlation between the two behaviors previously mentioned.

Papers included in this study were primarily conducted in different countries, which could lead to cultural differences. These limitations explain disproportionalities in the cross papers included in this study. Additionally, the presence of item bias included cultural-based papers was likely to be present. It is essential to note that poor choices of “cultural phrases” or inadequately assessed cultural items are considered as item bias (Study.com, 2016). Consequently, cultural differences should also be considered as behaviors of students from one school environment could differ from the other.

Unlike experimental studies which apply statistical findings, research based on reviewing the existing articles may have potential biases. The number of findings considered for this systematic review may contain risk of bias, as they could not be independently verified due to the fact that they were self-reported data in nature.

Recommendations

Tobacco use behavior among adolescents is an alarming public health challenge today. Finding appropriate causes that lead to this unhealthy behavior can be crucial in determining strategies to prevent adolescents from using tobacco. Unfortunately, the author did not find specific studies that described the root cause of this unsafe behavior. As a consequence, the number of adolescents using tobacco products is soaring tremendously.

Although comparing results from different sources is an appropriate method when conducting a systematic review (Barrat & Kirwan, 2009), this study does not fully justify that peer relationships among adolescents are strategic channels to promote tobacco use prevention in school environments. Furthermore, the author did not find evidence that described the correlation between tobacco use behavior and peer relationships among adolescents in school environments. Thus, promotion of tobacco use cessation programs should be critically assessed before actual implementation.

Findings from this study suggested that further research is needed regarding the impact of peer influence as it relates to adolescent tobacco use behavior in school environments. Schools and school personnel play a vital role in promoting students’ overall health; therefore, research which focuses on tobacco use among adolescents should consider school staff as participants in the effort of preventing this harmful behavior.

As a global issue, adolescent tobacco use has far-reaching effects as it can have a significant positive impact on the health of current and future generations. If governments and health professionals around the world are willing to work with stakeholders in considering and addressing the seriousness and magnitude of this issue, support studies designed to provide a clear understanding of the motivation for adolescents to use tobacco, and join in the effort of combating and eradicating tobacco use, especially in school environments, a significant reduction of this health risks within citizens would be the likely result. On the other hand, if the necessary efforts are not put forth society will continue to be placed at risk for myriad health problems for generations to come.

References

Appendix B: Percentage of middle and high school students currently using tobacco products, by school level, sex, race/ethnicity, and product type — National Youth Tobacco Survey, United States, 2011 and 2012. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6245a2.htm

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http://www.healthknowledge.org.uk /public-health-textbook/research-methods/1a-epidemiology/systematic-reviews-methods-combining-data

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Centers for Disease Control and Prevention (2015). Developmental milestone. Retrieved from http://www.cdc.gov/ncbddd/childdevelopment/positiveparenting/adolescence2.html

Centers for Diseases Control and Prevention (2015). Health effects of cigarette smoking. Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/

Centers for Disease Control and Prevention (2015). Youth and tobacco use. Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/

Centers for Diseases Control and Prevention (2013). Youth and tobacco. Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/

Centers from Disease Control and Prevention (2010). Tobacco use among middle and high school students. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6245a2.htm

DiClemente, R.J., Salazar, L.F., & Crosby, R.A. (2013). Health behavior theory for public health. Burlington, MA: Jones and Bartlett.

Forman, A. A. (2015). Facets of peer relationships and their associations with adolescent risk-taking behavior. American Psychological Association. Retrieved from https://www.apa.org/pi/families/resources/newsletter/2015/12/adolescent-risk-taking.aspx

Jeanfrau, S. and Jack, L. (2010) Appraising qualitative research in health education: Guidelines for public health educators. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3012622/

Lakon, C., Hipp, J., & Timberlake, D. (2010). The social context of adolescent smoking: A systems perspective. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2882398/

Mercken, L., Snijders, T., Steglich, C. & Hein de Vries, A. (2009). Dynamics of adolescent friendship networks and smoking behavior: Social network analyses in six European countries. Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi= 10.1.1.663.8121&rep=rep1&type=pdf type=pdf

Study.com (2016). Testing bias, cultural bias and language differences in assessments.       Retrieved from http://study.com/academy/lesson/testing-bias-cultural-bias-language-differences-in-assessments.html

Sussman, S. Arriaza, B. & Grigsby, T. (2014). Alcohol, tobacco, and other drug misuse prevention and cessation programming for alternative high school youth: A Review. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/josh. 12200/abstract

Tucker, J., Haye, Kennedy, D., Horta, M., Green, H., & Pollard, M. (2013). Peer influence and selection processes in adolescent smoking behavior: A comparative study. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22944605

U.S. Department of Education (2013). Friendships — Helping your child through early adolescence. Retrieved from   http://www2.ed.gov/parents/academic/          help/adolescence/part9.html

Wakefield, M., White, M., Durkin, J. & Coomber, K. (2015). What is the role of tobacco control advertising intensity and duration in reducing adolescent smoking prevalence? Findings from 16 years of tobacco control mass media advertising in Australia. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23988860

Wiium, N. & Wold, B. (2009). An ecological system approach to adolescent smoking behavior. Retrieved from https://www.ncjrs.gov/App/publications/abstract.aspx?ID=250647

World Health Organization (2015). Tobacco. Retrieved from http://www.who.int/mediacentre/factsheets/fs339/en/

Appendixes

Appendix A

Search Sources

Database searched	Period effectiveness searches
Centers for Diseases Control	2010-2016
Clinical Key	2010-2016
Cochrane Library	2010-2016
Concordia University of Nebraska Library	2010-2016
Journal articles from PubMed	2010-2016
Tobacco Control	2010-2016
U.S. Department of Health and Human Services	2010-2016
World Health Organization	2010-2016

Appendix B

Percentage of Middle and High Students Currently Using Tobacco Products

Practicum Final Paper

Costa Ndayisabye

Concordia University of Nebraska

Submitted April 20, 2016

Abstract

Practicum was an important opportunity for me to demonstrate what I have been learning for approximately the past two years in the profession of public health and to experience the reality of public health settings in real life Linda Campbell from the University of Georgia, one of the American Psychological Association staff, stated that “Practicum isn’t practicing anymore. It’s the real thing” (Chamberlin, 2016). I spent 75 practicum hours in Texas at the Amarillo Department of Public Health under supervision of Casie Stoughton who is the director. My plan was to work five hours a day for 15 days.

Introduction

The City of Amarillo Department of Public Health Overview  

The City of Amarillo Department of Public Health, located at 1000 Martin Road in Amarillo, Texas, is accountable to for implementing public health programs, mainly diseases prevention and health promotion to residents of Randall and Potter counties. The department is funded by the city of Amarillo. The director of the department is a Registered Nurse and has a Master’s in Public Health.

The City Amarillo Department of Public Health is organized into four small sections:

1. Disease Reporting: In this section the public health staff works closely with medical laboratories, school nurses, day cares centers, and other medical facilities to track any probable diseases. It is under this program that health education is provided to the citizens.
2. Immunization Program: This program has the objective to reduce “vaccine preventable diseases in Potter and Randall counties”. The Public Health Department has a mobile immunization clinic that is used during health promotion campaigns.
3. Refugee Services: The city of Amarillo receives an approximate 450 refugees each year, all of whom come from various countries with low public health attention. The Department of Public Health provides the new Amarillo residents (refugees) with an integration session on the American health system. Furthermore, refugees benefit from the city public health initial health screenings, immunizations and healthcare references.
4. HIV/ STD prevention: This program is responsible for assessing and treating sexually transmitted diseases of the clients. It is under this section where residents get important information regarding STD prevention.

