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Business and Health Administration Association

Division of MBAA International 2012 Meeting Chicago, Illinois

of MBAA International 2012 Meeting Chicago, Illinois BHAA President – Steve Szydlowski Program Chair –

BHAA President Steve Szydlowski Program Chair Avinandan Mukherjee Proceedings Editor - Scott J. Saccomano

PROCEEDINGS

of the

BUSINESS AND HEALTH ADMINISTRATION ASSOCIATION

CHICAGO, IL March 28-30, 2012

Copyright 2009 Business and Health Administration Association

All rights reserved. No part of these Proceedings may be reproduced, stored in a retrival system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording, or otherwise, without prior permission of the BHAA organization. The BHAA does encourage the author(s) of the enclosed articles to seek publication of their efforts in appropriate journals. All correspondence concerning purchase of these Proceedings or copyright release should be addressed to the Proceedings Editor.

2012 PROCEEDINGS EDITOR Dr. Scott J. Saccomano Herbert H. Lehman College Bronx, NY

Sample Footnote: Please use the following style when referring articles from the Proceedings:

Zakari, Nazik M.A. (2009), “The Influence of Academic Organizational Climate on Nursing Faculties Commitment in Saudi Arabia,” in Business & Health Administration Proceedings, Avinandan Mukherjee, Editor, p. 244.

Proceedings , Avinandan Mukherjee, Editor, p. 244. Business and Health Administration Association Annual
Proceedings , Avinandan Mukherjee, Editor, p. 244. Business and Health Administration Association Annual

Letter from the BHAA 2012 President

Letter from the BHAA 2012 President Steve Szydlowski University of Scranton Dear Colleagues and Friends, Welcome

Steve Szydlowski

University of Scranton

Dear Colleagues and Friends,

Welcome to the 2012 Business and Health Administration Association (BHAA) academic meeting. This year promises to be another year of high quality, diverse papers and presentations that have been the trademark of conference over the past years. It is with great honor and pleasure to serve as your President for the 2012 BHAA conference and hope you enjoy the academic, networking, and other educational events this week. Thank you again for you continuued support of the BHAA and I look foward to seeing you this week.

Sincerely, Dr. Steve Szydlowski President BHAA 2011/12

Sincerely, Dr. Steve Szydlowski President – BHAA 2011/12 Business and Health Administration Association Annual
Sincerely, Dr. Steve Szydlowski President – BHAA 2011/12 Business and Health Administration Association Annual

Letter from the BHAA 2011 Program Chair

Letter from the BHAA 2011 Program Chair Avinandan Mukherjee Montclair State University I take great pleasure

Avinandan Mukherjee

Montclair State University

I take great pleasure in extending greetings to all my friends and colleagues attending the 2012

Business and Health Administration Association (BHAA) Conference. As the Program Chair of the 2012 BHAA Conference, I am delighted to welcome you to Chicago. The Business and Health Administration Conference brings together scholars, teachers, students, practitioners, regulators and planners from a variety of business and health related disciplines, such as healthcare administration, pharmaceutical and healthcare marketing, pharmacy, healthcare management, health economics, health policy, medicine, public health, nursing, health informatics, global health, etc.

The BHAA is a growing and vibrant organization, under the umbrella of the MBAA International. The 2012 conference has a high quality program and is divided into fifteen distinct specialty tracks chaired by highly qualified and well-known individuals. Several outstanding papers have been submitted by individuals from world-renowned educational institutions and healthcare organizations.

I am confident you will find research presentations in this conference useful that will stimulate your thoughts and initiate dialogues and conversations on the state-of-the-art in theory and practice of business and health administration. I hope that your academic and professional pursuits will be enriched by networking and sharing your thoughts and expertise while reflecting on those of others, thus building a BHAA professional community that you will cherish to be a member of. Wish you an enjoyable and productive experience at the conference and have a great time in Chicago!

Note:

My special thanks to Naz Onel, Doctoral researcher at Montclair State University and Editorial Assistant for the International Journal of Pharmaceutical and Healthcare Marketing, for managing the flow of the manuscripts, communicating with the authors, and providing a professional look to

the proceedings.

Sincerely Dr. Avinandan Mukherjee Chair BHAA 2011/12

Sincerely Dr. Avinandan Mukherjee Chair – BHAA 2011/12 Business and Health Administration Association Annual
Sincerely Dr. Avinandan Mukherjee Chair – BHAA 2011/12 Business and Health Administration Association Annual

Letter from the BHAA 2011 Proceedings Editor

Letter from the BHAA 2011 Proceedings Editor Scott J. Saccomano Herbert H. Lehman College Dear BHAA

Scott J. Saccomano

Herbert H. Lehman College

Dear BHAA Colleagues:

I would like to take this time to welcome you to the BHHA conference. I have been attending this conference now for 10 years and I looked forward to attending and participating in the annual meeting each year due to its intellectually stimulating presentations and activities. BHAA offers everyone an opportunity to meet and work with colleagues from around the globe.

It was my pleasure and to serve as your Proceedings Editor for this year’s meeting. The variety and diversity of this year’s papers and abstracts continues to underscore the scope, complexity and constant challenges within the healthcare arena.

I want express a big “thank you” to Avinandan Mukherjee whose help in compiling the proceedings was invaluable and greatly appreciated.

Chicago holds a special place in my heart, I wish everyone an enjoyable and productive visit to the ‘windy city”

Dr. Scott J Saccomano Proceedings Editor - BHAA 2011/12

Dr. Scott J Saccomano Proceedings Editor - BHAA 2011/12 Business and Health Administration Association Annual
Dr. Scott J Saccomano Proceedings Editor - BHAA 2011/12 Business and Health Administration Association Annual

Best Paper Awards

BHAA OVERALL BEST PAPER AWARD

Avian and Pandemic Influenza (API) Beyond Control…It is Prevention!

Muhiuddin Haider, Jared Frank

Control…It is Prevention! Muhiuddin Haider, Jared Frank TRACK: HEALTH PROMOTION AND DISEASE PREVENTION Overweight

TRACK: HEALTH PROMOTION AND DISEASE PREVENTION

Overweight and Obesity and Physical Activity in Healthy People 2010: Where are We Now and where do We Go from Here?

Margaret J. Greene

TRACK: DISTANCE LEARNING AND ONLINE TEACHING

Assessing the Impacts of Anxiety and Gender on Student Attitudes toward Computer Learning Technology in a Saudi Nursing Academic Environment

Osama A. Samarkandi

TRACK: HUMAN RESOURCE MANAGEMENT IN HEALTHCARE

Strategic Human Resources Solutions for Healthcare Systems in Kenya, Rwanda, and Uganda

Neel H. Pathak, Daniel J. West, Jr.

Has Gender Equity Improved? An Examination of the Challenges Faced by Professional Women in Leadership

Michaeline Skiba, David P. Paul, III

TRACK: PHARMACOECONOMICS AND PHARMACEUTICAL INDUSTRY

Price Effects on Prescription Behavior of Physicians

Gurumurthy Kalyanaram, Demetrios Vakratsas, Mala Srivastava

TRACK: NATIONAL AND GLOBAL HEALTH POLICY

The Impact of the Millennium Development Goals in Argentina, Brazil and Chile

Jose D. Alicea-Rivera, Daniel J. West, Jr.

Brazil and Chile Jose D. Alicea-Rivera, Daniel J. West, Jr. Business and Health Administration Association Annual
Brazil and Chile Jose D. Alicea-Rivera, Daniel J. West, Jr. Business and Health Administration Association Annual

TRACK: ETHICAL & LEGAL ISSUES IN HEALTHCARE

What are Ethically Acceptable Options in the Protests of Physicians’ Trade Unions?

TRACK: HEALTHCARE EDUCATION

Eva Grey

Nutritional Provision in the Aurora Area: A Community-Participatory Effort

Ileana Brooks, Robert Daugherty

TRACK: GLOBAL HEALTH AND SOCIAL JUSTICE

Community Based Interventions against Proteincalorie Malnutrition: Examples from Programme “Goat” in Sudan, Rwanda and Burundi

Milan Schavel, Lucia Paskova, Eva Misikova, Michal Krcmery, Alexandra Mamova, Margareta Kacanyova, Petra Mikulasova, Renata Machalkova, Ivan Duraj, Andrea Bajcarova, George Benca, Jaroslava Sokolova, Nada Kulkova, Vladimir Krcmery, John Mutuku-Muli, Andrej Matel, Ivan Bartosovic

TRACK: HEALTHCARE AND HOSPITAL ADMINISTRATION

Vaccination Trends for Public and Private Sectors

Suzette Hershman, William B. Stroube

TRACK: HEALTH, WELLNESS AND QUALITY OF LIFE

National Culture, Human Development, and Environmental Health: A Cross National Analysis

Avinandan Mukherjee, Naz Onel

TRACK: FINANCE AND ACCOUNTING ISSUES IN HEALTHCARE

Increased Utilization of Direct Access to Physical Therapy: A Model for Reducing Healthcare Expenditures

TRACK: HEALTHCARE REFORM

Adam W. Walker, Zach Frank

Lack of Access in Healthcare Delivery: A Model for Using Dental Hygienists in a Cost Effective Manner to Help Address the Oral Healthcare Problem

Peter G. Fitzpatrick, Susan Duley

Oral Healthcare Problem Peter G. Fitzpatrick, Susan Duley Business and Health Administration Association Annual
Oral Healthcare Problem Peter G. Fitzpatrick, Susan Duley Business and Health Administration Association Annual

TRACK: HEALTHCARE MARKETING

Perceptions of New Jersey Physicians Regarding Medical Malpractice Insurance and the Impact of these Perceptions on Access to and Delivery of Medical Care in the State

TRACK: HEALTHCARE INFORMATICS

David P. Paul, III

Computer Physician Order Entry and Clinical Decision Support Systems: Benefits and Concerns

TRACK: NURSING ADMINISTRATION

Joseph Shaffer, Alberto Coustasse

Job Satisfaction and Retention in Clinical Care Nursing, Contributory Factors, the Effect on Patient Care Quality and an Integrated Solution

Ann D. Phillips

Care Quality and an Integrated Solution Ann D. Phillips Business and Health Administration Association Annual
Care Quality and an Integrated Solution Ann D. Phillips Business and Health Administration Association Annual

BUSINESS AND HEALTH ADMINISTRATION ASSOCIATION ABSTRACT AND PAPER PROCEEDINGS

- TABLE OF CONTENTS -

HEALTH PROMOTION AND DISEASE PREVENTION

Consumer Attitudes towards Adoption of DTC Genetic Testing in the U.S.A. Avinandan Mukherjee, Daniel Traum

16

A Prototype Design to Deliver Health Care System from Stakeholders’ In-fights and Save Many Lives Kuriakose Athappilly, Thomas Rienzo, Rajnish Sinha

18

Drinking Water Fluoridation for Dental Health; Controversy and Issues Naz Onel

21

Use of Allied Health Professionals as Leaders in Wellness and Health Promotion: A Cost Analysis and Guidelines for Implementation Kelsey Maxwell, Zach Frank

32

Overweight and Obesity and Physical Activity in Healthy People 2010: Where Are We Now and Where Do We Go From Here? Margaret J. Greene

33

DISTANCE LEARNING AND ONLINE TEACHING

Strategies for Self Directed Learning in a Virtual Environment Scott J. Saccomano

42

Embarrassing New Information Technology in Teaching Global Health Hengameh Hosseini

43

A Nursing Education Challenge: E-Textbooks Josephine M. DeVito

44

Assessing the Impacts of Anxiety and Gender on Student Attitudes toward Computer Learning Technology in a Saudi Nursing Academic Environment Osama A. Samarkandi

45

HUMAN RESOURCE MANAGEMENT IN HEALTHCARE

Compensation as a Construct for Employee Motivation in Healthcare Allen C. Minor

55

Physician Shortages-How the gaps will be filled Robert J. Spinelli, Kathryn Semcheski

59

will be filled Robert J. Spinelli, Kathryn Semcheski 59 Business and Health Administration Association Annual
will be filled Robert J. Spinelli, Kathryn Semcheski 59 Business and Health Administration Association Annual

Strategic Human Resources Solutions for Healthcare Systems in Kenya, Rwanda, and Uganda

Neel H. Pathak, Daniel J. West,

 

60

Has Gender Equity Improved? An Examination of the Challenges Faced by Professional Women in Leadership Michaeline Skiba, David P. Paul, III

70

PHARMACOECONOMICS AND PHARMACEUTICAL INDUSTRY

 

Challenges in the Management of Pharmaceutical Industry in Kazakhstan

Gurumurthy

Kalyanaram,

Zhansulu

Baikenova,

Dilbar

Gimranova,

Alma

Alpeissova

78

Treating Methicillin-Resistant Staphylococcus Aureus with the Drug Vancomycin in a Home Infusion Therapy Setting Joshua L. Webb, Alberto Coustasse, Dennis Emmett

 

85

A Review of Research on Direct-to-Consumer Advertising of Prescription Drugs Yam Limbu, Avinandan Mukherjee

92

Price Effects on Prescription Behavior of Physicians Gurumurthy Kalyanaram, Demetrios Vakratsas, Mala Srivastava

105

NATIONAL AND GLOBAL HEALTH POLICY

 

International Health Management Education: Phase II Findings, Results and Implications Daniel J. West, Jr., Anthony C. Stanowski, S. Robert Hernandez, Bernardo Ramirez

110

The Impact of the Millennium Development Goals in Argentina, Brazil and Chile Jose D. Alicea-Rivera, Daniel J. West,

 

112

The Policies and Choices of Abortion Robert D. Fenstermacher, Daniel J. West

 

122

Cuban Pharmacy in the Context of its Healthcare System: Transitioning Toward Pharmaceutical Care Practice Alina Martinez Sanchez, J. Warren Salmon

 

131

Obesity in school-age children Nashat Zuraikat, Carla J. Baldessaro

 

144

ETHICAL & LEGAL ISSUES IN HEALTHCARE

 

Hospital Indicators Used by CEOs to Determine the Level of Ethical Integration in Their Organizations John J. Newhouse

146

Integration in Their Organizations John J. Newhouse 146 Business and Health Administration Association Annual
Integration in Their Organizations John J. Newhouse 146 Business and Health Administration Association Annual

The Doctors who Commit Medicare Fraud Vivek Pande, William Maas

147

When does a Non-Profit Become a For-Profit Organization? An Analysis of Hybrid Organizational Structure in the Healthcare and Insurance Industry Devlin Aaron Fisher, Christopher J Marquette

148

What are ethically acceptable options in the protests of physicians’ trade unions? Eva Grey

150

HEALTH CARE EDUCATION

A

Failing Grade for Abstinence Education in Today’s Social Climate William K. Willis

153

Competence Needed in Global Health Management Education Bander Alaqeel

154

Nutritional Provision in the Aurora Area: A Community-Participatory Effort Ileana Brooks, Robert Daugherty

155

Translating Web2.0/3.0 Technology from the Classroom to the Real World of Practice Bernardo Ramirez, Maysoun Dimachkie, Reid Oetjen, Dawn Oetjen

158

Barriers for Continuing Professional Development for Nurses in Saudi Arabia Ahmad Aboshaiqah

160

Examination of a Health Management Education and Training Grant Kevin C. Flynn, Daniel J. West,

161

GLOBAL HEALTH AND SOCIAL JUSTICE

System of Geriatric Care in Slovakia Ivan Bartošovič

163

A

Preliminary Study on Long Term Care in China: The Consumers’ Perspective Qiu Fang, Deborah Gritzmacher, Ronald Fuqua

165

Evaluation of the University Education in the Social Work Field of Study and Alumni Program Concept Milan Schavel, Miloslav Hettes

166

Expected Fertility, Marriage and Religiosity in Slovakia Jozef Matulník

168

Organisation and Management of Antimalnutrition Programmes in Kenya Vladimir Krcmery Dadline Kisundi, Jaroslava Sokolová, Victor Namulanda, Ann Nageudo, Nada Kulková, Daria Pecháčová, Mario Jančovič, Alexandra Mamová, Petra Stulerova, Anna Porazikova, Sona Revicka, Steve Szydlowsky, Daniel West, Petra Mikolasova

169

Steve Szydlowsky, Daniel West, Petra Mikolasova 169 Business and Health Administration Association Annual
Steve Szydlowsky, Daniel West, Petra Mikolasova 169 Business and Health Administration Association Annual

Management of Epidemic Famine in African Horn: Experience from Ethiopia Marian Karvaj, Petra Mikolasova, Gertruda Mikolasova, Kristina Pauerova, Jaroslava Sokolova, Vladimir Krcmery, Steve Szydlowsky, Nada Kulkova

172

Community Based Interventions against Proteincalorie Malnutrition: Examples from Programme „Goat“ in Sudan, Rwanda and Burundi Milan Schavel, Lucia Paskova, Eva Misikova, Michal Krcmery, Alexandra Mamova, Margareta Kacanyova, Petra Mikulasova, Renata Machalkova, Ivan Duraj, Andrea Bajcarova, George Benca, Jaroslava Sokolova, Nada Kulkova, Vladimir Krcmery, John Mutuku-Muli, Andrej Matel, Ivan Bartosovic

174

Social Service Management for Homeless People in Capital City of Slovakia and Their Surrounding Andrej Matel, Jozef Zuffa, Tibor Roman, Maria Romanova, Jaroslava Polonova, Robert Kovac, Terezia Dudasova, Maria Stepanovska, Peter Kadlecik

177

HEALTHCARE AND HOSPITAL ADMINISTRATION

Customers: Healthcare vs. Traditional

M.

Scott Stegall, Thomas McIlwain, Peter Fitzpatrick

181

Hospitals and Healthcare Systems The Need to Reduce Errors and Mistakes Robert J. Spinelli

183

Governance Issues in the transition to Accountable Care: A Case Study of Silver Cross Hospital Stephen G. Morrissette

184

Essential Differences: Healthcare vs. Business Administration

M.

