Running head: LUBBOCK COUNTY COMMUNITY ASSESSMENT
Lubbock County Community Assessment
Stacey Cropley, Inola Mello, Marguerite Fallon, Jeanette Moody, Mireya VanDerSlice
Texas Tech University Health Science Center School of Nursing
Population Health and Epidemiology
NURS 6345
Submitted to: Susan McBride RN PhD
February 25, 2010
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LUBBOCK COUNTY COMMUNITY ASSESSMENT
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Lubbock County Community Assessment
Introduction
The purpose of this document is to assess the health care needs of the population
Lubbock County in Texas. Health factors have been compared to state aggregate data,
subsequently analyzed, and patterns of critical importance identified. The assessment includes
existing resources, target areas for improvement, and a specific intervention is proposed for an
identified high prevalence of sexually transmitted disease within the community.
Landscape Assessment and Culture
Lubbock County, is a semi-arid and windy region with great air quality; the land is
dimpled with valuable and unique ecological systems called playa basins and the county was
founded in 1876 and named for Thomas Lubbock, a former Texas Ranger and confederate
officer in the Civil War (Best Places, n.d.; Gallagher, 2006; Glass, 2006; Haukos, & Smith,
1992; Nielson, & Adian, 2009). The city of Lubbock, originally populated by two competing
settlements joining together, was established in 1891 (Glass, 2006). Lubbock is known as the
‘Hub City of West Texas’ based on geographical positioning and distance from other large urban
areas; the city serves as the regions health care, education, and economic distributor (A History,
n.d.; Lubbock, n.d.). The elevation of Lubbock is 3,245 feet above sea level, the county consists
of 900 square miles, while Lubbock city limits include a total of 115 square miles (Lubbock at a
Glance, n.d.).
Originally segregated with separate hospitals for African Americans and Caucasians
(Lubbock-Avalanche, 2009; Texas Tech, n.d.), Lubbock now has multiple integrated health care
facilities. A windshield survey identified two large medical systems and a medical school, with
multiple smaller health care systems, including a specialized ‘Heart Hospital’. Two federally
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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qualified health clinics are located on the medically underserved east side of town. Schools are
scattered throughout Lubbock and surrounding towns and there are multiple private educational
institutions in various areas of the city. There are multiple schools of higher learning, including
the religious based institutions of Wayland Baptist and Lubbock Christian University. Texas
Tech University is a large campus and according to the Lubbock, Texas (n.d.) website, has the
6th largest student body in Texas.
The city appears industrialized on the north east, with a cotton mill, Purina feed mill,
warehouses, and a cattle feed lot. This area of town has lower income housing, many well kept,
some with bars on windows and doors. The south west area of the city has numerous available
shopping opportunities, many restaurants, and more expensive housing. There are many
extravagant and somewhat pretentious homes noted in south Lubbock. It is apparent grocery
stores, shopping, and restaurants are disproportionately located to the south-south west of the
city. Churches of many various denominations are seen in all areas of Lubbock, often several
within a short distance of each other.
Lubbock continues to be supported economically primarily through agriculture,
including cotton farming and cattle (Lubbock, n.d.). There are also several large, diverse
companies supporting the economy including a Coca-Cola bottling plant, UPS, the large medical
community, and X-Fab, whose parent company is in Germany, and sister company in Malaysia
(Lubbock, n.d.; X-Fab, n.d.). Unfortunately, Lubbock have a homeless community but no
specific homeless shelter open 24 hours. The homeless can be found at night, sleeping on the
well lit porches of a downtown library.
Lubbock’s landscape and culture have been shaped by a category F5 tornado that hit
downtown Lubbock on May 11, 1970 (A History, n.d.; Avalanche-Journal, 1970; Altenbaumer,
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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2000; Pratt, 2005; Blackburn, E. 2006)). The tornado traveled eight miles through downtown,
killing 26, injuring more than 2,000, and causing more than 135 million dollars damage (A
History, n.d.; Avalanche-Journal, 1970; Pratt, 2005). In spite of the devastation and subsequent
looting, the city worked together and ultimately built the Lubbock Memorial Civic Center and a
library in one of the most devastated areas (A History, n.d.; Avalanche-Journal, 1970; Pratt,
2005). The city also built a granite monument in memory of those killed in the tornado (Brown,
1997).
