If we want more evidence-based practice, we need more practice-based evidence.*

Home  Endnotes: Preface  Chap 1  Chap 2  Chap 4 Chap 5  Chap 6  Chap 7  Chap 8  Chap 9

Health Program Planning, 4th edition

New Endnotes, References, and Web Links

Chapter 3. The Epidemiological Diagnosis: Health, Behavioral, and Environmental Assessments  

In the 4th edition Chapter 3 combines what were Chapters 3 & 4 in 3rd edition.

For an online glossary of statistical terms used in epidemiology, click here. For other terms, go to the glossary in our 4th edition. For online biostatistics courses, click on "Descriptive Epidemiology" in the Table of Contents below.

INTRODUCTION

    Where's the Evidence?

    Organization of the chapter

STARTING IN THE MIDDLE: A REALITY FOR PRACTITIONERS AND PLANNERS

THREE REASONS WHY PLANNERS SHOULD KNOW THE WHOLE MODEL

     MAINTAINING RECIPROCAL BALANCE

DESCRIPTIVE EPIDEMIOLOGY [Part 1]

    EPIDEMIOLOGY: A DEFINITION

     WHAT IS THE PROBLEM?

        Rates

        Specific and Adjusted Rates

        Incidence and Prevalence Rates

        Surveillance

    Making Comparisons for Planning

           Obtaining Data to Make Comparisons

        Comparisons in Evaluation

SETTING PRIORITIES and OBJECTIVES FOR HEALTH PROGRAMS

    KEY QUESTIONS

     DEVELOPING HEALTH OBJECTIVES

ETIOLOGY: WHY DO THOSE WITH THE PROBLEM HAVE IT? [Part 2]

   RISK FACTORS: FINDING RELEVANCE FOR PLANNING

    RISK FACTOR SURVEILLANCE

    POPULATION-ATTRIBUTABLE RISK

    COST-BENEFIT ANALYSIS FROM POPULATION-ATTRIBUTABLE RISK

    DATA: FOLLOW THE SIGNS

    ECOLOGICAL CORRELATIONS

    AN EXAMPLE: COAL MINERS IN APPALACHIA

    "PROTECTIVE" FACTORS

BEHAVIORAL DIAGNOSIS

   THREE LEVELS OR CATEGORIES OF BEHAVIOR

    GENETIC-BEHAVIOR INTERACTIONS

    STEP 1: LISTING POTENTIAL BEHAVIORAL RISKS FOR THE HEALTH PROBLEM

    STEP 2: RATING BEHAVIORS ON IMPORTANCE

    STEP 3: RATING BEHAVIORS ON CHANGEABILITY

    STEP 4: SETTING BEHAVIORAL OBJECTIVES

    STEP 5: STATING BEHAVIOR OBJECTIVES

ENVIRONMENTAL DIAGNOSIS

    STEP 1: IDENTIFYING WHICH ENVIRONMENTAL FACTORS

    STEP 2: RATING ENVIRONMENTAL FACTORS ON RELATIVE IMPORTANCE

    STEP 3: RATING ENVIRONMENTAL FACTORS ON CHANGEABILITY

    STEP 4: CHOOSING THE ENVIRONMENTAL OBJECTS OF CHANGE

    STEP 5: STATING THE ENVIRONMENTAL OBJECTIVES

EVALUATION SUMMARY

PUBLIC HEALTH NEWS ON EPIDEMIOLOGY SINCE THIS BOOK WENT TO PRESS

ENDNOTES FOR CHAPTER 3: EPIDEMIOLOGICAL DIAGNOSIS

INTRODUCTION

1. The obesity epidemic trend maps. Details of this event based on personal conversations with Dr. William Dietz, Director, Division of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC); and Jeffrey P. Koplan, Vice President for Health Sciences at Emory University and former Director, CDC. Interviews conducted on (October 5 and 7, 2003).  To review the PowerPoint slides presenting obesity and diabetes trend data, see: http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm

    Where's the Evidence?

2. Role of public health professionals in surveillance, monitoring, analyzing and presenting health data. Institute of Medicine, 2003.

Institute of Medicine (2003). Who will keep the public healthy? Washington, DC: The National Academies Press.Full-text online

    Organization of the chapter

3. Starting in the middle. The algorithm on the title page of Chapters 2-5 shows how the planner can locate the most appropriate place in PRECEDE to undertake data collection and planning. [A version of the algorithm for Chapter 3 is reproduced above in the table of contents.]

4. Evaluation as an integrated element of planning phases, rather than as a separate phase. In previous editions of this book, and earlier renditions of the Precede-Proceed model, we have devoted a separate chapter and a separate phase to evaluation, following the diagnostic and implementation phases. We have discovered that a separate, end-of-planning evaluation chapter has had an unintended effect for some planners: putting off thinking about evaluation until the program is launched.  This leads to the neglect of evaluation considerations in the earlier phases of planning where it is so essential not only for making inevitable midcourse corrections but also for establishing the baselines needed for measuring, monitoring, and documenting the important outcomes. As Carol Weiss (1973) so famously said, "The sins of the program are often visited on the evaluation." (p. 54). For an updated perspective on these observations in the context on theory-based planning and evaluation, see Birckmayer & Weiss, 2000.*

Birckmayer JD, Weiss CH.* (2000). Theory-based evaluation in practice. What do we learn?
Eval Rev 2000 Aug;24(4):407-31.

Weiss, C. H. (1973). Between the cup and the lip. Evaluation, 1(2), 54.

*Material highlighted in yellow has been added since the manuscript went to press for the 4th edition. Note that authors names underlined are hyperlinked to the abstract of the article, or to the publisher's catalog description of the book.

STARTING IN THE MIDDLE: A REALITY FOR PRACTITIONERS AND PLANNERS

See the algorithm on the title page of the chapter, and in the table of contents above.

THREE REASONS WHY PLANNERS SHOULD KNOW THE WHOLE MODEL

5. Web-based tools for linking social and epidemiological diagnosis. MAPP is a refinement and extension of the CDC Planned Approach to Community Health or PATCH (which was based on the principles and methods of the Precede-Proceed model) and Assessment Protocol for Excellence in Public Health (APEX/PH).  For more details on the MAPP process, contact the National Association of County and City Health Officials, 1100 17^th Street, NW, Second Floor, Washington, DC 20036.  Phone: (202) 783-5550, Email: mapp@naccho.org. See endnote 36 in Chapter 2 for web links. Related to the MAPP Web-based tools are other resources designed to tie local planning efforts to national health objectives as part of the Healthy People 2010 initiatives, e.g., U.S. Department of Health and Human Services, 2001; 2002.