Scott Stegall, Thomas McIlwain, Peter Fitzpatrick

185

Vaccination Trends for Public and Private Sectors Suzette Hershman, William B. Stroube

187

A Comparative Analysis of Healthcare Systems: USA and Sweden Christopher A. Loftus, William B. Stroube

192

Drug testing in monitoring of patients on chronic opioid treatment

 

Ahmet

"Ozzie" Ozturk

196

Avian and Pandemic Influenza (API) Beyond Control…It is Prevention! Muhiuddin Haider, Jared Frank

197

Establishing an Effective and Comprehensive Palliative Care Program in an Acute Hospital Setting Ebony A. Smalls

210

Physician Behaviors Critical to Accountable Care Organizations (ACO) Leanne Hedberg Carlson, Lisa Wied, Renee Fraser

217

Leanne Hedberg Carlson, Lisa Wied, Renee Fraser 217 Business and Health Administration Association Annual
Leanne Hedberg Carlson, Lisa Wied, Renee Fraser 217 Business and Health Administration Association Annual

HEALTH, WELLNESS AND QUALITY OF LIFE

Fitness, Health and Productivity Mansour Sharifzadeh

219

Viewpoints on Elective Cosmetic Surgery: An Initial Inquiry into Consumption Practices from a Marketing Perspective Charles “Kirk” Moore

238

National Culture, Human Development, and Environmental Health: A Cross National Analyses Avinandan Mukherjee, Naz Onel

241

Is Elective Cosmetic Surgery a Luxury? Applying Berry’s “The Idea of Luxury” to Elective Cosmetic Surgery Charles “Kirk” Moore

256

Lifestyle Disease Triad: An empirical comparative assessment of the macro level predictors of Obesity, Diabetes, and Hypertension across the US MSAs Vivek S. Natarajan, Avinandan Mukherjee, Kabir Chandra Sen

258

FINANCE AND ACCOUNTING ISSUES IN HEALTHCARE

Financial Incentives: Pay for Performance (P4P) and the Effects with the Chronically Ill Patients

David Conley, Alberto Coustasse

260

Increased Utilization of Direct Access to Physical Therapy: A Model for Reducing Healthcare Expenditures Adam W. Walker, Zach Frank

266

The Affordable Care Act: Quality Requirements Despite Medicare Payment Reductions Means Significant Changes for Hospitals Stephanie Hill, Robert J. Spinelli

271

Poison Pills in the Pharmaceutical Industry: Effects on Value, Governance, and Strategic Posture

Isaac Wanasika

272

HEALTH CARE REFORM

Lack of Access in Healthcare Delivery: A Model for Using Dental Hygienists in a Cost Effective Manner to Help Address the Oral Healthcare Problem Peter G. Fitzpatrick, Susan Duley

275

Providing Large-Scale Emergency Medical Care in a Rural Setting: A Model Charles Braun, Jamie Field

286

The Evolution of Urgent Care Centers: Past, Present, and Future Helen Julia, Steven J. Szydlowski

287

and Future Helen Julia, Steven J. Szydlowski 287 Business and Health Administration Association Annual
and Future Helen Julia, Steven J. Szydlowski 287 Business and Health Administration Association Annual

HEALTHCARE MARKETING

The Prescription Drug Marketing Act of 1987: Consumer Protection or Restraint of Trade?

Gene C. Wunder

289

Perceptions of New Jersey Physicians Regarding Medical Malpractice Insurance and the Impact of these Perceptions on Access to and Delivery of Medical Care in the State David P. Paul, III

290

Determinants of Patient Satisfaction with Pharmaceutical Services Comparison between Multiple Pharmacy Formats Archana Kumar, John McGinnis, Avinandan Mukherjee

298

Strategic Positioning of Big Pharma in Pharmerging Markets Isaac Wanasika

303

Marketing implications for the Pharmaceutical Industry in Central and Eastern Europe:

Generics, Research and Development Steven J. Szydlowski, Robert Babela, Amy M. Szydlowski

305

HEALTH CARE INFORMATICS

H-1B Foreign Workers in Health IT Industry Stephan Chung, Salvador Esparza, Louis Rubino

307

Benefits and Constraints of Telepsychiatry Utilization in the United States Bruce Stec, Alberto Coustasse

309

Computer Physician Order Entry and Clinical Decision Support Systems: Benefits and Concerns Joseph Shaffer, Alberto Coustasse

316

Role of Information and Communication Technology (ICT) on Missionary Adaptive Selling Behavior and Salesforce Performance Yam Limbu, C. Jayachandran, Robin T. Peterson

324

NURSING ADMINISTRATION

Motivational Factors and Barriers Related to Saudi Arabian Nurses’ Pursuit of a Bachelor’s in Nursing Science Degree Majed Alamri

333

Violence among health care workers: From awareness to Action Nashat Zuraikat

334

Strategic Planning in Academic Nursing Education: the Road Toward Excellence in Saudi Arabia Adel S. Bashatah, Hanan A. Ezzat Alkorashy

335

Arabia Adel S. Bashatah, Hanan A. Ezzat Alkorashy 335 Business and Health Administration Association Annual
Arabia Adel S. Bashatah, Hanan A. Ezzat Alkorashy 335 Business and Health Administration Association Annual

Evidence-Based Practice Barriers in Saudi Arabia Majed Alamri

336

Job Satisfaction and Retention in Clinical Care Nursing, Contributory Factors, the Effect on Patient Care Quality and an Integrated Solution Ann D. Phillips

337

Quality and an Integrated Solution Ann D. Phillips 337 Business and Health Administration Association Annual
Quality and an Integrated Solution Ann D. Phillips 337 Business and Health Administration Association Annual

TRACK

HEALTH PROMOTION AND DISEASE PREVENTION

TRACK HEALTH PROMOTION AND DISEASE PREVENTION Business and Health Administration Association Annual Conference 2012 15
TRACK HEALTH PROMOTION AND DISEASE PREVENTION Business and Health Administration Association Annual Conference 2012 15

CONSUMER ATTITUDES TOWARDS ADOPTION OF DTC GENETIC TESTING IN THE U.S.A.

Avinandan Mukherjee, Montclair State University Daniel Traum, Montclair State University

ABSTRACT

The individuals’ ability to obtain adequate diagnosis and treatment in the medical context has become a pressing issue. The traditional approach to the investigation of medical problems, which was solely the job of the physician, has now shifted towards information search by the patient. Furthermore, the emergence of direct to consumer (DTC) genetic testing has begun to change the way that health information can be obtained. Physicians, nurses, pharmacists, insurance companies, and patients, all should be considered in the development and marketing activities of healthcare products. The perspectives of each differ not only based upon their knowledge base, but also through experiences and motivating factors.

The objective of this research was to determine the factors that contribute to overall attitudes that are influenced by genetic testing. The two dependent variables utilized are familiarity with genetic testing and whether the respondent has undergone genetic testing in the past. The independent variables were separated in to discreet categories of the following: interpersonal/communications, privacy/regulation, psychological/perceived cost, commitment/patient compliance, and patient education.

Data for this research was obtained from the U.S. Department of Health and Human Services, through the Health Information National Trends Survey (HINTS). This is a widely used survey, and quite comprehensive, consisting of responses from over 7,600 individuals. It is administered once every three years, and is adjusted to the changing environment of healthcare. The inherent nature of this research lends itself to some technicalities pertaining to the science behind these tests and the efficacy in the findings provided. Currently, this is still considered a new area of medical research, and much skepticism and critique remains. Some of the major concerns that surround this product are governmental oversight, privacy, and perhaps most importantly, comprehensiveness of the tests.

Logistic regression analysis was used principally to determine the relationship between two discreet questions pertaining to genetic testing to a variety of factors. Based upon quantitative data, there is statistical significance between several variables, however far from all that were tested. Taken separately, the first question showed significance in regression to one’s ability to take care of their own health, help uncovering uncertainty in one’s health, knowledge of cancer risk prior to diagnosis. With regard to the second question exclusively, significance lies with opportunity to ask questions of one’s healthcare provider, concern regarding product quality, difficulty in understanding health or medical topics, and numbers and statistical helpfulness in making health related decisions. Those factors that have significance in regard to both questions include the following: trust of some, but not all sources; healthcare providers providing attention and involving the patient in decision making; maintenance of a healthy weight; little can done to prevent getting cancer; and association of cancer with being a fatal disease.

The above factors would be beneficial in development of a successful marketing strategy that could be used by companies who promote DTC genetic tests to the consumer. Those questions that both show significance to the same aspects would likely expected to have greatest appeal to the most consumers. It would likely meet their needs for information and encourage them to use DTC genetic testing in order to better their own health.

use DTC genetic testing in order to better their own health. Business and Health Administration Association
use DTC genetic testing in order to better their own health. Business and Health Administration Association
use DTC genetic testing in order to better their own health. Business and Health Administration Association

Avinandan Mukherjee Professor and Chair, Department of Marketing Editor International Journal of Pharmaceutical and Healthcare Marketing Montclair State University School of Business Montclair, NJ 07043, USA Phone: (973) 655-5126; Fax: (973) 655-7673 Email: mukherjeeav@mail.montclair.edu

Daniel Traum Undergraduate Student Montclair State University Email: traumd1@mail.montclair.edu

Montclair State University Email: traumd1@mail.montclair.edu Business and Health Administration Association Annual
Montclair State University Email: traumd1@mail.montclair.edu Business and Health Administration Association Annual

A PROTOTYPE DESIGN TO DELIVER HEALTH CARE SYSTEM FROM STAKEHOLDERS’ IN-FIGHTS AND SAVE MANY LIVES

Kuriakose Athappilly, Western Michigan University Thomas Rienzo, Western Michigan University Rajnish Sinha, Western Michigan University

ABSTRACT

This paper proposes a design of a prototype which can substantially improve the present day health care system. The authors designed the prototype with three fundamental principles in mind. It must be: a) patient centric, b) IT-integrated deploying the best methodologies available and c) no-tolerant to error-prone human factor. Simply put, the authors believe that the technology is out there but today’s health care system is not up to the challenges in its entire spectrum among the providers, the competing stakeholders surrounding the providers and the patients.

To design the prototype the authors chose a life threatening situation, something like, ‘as the clock ticks towards the last breath IT must come to rescue’ enabling physicians to save many lives. The prototype consists of three major architectural components: a) web-enablement, b) integration of several IT layers such as transactional, analytical and decision-making,- much beyond the existing EMR and EHR systems, and c) incorporation AI technologies in particular. To develop and test the prototype, a specific disease needing critical care, in a specific geographical location with a specific health care provider must be chosen. Once the prototype is tested and is proven successful, it can be enhanced by expanding the specificity boundaries. The authors believe the proposed system will significantly impact healthcare by reducing costs and helping physicians provide superior care and above all saving lives which is otherwise almost impossible.

above all saving lives which is otherwise almost impossible. Business and Health Administration Association Annual
above all saving lives which is otherwise almost impossible. Business and Health Administration Association Annual

Design Model of the Study

Web Application Page group Firewall Workstation Web Server - Production WAP Server Development & Testing
Web Application
Page group
Firewall
Workstation
Web Server -
Production
WAP Server
Development &
Testing
Data Mining/ Business Intelligence Layer
Production
Development
Data Mart
Data Mart
Extraction/ Transformation
Data Repository
External Data
Internal Data
Data Repository External Data Internal Data Business and Health Administration Association Annual
Data Repository External Data Internal Data Business and Health Administration Association Annual

REFERENCES

Athappilly K. (2006). Kidney Dialysis Analysis Using Symbiotic Data Mining Approach, M SAS Data Mining

Conference, Poster presentation,

Las Vegas, USA.

Athappilly K. (2000). A dynamic web-based knowledge system for prototype development for extended enterprise, The Third International Conference on the Practical Application of Knowledge Management, PAKeM Proceedings 2000, Manchester, UK, pp:11-24.

Bates D.W., Leape L.L., Culle D.J., Laird N., Peterson L.A., Teich J.M., et al. (1998). Effect of computerized physician order and team intervention on prevention of serious medication erros, JAMA, 280, 1311-16.

Evans RS, Classen DC, Pestotnik SL,et al. (1994). Improving empiric antibiotic selection using computer decision support. Archives of Internal Medicine 154(8):878-84.

Frize M., Ennett C.M., Stevenson M., Trigg H.C.E. (2001). Clinical decision-support systems for intensive care units using artificial neural networks. Medical Engineering and Physics, 23(3), 217-225.

Frize M., Frasson C. (2000). Decision-support and intelligent tutoring systems in medical education. Clinical and Investigative Medicine, Aug;23(4), 266-269.

Frize M, Walker R. (2000). Clinical decision-support systems for intensive care units using case-based reasoning, Medical Engineering and Physics, Nov;22(9), 671-677.

Kohn L.T., Corrigan J.M., Donaldson M.S. (1999). Eds. To err is human: building a safer health system. Washington D.C. National Press.

Overhage J.M., Tierney W.M., Zhou X.H., McDonald C.J. (1997). A randomized trial of corollary orders, to prevent errors of omission, JAMIA 4, 364-75.

Razi, M. and Athappilly, K. (2005). “A comparative predictive analysis of Neural Networks (NNs), Nonlinear Regression and Classification and Regression Tree (CART) models”. Expert Systems with Applications, Volume 29, Number 1, pp. 65-74.

Dr. Kuriakose Athappilly Department of Business Information Systems Haworth College of Business Western Michigan University, MI USA

269-387-5405

Dr. Thomas Rienzo Department of Business Information Systems Haworth College of Business Western Michigan University, MI USA

269-387-5405

Mr. Rajnish Sinha Department of Business Information Systems Haworth College of Business Western Michigan University, MI USA

269-387-5405

of Business Western Michigan University, MI USA 269-387-5405 Business and Health Administration Association Annual
of Business Western Michigan University, MI USA 269-387-5405 Business and Health Administration Association Annual

DRINKING WATER FLUORIDATION FOR DENTAL HEALTH: CONTROVERSY AND ISSUES

Naz Onel, Montclair State University

ABSTRACT

The fluoridation of public drinking water provided by local government agencies is a practice that has been adopted for decades in the U.S and some other countries around the world to prevent tooth decay. Fluoridation of community water is accepted by many to be one of the greatest public health and disease-preventive measures of the last few decades. Supporters of fluoridation see the implementation as effective, easy to deliver, safe, and most importantly, cost efficient. However, opposing views consider water fluoridation to be a form of enforced “mass medication” and find it to be an unethical practice. Furthermore, some others link fluoridation to enamel fluorosis and many chronic illnesses that present widely all around the world. This discussion paper examines both sides of the argument in detail with relevant examples. Although the current data on effectiveness and safety of the fluoridation are compelling, future studies are necessary to eliminate controversy and improve public health by adopting only essential actions. This study aims at creating a combined resource and, in this way, highlighting the facts for determining the future direction of the fluoridation practice.

Key Words: Water Fluoridation, Public Dental Health, Fluorosis.

INTRODUCTION

A form of dental disease, dental caries, understood as a multi-factorial disease which is an end result of a complex interaction between adopted diet, oral bacteria, and the host itself (Keyes, 1960). Dental caries have been linked to various undesirable outcomes such as decreased self-esteem, substantial pain, difficulty eating some kind of foods, reduced ability to sleep, as well as social discomfiture (Slade et al., 2005; Pahel et al., 2007). Although there are available individual treatments for dental caries, because such treatments are usually costly, it typically leads to delayed considerations until the pain level becomes unbearable (Armfield, 2010). It is believed that prevention of tooth decay is possible by increasing fluoride intake, especially during the formation of tooth enamel. Fluoride can help with preventing and, in some cases, reversing tooth decay by rebuilding tooth enamel (CDCP, 1991, 1999) via various topical mechanisms (Featherstone, 1999) (Fig. 1). Therefore, it is generally supported that if the individual keeps the fluoride constantly present in his/her oral environment (e.g. saliva, enamel surface), the person would be less susceptible to dental caries (Frazao et al., 2011). Enduring this presence, on the other hand, is possible both through topical use, such as toothpaste, mouth rinses, and gels, as well as through increasing general daily use of fluoridated water and salt (Cury and Tenuta, 2008). When all the available systemic fluoridation methods are compared (e.g. fluoride toothpastes, fluoridated water, sugar, milk, salt, soft drinks, and fluoride supplements), however, it is argued that water fluoridation is the only cost-effective, fair, and safe way of providing tooth decay protection to the communities (Ludlow et al., 2007). Therefore, it is the most widely implemented one as a public health intervention strategy (Armfield, 2010).

In general, all water sources in nature contain some amount of fluoride. Studies in the early 1940s showed that people with fewer dental cavities lived where drinking-water supplies had a certain amount of naturally occurring-fluoride (approximately 1 ppm). Many different studies over time supported this finding (CDCP, 1991). Following the recommendations of scientists, the department of health and various public health organizations voted for the addition of fluoride to public water supply with the aim of improving public dental health. As a result, beginning with the 1945 Grand Rapids drinking-water fluoridation in Michigan, most of the U.S. population started to receive fluoridated water (NIDCR, 2011). In 1951, fluoridation of water supplies became an official policy in the US (Frazao, 2011). Today, approximately 67 percent of the U.S. population has access to public water supplies that had already been fluoridated (CDPH, 2011) and nearly 60 countries practice the same technique as a dental caries prevention strategy (Frazao, 2011).

as a dental caries prevention strategy (Frazao, 2011). Business and Health Administration Association Annual
as a dental caries prevention strategy (Frazao, 2011). Business and Health Administration Association Annual

Processes of the demineralization and re-mineralization

Processes of the demineralization and re-mineralization Figure 1. Processes of the demineralization and

Figure 1. Processes of the demineralization and re-mineralization.Source: Adapted from CDC (2001) Centers for Disease Control and Prevention.

CONTROVERSY AND ISSUES

Oppositions to water fluoridation

Despite considerable evidence regarding the effectiveness of water fluoridation, however, lately various opposing views have emerged (e.g. Armfield, 2010; Gupta et al., 2009; Tenuta and Cury, 2010). Many consider water fluoridation to be a form of enforced “mass medication” and find it to be an unethical practice (Cohen and Locker, 2002). According to this point of view, the public cannot be forced into receiving any kind of medication without their consent. In addition to this view, Jinadasa et al.(1988) in their article state that high fluoride concentrations (i.e. more than 1.50 ppm) in drinking water can be linked to various adverse health issues. Numerous studies also show that above a certain concentration of fluoride, it is common to see significant increase in the prevalence of dental (enamel) fluorosis (e.g. National Academies, 2006; McDonagh, 2000; NIDCR, 2011; Frazao et al., 2011). When fluoride concentration becomes higher than 1.0 ppm in the water supply, dense areas on the enamel surface of the teeth start to develop visible white color stains (Robinson et al., 2004) (Fig. 2). Frazao, et al. (2011) indicate the importance of amount of fluoridated water consumption when determining the effect of fluoride on tooth enamel. They consider that this “effect of fluoride on tooth enamel is dose-dependent.” (p4) If the intake becomes too high, severe cases of fluorosis can be seen (Fig. 3). This theory can also explain why children living in warmer areas have more fluorosis but less caries compared to children from colder areas with same drinking water fluoride level (Frazao, et al., 2011).