Even though the weather is Lubbock is typically moderate and enjoyable, West Texas
and Lubbock has a reputation for its unpredictable weather. Lee, Moffett, Allen, Peterson, &
Gregory (1993) published an article related to occurrences of decreased visibility due to blowing
dust. Little (2009) is reported on wind gusts of 68 mph, winds so strong utility poles were blown
over and bricks were sheared off the side of an apartment complex.
Residents of Lubbock describe it as friendly, a great place to raise children (L Mannon,
personal communication, February 15, 2010). People who have lived in Lubbock their entire
lives say locals can tend to be somewhat nosey, and “in your business” (J. Thomas, personal
communication, February 13, 2010). A Lubbockite who moved here from Wisconsin during
early 1980 noted she was shocked how interested people were about others finances (M.
Houghton, personal communication, February 16, 2010).
Locale – Lubbock, the county seat of Lubbock County, is located at the approximate center of
the county (at 33°35' N, 101°51' W) at an elevation of 3,256 feet above sea level. The city, the
largest on the South Plains, is on Interstate Highway 27, 327 miles northwest of Dallas and 122
miles south of Amarillo. In the last several years the housing needs of Lubbock have changed,
investors have transformed the area across from Main campus Texas Tech to a revitalization
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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project. Multiple apartment complexes have been established with the Overton project. water
supply, protection from climate, presence of slums, public housing. Choices of transportation,
State and national projects, highways, railroads, pollution, (air quality) (soil lead) (groundwater
contamination) slum prevention, GIPS mapping, role of government to environmental protection,
agricultural support in which farming subsidies and has the main income for many native
families
Ancestry –Lubbock was founded as a part of the movement westward onto the High Plains of
Texas by ranchers and farmers. In 1876 the county had been named for Thomas Lubbock, former
Texas Ranger and brother of Francis Lubbock, Governor of Texas during the Civil War.
Community valuing of first families, extended kin systems and homesteaders, how does
community value past? (Ranch and Heritage Center). State and nationals policies for census, data
collection, History of groups suffering prejudice.
Culture – Community valuing of ethnic groups, diversity, community with a painful past,
segregation, discrimination, state and national diversity, immigration policies, regional and state
support of ethnic groups, border policies (migrants) , legacy of discrimination, degree of national
valuing of ethnic diversity, valuing the foreign born.
Economics - health of local economy (unemployment and housing) job forecasts,(Chamber of
Commerce) tourists, seasonal residents, poverty rates, welfare numbers, status of national
economy and global commodities.
Health: The high rate of Sexual Transmitted Disease (STD) in Lubbock is a familiar
phrase to school Nurse L. Mannon (personal communication, February 15, 2010). As a schoolbased position, her role requires referring students to the nearby STD clinic for testing however;
Ms Mannon noted that few students ask for this type of services. One of the drawbacks identified
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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by a school nurse to STD health is the inability to provide prophylactics to students. However,
the underserved area of Lubbock in a clinic in east of town, condoms are provided to anyone.
Synthesis
Characteristics of the Population
Geography:
Lubbock County is located in the United States of Texas. According to the U.S. Census Bureau,
the county has a total area of 901 square miles, of which, 899.49 square miles of it is land and
1 square miles of it (0.13%) is water. There is an estimated 269.9 persons per square mile.
Lubbock County is a part of Texas’s Public Health Service Region 1 along with Armstrong,
Bailey, Briscoe, Carson, Castro, Childress, Cochran, Collingsworth, Crosby, Dallam, Deaf
Smith, Dickens, Donley, Floyd, Garza, Gray, Hale, Hall, Hansford, Hartley, Hemphill, Hockley,
Hutchinson, King, Lamb, Lipscomb, Lynn, Moore, Motley, Ochiltree, Oldham, Parmer, Potter,
Randall, Roberts, Sherman, Swisher, Terry, Wheeler, and Yoakum. Can we say several west
Texas counties to shorten this paragraph?