Due to the high demand of workers in the meat packaging factories and newly created windmill businesses, the population of Amarillo is growing day by day. The population of Amarillo is growing day by day, which has a significant impact on the community. However, despite of the growing amount of businesses, the city still has substantial number low-income communities. According to a report from City-Data.Com (2013), the city of Amarillo has 42% of indigents who did not complete high school and are not living in families. With such a large number of indigents, the City Public Health Department has a crucial responsibility to monitor their health and ensure they are getting any medical assistance they need     Briefly the Amarillo Public Health Department’s responsibility is to oversee the quality of care of the residents overall.

There are two main healthcare partners that the city department of public health works with to ensure indigents are receiving care they need. These are JO Wyatt and Northwest Women’s and Children’s Healthcare Center (WCHC).

JO Wyatt and WCHC are health centers that provide care to eligible low-income population in the city of Amarillo. Based on the city public health board meeting, it has been necessary to conduct quality assessments of the different services that are provided by JO Wyatt and WCHC. I was, therefore, assigned to evaluate quality of care based on a quality indicator report assembled by the City Public Health Department and compared to the national standard reports.

Discussion

The first day of my internship, the Director of the Amarillo Public Health Department and the assistant Director briefed me on the entire duties of the city as far as public health is concerned. They both told me that the city’s major public health major concern is the quality of health that is being provided to poor communities. Both JO Wyatt and WCHC clinics that closely work with the city to provide health care for indigents do not have a quality standard of the services they render. I was, therefore, also assigned the task of gathering health care quality data that portrayed the national standards in different sections of health care and comparing the data with the reports provided by the JO Wyatt and WCHC health care centers.

Data from the JO Wyatt and WCHC reports were combined into one comparative report (Appendix 1), which I utilized as a governing tool for the data extractions.

Data Extraction

Finding reports that indicate national standards of quality of care needed by Americans is very difficult. I conducted the data extraction process from the Agency for Healthcare Research and Quality (AHRQ), which is mostly responsible for developing and maintaining Quality Indicators (QIs) that can be used to measure health care performance. QIs evaluation and comparison were therefore very important tools for my internship. According to Farquhar (2008), “QIs are evidence based and can be used to identify variations in the quality of care provided on both an inpatient and outpatient basis.”

Electronic searches from the Department of Health and Human Services, MEDLINE, CDC, and peer reviews from PubMed, Google and Cochrane database were also used to extract important evidence. Additionally, there were also independent publications on quality of health care on specific service that were reviewed for this evaluation. Quality indicators were obtained and compared to the report from the Amarillo Department of Public Health denoted ADPH as discussed in the following paragraphs. It is important to note that evaluation report provided by APHD covered information from 2006 to 2014.

Timely Care

Appointment with Primary Care Provider                                                                 From the research I conducted, I found well-timed care depends on states or cities. Reports reviewed did not explicitly find a national law that standardizes time patients should wait to get the needed health care service. However, there were evaluations that provide the best health quality as far as wait time is concerned. A report published by Rosenthal (2014) from the New York Times indicated that the twin cities of Dallas-Forth Worth had the lowest wait time for new patient appointments with family practice physicians, which is five days compared to Boston, where new patients could wait up to 60 days. The report from the APHD indicated that patients who visit JO Wyatt and WCHC clinics have a wait time of two days indicated which I found reasonable.

Initial Prenatal Checkup

The current report found that contained Quality Indicators was the Survey of Patient Appointment Wait Times published by the Merritt Hawkins (2014). This report indicated that Boston has the highest cumulative average for obstetrics/gynecology physician appointments in the country and Dallas has the lowest. The same report mentioned that Boston has the longest average physician appointment wait times of the 15 metro markets surveyed: 72 days to see a dermatologist, 66 days to see a family physician, 46 days to see an ob/gyn, 27 days to see a cardiologist, and 16 days to see an orthopedic surgeon. On average, new patients will have to wait up to 45 days or more to be visited by a specialist in Boston. The national wait time average was 28 days while time range depicted on the Quality Indicator sheet from the city of Amarillo Public Health Department indicated a four-day difference compared to the cumulative average for OB appointments in Dallas.

Percentage of Children Two Years Old with Up-to-Date Immunizations

Before extracting necessary data to compare with the report from the Amarillo Public Health Department, I discussed with the director whether or not parents who visit JO Wyatt and WCHC health clinics understand why their toddlers need vaccines. According to CDC, vaccines have a positive impact on children’s health (2015). It helps to prevent people from different types of disease such as hepatitis A and B, haemophilus influenzae type B, influenza, pneumococcal disease, rotavirus, polio, chickenpox, diphtheria, tetanus, pertussis, measles, mumps, and rubella (CDC, 2015). The report from the APHD showed that 88% of children 2 years old got the updated required vaccine, while the national average was 78% as reported by the Children Trends Data Bank (2015).

Percentage of Diabetics Referred for Eye Exam

According to the APHD director, some of the indigents served by JO Wyatt and WCHC have diabetes and the staff try to ensure that patients are receiving appropriate care they need to delay the severity of the disease. One of the most important exams is to regularly check their clients with diabetes to determine if they have any risk of diabetic retinopathy and, if so, refer them to an ophthalmologist for treatment. The report from the APHD mentioned that an average of 82% of clients with diabetes were referred to the eye clinic for the period 2006-2014. The was no a current national QI for retinal eye exam; however, a 2013 report published by the National Committee for Quality Assurance asserted that only 52% of diabetics went thorough retinal testing (NCQA, 2015).

Percentage of Diabetics Receiving Blood Sugar Control                                                        Individuals with diabetes may have a consistently high blood sugar level. Having a regular control protocol can help to reduce risks related to many other health problem. During the search I conducted, I did not find specific data that tells the number of U.S. citizens with diabetes who receive blood sugar test regularly. However a report produced by the Nation Institute for Diabetes and Digestive and Kidney Diseases stated that “Nearly 24 million people in the United States have diabetes, 2 out of nearly 180,000 people are living with kidney failure as a result of diabetes” (NIH, 2014) which means 100% of individuals diagnosed with diabetes should go through microalbuminuria screening (2014). Data obtained from the APHD report indicated that 95% of indigent people with diabetes received blood sugar testing in the period of 2006-2014. Keeping this percentage high can help to prevent hearth diseases of the population served by both JO Wyatt and WCHC centers.

Women Referred for Mammograms

Even though there was no available data that indicates the national average number of women who are referred for mammograms, the Qis reported by both JO Wyatt and WCHC clinics mentioned that an average of 76% to 88% were referred and got mammograms respectively for the period of 2006-2012 (report attached).

Length of Time to Eligibility Approval                                                                                    As above mentioned, JO Wyatt and WCHC centers primarily treat Medicare, Medicaid and uninsured patients and qualified Amarillo indigents who need to prove their eligibility. The eligibility process is analyzed by the clinics and clients are informed of the results. After assessing different information that provided the eligibility requirements, I found both JO Wyatt and WCHC have four days until they decide on a benefit application, while for in the State of Texas it takes up to 30 days for to receive a response.

