Implementing evidence-based practice in community mental health agencies: a multiple stakeholder analysis

OBJECTIVES

We sought to identify factors believed to facilitate or hinder evidence-based practice (EBP) implementation in public mental health service systems as a step in developing theory to be tested in future studies.

METHODS

Focusing across levels of an entire large public sector mental health service system for youths, we engaged participants from 6 stakeholder groups: county officials, agency directors, program managers, clinical staff, administrative staff, and consumers.

RESULTS

Participants generated 105 unique statements identifying implementation barriers and facilitators. Participants rated each statement on importance and changeability (i.e., the degree to which each barrier or facilitator is considered changeable). Data analyses distilled statements into 14 factors or dimensions. Descriptive analyses suggest that perceptions of importance and changeability varied across stakeholder groups.

CONCLUSIONS

Implementation of EBP is a complex process. Cross-system-level approaches are needed to bring divergent and convergent perspectives to light. Examples include agency and program directors facilitating EBP implementation by supporting staff, actively sharing information with policymakers and administrators about EBP effectiveness and fit with clients' needs and preferences, and helping clinicians to present and deliver EBPs and address consumer concerns.

Cancer treatment adherence among low-income women with breast or gynecologic cancer: a randomized controlled trial of patient navigation

BACKGROUND

The authors implemented a controlled, randomized trial that compared 2 interventions: the provision of written resource navigation information (enhanced usual care [EUC]) versus written information plus patient navigation (TPN) aimed at improving adjuvant treatment adherence and follow-up among 487 low-income, predominantly Hispanic women with breast cancer or gynecologic cancer.

METHODS

Women were randomized to receive either TPN or EUC; and chemotherapy, radiation therapy, hormone therapy, and follow-up were assessed over 12 months. Patients with breast cancer were analyzed separately from patients with gynecologic cancer.

RESULTS

Overall adherence rates ranged from 87% to 94%, and there were no significant differences between the TPN group and the EUC group. Among women with breast cancer, 90% of the EUC group and 88% of the TPN group completed chemotherapy (14% of the EUC group and 26% of the TPN group delayed the completion of chemotherapy), 2% of the EUC group and 4% of the TPN group failed to complete chemotherapy, and 8% of the EUC group and 7% of the TPN group refused chemotherapy. Radiation treatment adherence was similar between the groups: Ninety percent of patients completed radiation (40% of the EUC group and 42% of the TPN group delayed the completion of radiation); in both groups, 2% failed to complete radiation, and 8% refused radiation. Among gynecologic patients, 87% of the EUC group and 94% of the TPN group completed chemotherapy (41% of the EUC group and 31% of the TPN group completed it with delays), 7% of the EUC group and 6% of the TPN group failed to complete chemotherapy, 6% of the EUC refused chemotherapy, 87% of the EUC group and 84% of the TPN group completed radiation (51% of the EUC group and 42% of the TPN with delays), 5% of the EUC group and 8% of the TPN group failed to complete radiation, and 8% of the EUC group and 5% of the TPN group refused radiation.

CONCLUSIONS

Treatment adherence across randomized groups was notably higher than reported in previous studies, suggesting that active telephone patient navigation or written resource informational materials may facilitate adherence among low-income, predominantly Hispanic women. Adherence also may have be facilitated by federal-state breast and cervical cancer treatment funding.

Reflections on International Translation of Evidence-Based Health Behavior Programs

In this concluding article, the authors describe factors that influence the international translation of programs. These include language, control over the translation process, local normative challenges to translation, program adaptation, and globalization. The authors suggest that systematic efforts at language translation, program adaptation partnership, and compromise are general principals needed to surmount these challenges.

An ethnographic study of implementation of evidence-based treatments in child mental health: first steps

OBJECTIVE

The experiences of clinicians in regard to initial and long-term intention to use evidence-based treatments were examined in order to better understand factors involved in implementation of innovative treatments.

METHODS

Ethnographic methods of participant observation and extended semistructured interviews with four trainers, six clinical supervisors, and 52 clinicians at five agencies in Honolulu and six in Boston were used to understand treatment implementation in the Clinic Treatment Project, a randomized effectiveness trial of evidence-based treatments for depression, anxiety, and conduct problems of children. Grounded-theory analytic methods were used to analyze field notes, interview transcripts, and meeting minutes.

RESULTS

Three patterns in regard to long-term intention to implement the treatments were evident: application of the treatments with fidelity, abandonment of the treatments, and selective or partial application. These patterns were perceived to be associated with three preimplementation factors: lag time between initial training in the treatment protocol and treatment use in practice, clinician engagement with the project, and clinician-treatment fit. Four additional factors were proximal outcomes of the three determinants as well as first steps of implementation: clinicians' first impressions of the evidence-based treatments after initial use, competence in treatment use, clinician and researcher adaptability, and clinician-researcher interactions.

CONCLUSIONS

Interactions between preimplementation factors and initial implementation experiences and between researchers and clinicians during the early implementation steps were related to intentions to sustain treatment.

Country Prototypes and Translation of Health Programs

This article introduces the topic of international translation of health programs. Different perspectives toward the study of national-level variables that are relevant to translation of evidence-based programming developed outside of or in a country are discussed. Concepts including national prototypes, national stereotypes, country clusters, knowledge incompatibility, and absorptive capacity are introduced. The ideas expressed in this article serve to provide direction when considering developing a health behavior program for a country, using previous programmatic knowledge from elsewhere.

Azúcar y nervios: explanatory models and treatment experiences of Hispanics with diabetes and depression

This study examined the explanatory models of depression, perceived relationships between diabetes and depression, and depression treatment experiences of low-income, Spanish-speaking, Hispanics with diabetes and depression. A purposive sample (n=19) was selected from participants enrolled in a randomized controlled trial conducted in Los Angeles, California (United States) testing the effectiveness of a health services quality improvement intervention. Four focus groups followed by 10 in-depth semi-structured qualitative interviews were conducted. Data were analyzed using the methodology of coding, consensus, co-occurrence, and comparison, an analytical strategy rooted in grounded theory. Depression was perceived as a serious condition linked to the accumulation of social stressors. Somatic and anxiety-like symptoms and the cultural idiom of nervios were central themes in low-income Hispanics' explanatory models of depression. The perceived reciprocal relationships between diabetes and depression highlighted the multiple pathways by which these two illnesses impact each other and support the integration of diabetes and depression treatments. Concerns about depression treatments included fears about the addictive and harmful properties of antidepressants, worries about taking too many pills, and the stigma attached to taking psychotropic medications. This study provides important insights about the cultural and social dynamics that shape low-income Hispanics' illness and treatment experiences and support the use of patient-centered approaches to reduce the morbidity and mortality associated with diabetes and depression.

