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Research Briefs

KDHRC has things to say. You can find our research in top journals,
leading conferences, and right here, in our Informing Public Health research briefs,
which summarize our research advances.

May 2023

Nicole I. Wanty, Dexter L. Cooper, Andrew Simkus, Kristen D. Holtz

Systemic lupus erythematosus (SLE) is an autoimmune disorder that disproportionately affects women and minorities. Estimates report up to 90% of lupus patients are women. Black and Latino individuals experience up to three-times the lupus incidence rate, more severe disease symptoms, a higher frequency of lupus-related complications, and a sharply higher mortality rate compared to non-Latino White individuals.

January 2023

Dexter L. Cooper, Morgan L. Fleming, Kristen D. Holtz, Nicole I. Wanty, and Andrew Simkus

Tooth decay, the most common and preventable chronic disease among children in the U.S., afflicts nearly one of four Americans ages 3 to 5. The prevalence of tooth decay increases from 21 percent among children ages 2-5 to 54-59 percent among adolescents ages 12-19, which indicates a persistent pattern of oral health problems that worsens with age.  Tooth decay, especially when untreated, creates lasting and substantial physical and psychosocial consequences for children and adolescents.

November 2019

Kristen D. Holtz, Eric C. Twombly, Nicole I. Wanty, Dianna Bonilla, Motolani Aina, and Fakari J. Gresham

Since their introduction to the marketplace only a decade ago, electronic cigarettes (more commonly called vapes) have been rapidly adopted for use by youth, creating a public health epidemic. In the U.S., from 2017 to 2018, vaping by youth increased by 78 percent. Now, more than 3.6 million middle and high school students – roughly one in five high school students and one in twenty middle school students – have vaped in the past year.1 Vapes are the most commonly used tobacco delivery product among youth and show youth usage rates substantially higher than any other drugs of abuse.

April 2019

Nicole I. Wanty, Eric C. Twombly, Dianna Bonilla, and Kristen D. Holtz

Childhood tooth decay is a significant public health problem in the United States (U.S.) and one of the country’s greatest unmet health needs (Boyles, 2011). Not only can tooth decay produce lasting physical pain and emotional suffering for children afflicted with it, but it also has substantial societal ramifications, such as costing U.S. taxpayers hundreds of millions of dollars annually, mostly because of emergency room care for preventable tooth pain (Pettinato, Webb, & Seale, 2000; The Pew Center on the States, 2012). And though all children are susceptible to tooth decay, it is disproportionately evident in specific demographic groups. Indeed, Latino children and children living in poverty have greater amounts of tooth decay, more severe tooth decay, and more untreated decay (National Institute of Dental and Craniofacial Research [NIDCR], 2011).

May 2018

Eric C. Twombly, Kristen D. Holtz, and Robin M. Campbell

Health nonprofits increasingly use promotores de salud (promotores) to connect low-income Latinos with health services, provide health education, and empower clients with positive coping skills (Vega, Rodriguez, & Gruskin, 2009). Because promotores typically come from the communities in which they serve, they are culturally competent peers who can help many Latinos overcome the language barriers and institutional distrust that limit their willingness to seek services (Elder, Ayala, Parra-Medina, & Talavera, 2009; Nemcek & Sabatier, 2003).

November 2017

Eric C. Twombly, Rosa M. Smith, Debra S. Kozlowski, and Kristen D. Holtz

In recent years, local nonprofit community-based health providers who serve Latino populations have increasingly turned to promotores, or community lay health workers, to facilitate their service provision. Promotores work in a variety of capacities at nonprofits: as front-line service providers who supply basic services and as health educators who give valuable information on important health topics. The rationale is that promotores’ lay status as community members allows them to connect with Latinos in culturally competent and sensitive ways, thereby creating trustworthy relationships between nonprofit providers and Latinos. These relationships can help overcome Latinos’ mistrust of the mainstream medical system and reduce other barriers to care.

November 2017

Eric C. Twombly, Rosa M. Smith, Debra S. Kozlowski, and Kristen D. Holtz

From primary and preventive care provision to health education, community-based nonprofit organizations are key components in health service delivery in the United States, particularly in low-income areas. But community-based nonprofits are tasked with more than treating the physical and mental health conditions of their clients. They must navigate complex community environments where client characteristics and institutional factors combine to make providing quality health care difficult and costly. For example, local nonprofit health providers in low-income, Latino communities not only treat clients who suffer from significant health disparities, compared with the general U.S. population, but they must also overcome their clients’ language barriers, relatively low rates of health insurance, and pervasive mistrust of the mainstream medical system (Huerta, 2003; Hirota et al., 2006; Centers for Disease Control and Prevention, 2007). These compounding factors raise service costs, stress organizational resources and staff, and prompt local nonprofits to search for innovative, cost-effective, and culturally sensitive methods to treat those in need.