U.S. Department of Health and Human Services, 2001. Healthy people in healthy communities. Washington, DC: U.S. Government Printing Office.

U.S. Department of Health and Human Services (2002). Healthy people 2010 toolkit: A field guide to health planning. Washington, DC: The Public Health Foundation.  http://www.health.gov/healthypeople/state/toolkit.

6. International example of linking health with social functioning. First published by the World Health Organization in 1980, the WHO International Classification of Functioning, Disability and Health, 2001, is now available on line at http://www.who.int/classification/icf/intros/ICF-Eng-Intro.pdf, and bundled with the companion International Classification of Diseases (ICD-10) in book and CD-ROM.

World Health Organization. (2001). International Classification of Functioning, Disability and Health. Geneva: World Health Organization. http://www.who.int/classification/icf/oderform/orderform.pdf. Accessed Dec 2, 2003.

7. Potential social consequences of health objectives. E.g., on youth violence, Rigby, 2003. On parental alcohol abuse, Christoffersen, & Soothill, 2003.

Rigby, K. (2003). Consequences of bullying in schools. Canadian Journal of Psychiatry, 48, 583-90.

Christoffersen, M. N., & Soothill, K. (2003). The long-term consequences of parental alcohol abuse: a cohort study of children in Denmark. Journal of Substance Abuse Treatment, 25, 107-16.

8. Working knowledge of trends, technologies, and recent evaluations of programs on similar health problems helps set up evaluation baseline measures. E.g., CDC, 2003, http://www.cdc.gov/cancer/ncccp/guidelines/index.htm

Centers for Disease Control and Prevention. (2003).  Guidance for comprehensive cancer control planning: Guidelines.  Vol 1 CDC, 2003: http://www.cdc.gov/cancer/ncccp/guidelines/index.htm.

     MAINTAINING RECIPROCAL BALANCE

9. Growing evidence of the social gradient in morbidity and mortality. E.g., Evans, Barer, & Stoddard, 1994; Smedley, & Syme, 2000; Wilkinson, 1996; Yen & Syme, 1999. See also endnote 2, Chapter 2.

Evans, R. G., Barer, M. L.,& Marmor, T. L. (Eds.). (1994). Why are some people healthy and others not?  Hawthorne, New York: Aldine De Guyter.

Smedley, B. D., & Syme, L. S. (2000). Promoting health: Intervention strategies from social and behavioral research. Washington, DC: National Academy Press.

Wilkinson, R.(1996). Unhealthy societies: The afflictions of inequality. London: Routledge, 1996.

Yen, I., Syme, S.L. (1999). The social environment and health: A discussion of the epidemiologic literature. Annual Review of Public Health 20: 287-308.

10. Poverty, racial, and ethnic factors in health disparities. E.g., Stewart & Napoles-Springer, 2003; Whaley, & Geller, 2003; Zuvekas, & Taliaferro, 2003.

Stewart, A. L., & Napoles-Springer, A. M. (2003). Advancing health disparities research: can we afford to ignore measurement issues? Med Care, 41, 1207-20.

Whaley, A. L., & Geller, P. A. (2003). Ethnic/racial differences in psychiatric disorders: a test of four hypotheses. Ethnicity & Disease, 13, 499-512.

Zuvekas, S. H., & Taliaferro, G. S. (2003). Pathways to access: health insurance, the health care delivery system, and racial/ethnic disparities, 1996-1999. Health Affairs (Millwood), 22, 139-53.

11. Participatory research engaging intersectoral collaboration on social determinants of health. E.g., Krieger, Cheadle, et al., 2002.

Krieger, J. W., Cheadle, A. C, Higgins D, Schier, J., Senturia, K., & Sullivan, M. (2002). Using community-based participatory research to address social determinants of health: Lessons learned from Seattle Partners for Healthy Communities. Health Education and Behavior, 29, 361-82.

DESCRIPTIVE EPIDEMIOLOGY

    EPIDEMIOLOGY: A DEFINITION

10>12. Definition of epidemiology. Last, 2000, pp. 62ff. The definition and explanation of epidemiology has been paraphrased from several pages of  Last, which he assures us was a committee product and never considered to be cast in stone (personal correspondence, Dec. 3, 2003). For variations on this definition, see Green & Ottoson, 1999, p. 70; Timmerick, 1997, pp. 221–2.

Last, J. (2000). Dictionary of epidemiology, 4^th edition. New York: Oxford University Press.

Timmerick, T. C. (1997). Health services cyclopedic dictionary. 3^rd ed. Sudbury, MA: Jones and Bartlett Publishers.

Because epidemiology relies on biostatistical methods, readers of this book who have not had a course either in biostatistics or epidemiology might want to consider http://statistics.com for current announcements of online courses, or one of the following online courses:

http://www.eric.seattle.med.va.gov/education/seattle_eric_cyber.htm
This is a web-TV course. Various lectures are on video, along with other
assignments via the web.

http://garnet.indstate.edu/bell/hs340/coursesyll.htm.
This Indiana State University course is undergraduate level.

http://www.uic.edu/depts/spha/
Only those who have been admitted to an MPH degree program can take this.

http://www.sph.emory.edu/CMPH/ Emory's course has students meet in person at the beginning and the end
of the course, with assignments in the interim period.

http://www.sph.unc.edu/nciph/certificate/curriculum.htm

http://hsc.usf.edu/publichealth/dlp/epbphc6050.html
This University of South Florida School of Public Health course is a satellite course. Not just on-line.

http://distance.jhsph.edu/statr1/
Bloomberg School of Public Health, Johns Hopkins University. Distance education. Note that this source of credit courses from Johns Hopkins differs from the Free "Open Access" courses described and linked below. 

Johns Hopkins Bloomberg School of Public Health Offers Free Courses Online

Demystifying Data: Accessing, Interpreting, and Using Health Data -- May 9 - June 27, 2005

Online course: Fundamentals of Epidemiology -- June 10 - July 15, 2005

15>13. Measures of quality of life. E.g., Centers for Disease Control and Prevention, 2000; see also Chapter 2, endnotes 5 and 16-22.