Total Population:
The last U.S. Census completed in 2000 counted the population of Lubbock County as 242,628.
The population of the state of Texas as a whole has increased secondary to immigrant migration
from border countries like Mexico. Consequently, the total number of people within Lubbock
County as of 2008 is an estimate. According to the U.S. Census Bureau the 2007 estimated
population in Lubbock County is 260,258. With a population percent change from April 1, 2000
to July 1, 2008 of 9% (U.S. Census Bureau, 2009).
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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Population
Year Lubbock County Region 1
Texas
Total Population
2007
260,258
809,902 23,904,380
Male Population
2007
128,291
404,971 11,964,630
Female Population
2007
131,967
404,931 11,939,750
Median Age
2007
30.4
33.4
33.2
Population Per Square Mile 2007
289.3
20.5
83.2
2000
899.5
Area in Square Miles
39,429.4 261,797.1
Do we need to move the tables to the end of the paper and here refer to table 1: shows the population of
Lubbock compared to the state? If left here we need to cite by APA.
Demography
As of 2007 there were 92,516 households and 60,135 families residing in the county. The
population density was 289 people per square mile. There were 100,595 housing units at an
average density of 112 per square mile.
There were 92,516 households out of which 31.70% had children under the age of 18
living with them, 48.20% were married couples living together, 12.60% had a female
householder with no husband present, and 35.00% were non-families. 26.90% of all households
were made up of individuals and 7.90% had someone living alone who was 65 years of age or
older. The average household size was 2.52 and the average family size was 3.10.
In the county, the population was spread out with 25.70% under the age of 18, 16.30% from 18
to 24, 27.90% from 25 to 44, 19.20% from 45 to 64, and 11.00% who were 65 years of age or
older. The median age was 30 years. For every 100 females there were 95.80 males. For every
100 females age 18 and over, there were 92.60 males.
Age Distribution:
Age distribution of a community will have a major influence on health needs. The older
and younger age groups in a population have greater health care needs. Lubbock County has a
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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youthful population with a median age of 31 compared to the state median of 33.2, which may be
driven by the presence of a university in the region.
Population by Selected Age Groups
Year Lubbock County Region 1
Texas
Age 0-4
2007
20,149
62,043
1,906,500
Age 5-14
2007
33,476
111,479
3,425,629
Age 15-44
2007
123,229
350,291
10,716,819
Age 45-64
2007
54,728
184,079
5,508,436
Age 65+
2007
28,676
102,010
2,346,996
Age 13-17
2007
16,891
58,149
1,817,033
Age 13-19
2007
27,595
86,003
2,551,354
Age <18
2007
68,483
222,550
6,806,365
Age 85+
2007
3,887
13,680
282,506
Natality
Year
Lubbock County Region 1
Texas
Total Live Births
2006
4,154
12,919 399,309
Adolescent Mothers Under 18 Years of Age
2006
259
826 19,453
Adolescent Mothers Under 18 Years of Age (%)
2006
6.2%
Reported Pregnancies to Women Age 13-17
2006
288
909 22,899
Reported Pregnancies to Women Age 13-17 (Rate)
2006
35.7
31.9
Unmarried Mothers
2006
1,630
Unmarried Mothers (%)
2006
39.2%
Low Birth Weight
2006
451
Low Birth Weight (%)
2006
10.9%
Onset of Prenatal Care within First Trimester
2006
2,480
Onset of Prenatal Care within First Trimester (%)
2006
60.3%
60.4%
61.0%
Fertility Rate
2006
70.1
77.2
77.6
6.4%
4.9%
26.0
5,146 157,929
39.8%
39.6%
1,289 33,749
10.0%
8.5%
7,677 237,243
Reference for tables
Ethnicity and Race
A lack of awareness can result in a community health needs assessment that may not
include the most vulnerable groups. Ethnicity and cultural background have a significant impact
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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on health, and individuals, whatever their ethnic background, are entitled to equal access to
health care. The racial makeup of Lubbock County in 2007 was 58% White, 7.9% Black or
African American, 0.59% Native American, 1.31% Asian, 0.04% Pacific Islander, 2.3% from
other races, and 1.96% from two or more races. 31% of the population was Hispanic or Latino of
any race.