Exposure to fluoride in high levels can also cause skeletal fluorosis which is an increase in bone density that leads to joint stiffness and pain (Gupta et al., 2001). The condition can severely affect mobility in later stages (called the crippling stage). Fluoridation has been also linked to many chronic Pain-Fatigue Syndromes (e.g. FMS- Fibromyalgia, CFS Chronic fatigue syndrome), and some other chronic illnesses, which present growing wide- spread public health concerns (Laylander, 1999). Many studies also confirm the link between induced fractures of the bones in elderly and fluoride intake (e.g. Hedlund and Gallagher, 1989; Bayley et al., 1990; Jacobsen et al., 1992; Danielson et al., 1992; Jacqmin-Gadda et al., 1995). For example, Danielson, et al. (1992) found a small but significant relationship between hip fracture and artificial fluoridation at 1 ppm in Utah’s elderly population. Jacobsen, et al. (1992) found a similar result in their study conducted in 129 counties across the U.S. with public water fluoridation and 194 counties without fluoridation. In fluoridated and non-fluoridated counties the hip fracture of the elderly showed different results. The study found a small statistically significant positive relationship between fluoridation and fracture rates.

relationship between fluoridation and fracture rates. Business and Health Administration Association Annual
relationship between fluoridation and fracture rates. Business and Health Administration Association Annual

Apart from increase in dental fluorosis and fractures, He, et al. (1989) speculates that by crossing blood- brain barrier and building up in cerebral tissues, fluoride can affect the intelligence even before a child was born. With similar study, Zhao, et al. (1996) suggest that in children, high fluoride intake can lead to low IQ, poor school performance, decreased reading and writing abilities compared to children with normal level of fluoride intake. They indicate that the manifestations occur as a result of influenced calcium currents by fluoride which alters enzyme configuration that eventually affects the brain functions. Similarly, Gupta, et al. (2009) mention fluoride and its harmful neurological effects such as Attention Deficit Disorder (ADD). These important assumptions related to neurological functions, however, are limited to only a few studies. Likewise, the possible relationship between cancer and fluoridated water has been a debate issue by several researchers since the National Toxicology Program’s study found the possible link in male rats (Bucher, 1991; Cohn, 1992).

Mild dental fluorosis

male rats (Bucher, 1991; Cohn, 1992). Mild dental fluorosis Figure 2. Mild dental fluorosis occurs when

Figure 2. Mild dental fluorosis occurs when the stains cover between 25% and 50% of the surface (without esthetic or functional significance). Source: Frazao, et al. (2011).

Severe dental fluorosis

Source: Frazao, et al. (2011). Severe dental fluorosis Figure 3. Severe dental fluorosis caused by well

Figure 3. Severe dental fluorosis caused by well water containing 3.6 mg F/l (with esthetic and functional significance). Source: Frazao, et al. (2011).

The major concerns regarding fluoride use originate from the usage of a combination of methods (Tenuta and Cury, 2010). According to Gupta, et al.(2009), communities ingest fluoride beyond daily permissible limit (i.e. 1.5 ppm) because of consuming fluoridated drinking water in addition to other forms of fluoride intake, such as medications and tooth pastes. They also consider fluoridated drinking water as the most soluble and toxic form of fluoride. If the consumption is much higher than the permissible limits, it can be extremely toxic (Gupta, et al., 2009). According to Tenuta and Cury (2010), among the individual fluoride delivery methods, fluoridated toothpaste usage should be considered the most important one because it also helps with bio-film removal mechanically in

because it also helps with bio-film removal mechanically in Business and Health Administration Association Annual
because it also helps with bio-film removal mechanically in Business and Health Administration Association Annual

addition to providing fluoride. Therefore, it is accepted by some researchers as an efficient way of controlling caries (Marinho, 2003). In fact, decline in dental caries in many countries has been directly connected to usage of fluoridated toothpaste (Bratthall, 1996; Cury et al., 2004). When fluoridated toothpastes are used in a regular basis, high fluoride values in the biofilm are sustained even 10 hours after brushing the teeth (Tenuta and Cury, 2010). Gupta, et al.(2009) states that by brushing his/her teeth only once, an individual can get about 1.0 to 2.0 mg of fluoride, enough to maintain healthy teeth. Thus, if someone uses fluoride toothpaste regularly, no additional fluoride usage is recommended (Tenuta and Cury, 2010). When an individual gets more amount of fluoride because of extensive additional forms of usage, starting with increased prevalence of fluorosis (Catani et al. 2007), all other related health issues can be seen.

Besides, Armfield (2007) points out the growing doubt in terms of fluoridation’s role in reducing tooth decay. According to him, many opponents of water fluoridation find no “significant” tooth decay decrease resulting from fluoridated water consumption. He states that about 150 communities in the U.S. and Canada have rejected fluoridation of water since 1990 mainly because of perceived ineffectiveness and potential harm. There are also some countries such as China, Austria, Belgium, Germany, Japan, Denmark, and Switzerland did not accept fluoride addition to their drinking water because of legal reasons and potential risks (Gupta et al., 2009). When we look at studies from Canada, Finland, Germany and Cuba which focus on the dental decay issues of the communities after the discontinuation of fluoridation, interestingly, we see a decreasing amount of dental decay instead of an increasing amount (Kunzel and Fischer, 1997, 2000; Maupome et al., 2001; Kunzel et al., 2000; Seppa et al., 2000).

All these aforementioned studies and findings explain why the oppositions perceive the practice as “unnecessary” and “harmful”.

Supporters of fluoridation

Fluoridation of community water is accepted by many to be one of the greatest public health and disease- preventive measures of the last few decades. Supporters of fluoridation see the implementation as effective, easy to deliver, safe, and most importantly, cost efficient (Horowitz, 1996). Supporters believe that visits to dental health professionals have been reduced with improved dental health, and therefore, have lowered costs to the public. They also believe there is no harm from adding fluoride to drinking water.

Because of increasing wide-spread concerns regarding the safety of the usage of fluoride in drinking water, in 1999, the Department of Health commissioned a group of researchers from University of York to examine the effects of the practice in more detail. By examining 735 research studies, the team concluded that water fluoridation and systemic illness showed no evidence of a casual relationship (Cockcroft and Donaldson, 2007). The researchers of the York Team also found that 15% more children without tooth decay reported in the areas received fluoridated water. Furthermore, dental decay in adults has decreased by 27% in those areas.

Contrary to the opposing view, supporters of fluoridation believe fluoridated toothpastes cannot be a solution by itself to reduce oral health inequalities in communities because the usage of these products depends solely on individual actions. On the other hand, population based “targeted fluoridation schemes” such as public drinking water fluoridation offers much greater potential outcomes (Cockcroft and Donaldson, 2007). In their article, Cheng, et al. (2007) mention the significance of water supply fluoridation in reducing the burden of dental disease and its potential to deal with ongoing oral health inequalities. Furthermore, contrary to the oppositions’ statement of “mass medication” (Cohen and Locker, 2002), the Medicines and Healthcare Products Regulatory Agency states that since drinking water (fluoridated or not) is a “food”, it cannot be categorized as medicine and therefore should not be subject to medication requirements as suggested (Cockcroft and Donaldson, 2007). According to Cockcroft and Donaldson (2007), there is an ethical justification of the practice because of significant benefit to the public health. Since there are ongoing oral health inequalities in different communities, this justification is supported by many authorities, including the U.S. Congress. Consequently, water providers and strategic health authorities can provide necessary fluoride to the communities after broad and open consultations.

Morris (1995) argues against the postulate of link between fluoridation of water and cancer risk, and states that fluoridated water consumption can have little or no carcinogenic affect. He and some other scientists (e.g. Mahoney et al., 1991; Freni and Gaylor, 1992) believe that the researchers against this idea have little or no proof to speculate the link.

this idea have little or no proof to speculate the link. Business and Health Administration Association
this idea have little or no proof to speculate the link. Business and Health Administration Association

Osteoporosis (i.e. loss of bone density), its related fractures, and their potential connection to fluoridation of community water supplies were examined by various scientists. For instance, Cauley, et al.’s (1991) study in Pennsylvania on 1,878 women between the ages of 65 and 93 showed no relation between bone mineral density, history of fracture, and exposure to fluoridated water. A similar study by Cauley, et al. (1991) also showed very similar results. The study on 2076 women with the age of 65 and older in a Pittsburgh clinic showed no statistically significant relationship between wrist, hip or spinal fractures and fluoridation. Demos, et al. (2001) also found no adverse effect of fluoride intake on bone resistance, bone mineral density (BMD) or fracture incidences. A similar conclusion also came from the York studies. The study team found that of the 29 studies examined the relationship between water fluoridation and incidence of bone fracture, only four found a significant effect (Armfield, 2007). All these results oppose the studies mentioned in the previous section.

In his 2011 review, George (2011) states that it is inaccurate to link the U. S. Department of Health and Human Services’ decision to lower the added fluoride level of drinking water to the ineffectiveness of the practice. The reason for the dosage adjustment was to eliminate the potential risk of dental fluorosis in children when the infant formula is prepared with tap water. Also, because there is no confirmed evidence of “bone effects” or other kinds of detrimental impacts, fluorosis is the only consideration used by the U.S. Health Department to determine future actions. On the other hand, the reason that some municipalities decide to remove fluoride from their drinking water is solely a political decision rather than a scientifically supported one (MacGregor, 2011).

Because dental disease is “the number one chronic disease among children and adolescents in North America, and optimally fluoridated water is a safe and cost-effective public health benefit”, its use is supported by “90 national and international scientific and medical organizations” (MacGregor, 2011, p1173). Additionally, many studies conducted by relevant authorities based in the US, UK, and Australia provided adequate amounts of evidence regarding safety and the effectiveness of drinking water fluoridation in today’s modern conditions (CDCP, 1991, 1999; Kumar, 2008).

Similar to the York Team’s study, Frazao, et al. (2011) mention a broad cross-sectional study from 2003 that shows one third reduction in the rate of dental caries in children and adolescents who live in cities with fluoridated water than those who live without this benefit. After examining various studies in the literature, Frazao, et al. (p3) concludes that “water fluoridation is an effective measure for preventing and controlling dental caries in children and adolescents.”

According to Tenuta and Cury (2010), most studies in the literature show little evidence on the hypothesized link in level of fluorosis and fluoridated water. Moreover, Frazao, et al. (2011) (p4) declares mild dental fluorosis as harmless and “without esthetic or functional significance” (Fig. 2). In fact, in some cases where there is an apparent fluorosis, the perceived condition could be seen as “improved oral health” rather than a “problem” (Chankanka, 2010).

The only issue that was not argued or cited by the oppositions was the cost effectiveness of fluoridation. The reason for this should be the clear advantage of fluoridation of public drinking water in terms of cost savings compared to the costs of disease aversion (i.e. dental cavities) and productivity losses (Griffin et al., 2001). Griffin, et al. (2001) determined annual per person cost savings to be between $15.95 for small size communities to $18.62 for large size communities which shows a clear cost saving for both. Table 1 and 2 illustrate fluoride treatment and disease prevention costs.

illustrate fluoride treatment and disease prevention costs. Business and Health Administration Association Annual
illustrate fluoride treatment and disease prevention costs. Business and Health Administration Association Annual

TABLE 1. Weighted per person discounted lifetime cost of carious surface initially occurring at various ages

cost of carious surface initially occurring at various ages Source: Griffin et al . (2001) TABLE

Source: Griffin et al. (2001)

TABLE 2. Range of estimates for annual per person water fluoridation costs for communities of various sizes

water fluoridation costs for communities of various sizes Table 2 shows that large size population gives

Table 2 shows that large size population gives less annual cost per person. Source: Griffin et al. (2001)

CURRENT STATE OF THE ISSUE AND FUTURE DIRECTION

Today, dental caries are accepted to be one of the most common diseases and water fluoridation believed to be the best population-level preventive strategy to this worldwide dental health problem (Armfield, 2007). Since the issue is widespread throughout the world, Armfield (2007) believes the appropriateness and effectiveness of the methodology used to prevent it should consider the population level effect, rather than individual results. This leads us to the necessity of community-wide approaches.

Due to the aforementioned effectiveness of the fluoridation in caries prevention, Public Health Services (PHS) recommends fluoride addition to community drinking water (CDCP, 2001). Through adopting a drinking water fluoridation strategy, by the end of 2000, more than 50% population of 38 states and the District of Columbia in the U.S. was receiving fluoridated public drinking water (Fig. 4). However, since there are ever-increasing levels of exposure to fluoride compounds by the public, such as thru dental products (toothpaste, mouth rinses), medications, tea and beverages (Kiritsy et al., 1996), the public health concern increases rapidly. Thus, recommendations by PHS include setting the highest safe limit to prevent any possible harm, especially enamel

safe limit to prevent any possible harm, especially enamel Business and Health Administration Association Annual
safe limit to prevent any possible harm, especially enamel Business and Health Administration Association Annual

fluorosis. Depending on the climate conditions of the given area (warm or cold), the amount of the fluoride addition changes between 0.7 ppm and 1.2 ppm. This range, recommended and maintained by PHS, constitutes the current federal fluoridation guideline adopted since 1962 (CDCP, 2001). In addition to this range, the Environmental Protection Agency (EPA) sets a 4.0 ppm maximum allowable fluoride limit in community drinking water to maintain the safety and quality of drinking water in the U.S. Moreover, the U.S. Food and Drug Administration (FDA) sets standards for the prescription and over-the-counter fluoride products in order to provide safe products to the public. The FDA also sets standards for labeling these fluoride contained products, including bottled water that are marketed in the U.S. In addition to these federal agencies, non-federal agencies develop programs to support a certain amount of fluoride intake as well (e.g. the American Dental Association (ADA)’s Seal of Acceptance program) (CDCP, 2001). They also publish studies and make recommendations to the public on acceptable amounts of fluoride dietary intake (Table 3) to maintain the highest safety standards.

Percentage of state populations with access to fluoridated water through public water systems

access to fluoridated water through public water systems Figure 4. Through adopted drinking water fluoridation

Figure 4. Through adopted drinking water fluoridation strategy, by the end of 2000, more than 50% population of 38 states and the District of Columbia in the U.S. was receiving fluoridated public drinking water. Source: CDC - Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States (CDCP, 2001).

TABLE 3. Recommended dietary fluoride supplement schedule

TABLE 3. Recommended dietary fluoride supplement schedule Table 3. Joint recommendations by ADA, American Academy of

Table 3. Joint recommendations by ADA, American Academy of Pediatric Dentistry (AAPD), and the American Academy of Pediatrics (AAP) on fluoride intake. Source: CDCP - Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States (CDCP, 2001).

Undoubtedly, considering the climate conditions of the regions (Frazao et al., 2011) is an appropriate way of determining the right level of fluoride concentration for communities. However, environmental and social

for communities. However, environmental and social Business and Health Administration Association Annual
for communities. However, environmental and social Business and Health Administration Association Annual

changes we have witnessed since 1962 should also be considered carefully (CDCP, 2001). For instance, today, we see increased usage of air conditioning in hot regions compared to the 1960’s. Also inactive life styles are more common nowadays. Furthermore, in some regions, we see shifting climate conditions which all can affect water drinking habits. Thus, constantly evaluating and updating safe and useful levels of fluoride additions can be a crucial strategy for the future.

CONCLUSION

Balancing the benefits and risks of fluoride use in public drinking water supplies is a continuous challenge. The fact that documenting fluoridation impacts is challenging because of delayed effects (Kumar, 2008), future research on the issue should continue to examine the strategy and try to determine the best acceptable level of fluoride in drinking water to minimize the possible risks related to high fluoride intake. This could be possible by assigning a group of scientists (similar to the York Team) and updating the review of the studies constantly. In addition to monitoring and reviewing the safety of the strategy, continuing discussions of the ethical aspects are also necessary to consider.

In the last few decades, it is found that in the countries experiencing caries decline, fluoride usage was adopted in some way (Tenuta and Cury, 2010). The Centers for Disease Control and Prevention claims drinking water fluoridation as: “one of the 10 major public health achievements of the 20th century, alongside vaccinations and the control of infectious diseases.” (Armfield, 2010) (p656) Thus, it should be accepted that fluoridation of drinking water may be the best and the most necessary option to maintain dental health equalities around the world.

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National Academies (March, 2006). The National Academy of Sciences. Fluoride in Drinking Water: A Scientific Review of EPA’s Standards. Retrieved from <http://dels.nas.edu/resources/static-assets/materials-based-on- reports/reports-in-brief/fluoride_brief_final.pdf> on November 16, 2011.

NIDCR.gov (2011). National Institute of Dental and Craniofacial Research. The Story of Fluoridation. National Institute of Health. Retrieved from http://www.nidcr.nih.gov/oralhealth/topics/fluoride/thestoryoffluoridation.htm on November, 19, 2011.

Pahel B.T., Rozier R.G., Slade G.D. (2007). Parental perceptions of children’s oral health: the Early Childhood Oral Health Impact Scale (ECOHIS). Health Qual Life Outcomes;5, 6.

Robinson C., Connell S., Kirkham J., Brookes S.J., Shore R.C., Smith A.M. (2004). The effect of fluoride on the developing tooth. Caries Res., 38(3), 268-76.

Seppa, L., Karkkaimen, S. and Hausen, H. (2000). Caries trends 1992-98 in two low-fluoride Finnish towns formerly with and without fluoride. Caries Research 34(6), 462-8.

Slade G.D., Nuttall N., Sanders A.E., Steele J.G., Allen P.F., Lahti S. (2005). Impacts of oral disorders in the United Kingdom and Australia. Br Dent J, 198, 489-93.

Tenuta, L. M. A. & Cury, J. A. (2010). Fluoride: its role in dentistry. Braz. Oral Res. 24(1), 9-17.