Psychological effects of polar expeditions

Polar expeditions include treks and stays at summer camps or year-round research stations. People on such expeditions generally undergo psychological changes resulting from exposure to long periods of isolation and confinement, and the extreme physical environment. Symptoms include disturbed sleep, impaired cognitive ability, negative affect, and interpersonal tension and conflict. Seasonal occurrence of these symptoms suggests the existence of three overlapping syndromes: the winter-over syndrome, the polar T3 syndrome, and subsyndromal seasonal affective disorder. About 5% of people on expeditions meet DSM-IV or ICD criteria for psychiatric disorders. However, they also experience positive or so-called salutogenic outcomes resulting from successfully coping with stress and enhanced self-sufficiency, improved health, and personal growth. Prevention of pathogenic psychological outcomes is best accomplished by psychological and psychiatric screening procedures to select out unsuitable candidates, and by providing access to psychological support, including telephone counselling. Promotion of salutogenic experiences is best accomplished by screening for suitable personality traits, and training participants in individual coping strategies, group interaction, and team leadership.

Maintaining Sibling Relationships for Children in Foster and Adoptive Placements

To better understand the nature of sibling relationships among children in foster or adoptive placement and the challenges and processes involved in maintaining these relationships, we conducted an exploratory analysis of data collected from semi-structured interviews with caregivers of 14 foster and adopted children in San Diego County. We identified three patterns of placement histories and living situations which appeared to impact the degree of contact maintained with siblings: (1) children who had never lived together and were not currently placed together; (2) children who at some point lived with or were placed together with their siblings, but were now separated from them; and (3) children who had lived with their siblings all their life and were placed together with at least some of their siblings at the time of the interview. Children's current living situations and placement histories, caregivers' experiences and perceptions of feasibility and desirability of sibling contact, and the sibling relationship itself are primary determinants in the development and maintenance of contact between siblings. Implications for child welfare policy and practice are discussed.

Syringe possession arrests are associated with receptive syringe sharing in two Mexico-US border cities

AIMS

To identify factors associated with receptive syringe sharing among injection drug users (IDUs) and elucidate the association between syringe possession arrests and syringe sharing.

DESIGN

Cross-sectional study.

SETTING

Mexican border cities of Tijuana, Baja California and Ciudad Juarez, Chihuahua.

PARTICIPANTS

IDUs in Tijuana (n = 222) and Ciudad Juarez (n = 206) were recruited using respondent-driven sampling (RDS). IDUs were > or = 18 years and had injected illicit drugs in the past month.

MEASUREMENTS

An interviewer-administered survey was used to collect quantitative data on socio-demographic, behavioral and contextual characteristics, including self-reported syringe sharing and arrests for syringe possession. Associations with receptive syringe sharing were investigated using logistic regression with RDS adjustment.

FINDINGS

Overall, 48% of participants reported ever being arrested for carrying an unused/sterile syringe, even though syringe purchase and possession is legal in Mexico. Arrest for possessing unused/sterile syringes was associated independently with receptive syringe sharing [adjusted odds ratio (AOR) = 2.05; 95% confidence interval (CI): 1.26, 3.35], as was injecting in a shooting gallery (AOR = 3.60; 95% CI: 2.21, 5.87), injecting in the street (AOR = 2.05; 95% CI: 1.18, 3.54) and injecting methamphetamine (AOR = 2.77; 95% CI: 1.41, 5.47) or cocaine (AOR = 1.96; 95% CI: 1.15, 3.36). More than half of participants (57%) had been arrested for possessing a used syringe; in a second model, arrest for used syringe possession was also associated independently with receptive sharing (AOR = 2.87; 95% CI: 1.76, 4.69).

CONCLUSIONS

We documented high levels of syringe-related arrests in two Mexican-US border cities and an independent association between these arrests and risky injection practices. Public health collaborations with law enforcement to modify the risk environment in which drug use occurs are essential to facilitate safer injection practices.

Environmental influences on hypothalamic–pituitary–thyroid function and behavior in Antarctica

We examined the physiological and psychological status of men and women who spent the summer (n=100) and/or winter (n=85) seasons in Antarctica at McMurdo (latitude 78.48 S, elevation 12 m) and South Pole (latitude 90 S, elevation 3880 m) stations to determine whether there were any significant differences by severity of the stations' physical environment. Physiological measures (body mass index, blood pressure, heart rate, tympanic temperature), serum measures of thyroid hormones, cortisol, and lipids and plasma catecholamines were obtained at predeployment (Sep-Oct) and the beginning of the summer (November) and winter (Mar-Apr) seasons. Cognitive performance and mood were assessed using the Automatic Neuropsychological Assessment Metric - Isolated and Confined Environments (ANAM-ICE), a computerized test battery. South Pole residents had a lower body mass index (p<0.05) and body temperature (p<0.01) and higher levels of plasma norepinephrine (p<0.05) in summer and winter than McMurdo residents. Upon deployment from the United States and during the summer, South Pole residents experienced significantly higher thyroid hormone values (free and total T(3) and T(4)) (p<0.01) than McMurdo residents; in summer they also experienced lower levels of triglycerides (p<0.01) cortisol (p<0.05) and LDL (p<0.05). In winter, South Pole residents also experienced a 39% decrease in serum TSH compared with a 31.9% increase in McMurdo (p<0.05). South Pole residents also were significantly more accurate (p<0.05) and efficient (p<0.01) in performance of complex cognitive tasks in summer and winter. Higher thyroid hormone levels, combined with lower BMI and body temperature, may reflect increased metabolic and physiological responses to colder temperatures and/or higher altitude at South Pole with no apparent adverse effect on mood and cognition.

Psychoneuroendocrine effects of combined thyroxine and triiodothyronine versus tyrosine during prolonged Antarctic residence

OBJECTIVES

We previously reported that cognitive function improves with thyroxine and that there is a circannual pattern to mood and human TSH during Antarctic residence. To extend these findings, we examined the effects of tyrosine and a combined levothyroxine/liothyronine supplement in euthyroid men and women who spent the austral summer (n = 43) and/or winter (n = 42) in Antarctica.

STUDY DESIGN

Randomized, placebo-controlled, clinical trial.