Centers for Disease Control and Prevention (2000). Measuring healthy days: Population assessment of health-related quality of life. Atlanta, GA, Health Care and Aging Studies Branch, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

     WHAT IS THE PROBLEM?

16>14. Years of potential life lost (YPLL) measure the impact of diseases and injuries that kill people before the customary age of retirement. It is computed as the sum of products over all age groups up to age 65, sometimes 75, each product being the annual number of deaths in an age group multiplied by the average number of years remaining before the age of 65 for that age group. See, e.g., Fellows, Tosclair, et al., 2002; O'Shea, 2003.

Fellows, J. L., Trosclair, A., Adams, E. K., &  Rivera, C. C. (2002). Annual smoking-attributable mortality, years of potential life lost, and economic costs--United States, 1995-1999. MMWR Morbidity & Mortality Weekly Report, 51, 300-3. [full text]

O'Shea E. (2003). Social gradients in years of potential life lost in Ireland. European Journal of Public Health, 13, 327-33.

        Rates

        Specific and Adjusted Rates

        Incidence and Prevalence Rates

        Surveillance

17>15. Definition of surveillance. Hockin, 2002, p. 1171. Earlier definitions from the communicable disease era of public health had emphasized "continuous" rather than "ongoing" collection of data, but because surveillance of chronic diseases calls upon public health to have earlier warnings of emerging diseases than the symptoms that are detected in continuous reporting by doctors, surveys of population health practices and lifestyles have been required to detect risk factors like smoking or obesity that would predict oncoming epidemics like cancer and diabetes. Surveys usually cannot be done continuously, hence the shift in definition of surveillance. The Behavioral Risk Factor Surveillance System (BRFSS), however, has a rolling sampling method within states that makes it virtually continuous (e.g., CDC, 2004).

Centers for Disease Control and Prevention (CDC). (2004). Declining prevalence of no known major risk factors for heart disease and stroke among adults--United States, 1991-2001. MMWR Morbidity & Mortality Weekly Reports, 53, 4-7. [Full text]

Hockin, J. (2002). Suveillance. In L. Breslow, B. Goldstein, L. W. Green, C. W. Keck, J. M. Last, & M. McGinnis (Eds.). Encyclopedia of public health, vol. 4, S-Z (pp. 1171-72). New York: Macmillan Reference USA.

16. Canadian federal compilation of surveillance data. Go to: http://www.hc-sc.gc.ca/pphb-dgspsp/, accessed Dec. 3, 2003.

    Making Comparisons for Planning

           Obtaining Data to Make Comparisons

17. New York City Community Health Profiles, New York City Department of Health and Mental Hygiene. Website: http://www.ci.nyc.ny.us/html/doh/html/data/data.html, accessed Dec. 3, 2003.

        Comparisons in Evaluation

SETTING PRIORITIES FOR HEALTH PROGRAMS

    KEY QUESTIONS

     DEVELOPING HEALTH OBJECTIVES

24>18. Some applications of PRECEDE illustrating epidemiological assessments and setting of health objectives include Antoniades & Lubker, 1997; Cadman, 1996; Cain, Schyulze, & Preston, 2001; Castilla y Leon, 1993; Clarke, Frankish, & Green, 1997; Farthing, 1994; Gielen, 1992; Green, Mullen, & Friedman, 1991; Green, Wilson, & Bauer, 1983; Howatt, Jones, et al., 1997; Livingston, 1985; Simons-Morton, Parcel, Brink, Harvey, & Tiernan, 1991; Stevenson, Jones, Cross, Howatt, & Hall, 1996; Stevenson, Jones, et al., 1996; Timmerick, 1998, pp. 338–340; Walter, Hoffman, Connelly, et al., 1985; 1986. See also Chapter 1, endnote 26.

Antoniadis, A., & Lubker, B. B. (1997). Epidemiology as an essential tool for establishing prevention programs and evaluating their impact and outcome. Journal of Communication Disorders 30, 269-83; quiz 283-4. Review.

Cadman, R.  (1996). Ski injury prevention - An epidemiological investigation of the social, behavioural, and environmental determinants of injury. Vancouver, BC: Institute of Health Promotion Research, Faculty of Graduate Studies, University of British Columbia, Unpublished doctoral dissertation.

Cain, R. E., Schyulze, R. W., & Preston, D. B. (2001). Developing a partnership for HIV primary prevention for men at high risk for HIV infection in rural communities. Promotion and Education: International Journal of Health Promotion and Education, 8, 75-8.

Castilla y Leon, Junta de (1993). Plan sectorial de educacion para la salud. Madrid: Graficas Don Bosco, Arganda del Rey. [Consejeria de Sanidad y Bienestar Social, Direccion General de Salud Publica y Asistencia, Avenida de Burgos, 5-47071 Valladolid, Spain]

Clarke, V., Frankish, C. J., & Green, L. W. (1997). Understanding suicide among indigenous adolescents: A review using the Precede model.  Injury Prevention 3: 126-34.

Farthing, M. (1994).  Health education needs of a Hutterite colony. The Canadian Nurse/L'Infirmiere Canadienne, 90, 20-6.

Gielen, A. C. (1992).  Health education and injury control: Integrating approaches. Health Education Quarterly, 19, 203-18.

Green, L. W., Mullen, P. D., & Friedman, R. (1986). An epidemiological approach to targeting drug information. Patient Education & Counseling, 8, 255-68.

Green, L. W.,  Wilson, R. W., &  Bauer, K. G.(1983). Data required to measure progress on the objectives for the nation in disease prevention and health promotion. American Journal of Public Health, 73, 18-24.

Howat, P., Jones, S., Hall, M., Cross, D., & Stevenson, M. (1997). The PRECEDE-PROCEED model: Application to planning a child pedestrian injury prevention program. Injury Prevention, 3, 282-7.

Livingston, I. L. (1985). Hypertension and health education intervention in the Caribbean: A public health appraisal. Journal of the National Medical Association, 77, 273-80.

Stevenson, M., Iredell, H., Howat, P., Cross, D., Hall, M.  (1999).  Measuring community/environmental interventions: The Child Pedestrian Injury Prevention Project.  Injury Prevention, 5, 26-30. 