In the beginning of the internship, it was difficult to understand the complex context of public health settings in the city. It was also difficult to get a response from the department staff as the busy Director could hardly ever be reached. However, I found that communicating with her through emails got a reply in three days or more. I noticed that the director was at the center of everything, which limited other department employees from being involved in the management of the department. For example, I scheduled a meeting to with the Director and had to wait and reschedule three times before we were able to meet to discuss some challenges I had encountered in completing tasks I was assigned to do.

Personal Assessment

Without the courses I have taken in the public health programs, I would not have been able to accomplish the internship at the Amarillo Public Health Department. It was through the skills I attained from my courses that I had the confidence to prove to the APHD Director and her assistant that I was the right choice for an internee. I was able to discuss with them the various skills I had learned to prevent to reduce infectious and chronic diseases, especially from the course MPH 520 Concepts of Environmental Health. What I learned in this course helped me to understand the concept of disease prevention that the city of Amarillo is involved in which are designed to ensure residents have reduced health risks.

Conducting the evaluation of health care quality indicators, I was able to apply the skills learned in MPH 525 Health Policy and Management more specifically on individual rights versus population rights in public health and the law. Additionally, I managed to ask and understand the concept of ethical principles and how they apply to access to healthcare, health promotion and disease prevention in the community. Furthermore, I learned and discussed with the staff at the APHD issues regarding individual’s rights to the health care. I shared my personal experience when I had an appointment with PCP at one of the health centers that mostly serves low-income communities under Medicaid. For this appointment I was asked to fast and to arrive at 10:00 a.m., which I respected and arrived on time. After checking in, I met the LVN for vital signs at 12:00 p.m. and then put in the doctor’s waiting room. I waited until 1:25 p.m. and had not seen anyone, at which time I decided to leave the room and go to reschedule my appointment. I am sure many patients have faced the same experience all over the country. This happened this year 2016 after I had stepped into the public health bay. I knew most of patients there, would not know how to professionally address this issue. As a result of this experience, I decided to do something that has changed health center effectiveness a great deal. I knew my rights because of various understandings regarding public health settings I had learned from my class, which included a patient’s right to health care.

Given the soaring number of communicable diseases, the government is now being forced to restructure its healthcare system with much emphasis on public health. I believe to implement programs to reduce preventable diseases governments have a sole choice, which is to involve skills from Public Health practitioners. Skills obtained from the course MPH 588 – Marketing in Public Health were crucial and helped me to discuss with the APHD staff on the usefulness of creating more strategies that will help to prevent diseases.

Conclusions and Recommendations

Among other duties the main work I performed at the Amarillo Public Health Department was to gather national Quality Indicators and compare it with the report from the two major partners of the city that are JO Wyatt and WCHC centers. It was a meaningful experience to me as a new public health professional. I was able to learn the weaknesses and strengths of the APHD and the two clinic data and also knowing how their health care QIs stand nationally. It is a privilege for the more than two hundred thousand Amarillo residents to have a public health department that serves them locally as the absence of an effective public health system at local levels is one the primary causes that hinder the implementation of public health programs.

My recommendation is that the APHD should design an annual monitoring and evaluation plan that would assess the quality of care that is provided by their partners. Another recommendation I discussed with the director of the APHD was to design patient questionnaires that could be used to compare with corresponding clinic reports. A further critical point I discussed with the director was to plan for public health campaigns that will increase awareness and encourage the community, especially the indigent population, to adopt healthy behaviors.

As a member of APHA, I believe public health advocates play a significant role as mediators between federal and state governments. For example, the APHA commitment to ensure reasonable access to care, to protect funding for core public health programs and services and to eliminate health disparities has been one of the vital plans undertaken by public health professionals.

References

Child Trends Data Bank (2015). Immunization. Retrieved from       http://www.childtrends.org/?indicators=immunization

Centers for Disease Control and Prevention (2015). Parents’ guide to childhood immunizations.    Retrieved from http://www.cdc.gov/vaccines/pubs/Parents-Guide/default.htm

City-Data.Com (2013). Amarillo, Texas (TX) poverty rate data. Retrieved from http://www.city- data.com/poverty/poverty-Amarillo-Texas.html

Farquhar, M. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK2664/

National Committee for Quality Assurance (2015). What is the Current State of Quality of Care in Diabetes? Retrieved from: http://www.ncqa.org/PublicationsProducts/OtherProducts/QualityProfiles/FocusonDiabetes/WhatistheCurrentStateofQualityofCare.aspx#sthash.BSac0rdy.dpuf

Nation Institute for Diabetes and Digestive and Kidney Diseases (2014). Kidney disease of diabetes. Retrieved from http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/kidney-disease-of-diabetes/Pages/facts.aspx

MPH Practicum

Quality and Access to Care Evaluation

Health Centers: JOWyatt and WCHC

Amarillo Public Health Department

Compiled by Costa Ndayisabye

March 21, 2016

Introduction

In order to ensure patients are receiving the appropriate health services that reflect the national or universal standards, health care quality assessment is an important element that health care providers should consider in their routine.

As per the assignment, this quality indicator assessment was conducted through a systematic comparison of data provided by the Amarillo Public Health Department to the national health care quality standards. The major issue of this quality assessment focuses on “Patient wait times to receive health care”.

Data Comparison

Timely care varies depending on states or cities. Research conducted did not specifically find the national law that standardizes time patients should wait to get the wanted health care service. However, there are many reports that provide the best health quality as far as wait time is concerned. These reports, therefore, were critically reviewed to extract data that would be compared to the Quality Indicator sheet from the City of Amarillo Public Health Department (Denoted APHD in this evaluation). To ensure accuracy of relevant data extraction reports from trusted sources such as GIGAOM, the Agency for Healthcare and Quality from the Department of Health and Human Services, Huffington Post, New York Times, Vital.com, etc. were examined.

1. Wait time for a new patient appointment with a PCP for patient with an acute condition.

According to Rosenthal (2014) from the New York Times a survey has indicated that the twin cities of Dallas-Forth Worth have the lowest wait time for new patient appointments with family practice physicians, which is 5 days compared to Boston, where new patients could wait up to 60 days. The maximum wait time of 2 days indicated in the Quality Indicator sheet from the city of Amarillo Public Health Department is reasonable. Median: 32.5

2. Average wait time for a new patient appointment after FNAC approval:

Average (year 2006-2013): 30 Hours

I would refer this point to the aforementioned standard in description 1, where the average wait time for new patient appointment with a PCP for patient with an acute condition is 5 days as portrayed on in the chat 2.

3. Average or range of wait time from initial contact with clinic to first prenatal appointment

According to Merritt Hawkins (2014) Boston has the highest cumulative average for OB physician appointment in the country and Dallas has the lowest.

Chat 2: Survey of Patient Appointment Wait Times (Merritt Hawkins, 2014).

Average (year 2006-2013): 9 days (APHD)

National Report: 28 days

With the above information time range depicted on the Quality Indicator sheet from the city of Amarillo Public Health Department indicated 4-day difference with cumulative average for OB appointment in Dallas.