Population by Race/Ethnicity
Year Lubbock County Region 1
Texas
Total Anglo
2007
151,083 484,697 11,337,714
Total Black
2007
20,601
Total Hispanic
2007
82,481 262,498 8,791,986
Total Other
2007
6,093
16,169
991,804
Total Anglo (%)
2007
58.1%
59.8%
47.4%
Total Black (%)
2007
7.9%
5.7%
11.6%
Total Hispanic (%) 2007
31.7%
32.4%
36.8%
2007
2.3%
2.0%
Total Other (%)
Marriage and Divorce:
Marriage and Divorce
4.1%
46,538 2,782,876
Year Lubbock County Region 1 Texas
Marriages
2006
1,988
6,210 178,115
Divorces
2006
1,122
3,001 79,469
Marriage Rate per 1,000 Residents 2006
7.8
7.8
7.6
2006
4.4
3.7
3.4
Divorce Rate per 1,000 Residents
Reference for tables
Language and literacy
In response to a demand for estimates of the percentage of adults with low literacy in
individual states and counties, the National Center for Education Statistics (NCES) has produced
estimates of the percentage of adults lacking Basic Prose Literacy Skills (BPLS) for all states and
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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counties in the United States in 2003 and 1992. As of 2003 Lubbock County lack basic literacy
skills in 13% of the population.
Lubbock County: Texas 2003
Location
FIPS
code
Population size
Lubbock County 48303
183,345
Reference for tables1
Percent lacking basic 95% credible interval
prose literacy skills
Lower
Upper bound
bound
13
6.5
23.0
According to the CDC the top five (5) languages spoken in the home are English,
Spanish, German, Chinese, and French with English being the predominate language. (Centers
for Disease Control and Prevention, 2007).
Population Health Status
There are a number of measures commonly used to identify the health of a population. In
addressing the health of Lubbock County, statistical data (i.e. mortality and morbidity),
information from local health care workers and other agencies, and the community’s own view
of their health will be used. Mortality data (Texas Department of State Health Services, 2010)
Mortality Data
Deaths by Cause
Year Lubbock County Region 1 Texas
Deaths from All Causes
2006
2,031
7,063 156,525
Cardiovascular Disease Deaths
2006
595
2,190 50,892
Heart Disease Deaths
2006
443
1,627 38,487
Stroke Deaths
2006
112
All Cancer Deaths
2006
391
Lung Cancer Deaths
2006
111
397
9,677
Female Breast Cancer Deaths
2006
25
103
2,563
Chronic Lower Respiratory Disease Deaths 2006
154
544
7,599
419
9,332
1,418 34,776
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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Deaths by Cause
Year Lubbock County Region 1 Texas
Diabetes Deaths
2006
87
286
5,180
Infant Deaths
2006
28
78
2,476
Fetal Deaths
2006
27
65
2,216
Unintentional Injury (Accidents)
2006
117
416
9,006
2006
44
184
3,781
Homicide
2006
20
31
1,450
Suicide
Morbidity Data
2006
27
91
2,332
Motor Vehicle Injury
Add data here
Behavior measures
Add data here
Community and Social Dynamics
Social cohesion
Social support is essential for the well being of a community.
Networks
Family and friendship networks provide people with the emotional support that is
fundamental to wellbeing. Social networks can be hard to describe and quantify.
Migration
Migration causes disruption to a population, as large numbers of people move location. It
is often the younger working-age population who emigrate, and this is a loss to the population
left behind while a gain to the community they move to. Immigrants are usually poorer than the
native population and may not be able to communicate because of language difficulties.
Pleasure and Leisure
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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The opportunities for non-work social activities are signposts that can be used to indicate
the extent of social cohesion and support in a community. Such activities reinforce a
community’s identity and the emotional wellbeing of individuals.