Zhao L.B., Liang G.H., Zhang D.N., Wu X.R. (1996). Effect of a high fluoride water supply on children’s intelligence. Fluoride, 29, 190-192.

Naz Onel, MBA Ph.D. Student, Environmental Management Earth and Environmental Studies College of Science and Mathematics Doctoral Assistant, Department of Marketing School of Business Montclair State University Montclair, NJ 07043, USA Ph: (973) 655-7037; Fax: (973) 655-7673 Email: onelgarmkhb1@mail.montclair.edu

Fax: (973) 655-7673 Email: onelgarmkhb1@mail.montclair.edu Business and Health Administration Association Annual
Fax: (973) 655-7673 Email: onelgarmkhb1@mail.montclair.edu Business and Health Administration Association Annual

USE OF ALLIED HEALTH PROFESSIONALS AS LEADERS IN WELLNESS AND HEALTH PROMOTION:

A COST ANALYSIS AND GUIDELINES FOR IMPLEMENTATION

Kelsey Maxwell, Washburn University Zach Frank, Washburn University

ABSTRACT

The costs associated with healthcare in this country have become a tremendous economical burden, and yet a number of costly health conditions are preventable. Health promotion has historically been the responsibility of primary care physicians and specialists within the public health sector, yet multiple healthcare providers are qualified to educate patients about prevention and health promotion. The rehabilitation sector employs a high number of qualified individuals including physical therapists (PTs) and physical therapist assistants (PTAs) that are at the forefront of the shift to prevention in terms of healthcare for this country. The economical impact of prevention cannot be overstated and Physical Therapists and Physical Therapist Assistants possess the background that prepares the respective professions to educate and counsel patients in preventive matters. Such efforts can result in reduced overall healthcare expenditures.

Research indicates certain healthcare professionals do not feel confident in their abilities or possess the time to discuss promotion and prevention with patients; a strategy that could have a profound impact on reducing costs associated with healthcare today. Compared to primary care physicians and physicians in other areas of healthcare, PTs and PTAs felt qualified to promote prevention through sessions with patients. PTs and PTAs utilize both rehabilitative and preventive measures in the treatment and education of patients. As a result of increased individualized time with the patient in comparison to other professions, PTs and PTAs may be positioned well to have a greater role in prevention of disease and the role it plays in the reduction of healthcare costs. Many physicians feel that in addition to the high caseloads experienced on a day to day basis, they do not have the time or confidence to promote healthy behaviors and individually tailor this promotion to patients in a way that would impact the extremely high healthcare costs. The background of PTs and PTAs, both educationally and clinically, allows these professionals greater opportunity to educate patients about the importance of prevention and good health promotion, and potentially accelerates the reduction of healthcare costs in this country.

This paper will analyze the financial impact of using allied health professionals such as PTs and PTAs as the leaders in wellness promotion and disease prevention. It will then identify strategies for successful implementation of such a program.

Kelsey Maxwell Student Physical Therapist Assistant 2920 James, Manhattan, KS, 66502 (785) 341-3240 Kelsey.Maxwell@washburn.edu

Zach Frank PTA Program Director 1700 SW College Ave, Topeka, KS 66621 (785) 670-1406 Zach.Frank@washburn.edu

Ave, Topeka, KS 66621 (785) 670-1406 Zach.Frank@washburn.edu Business and Health Administration Association Annual
Ave, Topeka, KS 66621 (785) 670-1406 Zach.Frank@washburn.edu Business and Health Administration Association Annual

OVERWEIGHT AND OBESITY AND PHYSICAL ACTIVITY IN HEALTHY PEOPLE 2010:

WHERE ARE WE NOW AND WHERE DO WE GO FROM HERE?

Margaret J. Greene, Ramapo College of New Jersey

ABSTRACT

The United States Department of Health and Human Services (USDHHS) aims to promote health for all citizens. Healthy People 2010 was written ten years ago in 2000, outlining “the most significant preventable threats to health” as well as establishing “national goals to reduce these threats” by the end of the decade (USDHHS, U.S. Public Health Service, 2000). Two critical health indicators are overweight and obesity and physical activity which continue to be challenging problems in American society today. This paper examines the efforts taken by the national government and local communities to improve the situation and includes future direction for Healthy People 2020, a guide for public health interventions in the next decade.

INTRODUCTION

In recent years, overweight and obesity have reached epidemic proportions in the United States. Attempting to lower obesity rates is imperative for ensuring the health of citizens because obesity and overweight are major contributors to many preventable conditions and causes of death. Among these are coronary heart disease, type 2 diabetes, cancers, hypertension, dyslipidemia, stroke, liver and gallbladder disease, sleep apnea, respiratory problems, osteoarthritis, and gynecological problems (Centers for Disease Control and Prevention, 2009). In addition to health problems, overweight and obesity create significant economic problems. Direct costs result from prevention, diagnosis, and treatment of obesity-related conditions, and indirect costs include morbidity and mortality costs (CDC, 2009). Morbidity costs are defined as “the value of income lost from decreased productivity, restricted activity, absenteeism, and bed days,” and mortality costs are the “value of future income lost by premature death” (CDC, 2009). The total estimated direct and indirect costs resulting from overweight and obesity is estimated to be as high as $147 billion annually, based on data from 2006 (Holden, 2010). Compared to normal weight people, obese people spent $1,429 (42 percent) more for medical care during that year (CDC, 2009). Other studies have shown additional effects of obesity, specifically regarding children. Research has found that obesity and poor nutrition negatively affect school achievement, with severely obese children having lower IQs, poorer school performance, and lower test scores than other children (Hollar et al., 2010). Another important consequence of obesity is its social effects including possible stigmatization, discrimination, and lowered self-esteem (LHI). The effects of overweight and obesity are far-reaching, making apparent its inclusion as one of the ten leading indicators in Healthy People 2010.

HEALTH ISSUES

Overweight and obesity are determined by body mass index (BMI), which is based on height and weight and usually correlates to the amount of body fat. For adults, overweight is defined as having a BMI between 25 and 29.9, and obesity is defined as having a BMI of 30 or above (CDC, 2010). BMI measurements in children take into account differences between boys and girls in body fat distribution (CDC, 2010).

There are many contributing factors as to why people become overweight or obese. The basic underlying cause is an imbalance in energy requirements: people are consuming too many calories and not exercising enough. This has become a serious problem in recent decades due to changing societal and environmental factors. Notably, some Americans have less access to stores and markets that provide healthy, affordable food such as fruits and vegetables, especially in rural, minority and lower-income neighborhoods” (CDC, 2010). There has also been an

income neighborhoods” (CDC, 2010). There has also been an Business and Health Administration Association Annual
income neighborhoods” (CDC, 2010). There has also been an Business and Health Administration Association Annual

increase in consumption of foods prepared outside the home in the form of fast food, sit-down restaurants, and vending machines (Burton, 2006). This has lead to an increase in obesity rates since away-from-home food is highly palatable, consists of larger portions, and often has a higher energy density, making it frequently higher in calories and fat content (CDC, 2010). All of these factors combine to encourage overeating of often unhealthy foods. Another important societal factor leading to obesity is the fact that less healthy foods and beverages are often easier and cheaper to obtain than healthier options (CDC, 2010). Moreover, there has been an increase in advertising and marketing of foods high in sugar, fat, and salt, making these unhealthy items a highly visible aspect of American culture (CDC, 2010).

INTERVENTIONS

In conjunction with proper nutrition, physical activity is an important component of maintaining a healthy body weight. Physical activity has many beneficial effects on overall health status. In addition to preventing and controlling obesity, “it reduces the risk for many of the diseases associated with obesity, such as diabetes and heart disease” (USDHHS, Office of the Surgeon General, 2010). Other effects include building and maintaining healthy bones and lean muscle mass, reducing feelings of depression and anxiety, promoting psychological well being, enhancing independent living for older adults, and improving quality of life for all people (CDC, 2006). The U.S. Surgeon General recommends that “adults should do at least 150 minutes of moderate-intensity physical activity per week,” and “for children and teenagers, the recommendation is for 1 hour of daily physical activity that includes vigorous activities and activities that strengthen their bones” (2010). People can fulfill this recommendation through a variety of activities and by making small changes to their lifestyle, such as taking brisk walks and climbing the stairs instead of using the elevator. However, various barriers to physical activity may be encountered. For example, some communities are built in ways that make physical activity difficult or unsafe. Access to parks and recreation centers may be limited, safe routes for walking or biking to school or work may not exist, and daily physical education in school may not occur (CDC, 2010). Excessive television and computer use is another significant barrier, evidenced by the fact that 8-18 year olds spend over seven hours each day using entertainment technology (USDHHS, Office of the Surgeon General, 2010). In addition to contributing to a sedentary lifestyle, “the more time children spend watching television, the more likely they are to eat while doing so and the more likely they are to eat the high-calorie foods that are heavily advertised to both adults and children” (USDHHS, Office of the Surgeon General, 2010). To achieve an increase in physical activity for Americans, all of these barriers must be overcome.

HEALTHY PEOPLE 2010: OBESITY AND NUTRITION

Healthy People 2010 is organized into various objectives dealing with obesity and nutrition. These are related to weight status and growth, food and nutrient consumption, and schools, worksites, and nutrition counseling. Healthy People 2010 has set targets for improvement in all areas as follows (USDHHS, USPHS, 2000):

Objective

Baseline

Target

Increase the proportion of adults who are at a healthy weight.

42

60

Reduce the proportion of adults who are obese.

23

15

Reduce the proportion of children and adolescents who are overweight or obese.

11

5

Increase the proportion of persons aged 2 years and older who consume at least two daily servings of fruit.

28

75

Increase the proportion of persons aged 2 years and older who consume at least three daily servings of vegetables, with at least one-third being dark green or orange vegetables.

3

50

Increase the proportion of persons aged 2 years and older who consume at least six daily servings of grain products, with at least three being whole grains.

7

50

Increase the proportion of persons aged 2 years and older who consume less than 10 percent of calories from saturated fat.

36

75

Increase the proportion of persons aged 2 years and older who consume no more than 30 percent of calories from total fat.

33

75

Increase the proportion of persons aged 2 years and older who consume 2,400 mg or less

21

65

2 years and older who consume 2,400 mg or less 21 65 Business and Health Administration
2 years and older who consume 2,400 mg or less 21 65 Business and Health Administration

of sodium daily.

   

Increase the proportion of persons aged 2 years and older who meet dietary recommendations for calcium.

46

75

Increase the proportion of children and adolescents aged 6 to 19 years whose intake of meals and snacks at school contributes to good overall dietary quality.

Developmental

Increase the proportion of worksites that offer nutrition or weight management classes or counseling.

55

85

Increase the proportion of physician office visits made by patients with a diagnosis of cardiovascular disease, diabetes, or hyperlipidemia that include counseling or education related to diet and nutrition.

42

75

Healthy People 2010 also established a set of objectives related to physical activity with accompanying targets. These include (USDHHS, USPHS, 2000):

Objective

Baseline

Target

Reduce the proportion of adults who engage in no leisure-time physical activity.

40

20

Increase the proportion of adults who engage regularly, preferably daily, in moderate physical activity for at least 30 minutes per day.

15

30

Increase the proportion of adults who engage in vigorous physical activity that promotes the development and maintenance of cardio-respiratory fitness 3 or more days per week for 20 or more minutes per occasion.

23

30

Increase the proportion of adults who perform physical activities that enhance and maintain muscular strength and endurance.

18

30

Increase the proportion of adults who perform physical activities that enhance and maintain flexibility.

30

43

Increase the proportion of adolescents who engage in moderate physical activity for at least 30 minutes on 5 or more of the previous 7 days.

27

35

Increase the proportion of adolescents who engage in vigorous physical activity that promotes cardio-respiratory fitness 3 or more days per week for 20 or more minutes per occasion.

65

85

Increase the proportion of the Nation’s public and private schools that require daily physical education for all students. (Middle schools)

17

25

Increase the proportion of the Nation’s public and private schools that require daily physical education for all students. (High schools)

2

5

Increase the proportion of adolescents who participate in daily school physical education.

29

50

Increase the proportion of adolescents who spend at least 50 percent of school physical education class time being physically active.

38

50

Increase the proportion of adolescents who view television 2 or fewer hours on a school day.

57

75

Increase the proportion of the Nation’s public and private schools that provide access to their physical activity spaces and facilities for all persons outside of normal school hours.

Developmental

Increase the proportion of worksites offering employer-sponsored physical activity and fitness programs.

46

75

Increase the proportion of trips made by walking. (Adults)

17

25

Increase the proportion of trips made by walking. (Children to school)

31

50

It is apparent that some of these are sizable goals, but with sufficient planning and strategies, substantial progress could hypothetically be reached in the span of ten years. Unfortunately, the majority of these goals have not been achieved due to a wide variety of reasons. An examination of the efforts already implemented show that the United States is headed in the right direction to lessen the obesity epidemic. However, there are still many goals left to be accomplished.

However, there are still many goals left to be accomplished. Business and Health Administration Association Annual
However, there are still many goals left to be accomplished. Business and Health Administration Association Annual

An important initiative to improving people’s diets deals with providing nutrition information on food packaging. Because away-from-home food consumption has greatly increased in recent years, research has been done to examine the effects of nutrition information in restaurants. Researchers have found that people significantly underestimate levels of calories, fat, and saturated fat in less-healthful restaurant items (Burton, 2006). Moreover, inclusion of nutrition information has a significant influence on people’s product attitudes, purchase intentions, and choices to consume (Burton, 2006). Many restaurants provide nutrition information on company websites or on premises if asked. However, after observing 4,311 consumers in fast food restaurants, a recent study found that only six people, or 0.1%, accessed nutrition information prior to purchasing their food (Roberto, 2009). Having the information available is only useful if people decide to specifically ask for it, so providing nutrition information to all consumers at the point of sale is much more beneficial. When people are aware of what they are eating, they are much more likely to make better choices.

In 2006, New York City adopted a law requiring chain restaurants to post calorie information on menu boards (NYC Department of Health and Mental Hygiene, 2006). Laws requiring nutrition information on menus and menu boards have since been adopted in other areas, including Oregon, Philadelphia, and King County, Washington, and many other municipalities are considering similar policies (Stein, 2010). Additionally, the Patient Protection and Affordable Care Act was signed into law March 23, 2010 by President Obama. This law includes a provision creating a uniform standard for nutrition-disclosure for restaurants across the country, requiring restaurant chains with more than 20 locations to post calorie values on menus, menu boards, or drive thru boards and keeping additional nutrition information available upon request. The Food and Drug Administration must now propose specific regulations within one year before changes can take effect (National Restaurant Association, 2010). Now, more people than ever before will be aware of the nutrition information of foods they consume in restaurants, and hopefully this will lead to an increase in healthier choices.

FOCUS ON EXERCISE

Physical activity can also be improved through government and community initiatives. One significant barrier to getting enough physical activity is living in an environment that is not safe for walking to and from school, work, and other destinations. Research has found that “neighborhood physical environments and perceived safety influence adults’ readiness to encourage children’s physical activity…in sports or exercise” (Miles, 2008). If the environment does not provide a safe place for physical activity, children and adults will likely spend more time engaging in sedentary activities indoors (USDHHS, USPHS, 2000). There are many ways governments can work to make communities safer and more conducive to physical activity. The following strategies have been recommended by the Surgeon General: “Improve access to outdoor recreational facilities, build or enhance infrastructures to support more walking and bicycling, support locating schools within easy walking distance of residential areas, improve access to public transportation…and enhance personal and traffic safety in areas where people are or could be physically active” (2010). These initiatives require sufficient funding, but some communities have implemented creative, economical strategies to provide safe passages for children between homes and neighborhoods, schools, and after school activities. For example, Let’s Move! is a campaign started in February 2010 by First Lady Michelle Obama to end childhood obesity in the United States. One strategy promoted through this campaign is the “walking school bus” model, in which adults walk to school with a group of children; many localities across the country have found this to be successful (USDHHS, 2010). Let’s Move! promotes many other strategies for parents, schools, and communities to decrease childhood obesity. These include limiting television time, spending family time outdoors being active, increasing physical education time, and creating parks and playgrounds where children can safely play (USDHHS, 2010). Solutions such as these can have a substantial impact on the health of America’s children.

FOCUS ON NUTRITION

Another component to preventing childhood obesity in schools is promoting good nutrition. One of the CDC’s recommended strategies to prevent obesity is that public service venues (e.g. schools) should increase the availability and affordability of healthier food and beverage choices (2010). This goal has been accomplished in many communities, and the results have often been promising. For example, school districts across the country have established nutrition standards that prohibit the sale or serving of “foods of minimal nutritional value” including soft drinks, candy bars, fried chips, and other high-fat snacks (U.S. Department of Agriculture, CDC, 2005). Other schools have prohibited all beverages besides water, milk, and 100% fruit juice. In addition to prohibiting certain items from menus, some schools have adopted guidelines requiring that only fruits and vegetables can be eaten as

requiring that only fruits and vegetables can be eaten as Business and Health Administration Association Annual
requiring that only fruits and vegetables can be eaten as Business and Health Administration Association Annual

snacks in classrooms. Another way school districts are promoting healthier eating is by reevaluating food and beverage contracts with outside vendors. Some districts have chosen to cancel contracts; however, this is not an option for all schools since many have come to rely on the generated revenue. Therefore, districts have attempted to renegotiate with vendors by initiating proposals that include increasing the percentage of healthful items available, improving nutritional quality of beverages available under an existing contract, or charging a lower price for healthier food and beverages (USDA & CDC, 2005). Schools can also adopt marketing techniques to encourage their students to make healthier choices. For example, they should “(1) identify and offer healthful products that are appealing and meet student needs, (2) use product placement to make healthful products easy to choose, (3) use promotion strategies so that students know about these products and are motivated to try them, and (4) set their price at a level that encourages students to purchase them” (USDA & CDC, 2005). Finally, fundraising activities should support student health. Students can be rewarded by walks with the principal rather than prizes such as a pizza party, and fundraisers should involve selling nutritious foods (e.g. fruit) or non-food items rather than candy (USDA & CDC, 2005).