METHODS

Subjects were randomized to receive the following each day for 91.6 +/- 3.2 days in summer and/or 138.0 +/- 3.2 days in winter: (1) 12g tyrosine mixed in 113g applesauce; (2) 50 microg of levothyroxine and 12.5 microg of liothyronine (T4-T3 Supplement); or (3) placebo. Cognitive performance and mood were assessed using the Automatic Neuropsychological Assessment Metric - Isolated and Confined Environments.

RESULTS

With placebo in summer, mood did not change while TSH decreased by 28%; in winter, there was a 136% degradation in mood (p < 0.01) and TSH increased by 18%. With combined T4-T3 supplement, there was a 51% degradation in mood in summer compared with placebo (p < 0.05) and TSH decreased by 57%; in winter there was a 135% degradation in mood while TSH was reduced by 26% (p < 0.05). Tyrosine use in summer was associated with no change in mood and a 30% decline in TSH, while in winter there was a 47% improvement in mood and TSH decreased by 28% along with a 6% increase in fT3 (p < 0.05).

CONCLUSIONS

Administration of tyrosine leads to a significant reduction in serum TSH and improvement in mood in winter compared with placebo, while the combined T4-T3 supplement leads to a worsening of mood in summer and no improvement in winter. There appears to be a seasonal influence on the psychological response to interventions and the relationship to changes in TSH reductions.

Psychological selection of Antarctic personnel: the "SOAP" instrument

INTRODUCTION

The potential advantage of including a psychological test battery in the selection process for service in the Antarctic was examined in 348 applicants for employment in Antarctica with the British Antarctic Survey (BAS).

METHODS

Applicants were screened with the Selection of Antarctic Personnel battery (SOAP) consisting of nine well-known psychological instruments. The SOAP scores were not revealed to the BAS selection panel members, who based the selection on operational criteria, interview, and a general medical examination. The SOAP scores of those selected (n = 177) were further compared with station commanders' reports of winter adaptation (n = 140), and subjective health complaints (SHC) (n = 86).

RESULTS

There were no significant agreements between SOAP scores (n = 348) and those actually selected by the BAS panel (121 accepted, 227 not accepted) (Cohen's Kappas for inter-rater agreement < 0.20). Participants characterized as exceptionally well adapted by the station commanders had higher scores on Openness on the NEO-FFI (the "Big Five" personality inventory) [Odds Ratio (OR) = 5.2], and higher levels of Emotion-Focused Coping (OR = 2.7) and fewer SHC (OR = 0.3). Participants rated by station commanders as "poor" had higher levels of Defensive Hostility (OR = 4.2), and lower levels of Emotion-Focused Coping (OR = 0.3). Women had higher rates of success in service than men, but were less likely to be selected.

DISCUSSION AND CONCLUSION

Adding a psychological test battery would improve the odds of selecting good performers, and reduce the odds of selecting poor performers.

Investigating ADHD treatment trajectories: listening to families' stories about medication use

OBJECTIVE

Policymakers, federal agencies, and researchers have called for more in-depth investigation of contextual mechanisms that may explain differences in medication use among youths with attention-deficit/hyperactivity disorder (ADHD).

METHOD

We conducted qualitative interviews with 28 families from varied socioeconomic and racial/ethnic and linguistic backgrounds regarding diagnostic and treatment trajectories for their children with symptoms consistent with ADHD, with a particular focus on whether and how medication use became a part of the trajectory.

RESULTS

Four longitudinal patterns of help-seeking trajectories emerged: (1) a pattern characterized by delay to diagnosis, common among youths with complicated clinical and/or environmental pictures or primarily inattentive ADHD symptoms; (2) an initial nonmedication treatment pattern in which parents at first chose to use other modalities of treatment; (3) a reluctant receipt of an ADHD diagnosis and/or treatment pattern, mainly seen among the low-income, Spanish-speaking families; and (4) a rapid engagement in medication use pattern, characterized by directed movement to and maintenance of medication use. These patterns resulted from a dynamic interplay of explanatory models regarding the cause, course, and cure of a child's problems; the influence of extended social networks; and factors previously examined in medical utilization models. Additional themes included (1) parents' need for more information about ADHD, (2) families' desire for additional mental health and school services making medications less necessary, and (3) the importance of cultural sensitivity and a longitudinal relationship between the caregiver and clinician to enhance communication between families and clinicians.

CONCLUSIONS

These findings deserve further study in a larger, more diverse sample.

Unmet needs for services for older adults with mental illness: comparison of views of different stakeholder groups

OBJECTIVE

The authors assessed the need for mental health services among older adults in San Diego County, California, by determining what needs were not being addressed by existing services, what services were necessary to address these needs, and how much consensus there was among different stakeholders with respect to the problems and solutions related to service delivery.

METHODS

Semistructured interviews were conducted with 23 health care and social service providers and administrators, 16 services consumers and other older adults (55 years of age and older), and 19 caregivers/family members and patient/client advocates. This was followed by four focus groups comprised of 18 providers and administrators, six focus groups comprised of 50 consumers and other older adults, and five focus groups comprised of 39 caregivers (family members and advocates).

RESULTS

The unmet needs fell into three categories: mental health services, physical health services, and social services. Two interrelated themes were identified by participants: 1) the need for age-appropriate and culturally appropriate services to overcome barriers to mental health services access, use, and quality; and 2) the interrelations between unmet needs that address prevention as well as treatment of mental illness, including socialization and social support, transportation, housing, and physical health care. Differences in stakeholder assessment of unmet needs were associated with respective roles in delivery and use of mental health services.

CONCLUSION

Age-appropriate and culturally appropriate solutions that address both prevention and treatment may represent the best strategies for addressing the challenges of mental illness and are most likely to be endorsed by all three groups of stakeholders.

Implementation of Evidence-based Practice in Child Welfare: Service Provider Perspectives

Implementation of evidence-based practices (EBP) in child welfare is a complex process that is often fraught with unanticipated events, conflicts, and resolutions. To some extent, the nature of the process, problems, and solutions may be dependent on the perspectives and experiences of a given stakeholder group. In order to better understand the implementation process in the child-welfare system, we interviewed comprehensive home-based services (CHBS) case managers who were actively engaged in implementing an EBP to reduce child neglect in a state youth services system. Six primary factors were identified as critical determinants of EBP implementation: (1) Acceptability of the EBP to the caseworker and to the family, (2) Suitability of the EBP to the needs of the family, (3) Caseworker motivations for using the EBP, (4) Experiences with being trained in the EBP, (5) Extent of organizational support for EBP implementation, and (6) Impact of EBP on process and outcome of services. These factors reflect two broader themes of attitudes toward or assessments of the EBP itself and experiences with learning and delivering the EBP. Eventual implementation is viewed as the consequence of perseverance, experience, and flexibility.