Socioeconomic Status
Texas has the fifth highest poverty rate among the states; one in six Texans is considered
poor. Texas has the eighth highest rate of senior citizens living in poverty. One half of children
in Texas live in poverty or are economically disadvantaged. Texas continues to be a low-wage,
low-benefit state. With that said, Texas has a crisis in coverage. The economic, educational,
cultural, and social strength of Texas depends upon the health of its citizens; alarmingly, about
24% of its population is without insurance - the highest in the nation.
Socioeconomic Indicators
Year
Lubbock
County
Texas
Region 1
Average Monthly
TANF Recipients
SFY2008
800
Average Monthly
SNAP (food stamp)
Participants
SFY2008
32,447
92,700 2,819,469
Unduplicated
Medicaid Clients
SFY2008
50,765
166,252 4,514,895
Unemployment Rate
2008
3.8%
3.7%
4.9%
Per Capita Personal
Income
2007
$30,212
$30,649
$37,083
FY2008
3,908
13,682
466,242
Average Monthly
CHIP enrollment
2,113
104,693
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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Educational Attainment for the Population 25 Years and Older
Year
Lubbock
County
Region 1
Texas
Did Not Complete
High School
2000
30,545
120,280
3,114,561
High School
Graduate
2000
35,738
130,808
3,176,743
Some College
2000
34,156
111,697
2,858,802
Associate's Degree or
Higher
2000
40,924
112,128
3,640,787
Did Not Complete
High School (%)
2000
21.6%
25.3%
24.3%
High School
Graduate (%)
2000
25.3%
27.5%
24.8%
Some College (%)
2000
24.2%
23.5%
22.4%
Associate's Degree or
Higher (%)
2000
28.9%
23.6%
28.5%
Did Not Complete
High School (ACS
%)
2006-2008
16.6%
NA
20.8%
High School
Graduate (ACS %)
2006-2008
27.6%
NA
26.5%
Some College (ACS
%)
2006-2008
22.5%
NA
21.2%
Associate's Degree or
Higher (ACS %)
2006-2008
33.2%
NA
31.4%
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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Health Insurance
Year
Lubbock Region
County
1
Texas
18 Years and Younger, Without
Health Insurance
2006
14,980 45,489
18 Years and Younger, Without
Health Insurance (%)
2006
21.7%
20.4%
20.8%
Younger than 65 Years, Without
Health Insurance
2006
66,485 186,565
5,854,740
Younger than 65 Years, Without
Health Insurance (%)
2006
29.4%
27.4%
1,445,397
27.6%
Local factors affecting health
A number of local factors affect health of the Lubbock County population. Lubbock,
Texas, especially within service areas, also faces economic and healthcare challenges. Because
of its diverse economy, which is grounded in agriculture, manufacturing, and trade, there is a
significant migration of both permanent and temporary dwellers into the area.
Work and employment
Lubbock’s diverse labor force is one of its finest assets. Each year, the labor supply replenishes
the area with 2,600 new high school graduates and nearly 6,000 college graduates. The Lubbock
Economic Development Alliance has aggressively addressed workforce development as its key
cornerstone since 2000. The healthcare sector is a vital part of the workforce and contributes
over $700 million to the local economy each year. Lubbock is known as the “medical center” for
West Texas and eastern New Mexico, offering the most comprehensive healthcare between
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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Dallas and Phoenix. Lubbock is home to one of the state’s premier academic health science
centers. Texas Tech University Health Science Center houses schools of medicine, allied health,
and nursing. In addition, migrant workers and their families have a significant impact on the
county workforce.
Poverty and Income
As of 200, the median income for a household in the county was $32,198, and the median
income for a family was $41,067. Males had a median income of $29,961 versus $21,591 for
females. The per capita income for the county was $17,323. About 12.00% of families and
17.80% of the population were below the poverty line, including 21.60% of those under age 18
and 10.70% of those age 65 or over.