PROGRESS MADE

Many school districts across the country have seen improvements in nutrition, wellness education, and physical fitness. For example, in Grand Forks, North Dakota, milk, bottled water, and baby carrots are now sold at extra-curricular school events, which has helped make healthful choices the norm and has also increased fundraising revenue. Additionally, a school-wide classroom snack policy of fruits or vegetables only has been adopted. This policy has generally been well received and is now accepted school practice (USDA & CDC, 2005). In Mercedes, Texas, candy is no longer a fundraiser, soft drinks have been banned, and new options, such as fat-free ice cream bars, yogurt, and string cheese, have been added to the à la carte menu. Sales of the new items have been strong, and there has been no significant change in food revenue (USDA & CDC, 2005).

In addition to anecdotal evidence in support of these measures, various studies have also been performed. Hollar et. al. (2010) examined the effect of a school-based obesity prevention program that included dietary, educational, and physical activity components on BMI and academic performance among low-income elementary students. Modifications to school menus included more high-fiber items, fewer high-glycemic items, and lower levels of total, saturated, and trans fats. The curricula component consisted of a “holistic nutrition and healthy lifestyle management program” that “sought to teach children, parents, and school staff about good nutrition and the benefits of daily physical activity with the goal of improving the health and academic achievement of children in a replicable and sustainable manner.” The physical activity component provided increased opportunities for physical activity during the school day for students. After two years, 52.1% of students in the experimental condition stayed within normal BMI percentile ranges compared to only 40.7% of those in the control group, and intervention students scored, on average, 10.9-31.7 points higher on the math section of the Florida Comprehensive Achievement Test than students in the control group (Hollar, et. al. 2010). Interventions by schools can have a highly influential effect not only on the physical health of students, but an increase in academic performance may result as well. Although many valuable initiatives have been taken across the country to reduce obesity and increase physical fitness, the most recent round of progress reviews for Healthy People 2010 by the CDC/National Center for Health Statistics has found an overall decline in values for these indicators. Notably, “all objectives related to overweight and obesity are moving away from their targets” (2008). The proportion of adults whose weight is in the healthy range was 32 percent in the period 2003-2006, down from 42 percent in the period 1988-1994. The target for 2010 was 60 percent. Additionally, 33 percent of adults are now obese, compared to only 23 percent in 1988-1994. The target for this measure is 15 percent. Progress for children and adolescents is similarly discouraging: “overweight and obesity in children aged 6 to 11 years increased from 11 percent in 19881994 to 17 percent in 20032006. In adolescents aged 12 to 19 years, the increase over the same period was from 11 percent to 18 percent. The target for both children and adolescents is 5 percent.” Several barriers to preventing obesity have been identified. “Away from home foods,” which are ready-to-eat items purchased at restaurants, prepared-food counters at grocery stores, and institutional settings such as schools, make it difficult to make healthy choices and limit portion control (USDHHS, 2008). Additionally, encouraging people to maintain behavioral changes for lifelong weight management “can be extremely difficult” (USDHHS, 2008). States and local communities have the authority to regulate foods and beverages sold in schools, but many localities have not yet taken action (USDHHS, 2008).

many localities have not yet taken action (USDHHS, 2008). Business and Health Administration Association Annual
many localities have not yet taken action (USDHHS, 2008). Business and Health Administration Association Annual

STRATEGIES FOR THE FUTURE

The federal government recognizes these barriers to success, but they have also outlined strategies for the future. Public awareness of overweight and obesity must be increased at the individual and population levels, and communication must be improved to provide the public with recommended actions that can be effective in weight management (USDHHS, 2008). More scientific research needs to be conducted to determine the most effective ways to achieve sustained lifestyle modification so that people will be inspired to make healthy decisions for years to come. Federal nutrition assistance programs should be used to increase the availability of fruits, vegetables, and whole grains and decrease higher-fat dairy products to low-income families. Additionally, school health and physical education programs need more governmental support (USDHHS, 2008).

One way the government is beginning to fulfill these promises is through funding by the Centers for Disease Control and Prevention’s Division of Nutrition, Physical Activity, and Obesity. Currently, 25 states receive funding to help create policies and environmental changes that will improve the health of Americans. The principal target areas include increasing physical activity, increasing fruit and vegetable consumption, decreasing the consumption of sugar sweetened beverages, reducing the consumption of high calorie foods, and decreasing television watching (CDC, 2010). New Jersey is one of the states that have been receiving funding since 2008. The state government created the New Jersey Obesity Action Plan in 2006, which is providing a framework as to how the funds will be spent. One of the objectives that has been developed involves the N.J. Department of Transportation, which will work to promote physical activity by implementing a statewide pedestrian safety campaign, increase funding to the Safe Routes to Schools program which makes it safer and easier for children to walk to school, and create pedestrian and bike paths whenever possible. The Department of Health and Senior Services (DHSS) has created the N.J. Council on Physical Fitness and Sports, which distributes $100,000 grants to communities for policy and environmental change projects. The DHSS is also receiving funding jointly with the Department of Education to promote obesity and tobacco control in schools (CDC, 2010).

One of the programs that have been developed since the initial creation of the New Jersey Obesity Action Plan is the “Choosing Healthy Life by Making Healthy Choices Program.” Lead by the NJ Pediatric Council on Research and Education (PCORE), this campaign encourages children to make healthy choices about nutrition, exercise, and overall well-being. Pediatricians play an important role by providing information and guidelines to parents, and after-school programs promote health by providing 20-30 minutes of physical activity five days a week and teaching children how to make good decisions about food, portion size, and physical activity. After one year of being implemented in schools in Long Branch, NJ, “the BMI (Body Mass Index) outcomes for participants showed a 5.7% decrease in children who were overweight/obese,” and after two years, “there was a 12.7% increase in children who had healthy weight, 8.4% drop in children who were overweight, and a 13.7% drop in children who were obese” (NJPCORE, 2009). These are promising results, and researchers hope to expand the program to other school districts.

Obesity has had a profound impact in New Jersey. According to Behavioral Risk Factor Surveillance System data from 2007, 38% of adults are considered overweight and another 24% are considered obese (CDC, 2008). Obesity is a significant problem with children as well: New Jersey has the highest reported rate of obesity in the nation for low-income children ages 2-5, and 15% of 9 th -12 th graders are overweight with an additional 11% being obese (CDC, 2008). A major survey of childhood obesity in the state has not yet been conducted since actions by the NJ Obesity Action Plan have begun; only time will tell if the nationally-funded initiatives are significantly improving the health status of New Jersey’s residents compared to this baseline data.

HEALTHY PEOPLE 2020

Virtually all of the indicators related to obesity and physical activity have not been met; these goals will continue to be an issue in future years. In fact, they have been included as objectives in Healthy People 2020, which will guide the nation’s health promotion initiatives for the next ten years (USDHHS, USPHS, 2010). In regards to nutrition and weight status, many of the objectives are the same as in Healthy People 2010, including increasing “the proportion of adults who are at a healthy weight,” reducing “the proportion of adults who are obese,” reducing “the proportion of children and adolescents who are overweight or obese,” and reducing “the proportion of adults who engage in no leisure-time physical activity.” New objectives include preventing “inappropriate weight gain in youth and adults,” increasing “the number of states that have state-level policies that incentivize food retail outlets to

-level policies that incentivize food retail outlets to Business and Health Administration Association Annual
-level policies that incentivize food retail outlets to Business and Health Administration Association Annual

provide foods that are encouraged by the Dietary Guidelines,” and increasing “the proportion of Americans who have access to a food retail outlet that sells a variety of foods that are encouraged by the Dietary Guidelines” (USDHHS, USPHS, 2010).

The objectives related to physical activity have remained similar as well. For example, Healthy People 2020 once again aims to “reduce the proportion of adults who engage in no leisure-time physical activity”, “increase the proportion of trips made by walking,” “increase the proportion of employed adults who have access to and participate in employer-based exercise facilities and exercise programs,” “increase the proportion of children and adolescents who do not exceed recommended limits for screen time,” and “increase the proportion of the nation’s public and private schools that require daily physical education for all students.” However, there are a few new objectives, such as increasing “regularly scheduled elementary school recess,” “increasing legislative policies for the built environment that enhance access to and availability of physical activity opportunities,” and increasing “the proportion of physician office visits that include counseling or education related to physical activity” (USDHHS, USPHS, 2010). With the publication of Healthy People 2020, America’s lawmakers and citizens hopefully have a renewed focus on improving health in the important areas of overweight and obesity and physical activity. Since all of the strategies have been developed, hopefully we will see measurable improvements in the next ten years and into the future.

REFERENCES

Burton, S., Creyer, E., Kees, J., & Huggins, K. (2006). Attacking the obesity epidemic: The potential health benefits of providing nutrition information in restaurants. American Journal of Public Health. Retrieved from

Centers for Disease Control and Prevention (2010, August 3). CDC vital signs: Adult Obesity. Retrieved from http://www.cdc.gov/vitalsigns/AdultObesity/index.html.

Centers for Disease Control and Prevention (2010, September 30). Overweight and obesity. Retrieved from http://www.cdc.gov/obesity/index.html.

Holden, D. (2010, February 9). Fact check: The cost of obesity. Retrieved from

Hollar, D., Messiah, S., Lopez-Mitnik, G., Hollar, T., Almon, M., & Agatston, A. (2010). Effect of a two-year obesity prevention intervention on percentile changes in body mass index and academic performance in low-income elementary school children. American Journal of Public Health, 100(4), 646-653. doi:10.2105/AJPH.2009.165746.

Miles, R. (2008). Neighborhood disorder, perceived safety, and readiness to encourage use of local playgrounds. American Journal of Preventive Medicine, 34(4), 275-281.

National Restaurant Association. (2010). Public policy issue briefs. Retrieved from http://www.restaurant.org/advocacy/issues/issue/?Issue=menulabel.

New Jersey Department of Health and Senior Services. (2006). The New Jersey obesity prevention action plan. Retrieved from http://www.state.nj.us/health/fhs/documents/obesity_prevention.pdf.

Roberto, C., Agnew, H., & Brownell, K. (2009). An observational study of consumers' accessing of nutrition information in chain restaurants. American Journal of Public Health, 99(5), 820-821. Retrieved from CINAHL database.

Stein, J. (2010, February 19). Menus to carry nutrition info starting next year. Los Angeles Times. Retrieved from

U.S. Department of Agriculture, & Centers for Disease Control and Prevention (2005). Making it happen: School nutrition success stories. Retrieved from http://www.cdc.gov/HealthyYouth/nutrition/Making-It- Happen/download.htm.

Happen/download.htm. Business and Health Administration Association Annual
Happen/download.htm. Business and Health Administration Association Annual

U.S. Department of Health and Human Services, Public Health Service (2000). Healthy people 2010. Retrieved from http://www.healthypeople.gov/2010/Document/tableofcontents.htm#tracking.

U.S. Department of Health and Human Services, Public Health Service (2006). Healthy people 2010 midcourse review. Retrieved from www.healthypeople.gov/Data/midcourse/.

U.S. Department of Health & Human Services, Public Health Service (2008, June 26). Progress review: Physical activity and fitness. Retrieved from http://healthypeople.gov/data/2010prog/focus22/.

U.S. Department of Health and Human Services, Public Health Service (2008, April 3). Nutrition and overweight:

U.S. Department of Health and Human Services, Public Health Service (2010). Healthy people 2020. Retrieved from http://healthypeople.gov/2020/default.aspx.

U.S. Department of Health and Human Services (2009, July 27). Study estimates medical cost of obesity may be as high as $147 billion annually. Retrieved from Centers for Disease Control and Prevention website:

U.S. Department of Health and Human Services (2010). Let's Move! Retrieved from http://www.letsmove.gov/.

U.S. Department of Health and Human Services, Office of the Surgeon General (2010, January). The Surgeon General’s vision for a healthy and fit nation. Rockville, MD: U.S. Retrieved at

Dr. Margaret J. Greene Ramapo College of New Jersey 505 Ramapo Valley Road, Mahwah, New Jersey 07430 Phone: (201) 684-7206, Fax: (201) 760-2461 E-mail: mgreene1@ramapo.edu

684-7206, Fax: (201) 760-2461 E-mail: mgreene1@ramapo.edu Business and Health Administration Association Annual
684-7206, Fax: (201) 760-2461 E-mail: mgreene1@ramapo.edu Business and Health Administration Association Annual

TRACK

DISTANCE LEARNING AND ONLINE TEACHING

TRACK DISTANCE LEARNING AND ONLINE TEACHING Business and Health Administration Association Annual Conference 2012 41
TRACK DISTANCE LEARNING AND ONLINE TEACHING Business and Health Administration Association Annual Conference 2012 41

STRATEGIES FOR SELF-DIRECTED LEARNING IN A VIRTUAL ENVIRONMENT

Scott J. Saccomano, Herbert H Lehman College

ABSTRACT

Nursing educators are constantly faced with the challenge of providing students with educational experiences that promote critical thinking and self-directed learning. The goal of such activities is to prepare competent practitioners to deliver nursing care in a variety of settings. Adult learning is most advantageous when individuals are self-directed, identify their own learning goals, and participate in evaluating the learning experiences. Self-directed learning claims to increase students’ confidence and the capacity for independent learning.

Nursing educators are drawn to the self-directed learning model as it has significant implications for professional autonomy, a critical requirement for nursing practice. In order for self-directed learning to be successful, both teachers and learners need to be familiar with the concept and possess the required skills for development of the associated learning strategies. Students must possess a variety of skills, such as self-efficacy and organization, if they are to achieve the required learning objectives. To facilitate student participation in self- directed learning activities it is crucial to evaluate their purpose for learning.

Student attributes for self directed learning:

1. Motivation Why do students choose to participate in academic tasks?

2. Goal Oriented Does the student have the ability to make plans and set goals?

3. Organization - The ability to organize a course of action.

4. Control Do students have the ability to ascribe to achievements?

5. Reflection Students should continuously assess and reevaluate their learning goals.

Goals for nurse educators to facilitate self-directed learning:

1. Develop collaborative relationships with students to identify goals and objectives.

2. Identify individual learning styles.

3. Supervise the experience rather than be an information provider.

4. Encourage critical thinking skills.

5. Provider of resources to facilitate learning.

It is important with any teaching-learning strategy to assess its congruency with the course of study. The self-directed learning model can enhance the learning experience, improve student performance, and support academic achievement

Scott J. Saccomano Herbert H Lehman College Bronx, New York, 10468

J. Saccomano Herbert H Lehman College Bronx, New York, 10468 Business and Health Administration Association Annual
J. Saccomano Herbert H Lehman College Bronx, New York, 10468 Business and Health Administration Association Annual

EMBARRASSING NEW INFORMATION TECHNOLOGY IN TEACHING GLOBAL HEALTH

Hengameh Hosseini, Seton Hall University

ABSTRACT

This interdisciplinary global health course, taught from various social science perspectives, is designed to present an overview of salient issues in global health. The course explores the many ramifications of disease, in their social, cultural, economic, political, ethical, physiological, epidemiological, and public health dimensions. A significant portion of the course is devoted to the HIV/AIDS epidemic in the developing world. The author believes the course, which has been taught once before, can be enhanced by the utilization of new media technology (Blackboard, etc.) because today’s students, being technology savvy, can attain more information, and can also cause more active engagement of fellow students.

Keywords: Health, Global, Interdiciplinary

Hengameh Hosseini, PhD Assistant Professor Master of Healthcare Administration Political Science and Public Affairs 520 Jubilee Hall 400 South Orange South Orange NJ 07079 E-mail: hosseihe@shu.edu Tel: 973-761-9212

NJ 07079 E-mail: hosseihe@shu.edu Tel: 973-761-9212 Business and Health Administration Association Annual
NJ 07079 E-mail: hosseihe@shu.edu Tel: 973-761-9212 Business and Health Administration Association Annual

A NURSING EDUCATION CHALLENGE: E-TEXTBOOKS

Josephine M. DeVito, Seton Hall University

ABSTRACT

Within the current economic environment, education costs have to be considered in many areas, including tuition and textbooks. Nursing education has undergone many changes as more diverse students enter traditional and accelerated nursing programs. These factors influence the learning experience for students. Traditionally, students learned by buying new or used nursing textbooks. This was the norm, but as textbook prices increased and some students were unable to purchase the required textbooks for a course another option had to be made available.

The most interesting aspect of

electronic books is not the devices they can be accessed with, but that they are potentially, a creative technology

which provides a new kind of reading experience for the learner. Publishers are beginning to explore visual interfaces that include multimedia and collaborative elements.

The challenge that nursing education needs to consider is e-textbooks.

Pageburst is Elsevier’s digital textbook solution. Some of the features of Pageburst are that important concepts can be highlighted, students can make notes, and share notes with other students. It is important that the education of nurses move forward with technology as we move into the 21 st Century and e-textbooks can provide this opportunity.

The benefits of incorporating Pageburst into nursing curriculum:

1. Instructors and students can access the entire Elsevier library of Nursing e-textbooks, when the

curriculum commits to e-textbooks for its students and at a significant cost savings for the student

2. Pageburst can be accessed on line, offline (on computers or laptops), and mobile (on Apple iPhone, iPod

Touch, and iPad devices)

3. Creating folders to organize content

4. Text-to-speech features allows the digital book to be read to the student

5. Students and faculty will have access to Mosby’s Nursing Consult at no extra charge: this online reference offers additional resources including books, journals, drugs, clinical updates, images, evidence- based nursing, news, etc.

The objectives of this presentation will be to:

1. Understand the role e-textbooks in nursing education

2. Assess the advantages of e-textbooks in nursing education

3. Identify the role of the nurse educator in e-textbook nursing education

The outcome of this presentation will be that e-textbooks should be considered a learning strategy for nursing education. It will provide students the opportunity to be motivated and learn at their own pace while developing critical thinking skills.

Josephine M. DeVito Seton Hall University South Orange, New Jersey 07079

DeVito Seton Hall University South Orange, New Jersey 07079 Business and Health Administration Association Annual
DeVito Seton Hall University South Orange, New Jersey 07079 Business and Health Administration Association Annual

ASSESSING THE IMPACTS OF ANXIETY AND GENDER ON STUDENT ATTITUDES TOWARD COMPUTER LEARNING TECHNOLOGY IN A SAUDI NURSING ACADEMIC ENVIRONMENT

Osama A. Samarkandi, Al-Baha University

ABSTRACT

Computer knowledge and skills are becoming essential components technology in nursing education. Saudi nurses must be prepared to utilize these technologies for the advancement of science and nursing practice in local and global communities. Little attention has been directed to students’ attitudes about computer usage in academic communities in Saudi Arabia. Their attitudes about the use of computers for the enhancement of learning are relatively unknown. Few research studies have been identified that explicate Saudi Arabian nursing students’ attitudes toward computer usage for the acquisition of knowledge and skills.