Delayed diagnosis by physicians contributes to the development of coronary artery aneurysms in children with Kawasaki syndrome

BACKGROUND

A diagnosis of Kawasaki syndrome is based on clinical criteria with nonspecific laboratory findings, and there is a substantial risk of coronary artery aneurysms if treatment with intravenous immunoglobulin is delayed. In this study, we examined the contributions of sociodemographic factors and parent and physician behavior to the development of coronary artery aneurysms in children with Kawasaki syndrome.

METHODS

We performed a retrospective, case-control chart review of Kawasaki syndrome patients treated at our institution during an 11-year period (1991-2002). Of 324 patients, 21 patients had coronary artery aneurysms and were matched with 81 Kawasaki syndrome control patients without coronary artery aneurysms.

RESULTS

Patients who developed coronary artery aneurysms were more likely to have had their diagnosis established after 10 days of fever as a result of a delay in physician recognition of Kawasaki syndrome. In addition, these patients were also more likely to have been hospitalized at an outside facility with an erroneous diagnosis, to have had a greater number of healthcare visits before diagnosis, to have sought medical care in Mexico, to lack medical insurance and to speak Spanish as a primary language. Independent predictors of delayed diagnosis included incomplete clinical signs of Kawasaki syndrome, seeking health care in Mexico, and being hospitalized at an outside facility with a different diagnosis.

CONCLUSIONS

Increased risk of coronary artery aneurysms is associated with a delay in diagnosis by physicians and not with a delay in seeking medical consultation by parents. Sociodemographic factors influence the likelihood that patients will have a delayed diagnosis.

Building blocks of successful aging: a focus group study of older adults' perceived contributors to successful aging

OBJECTIVE

The purpose of this study was to solicit the opinions of older adults about factors related to successful aging using focus group methods.

METHODS

Twelve focus groups were conducted with an average of six individuals per group. Participants included 72 community-dwelling older adults (age range: 60-99 years) recruited primarily from retirement communities in San Diego County, California. Interview transcripts were analyzed using a grounded theory framework of "Coding Consensus, Co-occurrence, and Comparison."

RESULTS

A total of 33 factors were identified, out of which four major themes emerged: attitude/adaptation, security/stability, health/wellness, and engagement/stimulation. Every focus group emphasized the need for a positive attitude, realistic perspective, and the ability to adapt to change. Security and stability encapsulated one's living environment, social support, and financial resources. General physical health and wellness were frequently mentioned, with mixed opinions on their necessity for successful aging. Finally, a sense of engagement, reflected in pursuit of continued stimulation, learning, feeling a sense of purpose in life, and being useful to others and to society, was considered a prominent aspect of successful aging. All four themes appeared to be interrelated such that engagement required a foundation of security and stability while positive attitude and adaptation strategies often compensated for impaired physical health.

CONCLUSION

Older adults place greater emphasis on psychosocial factors as being key to successful aging, with less emphasis on factors such as longevity, genetics, absence of disease/disability, function, and independence.

Resting and exercise energy use in Antarctica: effect of 50% restriction in temperate climate energy requirements

OBJECTIVE

To determine the impact of energy restriction (ER) upon the previously reported increased resting and exercise-related oxygen utilization, reduced body temperature, increased serum TSH, and reduced serum free T3 concentrations found during Antarctic residence (AR).

DESIGN

Prospective, intervention with both paired controls and a similar reference control group (RG).

PATIENTS AND MEASUREMENTS

Seven subjects were assessed before and after a 50% ER period of 60 h. This ER was carried out within 30 days of arriving in Antarctica in October (OCT) and again after 10 months AR in August (AUG). During the periods of ER, mean energy consumption was 5662 +/- 1344 kJ/day in OCT and 5529 +/- 967 kJ/day in AUG. Resting metabolic rate (RMR), a calculated resting metabolic rate (RMR(reg)) using a submaximal work regression, serum TSH, FT3 and tympanic temperature (Tty) were measured. These values were compared with a similar RG of 12 subjects reported previously who were studied in California, USA before and then again during AR.

RESULTS

Weight declined by 1.1 +/- 0.1 kg/day (OCT) and 0.92 +/- 0.2 kg/day (AUG) with ER, resulting in a reduction of body weight by 3.1 +/- 0.4% in OCT (P = 0.0001) and 2.5 +/- 0.4% in AUG (P = 0.0015) during AR. The RMR before ER did not change with AR and it was not significantly different from the RG studied in California. With ER the RMR tended to decline in both OCT (132 +/- 5 to 122 +/- 4 mlO2/min/m2) and AUG (134 +/- 5 to 126 +/- 5 mlO2/min/m2), but these were not significant. By contrast, RMR(reg) obtained before ER was increased with AR by 22.5 +/- 7.8% (P = 0.01) in OCT and by 28.1 +/- 7.0% (P = 0.0008) in AUG over the RG values obtained in California. RMR(reg) did not decrease with ER in either OCT or AUG. The total energy expenditure derived from these measures of weight loss suggests that 24-h energy requirements are 74.4%[95% confidence interval (CI) 2.6-146.3; P < 0.05] more than those expected in temperate climates. Tty declined by 0.6 +/- 0.2 degrees C (P < 0.01) with AR compared with the RG measured in California, but was not affected by either period of ER. ER had no effect on FT3 but tended to decrease serum TSH in AUG (P = 0.06).

CONCLUSIONS

Exercise-related energy requirements are increased with AR. Moderate ER may reduce resting but not exercise-related energy expenditure and it is associated with a weight loss exceeding expectations for 50% restriction of temperate climate energy predictions.

Urinary melatonin: a noninvasive method to follow human pineal function as studied in three experimental conditions

The aim of this study was to examine whether urinary melatonin, rather than urinary 6-sulfatoxymelatonin (aMT6s), can be used as an indicator of diurnally and seasonally changing melatonin secretion. The subjects (n=15) spent three separate 24-hr periods in a climatic chamber during winter (n=7) and summer (n=8). Blood and urine samples were obtained during each period at 2- to 5-hr intervals. Serum melatonin and urinary melatonin and aMT6s were assayed by radioimmunoassay. The serum melatonin levels increased nearly 10-fold from low daytime to high nocturnal values. The mean nocturnal increase of urinary melatonin was 1.7-fold and that of urinary aMT6s was 4.6-fold. Both urinary melatonin and aMT6s correlated significantly with area under the curve melatonin in serum during the night, during the day and throughout the entire 24-hr observation period in all cases. The ratio between urinary melatonin and aMT6s excretion showed significant diurnal variation, being ninefold higher at 16:00 hr than at 07:00 or at 09:00 hr. The ninefold decrease in the urinary melatonin/aMT6s excretion ratio between the evening and the morning may reflect increased liver metabolism of melatonin during the night. Both urinary melatonin and aMT6s are good indicators of melatonin secretion, but the variation is significantly smaller for the former molecule.