4. Current wait time reported by ADPH for:
5. a) WCHC

Average (2006-2014)= 16 minutes (APHD)

1. b) JOWyatt

Average (2006-2014)= 22 minutes (APHD)

National Report patient average wait time to see the provider: 19 minutes. Alabama has the highest (23 min) and Wisconsin has the shortest (15 min) reported by Daily News (2015)  

5. Percent of 2-year olds seen in JOWyatt with up-to-date immunizations

Average: 88% (2006-2012) (APHD) Note: There are no data for years 2013 and 2014

National average: is standing at 78 percent in 2014 (Children Trends Data Bank, 2015)

4A: Percentage of diabetics receiving year referral to ophthalmologist for eye exam

Average: 82% (2006-2014)

No current statistics, however, a 2013 report indicated an average of 52% national for retinal eye exam (NCQA, 2015).

4B: Percentage of diabetics receiving controlled blood sugar services

Average: 95% (2006-2014) (APHD)

Sufficient data are not available to estimate the national average of diabetics who receive controlled blood sugar service.

4C: Percent of diabetics receiving microalbumin or creatinine clearance screening

There is no specific data (percentage) found, however a report produced by the Nation Institute for Diabetes and Digestive and Kidney Diseases stated that “Nearly 24 million people in the United States have diabetes, 2 and nearly 180,000 people are living with kidney failure as a result of diabetes” (NIH, 2014) which means 100% of individual diagnosed with diabetes should go through microalbuminuria screening (2014)

4D: Percent of diabetics receiving annual foot exams

Average: 84% (2006-2014) (APHD)

National Average: 74% (CDC, 2012).

5A: Percent of women 50+ of age referred for yearly mammograms:

Average: 92% (2006-2014) (JOWyatt)

Average: 86% (2006-2014) (WCHC)

National average: 66.8% (2013) (CDC, 2015).

5B: Percent of women referred for mammograms that received mammograms.

Average: 76% (2006-2012) (JOWyatt)

Average: 80% (2006-2012) (WCHC)

National average: no data available

8. Customer Satisfaction:

Average: 90% (2006-2014) (JOWyatt)

Average: 95% (2006-2014) (WCHC)

National Average: N/A

9. Body Mass Index

7A: Patients with height and weight

Average: 99% (2006-2014) (APHD)

7B: Patients with Body Mass Index over 30.

Average: 45% (2006-2014) (APHD)

7C: Patients with BMI over 30 referred for weight management consultation

Average: 100% (2014) (APHD)

10. Smoking

8A: Patients 18 and over asked about smoking

Average: 95% (2006-2014) (APHD)

National average: 62.7% (2005-2009) (CDC, 2012)

8B: Patients with whom providers discussed cessation on smoking

Average: 95% (2006-2014) (APHD)

National average: N/A

CDC recommendation: No matter what your specialty is, you know the health risks of smoking. Health care professionals can help patients to quit smoking with simple talking points, educational materials, videos related to the hazard of smoking (2016)

 

11. Indigent qualified for FNAC clinic services as a % of total eligible indigents in Amarillo:

Suggested answer: This will depend on individual FPG. Those who fall in 21 % FPG income (with proof) should be qualified (Texas DSHS, 2016)

 

2A: Average length time from submission of application to approval of eligibility for JOWyatt services

-Average: 14 days (2004-2012) (APHD)

2B: Average length of time from the eligibility completed application to approval (JOWyatt)

-Average: 4 days (2004-2012) (APHD)

Comparison for both 2A and 2B: It takes up to four weeks (30 days) to know if you are qualified for benefits (Texas Workforce Commission, 2015)

3A: Percent of persons approved for JOWyatt services out of total applicants

3B: Reasons for FNAC denial of applicant

4: Percent of JOWyatt patients who receive Medicare or Medicaid benefits

Indication: Benefits approval depends on the applicant fulfilling the criteria set by the service. Based on the 2016 Federal Poverty Guideline (FPG), poverty line of 21 % FPG income is the standard (Texas DSHS, 2016)

 5A: Percent of lapsed appointments (no shows) out of total appointment set, at JOWyatt

Average (no shows at JOWyatt): 22% (2004-2014)

5B: Percent of lapsed appointments (no shows) out of total appointments set, at Women’s and Children’s for JOWyatt patients

Average (no shows at Women’s and Children’s): 24% (2004-2014)

6: Percent of lapsed appointments (no shows) out of total appointments set, at FNAC.

Average (no shows at FNAC): 37% (2004-2014)

Indication: In the country the national average of “no-show patients” was 5% in 2013 as reported by Medical Group Management (National Medical Fellowship, 2014). 

15. Claim denied for appropriateness (100%).

No available data to compare with. 

Conclusion

Data used in this paper were obtained from different sources. There was not an experiment; rather, it was an assessment of various reports on health care quality. Data obtained, therefore, can provide a representation as to how the services provided by the JOWyatt and WCHC compare nationally and can be serve as a tool to track and identify where more effort is needed.

References

Centers of Diseases Control and Prevention (2012). Diabetes report card. Retrieved from http://www.cdc.gov/diabetes/pubs/pdf/diabetesreportcard.pdf

Children Trends Data Bank (2015). Immunization. Retrieved from http://www.childtrends.org/?indicators=immunization

Centers of Diseases Control and Prevention (2012). Tobacco Use Screening and Counseling During Physician Office Visits Among Adults — National Ambulatory Medical Care Survey and National Health Interview Survey, United States, 2005–2009. Retrieved http://www.cdc.gov/mmwr/preview/mmwrhtml/su6102a7.htm

Centers for Diseases Control and Prevention (2016). Health care professionals:

Help your patients quit smoking Retrieved from

http://www.cdc.gov/tobacco/campaign/tips/partners/health/hcp/

Daily News (2015). Doctors’ office wait times get shorter: study. Retrieved from

http://www.nydailynews.com/life-style/health/doctors-office-wait-times-shorter-study-article-1.2161945

Merritt Hawkins (2014).  Survey of patient appointment wait times. Retrieved from http://www.merritthawkins.com/2014-survey/patientwaittime.aspx

National Committee for Quality Assurance (2015). What is the Current State of Quality of Care in Diabetes? Retrieved from: http://www.ncqa.org/PublicationsProducts/OtherProducts/QualityProfiles/

FocusonDiabetes/WhatistheCurrentStateofQualityofCare.aspx#sthash.BSac0rdy.d uf

Nation Institute for Diabetes and Digestive and Kidney Diseases (2014). Kidney disease of diabetes. Retrieved from http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/kidney-disease-of-diabetes/Pages/facts.aspx

National Medical Fellowship (2014). No show rate. Retrieved from http://www.nmfonline.org/file/pclp-project-database/Nowacki-Daryl-Paper.pdf

Rosenthal, E. (2014). The health care waiting Game: Long waits for doctors’ appointments have become the norm. Retrieved from http://www.nytimes.com/2014/07/06/sunday-review/long-waits-for-doctors-  appointments-have-become-the-norm.html?_r=0

Texas Department of State Health Services (2016). County indigent health Care program: Eligibility criteria. Retrieved from http://www.dshs.state.tx.us/cihcp/eligibility.shtm

Texas Workforce Commission (2015). Learning the Result of Your Application for Benefits. Retrieved from http://www.twc.state.tx.us/jobseekers/learning-result-your-application-benefits

 

Public Health Initiative

To ensure I put in practice skills I learned from my Master’s Program in Public Health, I co-founded the Green Morality Initiative to serve as a platform for health promotion. The organization was approved to work as 501 (c) (3) under IRS late 2015 and since then is operational. For more, please go to: http://www.greenmo.org/

The first health promotion activity that I designed through the Green Morality is listed below.