Males and females matriculate at King Saud University (KSU), but attend classes in gender-specific groups. This descriptive correlation study will contribute to the body of knowledge related to nursing students’ attitudes toward computer usage in their baccalaureate education at KSU. The research included all students enrolled in the College of Nursing at KSU in Riyadh, in the summer semester of the academic year 2009-2010. The total number of undergraduate nursing students were 600; 195 were males and 405 were females (KSU, 2008).

The findings (n = 335; nm= 133 & nf = 222) suggest that females were more anxious about computer usage (Mean=31.5; 32.7) than males. None of the independent variables explained the variance in the dependent variable, computer usage. Findings did indicate that students had less anxiety if they had access to a computer at home or at school; their anxiety was even less if they had computer exposure at both home and school. Implications of these findings are presented with regard to educating future nurses at KSU for complex roles in health care systems. The study also raises issues about the possibility of planning intervention studies for future research about computer learning, possibly using simulation-based approaches and virtual systems. Issues regarding gender, socioeconomic status, age, learner attitudes, and other variables will need to be systematically investigated. Future studies should assist with the unraveling of traditional cultural issues, including gender-specific roles and expectations for computer usage in nursing and health care delivery.

INTRODUCTION

As computer technology becomes a common component in educational institutions, its pedagogical use will continue to gain status and notoriety (Oblinger & Rush, 1997). Core curricula in many colleges and universities now include computer literacy as a basic requirement and for faculty and students. At some institutions, computer literacy is mandatory. Young (1997) listed a number of institutions (n = 8) that had begun mandatory computer literacy programs for their students. Beginning in the fall of 1998, these institutions required that all of their students either own or have access to a computer. Functionally, computers are used in education for three types of activities:

management; instruction and learning; and educational research (Forcier, 1996). The use of computers for management activities includes school and classroom applications in budgeting, accounting, record keeping, printed and electronic communication, and information retrieval. These management activities are essential for nurse leaders who are responsible for planning and implementing health programs in a variety of settings. Budgeting and accounting is activated at the unit level in many hospitals and clinics throughout the world.

Nurses are now responsible for nursing care and for financial management. Computer usage is essential in both instances. In addition, use of computers for instruction and learning involves teacher-centered interactions as

and learning involves teacher-centered interactions as Business and Health Administration Association Annual
and learning involves teacher-centered interactions as Business and Health Administration Association Annual

well as student-centered learning. Teacher-centered instruction provides teachers with greater control in the design, development, and delivery of instructional materials. Student-centered learning gives the individual more freedom to construct activities that would lead to learning, and this method could help the learner to acquire a sense of competence about the acquisition of knowledge and skills. Computers are also used in research, evidence-based practice, statistical analysis, and information retrieval and synthesis. Collectively, these activities contribute to the learning process and help to foster competency among nurses and others (Forcier, 1996; Freedman, 1996; Teo & Lim, 1996).

Technology usage is an important component of health care planning and delivery in Saudi Arabia and throughout the Middle East. Its use is expanding at a phenomenal rate. Technology will impact Saudi society in a way that is similar to its influence on other world communities. Specifically, technology will help the Saudis to increase their research efforts at the molecular levels of scientific investigations, such as in genetics. It is an essential tool for conducting epidemiological research and for implementing community-based research in large populations. Computer technology will enable Saudi scientists and clinicians to participate in research on the world stage and reduce costs by utilizing resources for implementing health care that are available in other global communities.

Importantly, the use of technology will enable the Saudi people to generate and utilize evidence-based practice approaches to health care, expand research, and generate new knowledge that is specific to the Saudi people. These novel approaches that are available because of technology also have challenges. The Saudi government, like other governments in the world community, will need to give in-depth consideration to technology-related issues such as confidentiality and ethical decision making. Nevertheless, the advantages of technology in Saudi Arabia have been embraced by the society and government. All health care providers are expected to become computer literate and utilize technology in their practice, research, and education and training (McLaughlin et. al, 2008).

It is anticipated that teaching and learning at all levels in society will be impacted by innovations that are associated with computer technology. The profound potential that is related to the use of computers will overlap all aspects of human life. Computer technology will also link Saudi Arabia to other Arab countries as well as every country in the global community (Al-Farsi, 2001; Mufti, 2002).

These technological advances have assisted the students by enhancing their learning. One practice, however, remains constant. Although King Saud University in Riyadh, the nation’s capital and largest city, invites males and females to its campus, the religious and cultural practices that dictate that males and females will be educated in different classrooms remains a strong basic value within Saudi culture. Hence, although the KSU male and female students share all resources, they continue to learn in separate classroom environments (KSU, 2008; Saudi Ministry of Higher Education, 2008; Moshaikeh, 1992).

COMPUTER USAGE IN NURSING EDUCATION IN SAUDI ARABIA

The Saudi Arabian School System adopted a gender-dual education system that is separate and different for males and females. The male education system was established in 1953 by the Ministry of Education, which is responsible for the development of a national educational policy that focuses on Saudi male learners. These institutions are located throughout the nation and are the hallmarks of education for the Saudi male learner (Al-Farsi, 2001). On the other hand, the female educational system was established in 1960 under the Presidency of Girls Education, a government body that was created specifically to handle educational matters for women (Al-Farsi, 2001). Females are required to attend the female gender institutions, and they, too, can matriculate in nursing at the baccalaureate level at the institutions that have been created for them.

STATEMENT OF THE PROBLEM

The College of Nursing at KSU has been selected as the setting for this research because it is the first and only school of nursing in Saudi Arabia that awards a baccalaureate degree in nursing (BSN) to both sexes (KSU, 2008; Saudi Ministry of Higher Education, 2008). This practice began in 2004. In Saudi Arabia, male and female nursing students in the same educational milieu represent a new and novel approach in nursing education. The future of this policy change (gender-integrated learning) will be evaluated over the next few years (Tumulty, 2001).

will be evaluated over the next few years (Tumulty, 2001). Business and Health Administration Association Annual
will be evaluated over the next few years (Tumulty, 2001). Business and Health Administration Association Annual

King Saud University’s College of Nursing now requires that all students successfully complete a computer course (Tech 227). This is a mandatory two-credit-hour class in which students spend 2 hours in the classroom where didactic learning occurs and an additional hour in the learning laboratory where skills are acquired. To accommodate the needs of students, the College of Nursing is equipped with laboratories that house state-of-the-art computer technology (KSU, 2007).

Attitudes toward computer use among Saudis have not been systematically studied. Attitudes are consistent opinions that are shaped by experiences, worldviews, cognition, and emotions that determine an individual’s opinion about computers, or people, or events (Ajzen & Fishbein, 1975). This perspective suggests that attitudes influence the reactions that people have toward computers, others, and events that occur over time. Furthermore, it suggests that students who are exposed to computers in their academic programs might have some preexisting opinions about the use of computers as an enhancement for the acquisition of knowledge and skills in nursing.

RESEARCH QUESTION

The research question explored in this study was the following:

Does anxiety about computer usage in academic learning vary among males and females at King Saud University College of Nursing?

THEORETICAL AND OPERATIONAL DEFINITIONS OF STUDY

Computer, Theoretical Definition

Computer: An electronic device that is capable of storing, manipulating, and retrieving information as designed through the use of precise mathematical instructions that are guided by software (Merriam-Webster, 2007). An example of software that manages data is Excel, a spreadsheet program.

Computer, Operational Definition

In this study, a Dell Inspiron computer (electronic device) will be used to manipulate several software programs including Word, Excel, and Statistical Package for the Social Sciences SPSS 18.

Attitude, Theoretical Definition

Attitude is an enduring view regarding a person, object, or activity that consists of a cognitive element (perceptions and beliefs) and an emotional element (positive or negative feelings). It is also conceptualized as a positive or negative mental state of readiness, learned and organized through experience that influences the individual’s response/reaction to people, objects, places, and situations (Ajzen & Fishbein, 1975). Attitudes affect the behaviors of people toward objects, events, and individuals (Scarpa, Smeltzer, & Jasion, 1992).

Attitude, Operational Definition

Student’s attitude toward computers is defined as the total score on the four subscales as measured by the Computer Attitudes Scale (CAS): computer anxiety, computer confidence, computer liking, and computer usefulness (Loyd & Gressard, 1985; 1987).

Anxiety, Theoretical Definition

Computer anxiety is defined as the sense of fear or negative feelings toward computers and a reluctance to learn or manipulate the computer in the academic environment. Computer anxiety involves an array of emotional reactions including fear, apprehension, uneasiness, and distrust of computer technology in general (Loyd & Gressard, 1987). It can also be defined as hesitation or self-doubt in one’s own ability to learn about and use computers in the academic environment. This type of anxiety is related to one’s sense of self-efficacy about learning and mastering the use of computers (Loyd & Gressard, 1987).

mastering the use of computers (Loyd & Gressard, 1987). Business and Health Administration Association Annual
mastering the use of computers (Loyd & Gressard, 1987). Business and Health Administration Association Annual

Anxiety, Operational Definition

The CAS questionnaire will be used to determine the level of computer anxiety that the students manifest. Specifically, items 1, 5, 9, 13, 17, 21, 25, 29, 33, and 37on the CAS measure will be used to determine computer anxiety levels among the students (Loyd & Gressard, 1987).

Computer Confidence, Theoretical Definition

Computer confidence is associated with the inherent belief in one’s ability to master the use of computers in the academic environment and to use this technology to enhance individual and group learning (Loyd & Gressard,

1987).

Computer Confidence, Operational Definition

Items on the Computer Attitudes Scale will be used to measure computer confidence. As indicated on the questionnaire, an expression of computer confidence (or lack thereof) may include statements like “I am sure I could do work with computers,” “I’m not the type to do well with computers,” and “I could get good grades in computer courses.” Questionnaire items 2, 6, 10, 14, l8, 22, 26, 30, 34, and 38 are concerned with computer confidence on CAS (Loyd & Gressard, 1987).

Computer Liking, Theoretical Definition

Computer liking is defined as the internal feeling of enjoyment and stimulation, or the desire to learn about, think about, or converse with others about the characteristics and advantages of the computer and its multiple uses (Loyd & Gressard, 1987).

Computer Liking, Operational Definition

Computer liking will be measured by statements such as “I would like to work with computers,” or “Once I start to work with the computer, I would find it hard to stop,” or “I don’t understand how some people can spend so much time working with computers and seem to enjoy it.” Items 3, 7, 11, 15, 19, 23, 27, 31, 35, and 39 on the Computer Attitudes Scale will be used to measure this concept (Loyd & Gressard, 1987).

Computer Usefulness, Theoretical Definition

Computer usefulness is the extent to which a person believes that using a computer system could/will enhance his or her job performance and improve his/her knowledge and skills (Loyd & Gressard, 1987).

Computer Usefulness, Operational Definition

Computer usefulness, in this study, will be measured by computing items 4, 8, 12, 16, 20, 24, 28, 32, 36, and 40 on the Computer Attitudes Scale.

Design

RESEARCH METHODS

The study utilized a descriptive correlation design, appropriate for the investigation of the relationships of demographic characteristics (e.g., age, gender, socioeconomic status, previous exposure to computers, years of study at KSU, successful completion of a computer class [Tech 227], and students’ attitudes toward computer usage at KSU). The independent variables in the study were gender, age, socioeconomic status, academic classification, grade point average, length of previous computer experience before enrolling at KSU, access to computers outside of KSU, number of household members who use the household’s computer, marital status, geographical region of the nation that is considered to be the students’ home, and completion of the mandatory computer classes (Tech

and completion of the mandatory computer classes (Tech Business and Health Administration Association Annual
and completion of the mandatory computer classes (Tech Business and Health Administration Association Annual

227). There were four dependent variables that were derived from the subscales on one instrument, the CAS measure. These subscales include computer anxiety, computer confidence, liking of computers, and computer usefulness. Collectively, they were used to describe the nursing students’ attitudes toward computer use at KSU.

Sample

The researcher invited all officially enrolled students at the College of Nursing at KSU in Riyadh, Saudi Arabia in the summer semester of the academic year 2009 who met the criteria to participate. Recent (2007-2008) statistical data revealed that there were a total of 63,315 undergraduate students at KSU: 38,092 males and 25,223 females. More specifically, the total number of undergraduate nursing students was 600: 195 males and 405 females (KSU, 2008). From these data, it was hypothesized that the majority of the study sample might be females.

The inclusion criteria for participation in the study were: (a) both sexes (males and females), (b) all educational levels at the university (freshman, sophomore, junior, and senior), (c) 18 years of age or older, (d) enrolled as full-time students at KSU, (e) a Saudi citizen, and (f) willingness to participant in this study as evidenced by the signed Informed Consent Form that was completed by each participant before he/she could enter the research study. Other students who did not fit these criteria were not invited to participate in this research study. A clear explanation was provided to the students. See Table 1 for a demographic profile of study participants.

Table 1: Demographic Profile of Study Participants

 

Mean-Male

Mean-Female

Mean-Total

SD-Male

SD-Female

SD-Total

Age

21.98

21.20

21.47

1.98

1.72

1.84

GPA

3.08

3.38

3.27

0.85

0.89

0.89

Family

8.24

7.78

7.95

3.81

2.80

3.20

Members

Income

8,000-9,999

8,000-9,999

8,000-9,999

4,877.56

5,067.53

4,977.51

Computer

49.86

34.73

40.15

3.79

3.53

3.69

Experience

Anxiety

32.97

31.54

32.04

4.44

4.85

4.75

Score

Confidence

           

Score

31.63

30.77

31.08

4.84

4.94

4.88

Liking Score

29.28

29.61

29.49

3.82

4.20

4.07

Usefulness

           

Score

33.21

32.87

32.99

3.30

4.25

3.93

Total Score

127.10

124.77

125.60

13.81

15.91

15.21

SD=Standard deviation Source: O. A. Samarkandi, Students attitudes toward computers at the College of Nursing at King Saud University (KSU), Table 11, p. 63. Ph.D. Dissertation, Case Western Reserve University, 2011.

Demographic Questionnaire

INSTRUMENTATION

The Demographic Questionnaire was used to collect data about the personal characteristics of the enrolled students in the sample. This questionnaire has 13 items that query the subjects about variables such as age, gender, family income, number of years of previous exposure to computer usage, perceived level of expertise in computer

to computer usage, perceived level of expertise in computer Business and Health Administration Association Annual
to computer usage, perceived level of expertise in computer Business and Health Administration Association Annual

usage, years of matriculation at KSU, marital status, and geographical region of the nation that is considered to be home. The instrument was developed by the researcher and was administered in the Arabic language.

Computer Attitude Scale (CAS)

The Arabic Version of the Computer Attitude Scale (CAS) was used in this study to describe the students’ attitudes toward computer usage. The CAS was developed by Loyd and Loyd in 1984 and was modified 1985. It is a four-point Likert-like scale consisting of 40 items distributed among four 10-item subscales that measure computer anxiety, computer confidence, liking of computers, and perceptions of the usefulness of computers. The total CAS score can range from 40-160; higher scores correspond to more positive attitudes about computer usage. Subscales measuring variable constructs included: Computer Anxiety, Computer Usefulness, Computer Liking, and Computer Confidence. This study used the revised version of the CAS by Loyd and Gressard (1987). The CAS has been employed by a diverse group of researchers in numerous global communities, including Israel (Francis et al., 2000), China (Chin, 2001), South Africa (Burger & Blignaut, 2004), and Saudi Arabia (Abanmie, 2002; Alsebail, 2004).

Reliability and validity of the instrument have been well-established. The reliability coefficient for the Arabic version is 0.91 for the total scale. Validity has been evaluated by Loyd and Gressard (1987), and the measure was found to be an effective tool for differentiating learners’ attitudes based on varying degrees of computer experiences. Each of the subscales was able to stand alone and produce their own psychometric properties, including validity and reliability. Total instrument Cronbach alphas ranged from .78 in Arabic (Alsebail, 2004), to .89 in English (Burger & Blignaut, 2004), and .95 in English (Loyd & Gressard, 1987), to a high of .95 in Hebrew (Francis, Katz, & Jones, 2000). Subscale alphas ranged from .71 (Computer Liking, Alsebail, 2004, in Arabic) to .95 (Computer Liking, Burger & Blignaut, 2004, in English).

Data Collection and Analysis

This study was approved by institutional review boards at both the participating university in the U.S. and by King Saud University. Data were collected from students at KSU who volunteered to participate in the study. The researcher emphasized to prospective student participants that the data collection process was confidential and that no one at the school, or any place else, would have information about their responses to the demographic data form and the CSA questionnaire. Students were informed about their rights to refuse to participate in the study or to withdraw from the study at any time during the process of data collection without reprisals or disapproval. They were also told that there were no foreseeable risks associated with participating in this study. SPSS 18 was used to compute and analyze the data. The study sample was described by mean, median, range, standard deviation, and frequency statistics. Missing data were delineated by the numbers 9999. Pie charts and bar graphs were created to visually describe the demographic variables and the distribution of the subscales of students’ attitudes toward computers.

DATA ANALYSIS PLAN FOR THE RESEARCH QUESTION

Research Question

Does anxiety about computer usage in academic learning vary among males and females at KSU College of Nursing?

Data Analysis Plan

Summary measures including mean, standard deviations, and variance along with t-tests were used to determine the difference between the two groups (males and females).

Results

The purpose of this study was to examine the attitudes of baccalaureate-degree seeking student nurses’ attitudes toward computer usage in the College of Nursing at King Saud University (KSU), Riyadh, Saudi Arabia. Specifically, the study was designed to investigate the influence of gender, age, socioeconomic status, academic classification, grade point average, and mandatory computer classes on students’ attitudes toward computer usage.

classes on students’ attitudes toward computer usage. Business and Health Administration Association Annual
classes on students’ attitudes toward computer usage. Business and Health Administration Association Annual

The data were collected at KSU during the summer of 2009. All data collection activities were done under the guidance of the researcher and the administrators of KSU. A total of 355 questionnaires were completed (males = 133 and females = 222). Twenty questionnaires were excluded because of missing values (males = 13; females = 7). The actual number of completed and accepted questionnaires was 335 (males = 120 and females = 215). This number reflects more than half of the total student body (n = 600) during the 2009 summer academic semester at the university.