Stevenson, M., Jones, S., Cross D., Howat, P., & Hall, M. (1996).  The child pedestrian injury prevention project. Health Promotion Journal of Australia, 6, 32-6. [Department of Epidemiology and Biostatistics, School of Public Health, Curtin University of Technology, Perth, Australia.]

Timmerick, T. C. (1998). An introduction to epidemiology (2nd ed.). Boston: Jones & Bartlett.

Walter, H. J., Hofman, A., Connelly, P. A., Barrett, L. T., & Kost, K. L. (1985). Primary prevention of chronic disease in childhood: changes in risk factors after one year of intervention. American Journal of Epidemiology, 122, 772-81.

Walter, H. J., Hofman, A., Connelly, P. A., Barrett, L. T., & Kost, K. L. (1986). Coronary heart disease prevention in childhood: one-year results of a randomized intervention study. American Journal of Preventive Medicine, 2, 239-45.
 

ETIOLOGY: WHY DO THOSE WITH THE PROBLEM HAVE IT?

19. Social determinants of health. E.g., Karpati, Galea, et al., 2002; Marmot, 2000; Marmott, & Wilkinson, 1999; Wallerstein, Duran, et al., 2003; Wilkinson, & Marmot, 1998.

Karpati, A., Galea, S., Awerbuch, T., & Levins, R. (2002). Variability and vulnerability at the ecological level: Implications for understanding the social determinants of health. American Journal of Public Health, 92, 1768-72.

Marmot, M. (2000). Social determinants of health: From observation to policy. Medical Journal of Australia, 17,: 541-44.

Marmot M. & Wilkenson, R.G. (Eds.). (1999). Social determinants of health. New York: Oxford University Press.

Wallerstein. N., Duran, B. M., Aguilar, J., Joe, L., Loretto, F., Toya, A., Yepa-Waquie, H., Padilla, R., &  Shendo, K. (2003). Jemez Pueblo: built and social-cultural environments and health within a rural American Indian community in the Southwest. American Journal of Public Health, 93, 1517-8.

Wilkinson, R. G., & Marmot, M. (Eds.) (1998). Social determinants of health: The solid facts. Geneva: World Health Organization.

The Influence of Community Factors on Health: An Annotated Bibliography provides insight into the findings of researchers who have investigated community effects on health, and the program and policy implications that can be drawn from their work. Developed by PolicyLink, and funded by The California Endowment, this annotated bibliography contains summaries of over 150 articles, reports, and books on how environmental, social, and economic conditions of community life affect health. The document is available in PDF form and in searchable web-based version at http://www.policylink.org/CHB/

 

20. Economic determinants of health. E.g., Green & Potvin, 2002; Hart, 2002; Wilkinson, 1996.

Green, L. W. &  Potvin, L. (2002). Education, health promotion, and social and lifestyle determinants of health and disease. In R. Detels, J. McEwen, R. Beaglehole, & H. Tanaka (Eds.). Oxford Textbook of public health: Vol 1: The scope of public health, 4^th edition (pp. 113-130). New York: Oxford University Press.

Hart, N. (2002). Social, economic, and cultural environment and human health. In R. Detels, J. McEwen, R. Beaglehole, & H. Tanaka (Eds.). Oxford Textbook of public health: Vol 1: The scope of public health, 4^th edition (pp. 89). New York: Oxford University Press.

Wilkinson, R. G. (1996). Unhealthy societies: The afflictions of inequality. London: Routledge.

21. Environmental risks. E.g., Dannenberg, Jackson, et al., 2003; Wallerstein, Duran, et al., 2003; Wright, & Fischer, 2003. See also Chapter 4, endnote 71.

Dannenberg, A. L., Jackson, R. J., Frumkin, H., Schieber, R. A.., Pratt, M., Kochtitzky, C., & Tilson, H. H. (2003). The impact of community design and land-use choices on public health: A scientific research agenda. American Journal of Public Health, 93, 1500-8.

Wallerstein. N., Duran, B. M., Aguilar, J., Joe, L., Loretto, F., Toya, A., Yepa-Waquie, H., Padilla, R., &  Shendo, K. (2003). Jemez Pueblo: built and social-cultural environments and health within a rural American Indian community in the Southwest. American Journal of Public Health, 93, 1517-8.

Wright, R. J., & Fischer, E. B. (2003). Putting asthma into context: Community influences on risk, behavior and interventions. In I. Kawachi, & L. F. Berkman (Eds.) Neighborhoods and health, pp. 222-262. New York: Oxford University Press Inc.

22. Cultural determinants of health. E.g., House, & Williams, 2000; Wright & Fisher, 2003.

House, J. S., & Williams, D. R. E. (2000). Understanding and reducing socioeconomic and racial/ethnic disparities in health. In Committee on Capitalizing on Social Science and Behavioral Health to Improve the Public’s Health, Institute of Medicine. Promoting health: Intervention strategies from social and behavioral research. Washington: National Academy Press, 2000. 

Full text online at: http://books.nap.edu/catalog/9939.html

Wright, R. J., & Fischer, E. B. (2003). Putting asthma into context: Community influences on risk, behavior and interventions. In I. Kawachi, & L. F. Berkman (Eds.) Neighborhoods and health, pp. 222-262. New York: Oxford University Press Inc.

23. "Determinants" might overstate the causal certainty of the connection, but not the consistent, cumulative weight of associational evidence.  Daniels, Kennedy, & Kawachi, 2000.

Daniels, N., Kennedy, B., & Kawachi, I. (2000). Justice is good for our health. Boston Review, February/March 2000.

24. Risk, risk perception, risk assessment. For a detailed review of these concepts and data related to them, see WHO, 2002, chapters 3, 4, & 5.

World Health Organization. (2002). The World Health Report 2002: Reducing risks, promoting healthy life. Geneva: World Health Organization.

    http://www.who.int/bookorders/anglais/detart1.jsp?sesslan=1&codlan=1&codcol=24&codcch=2002

In the March 10, 2004 Journal of the American Medical Association (291(10):1238-45), CDC researchers
updated the "actual causes of death" (see McGinnis and Foege's seminal piece on "actual causes of death," JAMA, 1990) to the year 2000.  The purpose of the new study was to determine whether lifestyle pattern changes over the past decade had influenced leading causes of mortality. They concluded that smoking remained the "real" cause of the most current deaths, but that with the declines in smoking and the increasing rates of obesity, diet and physical activity could soon overtake tobacco as the leading actual cause of death.