Topic: Preventable Non-Communicable Diseases

Goal: Self-Commitment To Deduce (NCDs) Incidences.

Participants: One Student selected from 8^th or 9^th Grade.

Building a strong community is not something hard to do but something that might be intricate to accomplish. Nowadays preventable non-communicable diseases are the leading causes of death in the world. According to CDC nearly 900,000 Americans die each year from five premature leading causes of death. Among those causes 20 percent to 40 percent could be prevented (CDC, 2014). Thinking of the death pole, one cannot ignore time and money spent taking care of our dear ones under medical conditions.

Yet youth are at risks to be exposed to preventable non-communication diseases, they constitute the potential preventive agents for our society. Peer relationships play a big role to create influences among youth. These influences can be either positives or negatives.

Though being at high risks youth can be best teachers of social change to their peers and to the entire community. It is under this perspective therefore, that we at Green Morality came up with this initiative to encourage youth especially those who are preparing to embrace high school life in the next one or two years (8^th and 9^th Grade) to start building strong and confident maturity as far as health is concerned while engaging them to a thoughtful stage to self-develop health risks preventive strategies. The slogan is “Green I know, Morality I share”.

Objectives of Green Morality initiative:

• Participants will self-assuredly be able to define preventable non-communicable diseases.
• Participants will be able to critically analyze risk factors that contribute to preventable non-communicable diseases and identify how prevention strategies can be distorted to fit our society’s definition to being healthy.
• Participants will be able to identify ways to maintain a healthy lifestyle and reduce health risks.
• Participants will consistently be confident to share with others (peers, parents, etc.) important skills related to community health.

School staff will select participant of the project competition. The selected participant (one for each school) will obtain permission from his/her parents or guardian prior to start working on the project.

Each participant will present his/her work to the public and the jury constituted by both school and city public health representative.

Note: This is an ongoing project, the winner(s) will have the privilege to compete with other schools in outside of Amarillo.

Green Morality reserves the right to screen the project to ensure its relevance prior to the presentation. Invitations will be sent to presenters with maximum time to allow comprehensive preparation.

References

Centers for Disease Control and Prevention (2014). Up to 40 percent of annual deaths from each of five leading US causes are preventable. Retrieved from http://www.cdc.gov/media/releases/2014/p0501-preventable-deaths.html

 

I credit the knowledge and motivation from all my MPH program at Concordia University Nebraska especially the following classes:

Concepts of  Environmental Health: MPH 520

Principles of Health Behaviors: MPH 515

Marketing in Public Health: MPH 588

Obesity among adolescents

Health communication is referred to the use of communication strategies to influence individuals’ behaviors toward the to improve health whereas social marketing is the use of marketing strategies to promote social change (The Community Guide, 2014). Both social marketing and health communication target behavior change persuasion through systematic strategies (Marketing and Communication).

The health issue I chose is the “Obesity among adolescents”. Obesity is defined as excessive body fat and considered risk factor of various diseases. According to CDC obesity has more quadrupled among adolescents. The percentage of adolescents with obesity aged 12-19 years has increased from 5% to nearly 21% between 1980 and 2012 (2015). There is a significant demographic difference among adolescents with obesity. For example children from Mexican or Africa-American families are more likely to be obese comparing to those from White families (Bishop, Middendorf, Babin & Tilson, 2005).

The soaring rate of obesity among adolescents is mostly caused by behaviors related to poor unhealthy diet or low physical exercises that can help to burn excess fat in the body. Obesity, therefore, can be prevented with the adoption of protective health behaviors. Social marketing and health communication are important tools to “put forth great effort to raise awareness, change attitudes, and teach skills related to engaging in healthy behaviors” (Crosby, DiClemente and Salazar, 2013).

In order to intervene to the obesity among adolescents it is important to primarily target parents or guardians. After the identification of obese adolescents, public health practitioners should craft plans that will promote education to parents or guardians on approaches to reduce the overweight children to a healthy weight. On of the approach is to educate a community who shares common interest such as same language or culture.

Communicating risks related to poor diet and physical inactivity is very important when educating on obesity. Designing the context of message distribution is very important step to consider in health communication planning.

Product: The product is the promotion of healthy diet and physical exercises among adolescents. The message will provide images and words that encourage children to go for health choices.

Price: Health communicators should ensure they have sufficient funds to sustain their programs and successfully achieve their major goal, to promote social change. Fund availability can help to push back competitors’ influences. I will ensure there is enough money to produce more good quality brochures. I will prove children with obesity necessary materials that support the new behavior adoption without they spend money for it. The most important will be to show both parents and children on how, if they comply with the message, children will be happy and active playing with others, no risks to be at the hospital regularly.

Place: To ensure an effective communication of the message I would work with the local schools, churches, football event organizers to distribute promote the campaign against obesity among the adolescents.

Promotion: Social marketing is very important to eradicate obesity among adolescents. Dealing with this health issue at a societal level will bring a good judgement between the benefits and risks of the behavior. For example, I would work with the schools to provide encouragement to the kids to have more salads on their plates.

Among the homework provided to children, there could be involved a physical activity homework such as jumping rope for 10 minutes daily. The child will be asked to encourage the parents to pair with him or her for the jumping rope exercise. The parents can supervise the child and sign on the paper if the child completed the assigned physical exercise.

Most of the time, public health programs tend to be on short period. This can cause relapse in individual’s change progress. To ensure the obesity is significantly reduced the health communication programs should be repetitive to reinforce the impact of the campaign’s goal (Crosby, DiClemente and Salazar, 2013). However, this can be costly especially due to the lack of strong support from funders.

References

Bishop, J., Middendorf, R., Babin, T., & Tilson, W., (2005). Childhood obesity.

Retrieved from http://aspe.hhs.gov/basic-report/aspe-childhood-obesity-white-paper.

Centers for Disease Control and Prevention (2015). Childhood obesity facts.                          Retrieved  from http://www.cdc.gov/healthyschools/obesity/facts.htm

DiClemente, R.J., Salazar, L.F., & Crosby, R. A. (2013). Chapter 6: Stage models                for health promotion. In Health Behavior Theory for Public Health.                          Burlington, MA. Jones & Bartlett.

The Community Guide (2014). Health communication and social marketing.                       Retrieved from http://www.thecommunityguide.org/                                                         healthcommunication/index.html

Application and Analysis: Precede-Proceed Model

Public health programs have the sole ultimate goal of protecting the health of the public (DiClemente, Salazar, & Crosby, 2013). For effective implementation of health change programs public health professionals should identify appropriate theories and techniques to incorporate in their planning process. Precede-Proceed Model is one of the significant tools to identify the health behavior situation and plan for intervention accordingly.

1. Explain how the PPM was used to address planning and intervention characteristics in the Cole & Horacek (2010) article.