An independent t-test was used to examine the research question. The results of the t-test demonstrated that females were significantly more anxious about computer usage in their academic programs than were their male counterparts (meanf = 31.53 vs. meanm = 32.97). This research helps to support the latter view. However, given the ubiquitous use of computers in health systems and the recent requirement in Saudi Arabia that health records be in electronic format, nurses, regardless of gender, will need to become proficient in computer use. Table 1 depicts the differences in scores between the males and females.

Table 2: Mean Anxiety Difference for Gender; Male and Female

         

Standard Error

Gender

N

Mean

σ

Mean

Anxiety Scores

Male

120

32.967

4.436

0.405

Female

215

31.526

4.854

0.331

Source: O. A. Samarkandi, Students attitudes toward computers at the College of Nursing at King Saud University (KSU), Table 12, p. 64. Ph.D. Dissertation, Case Western Reserve University, 2011.

SUMMARY AND IMPLICATIONS

The findings suggest that female students were somewhat more anxious about computer usage than were male students. Gender has been associated with computer anxiety (King et al., 2002), though results have been mixed. Whereas some researchers have reported that male students have lower levels of anxiety (Colley et al., 1994; Okebukola, 1993) than do female students, others posit that females have lower levels of computer anxiety than do males (Loyd et al., 1987; Siann et al., 1990). Still other studies have not reported any gender differences (Colley et al., 1994; Kay, 1992; King et al., 2002). What is clear is that the pervasive presence of technology, for both male and female students and later as clinical practitioners, is quickly becoming a way of life and the use of the computer as a communication device dominates the psyche of both males and females (King et al., 2002). Yet there is another perspective. According to Hass et al. (2002), women have traditionally been considered to be less “computer savvy” than men primarily because of the linkage between mathematics and computers. This was an early assumption that existed but appears to be changing. This research helps to support the latter view. However, given the ubiquitous use of computers in health systems and the recent requirement in Saudi Arabia that health records be in electronic format, nurses, regardless of gender, will need to become proficient in computer use.

The results can also be interpreted through the lens of academic expectations within the context of societal norms and the changing roles of women in academic settings (Henrion, 1997; Otomo, 1998). Perhaps if academic learning is delivered using computers at KSU, female students will become less anxious as their computer knowledge and skills increase. Finally, as demands in health-service-delivery systems for computer-literate nurses increase, nurses will, out of necessity, become more proficient with computers in general as well as in their application for the acquisition of knowledge and skills.

According to the findings of this study, males and females can learn through the use of computers even though females in the College of Nursing at KSU are more anxious than their male counterparts. Giving students access to computers in school would also help with their learning and provide an opportunity to increase their usage time and decrease their anxiety.

Recommendations for Nursing Education

1. Strengthen and continue to build computer knowledge and skills among the students at KSU School of Nursing,

and skills among the students at KSU School of Nursing, Business and Health Administration Association Annual
and skills among the students at KSU School of Nursing, Business and Health Administration Association Annual

2.

Provide opportunities for additional computer-based learning in various segments of the curriculum,

3. Increase public awareness of and support for the use of computer-based learning for advancing nursing knowledge.

Nurses who are expected to use computers during their undergraduate learning experiences would be better prepared to utilize computers in their practice and for their continuing learning needs. Given the growing frequency of the use of computers in educational settings and in practice systems, nurses will be expected to utilize computers for their personal learning and for quality patient care and safety (Kilbridge & Classen, 2008).

REFERENCES

Abanmie, A. (2002). Attitudes of high school students in Saudi Arabia toward computers (Unpublished doctoral dissertation, Mississippi State University).

Ajzen, I., & Fishbein, M. (1975). Belief, attitude, intention, behavior: An introduction to theory and research. Addison Wesley Publishing Company, Inc: Philippines.

Al-Farsi, F. (2001). Modernity and tradition: The Saudi equation. Knight Communication Ltd.: UK.

Alsebail, A. (2004). The College of Education students’ attitudes toward computers at King Saud University (Unpublished doctoral dissertation, Ohio University).

Burger, A., & Blignaut, P. (2004). A computer literacy course may initially be detrimental to students’ attitudes towards computers. Proceedings of SAICSIT, 10-14.

Chin, K. (2001). Attitudes of Taiwanese nontraditional commercial institute students toward computers (Unpublished doctoral dissertation, University of South Dakota, Vermillion).120

Colley, A. M., Gale, M., & Harris, T. A. (1994). Effects of gender role identity and experience on computer attitudes components. Journal of Educational ComputingResearch. 10(2), 129-137.

Forcier, R. C. (1996). The computer as productivity tool in education. Englewood Cliffs, NJ: Prentice-Hall.

Francis, L., Katz, Y., & Jones, H. (2000). The reliability and validity of the Hebrew version of the Computer Attitude Scale. Computers & Education, 35, 149-159.

Freedman, K., & Liu, M. (1996). The importance of computer experience, learning processes, and communication patterns in multicultural networking. Educational Technology Research and Development, 44(1), 43-59.

Hass, A., Tulley, C., & Blair, K. (2002). Mentors versus masters: Women’s and girls’ narratives of (re)negotiation in web-based writing spaces. Computers and Composition, 19, 231-249.

Henrion, C. (1997). Women in mathematics: The addition of difference. Indiana University Press.

Kay, R. H. (1992a). Gender differences in computer attitudes, literacy, locus of control and commitment. Journal of Research on Computing in Education, 21(3), 307-316.

Kilbridge, P., & Classen, D. (2008). The informatics opportunities at the intersection of patient safety and clinical informatics. Journal of the American Medical Informatics Association, 15(4), 397-407.

King, J., Bond, T., & S. Blanford. (2002). An investigation of computer anxiety by gender and grade. Computers in Human Behavior, 18, 69-84.

King Saud University (KSU). http://www.ksu.edu.sa.

, 69-84. King Saud University (KSU). http://www.ksu.edu.sa. Business and Health Administration Association Annual
, 69-84. King Saud University (KSU). http://www.ksu.edu.sa. Business and Health Administration Association Annual

Loyd, B. H., & Loyd, D. F. (1985). Reliability and factorial validity of Computer Attitude Scale. Educational Psychological Measurement, 44(2), 501-505.

Loyd, B. H., & Gressard, C. P. (1987). Gender and computer experience of teachers as a factors in computer attitudes of middle school students. Journal of Early Adolescence, 7(1), 13-19.

McLaughlin, S., Fitch, M., Goyal, D., Hayden, E., Kauh, C., Laack, T., Nowicki, T., Okuda, Y., Palm, K., Pozner, C., Vozenilek, J., Wang, W., Gordon, J., (2008). Simulation in graduate medical education. Academic Emergency Medicine, 15(11), 11171129.

Merriam-Webster's medical desk dictionary. (2007). Merriam-Webster's medical desk dictionary (Revised ed.). Merriam-Webster, Incorporated. New York: NY.

Moshaikeh, M. (1992). Implementing educational technology in Saudi Arabia. International Journal of Instructional Media, 19(1), 65-70.

Mufti, M. (2002). A case from a community and hospital-based long-term care facilities in Saudi Arabia. Annals of Saudi Medicine, 22(5-6), 336-338.

Oblinger, D. G., & Rush, S. C. (Eds.). (1997). The learning revolution: The challenge of information technology in academy. Boston, MA: Anker.

Okebukola, P. A. (1993). The gender factor in computer anxiety and interest among some Australian high school students. Educational Research, 35(2), 181-189.

Otomo, Y. (1998). The relationship of computer anxiety, mathematics anxiety, test anxiety, gender and demographic characteristics among community college students. Dissertation Abstracts International, 59(6A), 957A.

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Osama A. Samarkandi BSc, BSN, RN, MSN, Ph.D Department of Nursing Faculty of Applied Medical Science Director, International Collaboration Office Al-Baha University Al-Baha, Saudi Arabia osamarkandi@hotmail.com

University Al-Baha, Saudi Arabia osamarkandi@hotmail.com Business and Health Administration Association Annual
University Al-Baha, Saudi Arabia osamarkandi@hotmail.com Business and Health Administration Association Annual

TRACK

HUMAN RESOURCE MANAGEMENT IN HEALTHCARE

TRACK HUMAN RESOURCE MANAGEMENT IN HEALTHCARE Business and Health Administration Association Annual Conference 2012 54
TRACK HUMAN RESOURCE MANAGEMENT IN HEALTHCARE Business and Health Administration Association Annual Conference 2012 54

COMPENSATION AS A CONSTRUCT FOR EMPLOYEE MOTIVATION IN HEALTHCARE

Allen C. Minor, Misericordia University

ABSTRACT

There is no difference between performance of those employees receiving a salary as compensation for services and those employees receiving compensation based on output by the specific employee, (Null), or alternatively, incentive compensation results in increased employee productivity.

This issue has been debated historically and the debate continues.

This paper reviews the issue from a

historical perspective and includes contemporary research and concludes with implications for further research.

The Chinese

bureaucracy 1000 B.C. developed a theory of management based on rewards and Punishments as a way to manage productivity. Confucius, in the period 552 B.C. through 479 B.C. advocated that employee productivity could be

managed by improving morale (Wren, p. 14). In 35 A.D., the Egyptians used wage incentives to motivate workers (Lee, p. 42).

Employee motivation has been debated since the inception of management as a discipline.

In a study completed by Mercer, incentive compensation plans increased morale and increased productivity for those plans including all employees but not for firms offering incentive pay programs to only high-ranking managers (Wall Street Journal). Whitney argues that because of prejudices on the part of executives, wage and salary programs are poorly designed and, in most companies, are not true pay-for-performance programs. Evans argues that governmental regulations in unions demanding rewards based on seniority have eroded the pay-for- performance compensation programs (Evans, p. 726). Short-term incentive plans, however, are gaining popularity in the health care industry (Hospitals). Cash incentives have increased 5% to 10% in 2008 (Evans). Bonus payments are an (integral part of compensation) in healthcare. (Healthcare Facility Management) as bonuses will increase quality of healthcare and reduce costs (Armstrong). There are no consistent policies or body of theory regarding incentive compensation programs followed and practiced by organizations. It is clear, however, that incentive compensation programs are effective in increasing productivity if properly designed for the situation or goal to be accomplished. (Haman).

One such method of incentive compensation is payment based on the profitability of the organization. Charles Babbage “On the Economy of Machinery and Manufacturer” indicated “the mode of payment could be so arranged that every person employed should drive advantage from the success of the whole; that the profits of each individual should advance as the factory itself produces profit, without the necessity of making any change in wages” (Wren, p. 61). This was seen as a way to develop a synergy between the employee goals and the company goals from an economic point of view. Whitney maintains that good performance deserves a higher pay, and therefore poor performance should result in lower pay. If an organization’s profits were reduced, compensation should also be reduced. Because this is taboo in America’s culture, such plans will not work (Whitney p. 36). He argues that a bonus system would be a more effective way of rewarding high performers with a reduction in this program should the performance not be achieved. Whitney also argues that management rewards are based on power, compensation and prestige opposed to technical excellence and therefore such plans may not provide the appropriate incentives for executives to achieve the goals of the organization. If compensation is ‘based upon individual performance, cooperation among team members may be inhibited, whereas if compensation is based on team objectives, individuals may not work as diligently and may lean on other team members. Bonus systems are a way to achieve both team and individual performance based on appropriate measures and evaluations. However, if profitability drops and bonuses are not given, this may result in turnover or a feeling of mistrust on the part of the employee. This works successfully in the Japanese system, however, they have a concept of lifetime employment (Whitney, Part II, p. 47). Because there is not a direct relationship between individual employee

is not a direct relationship between individual employee Business and Health Administration Association Annual
is not a direct relationship between individual employee Business and Health Administration Association Annual

performance and compensation, the typical employee is unable to see a relationship between merit increases and his/her level of performance and therefore may not provide the incentive to increase productivity (Evans).

Another system of rewarding employees for performance is the merit system. This is a system whereby employees are evaluated based on their merit each year and given an increase based thereon. However, the typical employee is unable to see a relationship between the merit increase and his/her level of performance in most cases. Based on a study of certain Fortune 500 companies that contributed approximately 40% of the Gross National Product in the United States in 1968, “job performance is not the primary determinate of wage and salary progression for non-supervisor employees”. This is true even though “93# of the firms claims that they subscribe to the merit reward philosophy by advancing wage and salaries on the basis of job performance” (Evans, p. 730). Therefore, it appears that those companies, although of the opinion that incentive wage and salary programs influence employees to produce more, do not implement such programs in such a way as to increase productivity. Studies have indicated that “there is no significant link between paid performance and common merit pay programs” (Markham, p. 172).

One system of rewarding employees is to reward departments based on departmental productivity opposed to rewarding employees based on the organization’s profits. Henry R. Towne thought that profit sharing was inappropriate because it did not reward individuals for their efforts. He proposed a method of payment that would reward work units or departments for their efforts and to split productivity gains by departments; 50% to the employer and 50% to the workers (Wren, p. 91). Incentive compensation advocated by Towne was based on the thinking of See who promoted paying “higher wages to attract better workers” (Wren, p. 87). Edward Atkinson, anAmerican economist, suggested that “the cheapest labor is the best – paid labor” (Wren, p. 90) because more productivity will result and therefore unit cost will be lower leading to the concept that higher wages led to more productivity and therefore lower unit cost.

The individual performance incentives of compensation plans are the most attractive. Frederick Taylor suggested that the piece-rage system had failed because standards were poorly set and employers would game the system by cutting rates when productivity increased. This caused inefficiency and gaming of the system by the employees. Taylor developed his differential piece-rate incentive plan system at Midvale Steel (Wren, p. 106) based on time studies and set a rate where the standard for each element was determined b the time study. “This rate moved job performance from guess work and tradition to a more rational basis. The principle of the differential rate worked two ways: it forced those who did not meet the standard or receive a low rate of pay and greatly rewarded those who did attain the standard” (Wren, . 109). Taylor strongly opposed paying individuals based on averages of the group and therefore opposed union attempts to set quotas. He advocated that higher paid workers would be more productive and therefore lower unit cost and suggested that workers be paid “from 30% to 100% according to the nature of the work which he does, beyond the average of his class” (Wren, p. 110).

Gantt, a disciple of Taylor, also advocated incentive compensation as a way to increase employee performance. “Gantt devised his ‘task work with a bonus’ system that paid the worker a bonus of $.50 per day if he did all the work assigned for a particular day” (Wren, p. 134). He modified this plan to increase productivity by increasing wages for employees for completing a job below the standard as an incentive to increase productivity. In addition, foremen would receive a bonus if the workers performed better the standard providing an incentive for the foremen to teach the workers to be more productive. Harrington Emerson installed an individual reward system in the Burlington Railroad Company. In two years, output increased by 57%, average pay increased by 14% and the cost decreased by 36% (Wren, p. 148).

Physicians are highly motivated by compensation plans (Helman, Hemenway). Physicians’ concerns should be primarily for the patient’s well being, however, “physicians do appear to respond to economic stimuli occasioned by their contractual obligations to third party insurers” (Helman, p. 86). Health Maintenance Organizations (HMO) have been designed as a way to reduce health care costs by paying Physicians and other health care providers based on the number of enrollees in a plan as opposed to the number or quantity of services provided to patients. Therefore, physicians, in such a plan, are paid for not rendering services. One study showed that physicians on a salary based payment showed a reduction in hospital days of 13.1% and those on a capitation basis, i.e. paid for the subscribers in the program, also showed a reduction in hospital days (Helman, p.88). The study also showed there was a higher use of primary outpatient visits that are less expensive than inpatient care for HMO physicians. Bonuses were not found to be significant in terms of productivity. “Distribution of bonuses of

in terms of productivity. “Distribution of bonuses of Business and Health Administration Association Annual
in terms of productivity. “Distribution of bonuses of Business and Health Administration Association Annual

may lack effect because such incentives delay any reward. Physicians, like anyone else, respond to economic stimuli that are immediate rather than delayed” (Helman, p. 91). The Affordable Care Act has created Accountable Care Organizations. Organizations can apply for this program providing financial incentives to reduce health care cost through wellness programs for Medicare /Healthcare government. Also the JCAHO has provided financial incentives to reduce cost through core measures sets.

In a study of physician financial incentives in a for-profit care center, it was determined that “substantial monetary incentives based on individual performance may reduce a group of physicians to increase the intensity of their practice, even though not all of them benefit from the incentives” (Hemenway, p. 1059). Therefore, it is clear that individual incentive compensation plans, if properly designed, do result in increased productivity.

There are other factors that influence employee productivity in addition to compensation. (Whitney) Williams hypothesized that motivation for employees was based on their feelings rather than their thoughts (Wren, p. 167). He said that a person’s social standing is determined by his job. He indicated that “beyond a certain point, the increased wages are quite likely to lessen as to increased effort” (Wren, p. 168). Thus, salary is a negative motivator. Over-payment will not necessarily increase productivity but under-payment will cause decreased productivity, soldiering and turnover. Continuing this socialistic viewpoint, Henry DeMan viewed that work itself was a motivator and it was management’s job to remove the hindrances such inequitable wage systems that prevent workers from finding joy in work (Wren, p. 172).

Winn looked at incentive to increase sales opposed to incentives to increase net income. He hypothesized that because of “personal self interest” factors, managers tend to increase sales opposed to increase compensation based on incentives. In other words, executive salaries appear to be more closely “correlated with the scale of operations of a firm than and with their profitability (Winn).

Taylor and Gantt concepts of compensation based on individual performance including accurate and fair standards is worth further research and study.

Implications for further research

Current research on compensation plans is sketchy and in many cases flawed. There are many factors that affect employees motivation including political, social and economic. An attempt to isolate economic factors is difficult and the research therefore is not conclusive as to whether incentive compensation programs positively or negatively affect employee productivity. Managers have developed principals of wage and salary administration based on inadequate research and individual bias indicating that the academic community has not provided appropriate guidance for the practitioner in this area. This area is right for research and should include not only the economic factors but the social factors as barriers to implementing the programs to positively motivate employees. It is clear that unless American companies and American industry respond appropriately to a threat of international competition, it will not remain as a predominate economic power.