RISK FACTORS: FINDING RELEVANCE FOR PLANNING

            RISK FACTOR SURVEILLANCE

25. Limited surveillance capacity in most local jurisdictions. E.g., Ounpuu, Kreuger, et al., 2000; Remington, & Goodman, 1998; Teutsch, & Churchill, 2000.

Ounpuu, S., Kreuger, P., Vermeulen, M., Chambers, L. (2000). Using the U.S. Behavior[al] Risk Factor Surveillance System’s health related quality of life survey tool in a Canadian city. Canadian Journal of Public Health, 91, 67-72.

Remington, P. L., & Goodman, R. A. (1998). Chronic disease surveillance. In R. C. Brownson, P. L. Remington, & J. R. Davis (Eds.). Chronic Disease Epidemiology and Control, 2^nd ed. (pp. 55-76). Washington, DC, American Public Health Association.

Teutsch, S. M., & Churchill, R. E. (2000). Principles and practice of public health surveillance, 2^nd ed. Oxford, New York, Oxford University Press.

26. Making surveillance systems relevant to regional or local program planning. McQueen et al., 2003. See especially the analysis and interpretation of data from the BRFSS, Holtzman, 2003; and the bottom line, "Will they use it?" Ottoson & Wilson, 2003.

Holtzman, D. (2003). Analysis and interpretation of data from the U.S. Behavioral Risk Factor Surveillance System (BRFSS). In D. V. McQueen, & P. Puska (Eds.). (2003). Global behavioral risk factor surveillance, pp. 35-46. New York: Kluwer Academic/Plenum Publishers.

McQueen, D. V., Puska, P. (Eds.). (2003). Global behavioral risk factor surveillance. New York: Kluwer Academic/Plenum Publishers.

Ottoson, J. M., & Wilson, D. H. (2003). Did they use it? Beyond the collection of surveillance information. In D. V. McQueen, & P. Puska (Eds.). (2003). Global behavioral risk factor surveillance, pp.119-132. New York: Kluwer Academic/Plenum Publishers.

27. Accessing state risk factor survey data. The easiest way to access state specific data for the BRFSS is to go to the website for the Association of State and Territorial Health Officers at: www.astho.com. Once in that site, go to the map of the United States and click on the state or territory for which you are seeking data. Most state health departments now have some of their state data on health indicators available on their respective websites. One of the most thoroughly developed databases of health indicators is the IBIS-PH (Indicator-Based Information System for Public Health) of the Utah Department of Health. The following website will link you to categorized and alphabetical listings of all indicators, with links from there to each to the corresponding databases:  http://health.utah.gov/ibis-ph/. For an extensive guide to compiling such data in the context of a PRECEDE approach to planning, see the guides for the CDC PATCH planning process online and downloadable: http://www.cdc.gov/nccdphp/patch/.

    POPULATION-ATTRIBUTABLE RISK

    COST-BENEFIT ANALYSIS FROM POPULATION-ATTRIBUTABLE RISK

28. Smoking-attributable risk. The recent population-attributable risks and social costs for smoking are calculated for the U.S. in Fellows, Trosclair, et al., 2002; for full text of the article, click on the authors. For a review of health-related costs, see Max, 2001. Software for calculating smoking-attributable mortality and economic costs for adults and for maternal and child health are available from the Office on Smoking and Health, CDC, 2002, and at http://www.cdc.gov/tobacco/sammec.

Centers for Disease Control and Prevention. (2002). Smoking-attributable mortality, morbidity, and economic costs (SAMMEC): adult SAMMEC and maternal and child health (MCH) SAMMEC software. Atlanta: Office on Smoking and Health, National Center from Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention.

Fellows, J. L., Trosclair, A., Adams, E. K., &  Rivera, C. C. (2002). Annual smoking-attributable mortality, years of potential life lost, and economic costs--United States, 1995-1999. MMWR Morbidity & Mortality Weekly Report, 51, 300-3. [full text]

Max,W. (2001). The financial impact of smoking on health-related costs: a review of the literature. American Journal of Health Promotion, 15, 321-31.

    DATA: FOLLOW THE SIGNS

29. The Missouri data were taken from: Section IV, Chronic Disease, Risk Factor, and Preventive Services, Missouri, The Burden of Chronic Diseases and Their Risk Factors: National and State Perspectives 2002, at http://www.cdc.gov/nccdphp/statbook/statbook.htm, accessed Dec. 3, 2003. Any other state's data can be accessed from this site.

30. The report to the Missouri Board of Health. Missouri Foundation for Health, 2001, p. 20.

Missouri Foundation for Health. (2001). A report to the Board. Missouri State Department of Health. Missouri Foundation.

    ECOLOGICAL CORRELATIONS

31. Two studies on social capital and health. Kawachi, Kennedy, et al., 1997.

Kawachi, I., Kennedy, B. P., Lochner, K.& Prothro-Stith, D. (1997). Social capital, income inequality, and mortality. American Journal of  Public Health, 87, 1491-98.

    AN EXAMPLE: COAL MINERS IN APPALACHIA

32. The Appalachian mineworkers’ lung disease project. Terry, Wang, et al, 1981; Wang, Terry, et al 1979.

*Terry, P. B., Wang, V. L. Flynn, B. S., et al. (1981). A continuing medical education program in chronic obstructive pulmonary diseases: Design and outcome, American Review of Respiratory Diseases 123, 42-6.

*Wang VL, Terry P, Flynn BS, Williamson JW, Green LW, Faden R. (1979). Multiple indicators of continuing medical education priorities for chronic lung diseases in Appalachia, Journal of Medical Education, 54, 803-11.

    "PROTECTIVE" FACTORS

33. The Alameda County studies of protective health factors. Belloc, 1973; Belloc & Breslow, 1972; Berkman & Breslow, 1983; see also the retrospective reflections on this series of studies in an interview with Lester Breslow at age 89: Breslow, [Stallworth & Lennon], 2003.

Belloc, N. B. (1973). Relationship of health practices and mortality. Preventive Medicine, 3, 125-35.

Belloc, N. B., & Breslow, L. (1972). Relationship of physical health status and health practices. Preventive Medicine, 1, 409-21.