Obesity and socioeconomic status in children of Tijuana

BACKGROUND

Although obesity has been associated with socioeconomic status among Hispanics living in the United States, little is known about whether a similar association exists among Hispanics living in Mexico, particularly among those living along the U.S.-Mexico border.

OBJECTIVE

To determine the prevalence of obesity and its association with socioeconomic status in Mexican schoolchildren attending public and private schools in Tijuana, Baja California.

METHODS

Anthropometric measurements and socioeconomic status were assessed in a cross-sectional study of 1172 school children, aged 6 to 13 years from 55 schools in Tijuana in 2001-2002. Underweight (body mass index [BMI] for age 5th percentile or lower), risk of overweight (BMI at 85th percentile or higher), and overweight (BMI greater than 95th percentile) were assessed using charts published by the Centers for Disease Control and Prevention.

RESULTS

Abnormalities in weight were found in 46.3% of 587 boys and 43.7% of 585 girls in the study. Undernutrition was found in 3.7% of the boys and 3.8% of the girls. The general prevalence of overweight was 23.2% for boys and 21.7% for girls. Children living in low-income neighborhoods had the thickest biceps skinfolds (p<0.01), while children living in moderate-income neighborhoods and attending public schools had the thickest triceps skinfolds (p<0.001). Although boys living in high socioeconomic status neighborhoods were at decreased risk for being overweight, boys and girls attending private schools had a 75% increased risk (odds ratio, 1.75; confidence interval, 1.22-2.52) of being overweight than children attending public schools.

CONCLUSIONS

Adiposity varies by type of school and neighborhood socioeconomic status. The biphasic curve in risk for being overweight associated with neighborhood socioeconomic status suggests that Mexican children living along the U.S. border may be experiencing a nutrition transition with respect to an increased risk of obesity and related chronic disease.

Effect of repeated exposures to cold on cognitive performance in humans

The effects of repeated exposure to cold temperature on cognitive performance were examined in 10 male subjects who were exposed to control (25 degrees C) and cold (10 degrees C) conditions on 10 successive days. A cognitive test battery (ANAM-ICE) was administered each day to assess complex and simple cognitive functioning accuracy, efficiency and response time. Rectal (T(rect)) and skin temperatures, thermal sensations, metabolic rate (M) and cardiovascular reactivity were also recorded. With the used cold exposure, inducing cold sensations and discomfort, superficial skin cooling (6-7 degrees C) and a slightly lowered T(rect) (0.4 degrees C) we observed three distinct patterns of cognitive performance: 1) negative, reflected in increased response times and decreased accuracy and efficiency; 2) positive, reflected in decreased response time and increased efficiency; and 3) mixed, reflected in a pattern of increases in both accuracy and response time and decreases in efficiency, and a pattern of decreases in both accuracy and response time. T(rect), thermal sensations, diastolic blood pressure (DBP) and heart rate (HR) were independent predictors of decreased accuracy, but also decreased response time. Cognitive performance efficiency was significantly improved and response times shorter over the 10-d period both under control and cold exposures suggesting a learning effect. However, the changes in cognitive performance over the 10-d period did not differ markedly between control and cold, indicating that the changes in the thermal responses did not improve performance. The results suggest that cold affects cognitive performance negatively through the mechanisms of distraction and both positively and negatively through the mechanism of arousal.

Immigration reform and the health of Latino immigrants in California

This paper examines Latino immigrant health within the context of the current debate over immigration reform and the resulting cultural construction of public health in California. A review of epidemiologic and ethnographic data indicates that the subordinate socioeconomic status of Latino immigrants plays a major role in both disease etiology and access to health services. However, this status does not explain why certain patterns of health services utilization and disease morbidity and mortality persist although political and economic circumstances have changed. These patterns include the reluctance to utilize certain health services despite access to health insurance and the presence of an epidemiologic paradox in which Latinos have health status indicators comparable to or better than that of other ethnic groups despite high poverty, low education, and lack of access to care. An "economy of culture" model is used to explain these inconsistencies in the political economy model of Latino immigrant health.

Postural sway during single and repeated cold exposures

INTRODUCTION

Tissue cooling changes sensory and neuromuscular functions that are also involved in postural control. The purpose of the study was to determine how acute and repeated exposures to cold affect whole body postural control.

METHODS

Postural sway was measured from 10 subjects during standing with eyes open (EO) and closed (EC) using an inclinometer-based method. Sway was assessed at at 10 degrees C on 10 consecutive days and at 25 degrees C on days 1, 5, and 10. Sway path length, area, velocity, side-to-side and forward-backward movement were assessed. At the same time, rectal and skin temperatures, muscle tonus/ shivering, thermal sensations, and comfort were recorded.

RESULTS

Acute exposure to 10 degrees C caused thermal discomfort, significantly lowered (26.1-26.5 degrees C) mean skin temperatures, slightly lowered rectal temperature (36.7 degrees C) and increased (140-260%) muscle tone, increased sway path length (67-87%, p < 0.05), velocity (63-71%, p < 0.05), total sway area (42-67%, p < 0.05), and forward-backward movement (35-57%, p < 0.05) compared with 25 degrees C. Side-to-side movements were not altered in the cold. Postural sway increased with EC, and further when exposed to cold, but the effect of cold was smaller compared with EO. Repeated exposures over the 10-d period decreased sway 10-40% both at 25 degrees C and at 10 degrees C (p < 0.05-0.01), suggesting motor learning. The difference in sway between 25 degrees C and 10 micro C remained the same throughout the 10-d period, suggesting that the observed cold habituation responses do not affect sway.

CONCLUSIONS

The results demonstrate that postural control is impaired in cold, which may affect physical performance in cold environmental conditions.