“My Body Knows When” community campaign was developed through nine phases using the Precede-Proceed Model (PPM). PPM was used to identify health behavior issues of the community members, what they value the most, what their social major concerns are and possible available support (Cole & Horacek, 2010).

Precede Phase

The Precede Phase is the foundation of this public health program design. It enables the identification of the program goals: (1) It pinpoints necessary health priorities that describe community issues; (2) It identifies factors that can affect the behavior or attitude of the audience; (3) It identifies necessary stakeholders and factors that can influence health behavior implementation program (Gielen, A. C., & Eileen M. M. 1996).

Cole and Horacek (2010) stated that the program used five precede diagnostic phases during the designing process.

Phase 1- Social Analysis: A survey was conducted to identify the standard of life of participants that included the practice of physical activities, emotional eating and hunger as well as needs for encouragement (Cole & Horacek, 2010).

Phase 2 – Epidemiological Assessment: In this phase, researchers were committed to identifying health issues that might be associated with the lifestyle discussed in Phase one. At this Phase, body Max Index and other health related data were collected.

Phase 3 – Behavioral/Environmental Assessment: The identification of stressors and other health issues were then linked to the participants’ behaviors. Researchers categorized heath behavioral factors to influence participants’ lifestyle focusing on physical activities, eating habits, and feelings regarding their commitment to lose weight.

Phase 4 – Educational/Ecological Assessment: With the available data gathered in the previous precede phases, researchers were able to elaborate on the intervention program that will address the issues, which are “physical activities, self-image, emotional eating, hunger/fullness cues, and the need for incentives” (Cole & Horacek, 2010).

Phase 5 – Administrative/Policy Assessment: The identification of external resources to support health programs and other factors that might affect the implementation process is an important step to include in the planning process. In Phase 5, the “My Body Knows When” implementers identified resources, stakeholders and challenges that the program might encounter during the implementation.

Proceed Phase

Considered as the program development stage, the proceed phase mainly includes implementing the actual planned program and conducting both process and outcome evaluations.

Cole and Horacek (2010) stated that program implementation work started in Phase 6 whereas process evaluation of the program was biweekly conducted in Phase 7. During Phase 8, researchers evaluated participants’ perception to the intervention while assessing its impact. In Phase 9, researchers measured the impact of the program participants. There was no significant difference found between the control and the on intervention groups in regard to their body measurements.

2. Determine and explain if the use of the model made sense based on the description of the model in the appropriate textbook chapter and supplemental materials.

The application Precede-Proceed Model in the case of “My Body Knows When” program satisfied requirements to plan and implement the campaign. The model respected the planning steps and implementation process. Monitoring and evaluation were thoroughly conducted.

3. In review of your chosen secondary articles, how did the application of the model differ between the interventions? In your opinion, is one application a better use of the model than the other? Explain.

I believe the use of the model depends on the type of health intervention to be implemented and also on the type of both the primary and secondary audiences. I was interested in the article “Using the Precede–Proceed Model of Health Program Planning in Breast Cancer Nursing Research” (Tramm, McCarthy & Yates, 2011), which properly illustrated the use of PPM to develop a health program regarding breast cancer.

Different from the PPM application described by Cole and Horacek (2010), Tramm, et al. (2011) stated that to ensure effective use of the PPM, researchers should identify as many factors as possible that might influence the health behavior of the target group (1871). For example, the environmental factors such as economical, physical and social environment were critically analyzed in Phase 2 in order to provide necessary information for the effective planning process whereas in the “My Body Knows When” model, planning places its main focus on participants’ behavior.

Due to the significant role of the Precede-Proceed Model in effectively developing theoretical strategies when planning for health promotion in the communities, public health professionals should critically identify and analyze factors that affect target members’ behavior, source of resources and understand the implication of environmental factors to the behavior they intend to change.

References

Cole, R. E., Horacek, T. (2010). Effectiveness of the “my body knows when” intuitive-eating pilot program. Retrieved from http://www.ncbi.nlm.nih.gov/ pubmed/ 20001186

DiClemente, R.D., Salazar, L. F., & Crosby, R. A. (2013). Health behavior theory for public health. Burlington. Jones & Bartlett Learning.

Gielen, A. C., & Eileen M. M. (1996). Section 2. Precede/proceed. Retrieved fromhttp://ctb.ku.edu/en/table-contents/overview/other-models-promoting-community-health-and-development/preceder-proceder/main

Tramm, R., McCarthy, A., & Yates, P. (2011). Using the precede–proceed model of health program planning in breast cancer nursing research. Retrieved from Journal of Advance Nursing published 15 October 2011

 

 

Product and Positioning Project

By Costa Ndayisabye

MPH 588

Marketing Pubic Health

Lea Pounds

Product and Positioning

My aim is to conduct social change campaign among homeless populations to reduce tuberculosis incidences.

Positioning Statement

Public health professionals in the city of Texas that I refer in my assignment as “Home” noticed that homeless populations are at high risk to tuberculosis infection especially those who are infected by HIV. They plan to conduct a four-year-period campaign with a goal to increasing awareness on how HIV infected people are at high risk to tuberculosis infection. As objectives, the campaign plans to have 70% of the homeless population in the city of Home voluntarily go through both HIV and Tuberculosis tests within the four-year period.

Core Values/Core Product

Raising awareness of both HIV and TB infections is not a simple program and requires careful strategies especially when the campaign targets homeless populations. Promoters will identify the right product and ensure the right audience is represented. To ensure the appropriate audience is reached, the marketer will focus on individuals who are chronically homeless due to the critical health conditions that characterize their lives. The identification process will include the chronic homeless person’s name, age, sex and the place they frequently like to be. Behavioral change planners will have on hand the desired benefits of health the audience needs while designing the marketing process (Resnick and Siegel 2013). To promote behavior that benefits the homeless population within the city of Home in Texas, promoters will craft campaign strategies that fit with the target audience’s desire and freedom (core values); consequently, attract the audience’s attention to participate in the campaign.

Goods and Services

The product that the campaign targets (actual) is to have a high number of chronically homeless population within the city of Home tested with both HIV and tuberculosis infections. Framing strategies that will allow the chronic homeless population to keep their freedom while promoting behavioral change will be at high consideration. Safety is one of the biggest concerns to consider while promoting public health programs among homeless communities (Brenoff, 2014).

Public health practitioners will identify different activities that normally bring homeless populations together and once incorporated in the campaign development it can increase the desire and interest of participants. The campaign will host a “Barbeque for our Health Campaign,” which will involve volunteers from homeless populations who will be wearing the same t-shirts as the promoters during the event. The campaign will also focus on chronic homeless populations’ values to get their attention to a voluntarily commitment to the behavioral change program that is being offered to them. Onsite voluntarily HIV tests and tuberculosis sputum sample collections will be conducted to chronic homeless individuals. To ensure privacy, both health promoters and chronically homeless people will sign a discretion agreement before the actual tests. Furthermore the mobile clinic will be big enough with room to guarantee safety and privacy.

Focusing on people who are chronically homeless will not be enough to get the target audience to discover the benefits of the campaign and to encourage them to build a healthy environment. The campaign will, therefore, educate those who provide assistance to homeless communities on the risks of the tuberculosis threat among chronic homeless populations who can pose risks to those who interact with them such us peers and social workers unless healthy precautionary actions are considered. This strategy will increase the campaign effectiveness.