Berkman, L. F., &  Breslow, L. (1983). Health and ways of living: The Alameda County study. New York: Oxford University Press.

Breslow, L. (2003). An interview with Dr. Lester Breslow [interview by JoAna Stallworth and Jeffery L. Lennon]. American Journal of Public Health, 93, 1803-5.

34. The longer-term follow up of Alameda County cohort. Breslow & Egstrom, 1980.

Breslow, L., & Engstrom, J. D. (1980). Persistence of health habits and their relationship to mortality. Preventive Medicine, 9, 469-83.

35. Even bedridden, post-surgical patients can make a difference through participation in their care. Devine & Cook, 1983; Hughes, Hodgson, et al., 2000..

Devine, E. C., & Cook, T. D. (1983). A meta-analytic analysis of effects of psycho-educational interventions on length of postsurgical hospital stay. Nursing Research, 32, 267-74.

Hughes, L. C, Hodgson, N. A., Muller, P., Robinson, L. A., & McCorkle, R. (2000). Information needs of elderly postsurgical cancer patients during the transition from hospital to home. Journal of Nursing Scholarship, 32, 25-30.
 

BEHAVIORAL DIAGNOSIS

   THREE LEVELS OR CATEGORIES OF BEHAVIOR

36. The declines in smoking, lung cancer incidence, and heart mortality rates in California following passage of Proposition 99. Fichtenberg, & Glantz, 2000; MMWR, 2000.

Fichtenberg, C. M., & Glantz S. A. (2000). Association of the California Tobacco Control Program with declines in cigarette consumption and mortality from heart disease. New England Journal of Medicine, 343, 1772-7.

Cowling, D. W.,  Kwong, S. L.,  Schlag, R.,  Lloyd, J. C., & Bal, D. G. (2000). Decline in lung cancer rates – California, 1988-1997. Morbidity and Mortality Weekly Reports, 49: 1066-9. [Full text]

    GENETIC-BEHAVIOR INTERACTIONS

37. Genetic-behavioral-environmental interactions. Ridley, 1999, pp. 153-4. Our placement of behavior between "environment" and "genetics" in the generic Precede-Proceed logic model is consistent with the inclusion of behavior within the use of the term "environment" in most of the genetics literature.

Ridley, M. (1999). Genome: The autobiography of a species in 23 chapters. New York: Harper Collins.

38. Genetic variations, food, and susceptibility or resilience. The Pyramid Paradigm, Center of Excellence for Nutritional Genomics, University of California, Davis, http://nutigenomics.ucdavis.edu, accessed Dec 3, 2003.

39. Global obesity epidemic. WHO (2002).

World Health Organization. (2002). The World Health Report 2002: Reducing risks, promoting healthy life. Geneva: World Health Organization.

40. Gene-gene, gene-environment interactions in obesity.

Froguel, P., & Boutin, P. (2001). Genetics of pathways regulating bogy weight in the development of obesity in humans. Experimental Biology and Medicine, 226, 991-96. [Full text online]

STEP 1: LISTING POTENTIAL BEHAVIORAL RISKS FOR THE HEALTH PROBLEM

41. For examples of the application of PRECEDE in behavioral risk factor assessment in cardiovascular disease, see Arbeit et al., 1992; P. H. Bailey, Rukholm, Vanderlee, & Hyland, 1994; Berenson, Harsha, et al., 1998; Bruce, & Grove, 1994; Bush, Zuckerman, et al., 1987; 1989; Carlaw, Mittlemark, et al., 1984; Downey, Butcher, et al., 1987; Green, Lewis, & Levine, 1980; Kok, Matroos, et al., 1982; Mantell, DiVittis, & Auerbach, 1997, pp. 199–203; Morisky et al., 1981; Morrison, 1996; Nguyen, Grignon, Tremblay, & Delisle, 1995; Nguyen et al., 1995; O’Loughlin et al., 1995; Paradis et al., 1995; Zuckerman, Olevsky-Peleg, et al., 1989.

Arbeit, M. L., Johnson, C. C., Mott, D. S., Harsha, D. W., Nicklas, T. A., Webber, L. S., & Berenson, G. S. (1992). The Heart Smart Cardiovascular School Health Promotion: Behavior correlates of risk factor change. Preventive Medicine, 21, 18-21.

Bailey, P. H., Rukholm, E. E., Vanderlee, R., & Hyland, J. (1994). A heart health survey at the worksite: The first step to effective programming,  AAOHN Journal, 42, 9-14.

Berenson, G. S., Harsha, D. W., Hunter, S. M., Johnson, C. C., Levy, M., Little, S. D., Nicklas, T. A., Srinivasan, S. R., Virgilio, S. J., & Webber, L. S. (1998).  Introduction of comprehensive health promotion for elementary schools: The Health Ahead/Heart Smart Program.  New York: Vantage Press, esp. Chapters 3 & 6.

Bruce, S., & Grove, S. K. (1994).  The effect of a coronary artery risk evaluation program on serum lipid values and cardiovascular risk levels.  Applied Nursing Research,  7,  67-74.

Bush, P. J., Downey, A. M., Frank, L. S., & Webber, L. S. (1987).  Implementation of "Heart Smart": Cardiovascular school health promotion program. Journal of School Health, 57, 98-104.

Bush, P. J., Zuckerman, A. E., Theiss, P. K., Peleg, E. O., & Smith, S.A.  (1989). Cardiovascular risk factor prevention in black school children--2-year results of the Know Your Body Program. American Journal of Epidemiology, 129, 466-82.

Carlaw, R. W., Mittlemark, M., Bracht, N., & Luepker, R. (1984). Organization for a community cardiovascular health program: Experiences from the Minnesota Heart Health Program. Health Education Quarterly, 11, 243-52.

Downey, A. M., Butcher, A. H., Frank, G. C., Webber, L. S., Miner, M. H. & Berenson, G. S. (1987). Development and implementation of a school health promotion program for reduction of cardiovascular risk factors in children and prevention of adult coronary heart disease: 'Heart Smart'.  In B. Hetzel and G. S. Berenson, (Eds.), Cardiovascular risk factors in childhood: Epidemiology and prevention. Amsterdam, NY & Oxford: Elsevier Science Publishers B.V., pp. 103-121.