Influence of seasonally adjusted exposure to cold and darkness on cognitive performance in circumpolar residents

The effects of seasonally adjusted 24-h exposure to cold and darkness on cognitive performance in urban circumpolar residents was assessed in 15 male subjects who spent three 24-h periods in a climatic chamber at 65 degrees latitude during the winter (January-March) and/or summer (August-September). Each subject was exposed to three different environmental conditions in random order: (1) 22 degrees C temperature and 500 lx lighting; (2) 10 degrees C temperature and 500 lx lighting; and (3) 10 degrees C temperature and 0.5-l lx lighting. Accuracy on an addition-subtraction task was significantly greater in the summer than in the winter (p= 0.038), while accuracy on a repeated acquisition task was significantly greater in the winter than in the summer (p < 0.001). Independent of season, exposure to cold and darkness was significantly associated with a decline in response time on five cognitive tests, an improvement in accuracy on three tests measuring complex cognitive tasks, and a decline in accuracy on two tests measuring simple tasks. Increased performance on complex tasks may result from increased arousal in response to the combination of cold temperatures and dim light characteristic of the winter in urban circumpolar settings.

Models of research-operational collaboration for behavioral health in space

Addressing the behavioral health needs of astronauts clearly requires collaborations involving researchers, clinicians and operational support personnel, program administrators, and the astronauts themselves. However, such collaborations are often compromised by a failure to understand the needs, priorities, constraints, and preferences of potential collaborators. This failure, in turn, can lead to research of poor quality, implementation of programs and procedures that are not evidence-based, and an increased risk of morbidity and mission failure. The experiences of social marketing strategies in health promotion and disease prevention, cultural exchange between developers of evidence-based treatments and consumers, and dissemination and implementation of evidence-based practices in mental health services offer three different models of research-operational collaboration with relevance to behavioral health in space. Central to each of these models are the patterns of interpersonal relations and the individual, social, and organizational characteristics that influence these patterns. Any program or countermeasure for behavioral health in space must be both needs-based and evidence-based. The successful development, dissemination, implementation, and sustainability of such a program require communication, collaboration, and consensus among all key stakeholders. To accomplish this, all stakeholders must participate in creating a culture of operational research.

Early Intervention Practices for Children With Autism: Descriptions From Community Providers

Across the country, states are reporting increases in the number of children with autism enrolled in the education system. Although a few specific treatment methods have been established as efficacious for some children with autism in controlled settings, research examining the translation of these treatments into early intervention programs has been minimal. The current study examined provider self-reports of the use of interventions in community settings through focus groups. Providers report the use of both evidence-based and non-evidence-based techniques and indicate that they often combine and modify these techniques based on child, personal, and external factors. Few providers had a clear understanding of evidence-based practice, and all providers reported concerns about adequate training. Implications for early intervention research are discussed.

Cross-cultural differences in psychosocial adaptation to isolated and confined environments

INTRODUCTION

Differences in patterns of psychosocial adaptation under conditions of prolonged isolation and confinement in Antarctica were examined to determine the extent to which they were influenced by national culture in general and the individualist-collectivist orientation of national cultures in particular.

METHODS

The Profile of Mood States and measures of structural and functional social support were administered over an 8-mo period (March through October) to 13 winter-over crews from 5 nations operating research stations in the Antarctic: United States (3 crews, n = 77), Poland (3 crews, n = 40), Russia (3 crews, n = 34), China (3 crews, n = 40), and India (1 crew, n = 26).

RESULTS

Americans at South Pole Station reported significant increases in fatigue and anxiety and a significant decrease in vigor over the winter. During the same period, Russians at Vostok Station reported significant decreases in depression, anxiety, and confusion, and Indians at Maitri Station reported a significant decrease in anger. A significant decrease in social interaction with fellow crewmembers occurred at South Pole Station, Vostok Station, and Poland's Arctowski Station. Several differences were also observed between the five stations in correlations between mood scores and measures of structural and functional social support. An individualistic cultural orientation was significantly associated with low social support and low negative mood.

CONCLUSION

Cultural background is associated with mood and social support as well as changes in these measures during the austral winter. Cultural differences in patterns of psychosocial adaptation must be considered in the formation and training of multinational crews for long duration missions in space.

A prospective study of Type 2 diabetes and depressive symptoms in the elderly: the Rancho Bernardo Study

AIMS

The association between Type 2 diabetes and depressive symptoms was examined prospectively to assess possible causal relationships between the two diseases.

METHODS

A cohort of 971 men and women aged 50 and older from the adult population of Rancho Bernardo, California had an oral glucose tolerance test and completed the Beck Depression Inventory (BDI) at two clinic visits, 1984-87 and 1992-96.

RESULTS

Depressive symptoms at baseline were associated with higher follow-up levels of non-fasting plasma glucose (P = 0.001) and an increased risk of developing Type 2 diabetes [odds ratio (OR) = 2.50; 95% confidence interval (CI) = 1.29-4.87], independent of sex, age, exercise and body mass index. Conversely, baseline non-fasting plasma glucose was not significantly associated with follow-up depressive symptoms and Type 2 diabetes at baseline was not significantly associated with the onset of BDI scores > or = 11 by the second visit (OR = 0.73; 95% CI = 0.41-1.30).

CONCLUSIONS

Depressed mood is more likely to be a risk factor for Type 2 diabetes in older adults than the reverse.

The San Diego East County school shootings: a qualitative study of community-level post-traumatic stress

INTRODUCTION

Within one month (March 2001), two separate incidents of school shootings occurred at two different high schools within the same school district in San Diego's East County.

OBJECTIVE

To examine community-wide expressions of post-traumatic distress resulting from the shootings that may or may not fulfill DSM-IV criteria for post-traumatic stress disorder (PTSD), but which might interfere with treatment and the prevention of youth violence.

METHODS

A qualitative study was undertaken using Rapid Assessment Procedures (RAP) in four East San Diego County communities over a six-month period following the two events. Semi-structured interviews were conducted with 85 community residents identified through a maximum variation sampling technique. Interview transcripts were analyzed by coding consensus, co-occurrence, and comparison, using text analysis software.

RESULTS

Three community-wide patterns of response to the two events were identified: (1) 52.9% of respondents reported intrusive reminders of the trauma associated with intense media coverage and subsequent rumors, hoaxes, and threats of additional acts of school violence; (2) 44.7% reported efforts to avoid thoughts, feelings, conversations, or places (i.e., schools) associated with the events; negative assessment of media coverage; and belief that such events in general cannot be prevented; and (3) 30.6% reported anger, hyper-vigilance, and other forms of increased arousal. Twenty-three (27.1%) respondents reported symptoms of fear, anxiety, depression, drug use, and psychosomatic symptoms in themselves or others.