Poverty
Lubbock
Region
County
1
Year
Texas
Total Persons Living Below Poverty
2008
40,067 123,356 3,755,944
Total Persons Living Below Poverty (%)
2008
15.7%
16.0%
Related Children 0-17 Years, Living Below
Poverty
2008
13,337
46,186 1,492,668
Related Children 0-17 Years, Living Below
Poverty (%)
2008
20.2%
22.0%
18 Years and Over, Living Below Poverty
2008
26,730
77,170 2,263,276
18 Years and Over, Living Below Poverty (%)
Environment
2008
14.1%
13.8%
15.8%
22.5%
13.2%
The surroundings in which a population live and work directly affect health. Add elements of the
environment
Access to Care
Access to health care is one of the most urgent issues facing Lubbock County.
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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Local people’s views of their health needs and health services
A central part of this community assessment is gathering information on local people’s views of
their health needs and resources.
Local and national priorities
National priorities are often set by governments and influenced by the political and economic
agenda. Local priorities will reflect national priorities as well as issues identified by local groups,
practitioners, and communities. When undertaking a needs assessment you will need to discover
what these priorities are in relation to health. Sometimes there can be a conflict between the
national top-down agenda and the needs identified locally.
Population Health Issues
1. CV Disease/HTN
2. Diabetes
3. Obesity
4. Abuse
5. Sexually Transmitted Diseases (STD)
2007 Prevalence Rate >18
Lubbock
Texas
County
HTN
33.3%
27.8%
Diabetes
11.6%
10.4%
Abuse
Obesity
LUBBOCK COUNTY COMMUNITY ASSESSMENT
Overweight &
17
71.7%
67.5%
38.7%
28.6%
Obesity (BMI 25 or
Greater)
Obesity (BMI
30 or Greater)
STD:
Chlamydia
Gonorrhea
Syphilis
HIV/AIDS
The population health issue focus of this community assessment is sexually transmitted disease
(STD). STD cases by the zip code level were identified in Lubbock County.
Health Issue
The Lubbock Health Department STD clinic attended the needs of 171 patients in
January of 2010, almost double the number seen in January of 2009. The clinic staff agrees that
the number of cases in Lubbock appears to be high. Jamie Parker, STD team lead for the clinic
reports that there is an increase in the number of patients seen. Coincidentally, the City Council
voted in August of 2009 to shift responsibility previously retained by the STD clinic onto the
state. Since September the clinic has been funded by a state grant that must be renewed annually,
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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Parker stated. At the same time, the Department of State Health Services picked up disease
intervention services, which were previously handled by city-paid staff. The intervention staff
tracks the partners and acquaintances of people with STDs and tries to diagnose and treat them.
The change in funding means an additional nurse and availability of longer clinic hours, Parker
said. The expanded clinic hours may subsequently increase total STD numbers, but will be
beneficial in the long run, increasing treatments and minimizing spread she also stated. Parker
mentioned that two city-paid health educator positions were also cut by the City Council in
September, decreasing community education on topics such as breast cancer and smoking
(personal communication, February 13, 2010).
The high rate of STD's in Lubbock is familiar to school nurse L. Mannon (personal
communication, February 15, 2010). She goes on to say she does refer students to a nearby
clinic for free STD testing when they ask; however, she says students do not often ask about
STD's or STD testing. She continues that she does not believe the schools will ever come to the
point of providing condoms for students. On the other hand, condoms are given out freely in an
underserved clinic in east Lubbock.
Chlamydia trachomatis is the most commonly reported bacterial sexually transmitted infection
(STI) in the world (WHO, 2001). This is of concern as untreated infection can lead to serious
complications such as pelvic inflammatory disease, tubal infertility and ectopic pregnancy. Most
individuals infected with chlamydia are asymptomatic (Sutton, Martinko, Hale and Fairchok,
2003; Gaydos, Howell, Pare, Clark, Ellis, Hendrix, Gaydos, McKee, and Quinn, 1998). Thus
screening is necessary to detect cases and to reduce the risk of complications. Studies suggest
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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that the primary intervention of selective screening for chlamydia reduces the prevalence of
infection and the incidence of pelvic inflammatory disease (Mertz, Mosure, Berman, and Dorian,
1997; Scholes, Stergachis, Heidrich, Andrilla , Holmes and Stamm, 1996).