Kok, F. J., Matroos, A. W., van den Ban, A. W., & Hautvast, J. G. A. J.  (1982). Characteristics of individuals with multiple behavioral risk factors for coronary heart disease: the Netherlands, American Journal of Public Health, 72, 986-91.

Zuckerman, A. E., Olevsky-Peleg, E., Bush, P. J., Horowitz, C., Davidson, F. R., Brown, D. G., & Walter, H. (1989). Cardiovascular risk factors among Black schoolchildren: comparisons among four Know Your Body Studies. Preventive Medicine, 18, 113-32. 

 

   STEP 2: RATING BEHAVIORS ON IMPORTANCE

42. Teen smoking predicts adult smoking. Jacobsen, Lantz, et al., 2001.

Jacobsen, P. D., Lantz, P. M., Warner, K. E., Wasserman, J., Pollack, H. A., & Ahlstrom, A. A. (2001). Combating teen smoking: Research and policy strategies. Ann Arbor: The University of Michigan Press.

                STEP 3: RATING BEHAVIORS ON CHANGEABILITY

43. North Karelia project. Pietinen, Nissinen, et al., 1992; Puska, 1992; Puska & Uutela, 2000; Puska, Vartiainen, et al., 1998; Vartiainen, Jousilahti, et al., 2000.

Pietinen, P. Nissinen, A., Vartiainen, E., Tuomilehto, J., Uusitalo, U., Ketola, A., Moisio, S., & Puska, P. (1992). Dietary changes in the North Karelia Project (1972-1982). Preventive Medicine, 17,183-93;

Puska, P. (1992). The North Karelia Project: Nearly 20 years of successful prevention of CVD in Finland. Hygie: International Journal of Health Education, 11, 33-5.

Puska, P., Uutela, A. (2000). Community intervention in cardiovascular health promotion: North Karelia, 1972-1999. In: Schneiderman N, Speers MA, Silva JM, Tomes H, Gentry JH (Eds.), Integrating Behavioral and Social Sciences with Public Health. (pp. 73-96). United Book Press, Inc., Baltimore: American Psychological Association.

Puska, P., Vartiainen, E., Tuomilehto, J., Salomaa, V., & Nissinen, A. (1998). Changes in premature deaths in Finland: successful long-term prevention of cardiovascular diseases. WHO Bulletin, 76, 416-425.

Vartiainen, E., Jousilahti, P., Alfthan, G., Sundvall, J., Pietinen, P., Puska, P.. (2000). Cardiovascular risk factor changes in Finland, 1972-1997. International Journal of Epidemiology 29, 49-56. 

44. Limitations of the evidence for best practices in dietary behavior change. Agency for Healthcare Research and Quality, 2000. http://www.ahrq.gov/clinic/epcsums/dietsumm.htm.

Agency for Healthcare Research and Quality, 2000. Efficacy of interventions to modify dietary behavior related to cancer risk. Summary, Evidence Report/Technology Assessment: Number 25. Rockville, MD: Agency for Healthcare Research and Quality, AHRQ Publication No. 01-E028.  http://www.ahrq.gov/clinic/epcsums/dietsumm.htm

            STEP 4: CHOOSING BEHAVIORAL TARGETS

            STEP 5: STATING BEHAVIOR OBJECTIVES

        ENVIRONMENTAL DIAGNOSIS

46. Evidence of social-environmental factors in health. Cannuscio, Block, & Kawachi, 2003; Kreuter & Lezin, 2003; Lochner, Kawachi, et al., 2003.

Cannuscio, C., Block, J., Kawachi, I. (2003). Social capital and successful aging: the role of senior housing.  Annals of Internal Medicine, 139, (5 Pt 2), 395-9.

Kreuter, M. W., & Lezin, N. S. (2002). Social capital theory: Implications for community-based health promotion. In DiClementi, R.J., Crosby, R.A., Kegler, M.C. (Eds.). Emerging theories in health promotion practice and research: Strategies for improving public health (pp. 228-254). San Francisco, Jossey-Bass.

Lochner, K. A., Kawachi, I., Brennan, R. T., & Buka, S. L. (2003). Social capital and neighborhood mortality rates in Chicago. Social Science & Medicine, 56, 1797-805.

47. Ecological vision of influences on the population’s health. National Committee on Vital and Health Statistics. (2002).

National Committee on Vital and Health Statistics. (2002). Shaping a vision of health statistics for the 21^st century. Washington: National Center for Health Statistics, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.

48. The built environment. E.g., Dannenberg, Jackson, et al., 2003; Killingsworth, Earp, & Moore, 2003.

Dannenberg, A. L., Jackson, R. J., Frumkin, H., Schieber, R. A.., Pratt, M., Kochtitzky, C., & Tilson, H. H. (2003). The impact of community design and land-use choices on public health: A scientific research agenda. American Journal of Public Health, 93, 1500-8.

Killingsworth, R., Earp, J., & Moore, R. (2003). Supporting health through design: Challenges and opportunities. American Journal of Health Promotion, 18, 1-2.

49. Epidemiology of promoting safe walking and biking to school. Howatt, Jones, et al., 1997; Staunton, Hubsmith, & Kallins, 2003; Stevenson, Iredell, et al., 1999; Stevenson, Jones, et al., 1996. Preceed-Proceed applications marked with asterisk.

*Cross D, Stevenson M, Hall M, Burns S, Laughlin D, Officer J, Howat P. (2000). Child pedestrian injury prevention project: student results. Preventive Medicine, 30, 179-87.

*Howat, P., Cross, D., Hall, M., Iredell, H., Stevenson, M., Gibbs, S., Officer, J., Dillon, J., et al.   (2001). Community participation in road safety: barriers and enablers. Journal of Community Health. 26: 257-269.

*Howat, P., Jones, S., Hall, M., Cross, D., & Stevenson, M. (1997). The PRECEDE-PROCEED model: Application to planning a child pedestrian injury prevention program. Injury Prevention, 3, 282-7.

Staunton, C. E., Hubsmith, D., & Kallins, W. (2003). Promoting safe walking and biking to school: The Marin County success story. American Journal of Public Health, 93, 1431-4.

*Stevenson, M., Iredell, H., Howat, P., Cross, D., & Hall, M.  (1999).  Measuring community/environmental interventions: The Child Pedestrian Injury Prevention Project.  Injury Prevention, 5, 26-30. 