CONCLUSIONS

School shootings can precipitate symptoms of post-traumatic stress disorder at the community level. Such symptoms hinder the treatment of individuals with PTSD and the implementation of effective prevention strategies and programs.

Seasonal changes in thermal responses of urban residents to cold exposure

To determine whether urban circumpolar residents show seasonal acclimatisation to cold, thermoregulatory responses and thermal perception during cold exposure were examined in young men during January-March (n=7) and August-September (n=8). Subjects were exposed for 24 h to 22 and to 10 degrees C. Rectal (T(rect)) and skin temperatures were measured throughout the exposure. Oxygen consumption (VO(2)), finger skin blood flow (Q(f)), shivering and cold (CDT) and warm detection thresholds (WDT) were assessed four times during the exposure. Ratings of thermal sensations, comfort and tolerance were recorded using subjective judgement scales at 1-h intervals. During winter, subjects had a significantly higher mean skin temperature at both 22 and 10 degrees C compared with summer. However, skin temperatures decreased more at 10 degrees C in winter and remained higher only in the trunk. Finger skin temperature was higher at 22 degrees C, but lower at 10 degrees C in the winter suggesting an enhanced cold-induced vasoconstriction. Similarly, Q(f) decreased more in winter. The cold detection threshold of the hand was shifted to a lower level in the cold, and more substantially in the winter, which was related to lower skin temperatures in winter. Thermal sensations showed only slight seasonal variation. The observed seasonal differences in thermal responses suggest increased preservation of heat especially in the peripheral areas in winter. Blunted vasomotor and skin temperature responses, which are typical for habituation to cold, were not observed in winter. Instead, the responses in winter resemble aggravated reactions of non-cold acclimatised subjects.

Social support and depressed mood in isolated and confined environments

The influence of isolation and confinement on social support and depressed mood was examined in a study of 235 men and women who spent a year at McMurdo Station in Antarctica, and a study of 77 men and women who spent a year at the Amundson-Scott South Pole Station. Although availability of support remained unchanged, there was a significant decrease in reported satisfaction with support obtained, as well as a significant increase in depressed mood. Satisfaction with support was inversely associated with depressed mood at the beginning and end of isolation and confinement. At the end of winter, this association varied by source of support. High levels of tension-anxiety, depression and anger preceded an increase in advice seeking, but high levels of advice seeking also preceded an increase in tension-anxiety and depression. Results suggest a significant erosion of social support under conditions of prolonged isolation and confinement, leading to an increase in depressed mood.

Elevation in serum thyroglobulin during prolonged Antarctic residence: effect of thyroxine supplement in the polar 3,5,3'-triiodothyronine syndrome

Extended Antarctic residence (AR) is associated with an increase in serum TSH, a decrease in free T(4), and an increase in T(3) production and clearance. It is not clear whether these adaptations reflect changes in clearance alone or whether intrinsic thyroidal synthetic activity also changes. Thyroglobulin (Tg) secretion is an independent marker of intrinsic thyroid activity whose kinetics are independent of those of T(3) and T(4). In this study we examined changes in Tg levels in healthy subjects before and during AR and their responses to thyroid supplementation to help determine whether alterations in thyroid activity, and not just kinetics of clearance, underlie the changes seen with the polar T(3) syndrome. In cohort 1, we compared measurements of TSH and Tg in 12 subjects before deployment and monthly for 11 months during AR. In cohort 2, we compared the same measurements in 12 subjects monthly for 11 months of AR. Subjects were randomized to receive either placebo or levothyroxine in cohort 1 for 7 months and in cohort 2 for 11 months. Tg increased over baseline during the first 4 months of AR by 17.0 +/- 4.6% and after 7 more months by 31.7 +/- 4.3% over baseline in the placebo group of both cohorts (P < 0.0002). When L-T(4) was taken, Tg returned to a value not different from baseline (4.5 +/- 3.9%). The percent changes from baseline in serum TSH and Tg during AR were highly correlated (P < 0.00003) in the placebo group for both cohorts. The rise in Tg with TSH and the reduction in Tg with L-T(4) provide evidence of target tissue response to TSH and further confirm the TSH rise as physiologically significant. The results also suggest that the adaptive changes in thyroid hormone economy with AR reflect TSH-dependent changes in thyroid synthetic activity, which may help explain a portion of the increases in T(3) production found with AR.

The journey to wellness: stages of refugee health promotion and disease prevention

Refugees experience a threefold challenge to their health and well-being: 1) psychiatric disorders precipitated by the refugee experience, 2) infectious and parasitic diseases endemic to countries of origin, and 3) chronic diseases endemic to host countries. This paper documents the "journey to wellness" in which these challenges are faced in stages by the refugees themselves and by the array of health and social service agencies committed to providing refugee assistance. Using the experience of a consortium of agencies in San Diego as an example, we examine the interaction between these challenges and the mobilization of organizations to develop a program of health promotion and disease prevention for Somali and other East African refugees. This mobilization involves a series of steps designed to facilitate refugee confidence, comprehension, and compliance with prevention efforts through community-provider partnerships and negotiation between refugee and organizational explanatory models of disease causation and prevention.

Youth-violence prevention in the aftermath of the San Diego East county school shootings: a qualitative assessment of community explanatory models

BACKGROUND

In March, 2001, 2 separate incidents of school shootings occurred within the same school district in San Diego's East County.

OBJECTIVE

To examine community explanatory models of the causes of the school shootings and strategies for preventing such events.

DESIGN/METHODS

A qualitative study was undertaken in 4 East County communities over a 6-month period following the 2 events. Semistructured interviews were conducted with 85 community residents identified through maximum variation sampling. Interview transcripts were analyzed by coding consensus, co-occurrence and comparison, using NVivo text analysis software.

RESULTS

Four sets of theories as to the cause of these events were identified, based on the following: 1) unique or idiosyncratic characteristics of the 2 shooters (newcomer to community who was a victim of bullying, victim of child abuse with a history of mental illness), 2) universal factors (culture of violence, violence in the media), 3) family-centered characteristics (single-parent households, dysfunctional relationships), and 4) community-specific characteristics (reputation for social intolerance, widespread access to guns). Beliefs in family-centered and community-centered theories of etiology were associated with optimism in preventing such events from occurring in the future through increased recognition and response to problem behaviors, while beliefs in idiosyncratic or universal determinants of youth violence were associated with pessimistic assessments of prevention.

CONCLUSIONS

In this community, youth-violence-prevention programs that focus on taking responsibility for recognizing and responding to problem behaviors in at-risk youth are more likely to gain community support and participation than programs that focus on increased security, surveillance, or behavior change.