Actionable Information

Creating credible relationships between the target audience and public health practitioners has been a challenging fact to overcome for a long time. It has been proven that large numbers of people in these populations failed to value or believe in government intervention programs (Gerwin, 2012). With that said, the campaign will give many opportunities for chronic homeless populations to freely interact with promoters and peers during the event. Hospital professionals, caseworkers and the rest of the homeless populations not identified as chronically homeless, will act as secondary audience. Medical workers will be conducting onsite HIV tests and facilitate the collection of tuberculosis sputum. Homeless populations will be given brochures containing messages on tuberculosis prevention, TB symptoms, the usefulness of regular medical check ups and who to contact for a medical appointment. Each participant will get a t-shirt and reusable bottle of water labeled “My Health Counts,” the campaign slogan.

Conclusion

Low social status that characterizes chronic homeless populations can be a challenging point in promoting behavioral change. It is crucial for public health practitioners to design a participatory approach and request the views and perspectives from target audience members (UN Women, 2012). The Barbeque for our Health campaign will inform the audience that they have the primary responsibilities to protect themselves against tuberculosis infection and full freedom to adopt key strategies to stay healthy.

Recommendations

Campaign evaluation should be conducted to ensure the objectives are being attained. A product reframing process should be considered in case of low interest of the audience to the campaign. Possible further identification of elements that appeal the target audience emotions can be considered.

References

Brenoff, A. (2014). 7 myths about homeless people debunked. Retrieved from

http://www.huffingtonpost.com/2014/05/03/7-things-homeless-people-not-true_n_5206475.html

Gerwin, L. (2012). The challenge of providing the public with actionable information

during a pandemic. Retrieved from http://www.ghd-net.org/sites/default/files/

HFPB%20-%20October%202012_0.pdf

Resnick, E.A. & Siegel, M. (2013). Marketing public health: Strategies to promote social     change. (3rd ed.). Burlington, MA: Jones & Bartlett Learning, Inc.

United Nations for Entity for Gender Equality and Empowerment for Women (2012).

Key elements of the campaign message. Retrieved from http://www.

endvawnow.org /en/articles/1238-key-elements-of-the-campaign-message. html?next=1239

 

 

Performance Appraisal and Retention Strategies

MPH 548:

By Costa Ndayisabye

Professor: Dr. Hollie Pavlica

August 16, 2015

Performance Appraisal and Retention Strategies

Ms. Viki Bailey is an educator of infectious disease prevention at the Highland Park Public Health Department. Her role is to plan and implement activities that involve providing briefing to middle schools students and strategies to prevent infectious diseases. Vicki is supervised by the District Public Health Manager, Mr. Costa Ndayisabye, to whom she is accountable. Every six months I conduct Ms. Viki’s performance appraisal following Texas public health guidelines. On June 30, 2015, I employed two performance appraisal formats to conduct Ms. Viki Bailey’s semi-annual evaluation. The first form (See Form 1) was a questionnaire to assess if Ms. Viki was still attached to her work expectations and to evaluate how she projected her future achievements. The second form (See Form 2) had a direct rate format that was conducted by the direct supervisor.

Employees are one of the most significant assets for an organization. Knowing how employees are executing their tasks, what challenges they might have, and where their strengths are, is a better way to keep the organization aligned with its mission and goals. It is, therefore, very important to managers within an organization to conduct employee performance assessments to whether or not employees are meeting their expectations in regard to the company’s priorities. Fried and Fottler (2011) state that, “the intensive use of labor and the variability in professional practice require that leaders in the healthcare field manage the performance of the people involved in the delivery of services” (p. 3).

Currently, the healthcare market is characterized as having a high shortage of healthcare professionals, while the demand of health services is tremendously increasing. The high number of complaints behind the quality of health services is alarming and has become major problem. One of strategies to increase productivity in healthcare institutions is to regularly conduct employee performance assessments, which can bring to the table an individual’s consideration on the aspect of work and revealemployees’ behaviors. In the article “Why Organizations Do Employee Performance Evaluation” Heathfield (2015) stated that performance appraisal serves as both an evaluation and communication tool between managers and employees. Effective performance management helps to protect employees from doing wrong; conversely, it protects the organization from failures.

Effective performance appraisal should include essential elements that regularly tackle employees’ work environment based on their job responsibilities and ethics. What an employee can do well today, can be different from what he or she can do tomorrow. Employees’ performance may be influenced with various factors within and without of the organization. Managers should routinely conduct assessments to ensure employees are getting what they expected from the first day of hire and, in return, the organization is meeting maximum expectations from its employees. The article “Performance Management” published by the U.S. Office of Personnel Management (OPM) states that “Planning means setting performance expectations and goals for groups and individuals to channel their efforts toward achieving organizational objectives” (n.d.). It is very important to the human resource department to design a performance appraisal consist with the organization’s mission and goal. A reactive performance management should include a reasonable investigation, formal meeting, plan that gives employee the opportunity to improve within a determined period, review process and set alternative strategies (Flint, 2014).

Once an effective performance appraisal is conducted, managers can design strategies that would enhance employees’ expectations. Strategies may include rewarding employees for their performance and training those who drifted from their responsibilities due to insufficient skills or showing inadequate work performance. Outcomes from effective performance management can enhance employees’ attitudes toward the organization and reduce turnovers. According to Aylen (2015) employees’ performance appraisal helps managers to successfully implement employee retention within an organization. Therefore, it is essential for managers, to have in their priorities a systematic employee assessment plan to create a suitable environment conducive to organizational success.

Concisely, effective performance management is one that reflects the ideal purpose to motivate employees to exhibit their thoughts regarding work performance. Performance management is a tool for the organization to create an effective communication system between managers and employees on a regular basis. Furthermore, performance management is a vital review process to ensure both organization and employees’ expectations are successfully being achieved.

Due to the robust impact effective performance management has to organizational development, it is very important to involve everyone who contributes to the active life of the organization. I would recommend that the upper management team support the HR department in designing an organized performance plan. The organization should design a formal performance appraisal that will be conducted within a period of time preferably quarterly and day-to-day verbal performance appraisal, and to document the most sensitive findings to the organizational development team.

1. Form 1

PERFORMANCE APPRAISAL Town of Highland Park STAFF PERFORMANCE APPRAISAL EMPLOYEE NAME: Viki Bailey                                                             EMPLOYEE ID: 1975 DEPARTMENT: Infectious Disease Prevention                                  Title: Educator TYPE OF APPRAISAL: Semi Annual Attention: This questionnaire should be filled by employee
Name of employee:		Position:
Time period spent in current position:
State and analyze five goal set for last six months
Goals	Analysis		Achieved (yes/no)
Ensure the reduction of infectious disease among students	Equip schools with appropriate education materials regarding infection diseases		Yes
	Form students’ clubs against infectious diseases		No
	Conduct competitions on strategies to prevent infectious disease		Yes
State some goals for the next six months a)     Ensure all schools within the town are equipped with skills regarding infectious disease prevention b)    Ensure teachers are active to support their students to implement hygienic behaviors c)     Conduct survey on infectious disease prevalence among students.
What are the best aspects about your job? To contribute to students’ health improvement among children
What are the worst aspects about your job? Too much work
Which things could be done to improve your job satisfaction? Have more support from the management
What further training or experience would be beneficial in the improvement of your job performance? Infectious disease surveillance
Employee sign name and date: Viki Bailey, June 30, 2015.
Supervisor’s comments: The employee met her expectations. As recommendations the HR office should plan for Mr.Viki’s training on infectious disease surveillance. Management should involve community volunteers to help the employee to reach her goal.