Opportunistic screening of sexually active females less than 25 years of age for chlamydia in
primary care has been recommended in a number of industrialized countries (Expert Advisory
Group on Chlamydia trachomatis,London, Department of health, 2001; Australian College of
General Practitioners,2005). In Australia, over 80% of women aged 16–24 years visit a general
practitioner (GP) at least once a year for any reason and most chlamydial infections are
diagnosed in general practice (Fairley, Hocking, Gunn and Chen, 2005). However, despite the
widespread availability of non-invasive testing methods for chlamydia and single dose therapy
using azithromycin, chlamydia screening rates have overall remained low (Fairley, Hocking,
Gunn and Chen, 2005).
Ostensibly, this reflects barriers to testing that relate to both patients and health care providers.
For instance, adolescents may be reluctant to seek care for their sexual health because of
embarrassment or concerns about their confidentiality, while health care providers may have
limited awareness of chlamydia as an issue or lack the time, knowledge and skills to manage and
discuss sexual health issues (Verhoeven, Avonts, Vermeire, Debaene and Van Royen, 2004;
Poljski, Atkin and Williams, 2004). If any chlamydia screening program is to be implemented
successfully, such potential hurdles need to be identified and addressed. Preferably, this process
should be evidence based.
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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In previous studies, intervention clinics introduced a clinical improvement initiative aimed at
overcoming barriers to chlamydia screening at all levels of clinical practice. This intervention
was based on a model to change practice which consisted of 4 stages: (1) "engage", (2) "team
building", (3) "redesign clinical practice", and (4) "sustain the gain".
The first of these stages involved engagement with the health maintenance organization's leaders
by presenting evidence showing the gap between current and best practice with respect to
chlamydia screening. In addition, awareness among clinic staff was raised through a brief
introduction to the intervention and to team building concepts. The second step consisted of the
formation of adolescent care teams comprised of clinic staff who would act as champions for the
project. These teams completed a workshop that emphasized skill building and implementation
of a model for practice change. A toolkit was developed to facilitate incremental changes. This
included a customized clinic flow chart which helped team members to identify barriers to and
solutions for changing their practice. It also contained promotional material designed to raise
awareness about screening adolescent girls: logos on stickers used to cue charts, on buttons worn
by staff, and on pens and posters placed in the intervention clinics.
The third stage of the intervention consisted of monthly meetings of clinic team members, where
chlamydia screening rates and documentation on encounters with adolescents were reviewed to
assess the effectiveness of prior incremental measures aimed at increasing screening rates.
Barriers to screening were identified as well as strategies to overcome these. As part of this
process, all intervention clinics decided to institute universal urine specimen collection from all
adolescents at clinic registration, prior to their examination. As part of the final intervention
stage, the teams developed performance indicators (number of visits and chlamydia screening
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rates) and customized information infrastructure to assist in monitoring progress against these.
(Shafer, Tebb, Pantell, Wibbelsman, Neuhaus, Tipton, Kunin, Ko, Schweppe and Bergman,
2002).
In a study by Allison et al. (2005), 191 primary care physicians offices in the US were
randomized either to an internet-based continuing medical education (CME) program for
increasing chlamydia screening (n = 95) or to a control arm (n = 96). The intervention consisted
of 4 CME modules that were released every 3 months. The modules emphasized a number of
points: that young, sexually active women are at high risk for asymptomatic infection that may
lead to future serious health consequences; that recently developed urine-based screening allows
diagnosis without a pelvic examination; and that infection may be treated easily and effectively.
The mean chlamydia screening rates in women aged 16–26 years before, during and after the
intervention for the control offices were 18.9%, 13.0% and 12.4%, respectively. For the
intervention offices, they were 16.2%, 13.3%, and 15.5%, respectively (p = 0.044 for post
intervention differences after adjusting for baseline performance. The difference in post
intervention screening rates by study group remained significant when adjusting for both pre
intervention and intra intervention screening rates using repeated-measures analysis (p = 0.009).