Efficacy of transdermal ketoprofen for delayed onset muscle soreness

OBJECTIVE

To determine the efficacy of transdermal ketoprofen in reducing delayed-onset muscle soreness (DOMS), limiting systemic absorption, and improving postexercise function following repetitive muscle contraction.

DESIGN

Double-blind, placebo-controlled clinical trial.

SETTING

OrthoMed, University of California at San Diego, La Jolla, CA, U.S.A.

PARTICIPANTS

Thirty-two healthy males 18 to 35 years old.

INTERVENTIONS

Subjects performed a leg extension and flexion exercise program designed to create DOMS in quadriceps muscles. Subjects were randomly assigned to receive any combination of transdermal ketoprofen or placebo cream, applied TID, to their right and left quadriceps.

MAIN OUTCOME MEASURES

Subjective measure of DOMS in quadriceps muscles, serum ketoprofen levels, strength index scores (a measure of postexercise function), and adverse reactions were assessed at baseline, 24 hours, and 48 hours.

RESULTS

Within-subjects analysis (n = 16) showed a significant reduction in DOMS scores in legs receiving transdermal ketoprofen compared with legs receiving placebo cream (P = 0.002 at 48 hours and 0.000 at 24 and 48 hours combined). Between-subjects analysis (n = 16) showed a marginally significant reduction in DOMS scores at 48 hours (P = 0.05 in right legs and 0.053 in left legs). Systemic absorption was minimal, with serum ketoprofen levels in the ng/mL range. No differences in strength index scores were observed. No adverse reactions were reported.

CONCLUSIONS

Transdermal ketoprofen appears to be effective in reducing self-reported DOMS after repetitive muscle contraction, particularly after 48 hours. Systemic absorption of the drug was minimal. Treatment did not appear to have any effect on postexercise function, and there were no reported adverse reactions.

The psychology of isolated and confined environments. Understanding human behavior in Antarctica

Psychosocial adaptation to isolated and confined environments exhibits 4 distinct characteristics. First, it is seasonal: Variations in mood are associated with the altered diurnal cycle and psychological segmentation of the mission. Second, it is situational: Concurrent measures of personality, interpersonal needs, and coping styles are better predictors of mood and performance than are predeployment measures. Third, it is social: Members of expeditions with low social coherence report significantly more depression, anxiety, and anger than individuals belonging to expeditions with high social coherence. Fourth, it is salutogenic: Depressed mood is inversely associated with the severity of the physical environment of the station, and the winter-over experience is associated with reduced subsequent rates of hospital admissions, suggesting positive benefits for individuals seeking challenging experiences.

Social roles and the evolution of networks in extreme and isolated environments

This article reports on the evolution of network structure as it relates to formal and informal social roles in well-bounded, isolated groups. Research was conducted at the Amundsen-Scott South Pole Station. Data were collected on crewmembers' networks of social interaction over each of three winter-over periods, when the station is completely isolated. In addition, data were collected on the informal roles played by crewmembers (e.g., instrumental leadership, expressive leadership). The study found that globally coherent networks in winter-over groups were associated with group consensus on the presence of critically important informal social roles (e.g., expressive leadership) where global coherence is the extent to which a network forms a single group composed of a unitary core and periphery as opposed to being factionalized into two or more subgroups. Conversely, the evolution of multiple subgroups was associated with the absence of consensus on critical informal social roles, above all the critically important role of instrumental leader.

Varieties of health services utilization by underserved Mexican American women

Varieties of health services utilization by medically underserved patients were examined in 250 Mexican American women attending a primary care clinic in San Diego, California. Less than half (48.4 percent) of these medically underserved women had obtained clinical preventive services conforming to recommended guidelines, 34.4 percent reported having obtained an annual physical examination in the past year, and 66.0 percent reported visiting a doctor only when they were sick. Lack of any form of health insurance, including Medi-Cal, was associated with underutilization of primary care services to a greater degree than the other variables examined. However, other factors such as full-time employment, low education, dissatisfaction with primary care delivery, and cultural preference for traditional ethnomedical alternative forms of health care, constitute important barriers to utilization of primary care services. Efforts to provide health care to the medically underserved must take these barriers into consideration if they are to be successful.

Immigration, acculturation, and risk factors for obesity and cardiovascular disease: a comparison between Latinos of Peruvian descent in Peru and in the United States

OBJECTIVE

To determine whether migration and acculturation was associated with risk factors for obesity and cardiovascular disease, whether this association is linear or curvilinear, and whether the socio-cultural context alters the association between obesity and cardiovascular disease and individual-level variables.

SETTING

Lima, Peru, San Diego and San Francisco, California.

PARTICIPANTS

Ninety-two Peruvian residents of Lima and 83 Peruvian immigrant residents of California.

MAIN OUTCOME MEASURES

total cholesterol, blood pressure, body mass index, waist-to-hip ratio.

RESULTS

A significant linear association was found between migration and acculturation and alcohol consumption and total cholesterol in men and women, systolic (SBP) and diastolic (DBP) blood pressure and body mass index in men, and physical activity in women. Immigration/acculturation level was a significant independent predictor of total cholesterol. Age and body mass index were independent predictors of total cholesterol only in Peru. Sex was an independent predictor of DBP only in the United States. Body mass index was an in dependent predictor of DBP only in Peru. Household income was an independent predictor of SBP and DBP only in Peru and body mass index only in the United States, while level of education was inversely associated with body mass index only in Peru. Regular strenuous physical activity was an independent predictor of obesity measures only in the United States.

CONCLUSIONS

The socio-cultural context alters the risk of obesity and cardiovascular disease associated with individual-level variables and accounts for gender and cross-national differences in the migration-illness association.

Mental and cognitive performance in the cold

Vigilance, attention, memory, and motivation are essential to adapting to the physiological changes that occur with prolonged exposure to the cold and to avoiding both the environmental hazards associated with cold and the health-related consequences of these hazards. This paper summarizes the effects of cold temperatures on cognitive performance and mood. Although the effects of hypothermic-induced cold temperatures on cognitive performance and mood have been well documented, evidence of nonhypothermic effects has been inconsistent. There is evidence of a dose-response relation involving decrements in cognitive performance with respect to decline in core body temperature and complexity of tasks performed. However, it is unclear whether these effects are due to distraction or increased arousal. Likewise, further research is required to test the efficacy of existing and proposed pharmacologic and nutritional countermeasures.