Adapted from Sample Forms (2015)

 

References

Aylen, C. (2015). Employee retention strategies: What is performance profiling? Retrieved from

http://hub.talentchaser.com/

Flint, J. (2014). Seven steps to effective performance management. Retrieved from

http://www.shoosmiths.co.uk/client-resources/legal-updates/seven-steps-effective-performance-management-8818.aspx

Fried, B.J., and Fottler, M.D. (2011). Fundamentals of Human Resources in Healthcare.

Chicago, IL: Health Administration Press.

Heathfield, S. (2015). Why organizations do employees performance evaluation. Retrieved from

http://humanresources.about.com/od/performancemanagement

/qt/employee_evaluation.htm

HR Florida International University (2007). Staff performance appraisal. Retrieved from

http://hr.fiu.edu/uploads/file/forms/elr/usps_appraisal.pdf

Office of Personnel Management (n.d.). Performance management. Retrieved from

https://www.opm.gov/policy-data-oversight/performance-management/reference-materials/more-topics/effective-performance-management-doing-what-comes-naturally/

Sample Forms (2015). Performance appraisal form template. Retrieved from

http://www.sampleforms.org/performance-appraisal-form-template.html

 

 

 

 

Benefits/Total Rewards Plan

MPH 548: Human Resource Management:

By Costa Ndayisabye

Professor: Dr. Hollie Pavlica

Submitted: August 2, 2015 

                A well-organized company focuses to both successful recruitment to bring right person to its development and to strive on employees’ retention. The best strategy to retain employees is to have a well-designed benefit plan. Fried & Fottler (2011) stated that healthcare employer should explain to staff the module of “total compensation” which includes salary and other added benefit package (p 214). Attention should be paid to benefits that are mandated by both federal and state governments to avoid any future conflicts. Benefits should therefore be clearly details and written to enable employees to understand what is beneficial to them.

Salary itself does not provide sufficient security to employees unless it is supplemented by benefits to bring vital environment within organization. “Offering a competitive salary combined with benefits and perks can prove to be a win-win combination in promoting improved work habits and reducing employee turnover (Benz, 2014). Employees within organization have different needs, which means there should be different benefit options to enable employees to choose what fit with his or her needs. When designing for employees’ total compensation, I would specify different available benefits and what is included in each package.

Salary is the primary advantage that employee seeks while performing tasks, as it helps to cover human basic needs such as food, clothes and accommodation. Beside salary, benefits are important to secure for emergency needs such abrupt accident that may occur within or outside the organization, also to guarantee at least minimum support when employee does not have both physical and mental capacities to work. Benefits are therefore, securities to reduce turnover within organization and significant tool to promote uncertainty employees’ morale. According to the article “Compensation & Benefits” published by HR Council (2015), “Providing benefits to employees is seen as managing high-risk coverage at low costs and easing the company’s financial burden”.

Health coverage is among the most important benefits that employers should critically plan for. According to Harper (2012) “As work and family life absorb the bulk of an employee’s attention and finances, having medical costs defrayed by a generous benefit package can be both a comfort and an asset”. If I would be a human resource manager and were asked to design employees’ benefits I would focus on the following:

1. Inpatient care: This commitment can be costly to both employee and employer. It is very critical to analyze the cheap insurance market that will require reasonable premium and deductible.
2. Outpatient: This is a great motivation to every employee. It is therefore very important to the employer to insure employees are covered for inpatient care.
3. Eyes and dental care: Costs involved in eye and dental care are high and can put the employee to hard life situation. As a company’s benefit designer, this is not the point to ignore.
4. Drug prescription. With the current economic crisis, drugs are becoming expensive and employee should be supported to get insurance that will cover some percentage of the drug prescription cost.
5. Program to manage chronic illness: This is very important preventive strategy that needs to be included in benefit package. The more employee is healthy the less the number of hospital visits. Furthermore, a healthy employee is more productive than the one with medical condition. According to article published by Economist Intelligence Unit (EIU, 2012) chronic diseases exert a high toll on labor productivity.

The above 5 health benefits are among the ten published on “healthcare.gov” on August 22, 2013 to explicit essential insurance that marketplaces provide. Beside health coverage the employer benefits plan should also incorporate paid vacation, paid holidays, social security and Medicare, unemployment benefits, 401(k) contribution and tuition reimbursement as below benefits allocation table described.

Plan	Values ($)	Percentage (%)
Vacation Days (10 days)	3,846	3.85
Paid holidays (7 days)	2,692	2.69
Social Security and Medicare	7,650	7.65
Unemployment benefits	250	0.25
401(k)	5,000	5
Disability	480	0.48
Inpatient care	2,440	2.44
Outpatient	3,660	3.66
Eyes and dental care	1,480	1.48
Drug prescription	420	0.42
Program to manage chronic illness	240	0.24
Tuition	1,200	1.2
Total compensation	29,358	29.36

 

I would allocate $129,358 each year for one employee to ensure the above benefits and rewards are covered while maintaining employee’s annual salary of $100,000.

With above computed benefits, if I had to cut benefit budget by 20% ($29,358*0.2=$5871.6) I would reduce the size of the following benefits.

Benefits	Cuts ($)	Balance ($)	New benefit/total rewards ($)
Tuition	1200-600	600	1,23486.4
Vacation	3846-2240	1,606
401(k)	5000-2000	3,000
Paid holiday	2692-546	2,146
Inpatient	2440-485.6	1954.4

 

As detailed discussed in this paper, employees’ benefits are pillars to the development of the organization. It is very important to the employer to design systematic benefit plan that enhance employees’ safety and credibility within and out of the organization. When employees are satisfied with the benefits they get from the company, they can be useful to attract other skilled employees to fill in positions.

To ensure benefit plan is designed in accordance to employees’ satisfaction, I will recommend the company’s executive team to enable a periodic survey performance that will determine the effective and efficient employees’ benefits plan basing on employees’ opinions. I would collect ideas from each employee that I can use as a clue to allocate benefits appropriately. There should also be a common understanding among company’s executive team members on the benefit system framework.

 

 

Reference

Benz, J. (2014). The Importance of Employee Benefits

Retrieved from http://www.paychex.com/articles/employee-benefits/importance-of-employee-benefits

Compensation & Benefits (2015). HR Council.

Retrieved from http://hrcouncil.ca/hr-toolkit/compensation-employee.cfm

Economist Intelligence Unit (2012). The role of employers: Workplace initiatives to tackle chronic disease.

Retrieved from http://digitalresearch.eiu.com/extending-healthy-life-years/report/section/the-role-of-employers-workplace-initiatives-to-tackle-chronic-disease

Fried, B., & Fottler, M. (2011). Fundamentals of human resources in healthcare. Chicago, IL: Health Administration Press

Harper, J. (2012). 7 Reasons to take advantage of employee healthcare benefits

http://money.usnews.com/money/careers/articles/2012/08/28/7-reasons-to-take-advantage-of-employee-healthcare-benefits