Thus, the intervention appeared to forestall the significant decline in screening rates seen in the
control clinics.
A range of potentially effective strategies were identified in these studies. These included those
aimed at: increasing awareness of chlamydia and its sequelae; improving knowledge of screening
guidelines and non-invasive testing; improving physicians' communication skills, including
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sexual history taking; and overcoming barriers within clinic systems. A number of methods were
used to disseminate information and training, including written guidelines, video educational
packages, and internet based CME modules. The question remains as to which of these strategies
should be employed in primary care to increase chlamydia screening. It is not clear which would
be the most cost-effective and feasible, particularly in view of the competing priorities and time
constraints that clinicians invariably face. While the effect of the intervention seen in the study
by Shafer et al. (2002) appeared to be relatively large, the intensity of measures employed would
most likely be difficult to implement universally. By contrast, the internet based CME modules
used by Allison et al. (2005) would be easier to disseminate, relatively inexpensive and easily
accessible.
Intervention
Evaluation of interventional programming for Chlamydia
In an effort to evaluate the feasibility of the intervention that encompasses educational outreach
with the utilization of media resources, Oh et al (2002) focused on outcome measures such as
quantity and characteristics of incoming calls to educational staff in response to the Chlamydia
LUBBOCK COUNTY COMMUNITY ASSESSMENT
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educational campaign. Descriptive and bivariate analyses may be used to evaluate these
outcomes for improvement in incidence and educational awareness.
Cost-effectiveness of programming using case studies both before and after educational
intervention to determine the efficacy of education on average cost per patient. According to
Genc et al (1993), screening strategies reduced the overall costs when the prevalence of
chlamydial infection in adolescent males exceeded 10%.
According to MCclure et al (2006), the evaluation of provider attitudes is also a significant factor
in the evaluation of interventional programming. The authors indicate that routine chlamydia
screening among asymptomatic, at-risk adolescent females could be enhanced through additional
intervention targeting specific provider attitudes and beliefs about chlamydia screening. Provider
evaluation may be accomplished through provider surveys or self-reports. Through a
multivariate analyses, providers' perceived knowledge, confidence, comfort, and perceived
patient comfort may be analyzed using pre and post screening data controlling for other relevant
provider characteristics.
In terms of observance of a decrease in cases, the educational programming may initially cause a
notable increase in cases as more teens seek educational assistance and intervention. I believe the
facets of evaluation must include a fiscal cost-effectiveness component, a review of pre and post
interventional statistics regarding incidence/cases, and evaluation of provider attitudes and the
impact this may have on the program delivery, program utility through usage analysis and patient
satisfaction review, and finally a strategic or project plan and adherence to deadlines with an
evaluation of implementation barriers. The literature cited supports many of these endeavors for
the purposes of program evaluation.
LUBBOCK COUNTY COMMUNITY ASSESSMENT
Summary
Conclusion
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LUBBOCK COUNTY COMMUNITY ASSESSMENT
References
Genc, M., Ruusuvaara, L., Mardh, P., (1993). An economic evaluation of screening for
Chlamydia trachamatis in adolescent males. Journal of the American Medical Association,
270(17), 2057-2064.
MCclure, J.B., Sscholes, D., Grothaus, L., Fishman, P., Reid, R., Lindenbaum, J., Thompson,
R.S. (2006). Chlamydia screening in at-risk adolescent females: an evaluation of screening
practices and modifiable screening correlates. Journal of Adolescent Health, 38(6), 726-733.
Oh, M. Grimley, D., Merchant,J., Brown, P., Cecil, H., Hook, E. (2002). Mass media as a
population-level intervention tool for Chlamydia trachomatis screening: report of a pilot study.
Journal of Adolescent Health, 31 (1), 40-47.
Guys, please take a look at what the California is doing regarding Chlamydia intervention and
evaluation: http://www.igh.org/castd/scientific_committee.html
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