*Stevenson, M., Jones, S., Cross D., Howat, P., & Hall, M. (1996).  The child pedestrian injury prevention project.  Health Promotion Journal of Australia, 6, 32-6.

50. Indoor air example of emerging environmental threat. Lee, T. G. (2003)., Health and the Built Environment: Indoor Air Quality, Health and Well Being, Vital Signs Curriculum Project. http://arch.ced.berkeley.edu/vitalsigns/.

    STEP 1: IDENTIFYING WHICH ENVIRONMENTAL FACTORS

    STEP 2: RATING ENVIRONMENTAL FACTORS ON RELATIVE IMPORTANCE

    STEP 3: RATING ENVIRONMENTAL FACTORS ON CHANGEABILITY

51. Consulting with the community on environmental risk assessments. Commission on Risk Assessment and Risk Management, 1996. A debate in the community-based participatory research literature, which has been stimulated by such environmental assessment issues, is whether community participants in the research effort need to be involved in every aspect of the research, or whether, as the Commission suggests, they can be involved primarily at these two points in the formulation of the risk assessment research questions and the interpretation of the results. See, e.g., Green & Mercer, 2001.

Commission on Risk Assessment and Risk Management. (1996). Risk assessment and risk management in regulatory decision-making. Washington, DC: Author.

Green, L. W., & Mercer, S. L. (2001). Participatory research: Can public health researchers and agencies reconcile the push from funding bodies and the pull from communities? American Journal of Public Health, 91, 1926-9. [Full text online]

52. Risk assessment Vs risk perception, subjective and objective considerations. Amaro, Frazao, Pereira, & da Cunha Teles, 2004; Horey, Weaver, & Russell, 2004; Huang, Palta, et al., 2004; Pickles, 2004; Robb, Miles, & Wardle, 2004; Slovic, 1999; 2001.

Amaro F, Frazao C, Pereira ME, da Cunha Teles L. (2004). HIV/AIDS risk perception, attitudes and sexual behaviour in Portugal. International Journal of STD and AIDS, 15, 56-60.

Horey D, Weaver J, Russell H. (2004). Information for pregnant women about caesarean birth.
Cochrane Database Syst Rev. (1):CD003858.

Huang GH, Palta M, Allen C, LeCaire T, D'Alessio D. (2004). Self-rated Health among Young People with Type 1 Diabetes in Relation to Risk Factors in a Longitudinal Study. American Journal of Epidemiology, 159, 364-72.

Pickles T. (2004). What's a man to do? Treatment options for localized prostate cancer. Canadian Family Physician, 50, 65-72.

Robb KA, Miles A, Wardle J. (2004). Subjective and objective risk of colorectal cancer (UK).
Cancer Causes Control, 15, 21-5.

Slovic, P. (1999). Trust, emotion, sex, politics, and science: surveying the risk-assessment battlefield. Risk Analysis, 19, 689-701.

Slovic, P. (2001). The risk game. Journal of Hazardous Material, 86, 17-24.

53. Three ingredients for success in addressing “wicked” environmental problems. Goldsmith, 1969; Kreuter, DeRosa, et al., 2004.

Goldsmith JR. (1969). Air pollution epidemiology. A wicked problem, an informational maze, and a professional responsibility. Archives of Environmental Health, 18, 516-22.

Kreuter MW., DeRosa CR, Howze E, & Baldwin G. (2004). Understanding wicked problems: A key to environmental health promotion. Health Education and Behavior, 31, 441-54.

    STEP 4: CHOOSING THE ENVIRONMENTAL OBJECTS OF CHANGE

    STEP 5: STATING THE ENVIRONMENTAL OBJECTIVES

EVALUATION SUMMARY

SUPPLEMENTAL MATERIAL

In its 27th annual report on the overall health of Americans, the National Center for Health Statistics devoted an entire section to troubling gains in the incidence of diabetes, noting that 6.5 percent of adults were diagnosed with diabetes in 2002, compared with 5.1 percent in 1997, possibly bringing the total number of adults with diabetes to 12 million.

National Center for Health Statistics, CDC. (2003). The Health of Americans, 2003. Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.  http://www.healthinschools.org/2003/oct03_alert.asp

Physical activity: An example of reducing a complex behavior to multiple discrete behaviors or categories of behavior and the implications for health in terms of the amount of metabolic expenditure and type of health effect (aerobic vs anaerobic and musculoskeletal).

Physical Activity and Health Branch, Division of Nutrition and Physical Activity, and Cardiovascular Health Branch, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion; and an EIS Officer, CDC. (2001). Physical activity trends, United States--1990-1998. Morbidity and Mortality Weekly Report, 50, 166-9. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5009a3.htm

Standardized measurement of physical activity, and shifts in the measurement at points in the trend lines of national surveys, illustrated by the change in questions between the Behavioral Risk-Factor Surveillance System surveys in 2000 and 2001.

Source: Macera, C. A., Jones, D. A., Yore, M. M., Ham, S. A., Kohl, H. W., Kimsey, Jr, C. D., & Buchner, D. (2003). Prevalence of Physical Activity, Including Lifestyle Activities Among Adults --- United States, 2000--2001. Morbidity and Mortality Weekly Reports, 52, 764-769. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5232a2.htm

How the prevalence of a complex behavior can change from one year to the next as a result of a change in the definition and/or survey questions used to measure the behavior, as illustrated by the Behavioral Risk-Factor Surveillance System changes from the previous table.

Source: Macera, C. A., Jones, D. A., Yore, M. M., Ham, S. A., Kohl, H. W., Kimsey, Jr, C. D., & Buchner, D. (2003). Prevalence of Physical Activity, Including Lifestyle Activities Among Adults --- United States, 2000--2001. Morbidity and Mortality Weekly Reports, 52, 764-769. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5232a2.htm

Strath, S. J., Bassett, Jr., D. R., & Swartz, A. M. (2004). Comparison of the college alumnus questionnaire physical activity index with objective monitoring  Annals of Epidemiology, 14, 409-415.  

PUBLIC HEALTH NEWS ON EPIDEMIOLOGY SINCE THIS BOOK WENT TO PRESS

US leads developed countries in sexually transmitted disease rates. Newsday, Jan 26, 2005, from British Journal Sexually Transmitted Infections. Jan 27, 2005.

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