REFERENCES

Armstrong et.al. (2009). Realigning U.S. Health Care Incentives To Better Serve Patients and Taxpayers. Health CEO’s for Health Reform.

Evans (1970). Pay for Performance: Fact or Fable. Personnel Journal, 49 (9).

Evans (2008). We just don’t see a Slowdown. Modern Healthcare, 38(30).

Freundt (1990). Merit Increases for Top Executives to Average 5.2% in 1990. Hospitals.

Hanman, K., Newman (2008). The Effect of Disseminating Relative Performance Feedback in Tournament and Individual Performance Compensation Plans. The Accounting Review, 83(4).

Healthcare Facility Management (2009). 22 (7). Bonus Pay No Longer an Afterthought.

(2009). 22 (7). Bonus Pay No Longer an Afterthought. Business and Health Administration Association Annual
(2009). 22 (7). Bonus Pay No Longer an Afterthought. Business and Health Administration Association Annual

Accountable Care Organizations: Improving Care Coordination for People with Medicare. Retrieved from http://www.healthcare.gov (March 31, 2011).

Hemenway, K., & Cashman, P. B. (1990). Physicians Response to Financial Incentives. New England Journal of Medicine.

Hillman, P., & Kerstein (1989). How do Financial Incentives Affect Physicians Clinical Decisions and Financial Performance of Health Maintenance Organizations. New England Journal of Medicine.

Hospitals (1990). Merit Increase of Top Executives to Average 5.2% in 1990.

JCAHO (2010). Core Measure Sets.

Markham (1988), Pay for Performance Dilemma Revisited: Empirical Example of the Importance of Group Effects. Journal of Applied Psychology, 73(2).

Whitney (1988), Pay Concepts for the 1990’s Part I, Compensation and Benefits Review, 20 (2).

Whitney (1988). Pay Concepts for the 1990’s Part II. Compensation and Benefits Review, 20 (3).

Winn, S. (1988). Compensation-Based (DIS) Incentives for Revenue-Maximizing Behavior: A test of the Revised Baumol Hypothesis. The Review of Economics and Statistics, 70 (1).

Wisdom, D. (1989), Compensation Management In Practice Compensation and Benefits, 21(4).

Wren, D. (1987). Evolution of Management Thought. John Wiley and Sons: New York, NY.

Wall Street Journal (1992). Retrieved from http:// www.wallstreetjournal.com.

Allen C. Minor Assistant Professor Misericordia University 301 Lake Street Dallas, PA 18612 aminor@misericordia.edu

301 Lake Street Dallas, PA 18612 aminor@misericordia.edu Business and Health Administration Association Annual
301 Lake Street Dallas, PA 18612 aminor@misericordia.edu Business and Health Administration Association Annual

PHYSICIAN SHORTAGES - HOW THE GAPS WILL BE FILLED

Robert J. Spinelli, University of Scranton Kathryn Semcheski, University of Scranton

ABSTRACT

The United States population is aging just as quickly as the physicians. A challenge in the medical field today is keeping up with the physician shortages and trying to decipher how to fill the gaps. With the worsening conditions of the economy and job sectors, not many aspiring medical students can afford the cost of medical school. As many physicians are looking to retire, one must as the question of who will fill the voids? A career as a primary care physician is not as enticing to the younger population as is the career path of orthopedic surgeons. This presentation will discuss why we are encountering a physician shortage, what factors play a role in the decisions made by medical students to specialize and how medical professional are going to fix the physician shortage issue.

Robert J. Spinelli, DBA Assistant Professor Department of Health Administration and Human Resources The University of Scranton 423 McGurrin Hall, Scranton, PA 18510

spinellir2@scranton.edu

Kathryn Semcheski, MHA Student The University of Scranton Scranton, PA 18510

MHA Student The University of Scranton Scranton, PA 18510 Business and Health Administration Association Annual
MHA Student The University of Scranton Scranton, PA 18510 Business and Health Administration Association Annual

STRATEGIC HUMAN RESOURCES SOLUTIONS FOR HEALTHCARE SYSTEMS IN KENYA, RWANDA, AND UGANDA

Neel H. Pathak, University of Scranton Daniel J. West, Jr., University of Scranton

ABSTRACT

Health systems in Kenya, Rwanda, and Uganda are compared and contrasted on various economic, political and health delivery parameters. Comparisons reveal common factors contributing to an ineffective healthcare system. This article explores the human resources problems along with the health status and services for specific countries. Situational analysis on health status and service delivery is presented via a thorough examination of country specific National Health Sector Strategic Plans (NHSSP). Strategic solutions based on improving the Human Resources for Health (HRH) for all the three countries are explained. Also, World Health Organization’s (WHO) Millennium Development Goals (MDG) are examined.

INTRODUCTION

A well-functioning health system encompasses the core components of a healthcare triad; access, affordability and quality. The healthcare delivery system varies from country to country. The system’s balanced response to population needs and demands require maintaining a reliable healthcare network across the country. Detailed importance on country context, history, geography, health status and services is analyzed via comparing and contrasting of different systems of care. Facts about the country population, characteristics, economy, government, health status, health finances and human resources are tabulated.

The revelations in this paper highlight some similar problems for the aforementioned countries at a systems level. One significant factor that is present in all three countries is a shortage of the healthcare workforce. Thus, a collective strategic solution based on human resources would help to address the challenges and pave the way for an improved healthcare system.

The United Nations (UN) MDG’s are eight goals which all UN member states have agreed to achieve by the year 2015.It commits the world leaders to combat poverty, hunger, diseases, illiteracy, environmental degradation and discrimination against women. This research paper examines the MDG’s and suggests solutions on a HRH perspective twined with NHSSP plans which may help the country progress towards their specific MDG’s.

1. Eradicate extreme poverty and hunger

2. Promote gender equality and empower woman

3. Reduce child mortality

4. Improve maternal health

5. Combat HIV/AIDS, malaria and other diseases

6. Ensure environmental sustainability

7. Develop global partnership for development

COUNTRY OVERVIEW

Kenya is located in the eastern part of Africa. It borders the Indian Ocean between Somalia and Tanzania. Kenya’s total area comprises of 580,367 square kilometers. The size of Kenya is more than twice the size of Nevada. Nairobi is the Capital of Kenya. Around 85% of the total Kenyan population is literate. Table 1 gives a

of the total Kenyan population is literate. Table 1 gives a Business and Health Administration Association
of the total Kenyan population is literate. Table 1 gives a Business and Health Administration Association

brief outline on country’s geographic location, population, age characteristics, language, and religion. Also, the political map of Africa is portrayed in the Appendix.

Table 1: Country Population and Characteristics

Country

Geography

Population

Age Structure

Language

Religions

Kenya

East Africa

41,070,934

0-14 years- 42.2%

English

Protestants-45%

% Urban-22

15-64 years- 55.1%

Kiswahili

Roman Catholic- 33%

% Rural-78

65

years and over- 2.7%

Others-22%

Rwanda

Central

11,370,425

0-14 years- 42.9%

Kinyarwanda

Roman Catholic- 56.5% Protestant- 26% Others- 17.5%

Africa

% Urban-19

15-64 years- 54.7%

French

% Rural-81

65

years and over- 2.4%

English

 

Kiswahili

 

(Swahili)

Uganda

East Africa

34,612,250

0-14 years- 49.9%

English

Roman Catholic-41.9% Protestant- 42% Others- 16.1%

% Urban-13

15-64 years- 48.1%

Ganda

% Rural-87

65

years and over- 2%

(Luganda)

Source: Central Intelligence Agency, 2011

Rwanda is located in the central part of Africa. It lies to the east of the Democratic Republic of Congo. Rwanda’s total area comprises of 26,338 square kilometers. The size of Rwanda is slightly smaller than Maryland. Kigali is the capital of Rwanda. Around 50% of the Rwandan population is literate. Table 2 describes the country specific economic situation based on factors of Gross Domestic Product (GDP), population below poverty line and industrial production growth rate.

Table 2: Country Economy

   

Population Below

Industrial Production Growth Rate

Country

GDP Per Capita

Poverty Line

Kenya

$1,600 (2010 est.)

50% (2000 est.)

4% (2010 est.)

Rwanda

$1,100 (2010 est.)

60% (2001 est.)

7.5% (2010 est.)

Uganda

$1,200 (2010 est.)

35% (2001 est.)

6% (2010 est.)

Source: Central Intelligence Agency, 2011

Uganda is a part of East Africa. It lies to the west of Kenya. Uganda’s total area comprises of 241,038 square kilometers. The size of Uganda is slightly smaller than Oregon. Kampala is the capital of Uganda. Around 67% of the total Ugandan population is literate. Table 3 portrays the government types, components and forms implemented in Kenya, Rwanda, and Uganda.

and forms implemented in Kenya, Rwanda, and Uganda. Business and Health Administration Association Annual
and forms implemented in Kenya, Rwanda, and Uganda. Business and Health Administration Association Annual

Table 3: Country Government

Country

Type

Components

Forms

Kenya

Republic

7

Provinces

Executive Branch: Chief of State: President Mwai KIBAKI Legislative Branch: Unicameral National Assembly/Parliament Judicial Branch: Court of Appeal, High Court

Rwanda

Republic

4

Provinces

Executive Branch: Chief of State: President Paul KAGAME Legislative Branch: Bicameral Parliament consists of Senate and Chamber of Deputies Judicial Branch: Supreme Court, High Courts of the Republic, Provincial Courts

Uganda

Republic

80 Districts

Executive Branch: Chief of State: President Yoweri MUSEVENI Legislative Branch: unicameral National Assembly Judicial Branch: Court of Appeal, High Court

Source: Central Intelligence Agency, 2011

COMPARATIVE HEALTH SYSTEMS

Kenya

The healthcare system of Kenya is comprised of the public sector, the private sector, Non-Governmental Organizations (NGO’s) and Faith Based Organizations (FBO’s). The public sector includes the Ministry of Health (MOH) and quasi-governmental organizations. The public sector is comprised of national referral hospitals, provincial general hospital, district hospitals, health centers, and dispensaries.

According to the Ministry of Health statistics (May 2011) on number of healthcare facilities, Kenya has a total of 471 hospitals, 847 health centers, 3910 dispensaries, 182 nursing and maternity homes, 1987 medical clinics and 180 standalone private clinics and NGO’s. Different levels of care are distributed in these ranges of facilities. National referral hospitals provide the highest quality of care services. Moi Teaching and Referral Hospital and Kenyatta National Hospital serve as the national hospitals in Kenya.

The public sector provides more than 50% of all the healthcare services. Overall, healthcare delivery in Kenya is provided by a network of more than 7,500 facilities. The total number of hospital beds in Kenya including the public and the private sector is around 48,000. The private sector owns about 40% percent of the total hospital beds in Kenya.

The Government of Kenya (GOK) funds the MOH and its affiliated organizations. The National Health Insurance Fund (NHIF) is a quasi-governmental organization under the MOH. NHIF’s core function is to provide medical insurance to all its members. The NHIF membership is open to all Kenyans who are above 18 years of age and have a monthly income of more than Ksh 1,000. NHIF has contracted hospitals under three categories (A, B, and C) each having a different system of reimbursement. Private insurance companies include AAR and Jubilee insurance. They usually cover outpatient charges, not included in the NHIF.

Health personnel are directly affected by the nature of health systems. Kenyan Health Sector follows a tiered structure. Exercising such a tiered structure leads to unequal distribution of human resources for health (HRH). Top medical facilities may have more staffing than the district hospitals which might be the first contact for the patient. Along with the tiered system; brain drain, economic stagnation, poor remuneration and migration are also contributing factors to the workforce shortage. The establishment of private practices has exacerbated the workforce shortage in government organizations.

All these factors have created an unstable healthcare market. The effect of brain drain causes workers to leave and settle in a well-established setting. Poor remuneration also is a major reason why healthcare workforce succumbs to brain drain. Migration of these workers from the place where they are needed the most to other

from the place where they are needed the most to other Business and Health Administration Association
from the place where they are needed the most to other Business and Health Administration Association

developed areas creates instability both in the healthcare sector and the economic sector. A case in point for migration is noted by the fact that the number of physicians from Kenya working abroad was 2,733 in 2002.

The Government of Kenya recognized the aforementioned problems and declared the shortage of HRH to be a major challenge and took measures to address the problems. HRH mapping was undertaken in all healthcare delivery sites and understaffed areas were designated. There are only 4,506 physicians and 37,113 nurses in Kenya. (WHO statistics, 2006)The attrition rate for total number of health workers (all cadres involved) was not different based on the healthcare facility type. The highest attrition rate was for pharmacists, followed by doctors, nurses and lab staff. Table 4 gives an overview of the health status in the three countries based on Infant Mortality Rate, Life Expectancy at Birth, Prevalence of HIV/AIDS, and Prevalence of Tuberculosis (TB).

Table 4: Health Status

 

Infant Mortality Rate (per 1,000 live births)

Life Expectancy

HIV/AIDS Prevalence (adults,

15-49)

TB Prevalence (per 100,000 population)

Country

at Birth

Kenya

52.29

deaths

59.48

years

6.7%

888

Rwanda

64.04

deaths

58.02

years

5.1%

660

Uganda

62.47

deaths

53.24

years

4.1%

646

Source: Central Intelligence Agency, 2011 and WHO Country Health System Factsheet, 2006

Rwanda

Health services in Rwanda are channeled through a variety of settings. They include public sector, government assisted health facilities (GAHF), private sector, and traditional healers. The public sector is furthermore categorized into three levels namely the central level, the intermediate level and the district level. Each level has a predefined technical and administrative objective. Such objectives are known as the minimum package of activities. Butare Teaching Hospital and the Teaching hospital in Kigali are national referral hospitals.

GAHF constitute about 40% of the primary and secondary health facilities. They are usually run by religious groups and not for profit organizations. These facilities are integrated into the public health system. There are about 538 health care facilities providing basic services and qualified staff for the people of Rwanda. Of the 389 health centers, around 380 are partly or fully governmental. The provider type from the total number of facilities includes around 36% public hospitals, 30% private clinics and hospitals and other 34% include health centers, and dispensaries. There are a total of 568 physicians, 69751 nurses and midwives, and 2371 management and support staff in Rwanda according to the HRH factsheet by African Health Workforce Laboratory (AHWO), 2010.

Mutual health insurance groups in Rwanda are developed to increase access and decrease the financial burden of the population.

They are autonomous organizations managed by their members. The health insurance groups function on national, district, and sector level. The Government of Rwanda has promoted mechanisms such as La Rwandese d’ Assurance Maladies (RAMA), and Military Medical Insurance (MMI) which offer subsidized insurance rates to help the people of Rwanda.

A recent article in New York Times; A Poor Nation, with a Health Plan, revealed that 92% of the Rwandan population is insured with a fee of $2 per year. The coverage includes basic health care services. The services include maternity care, treatment of most common causes of death such as diarrhea, malaria, and infections. Also, most health centers have medicines that are on the WHO list of essential medicines. Some health centers also include diagnostic facilities of blood and urine analysis. This low cost insurance is possible because of the funding they receive from foreign countries under the humanitarian aid programs.

The MOH receives its funding from the Ministry of Finance and Economic Planning. An imbalance between the provision of services and financial resources always existed. The genocide affected Rwanda from a

always existed. The genocide affected Rwanda from a Business and Health Administration Association Annual
always existed. The genocide affected Rwanda from a Business and Health Administration Association Annual

social, economic and a human resources standpoint. The health care delivery system is still suffering its effects. There is a nationwide shortage of the healthcare workforce to respond the needs of health facilities clinically and managerially. There are a total of 401 physicians and 3593 nurses working across Rwanda. WHO statistics, 2006) Table 5 depicts the financing mechanisms used in the three countries based on %GDP spending, GDP per capita, government spending and private spending.

Table 5: Health Financing

 

% GDP

GDP-Per

Government

 

Country

Spending

Capita(USD)

Spending (%)

Private Spending (%)

Kenya

4.3

$1600

38.7

61.3

Rwanda

3.7

$1100

43.5

56.5

Uganda

7.3

$1300

30.4

69.6

Source: Central Intelligence Agency, 2011 and WHO Country Health System Factsheet, 2006

Uganda

Healthcare in Uganda is provided by a mix of the public sector, private sector including private health practitioners, traditional medicine practitioners, and community health workers. Ugandan health system is divided in village health teams/ community medicine distributors, Health Center II, Health Center III, Health Center IV and Hospitals. Different kinds of hospitals are general hospitals, regional referral hospitals and national referral hospitals. Butabika Hospital and the Mulago Hospital serve as the national hospitals in Uganda.

The government has faced a lot of challenges incorporating the National Health Insurance (NHI) program. It is still working towards its full implementation. Similar to Rwandan healthcare system, a minimum package of services is designed for health centers. This package is known as the Uganda Minimum Healthcare Package (UNMHCP). Some of the private insurance companies include Microcare and East African underwriters. The Uganda Catholic Medical Bureau, Uganda Moslem Medical Bureau and Uganda Protestant Medical Bureau coordinate and act as umbrella organizations for the private facilities in Uganda.

Healthcare in Uganda is delivered via a network of around 2545 facilities. The facilities consist of 2 national hospitals, 10 regional referral hospitals, 101 general hospitals and 2432 HC II, III and IV centers. HRH in Uganda consist of 3361 doctors, 664 nurses and midwives, and around 100 management and support staff.

Ugandan healthcare system faces a shortage of the healthcare workforce. There are only 2,209 physicians and 16,221 nurses working across Uganda. It is prone to the areas that have poor infrastructure and amenities. Inadequate funding for training human resources for health is of paramount concern. Training outputs do not match the service requirements. Poor remuneration and work environment also have an impact on the low retention.

A survey based on 3 hospitals in Uganda in 2006 including 139 participants concluded that 70% of the nurses would like to work outside Uganda. Those 70% of the nurses had structured plans to work either in the US (59%) or the UK (49%). One fourth of the respondents stated they would like to work in other countries of Africa. This is a major problem which in turn creates the other aforementioned problems for healthcare workforce in Uganda. Table 6 illustrates the human resources situation in the three countries based on the factors of physician density, nurses and midwives density, and health management and support staff.

midwives density, and health management and support staff. Business and Health Administration Association Annual
midwives density, and health management and support staff. Business and Health Administration Association Annual

Table 6: Human Resources

   

Nurses and

 

Country