November 2016

Eric C. Twombly, Nicole I. Wanty, & Kristen D. Holtz, KDH Research & Communication

Science literacy and academic achievement on science topics empower youth to think critically and understand and apply scientific findings in their daily lives. As youth age into adulthood, their scientific literacy allows them not only to make relatively informed medical, political, economic, and social decisions concerning individual and societal welfare, but it also provides them the impetus to contribute societally through scientific and technological inquiry and advancement (American Association for the Advancement of Sciences, 1993; Miller et al., 1992). One needs only to look at the technological and computing revolutions of the past two decades to understand the importance of promoting scientific inquiry. However, students in the United States perform lower on science achievement tests than many of their international peers (National Center for Education Statistics, 2004). Only 68 percent of fourth grade students perform at or above a basic achievement level. This rate drops to 59 percent by eighth grade and 54 percent by twelfth grade (National Assessment of Educational Progress, 2006). A key question becomes how can teachers, parents, academics, and policymakers in the U.S. improve the science performance of the nation’s youth, thereby making them more scientifically literate and empowered to significantly contribute scientifically as adults?

December 2014

Rosa M. Steen, Eric C. Twombly, Louise C. Palmer, & Kristen D. Holtz, KDH Research & Communication

A common public health question is how to effectively provide educational services to school-aged children with chronic illnesses. These children, whom we identify in this brief as “chronically ill learners” or “CIL,” suffer from a range of mild to severe chronic illnesses, such as asthma, HIV/AIDS, diabetes, cancer, sickle cell anemia, cystic fibrosis, among others (Kaffenberger, 2006; Taras & Potts-Datema, 2005; Moonie et al., 2006). There are an estimated 4.4 million CIL in the United States who miss school annually because of chronic illnesses (Kaffenberger, 2006; Shaw & McCabe, 2008). The average annual number of days that a child is absent from school varies by chronic illness, ranging from roughly eight to 12 days for a child with asthma to as many as 80 days for a child with cancer, but, on average, a child with a chronic illness is absent 16 days per year, compared with three days for a typically healthy child (Moonie et al., 2006; Vance & Eiser, 2001; McDougall et al., 2006).

October 2014

Louise C. Palmer, Rosa M. Steen, Eric C. Twombly, & Kristen D. Holtz, KDH Research & Communication

This research brief presents the evaluation findings of a prototype of Project PENCIL (Protecting the Educational Needs of Chronically Ill Learners), a training program to improve the ability of Kindergarten through fifth grade (K-5) teachers to provide educational accommodations in their classrooms for children with chronic illnesses. These children, or “chronically ill learners” (CIL), comprise roughly 20 percent of school-aged students in the United States. Their chronic illnesses range from mild to severe and include asthma, HIV/ AIDS, diabetes, cancer, sickle cell anemia, cystic fibrosis, and more (Kaffenberger, 2006; Moonie et al., 2006; Taras & Potts-Datema, 2005). Due to their illnesses, CIL miss an average of 16 school days annually, compared with three days for typically healthy children (McDougall et al., 2004). The combination of chronic illness and school absences negatively impacts these children’s academic and social experience (Kaffenberger, 2006; Shaw & McCabe, 2008; Thies, 1999).

April 2013

Nicole I. Wanty, Eric C. Twombly, Kristen D. Holtz, & Louise C. Palmer

This brief examines the effectiveness of a peer education intervention to build typical peers’ knowledge and positive attitudes to support the social acceptance of children with cochlear implants (CIs). Social acceptance is the extent to which a child can successfully initiate and maintain reciprocal relationships with his or her peers. Low social acceptance is often characterized by feelings of not fitting in or being left out (Punch & Hyde, 2011). If experienced early in life, low social acceptance often relates to lasting poor self-esteem and social isolation (Nicholas & Geers, 2003; “Peer acceptance,” 2012; Stinson & Whitmire, 2000).

November 2011

Louise C. Palmer, Jana Eisenstein, Eric C.Twombly, and Kristen D. Holtz

Until relatively recently, those who were profoundly deaf or hard of hearing had few options to overcome them. But in the 1980s, the United States (US) Food and Drug Administration (FDA) approved the limited use of cochlear implants (FDA, 2010). Cochlear implants bypass the damaged or nonfunctioning parts of the ear to create a representation of sound for the wearer. By December 2010, approximately 219,000 people worldwide had received cochlear implants, and, in the US alone, roughly 42,600 adults and 28,400 children had received the implants (National Institute on Deafness and Other Communication Disorders [NIDCD], 2011).

November 2011

Louise C. Palmer, Eric C. Twombly, Kristen D. Holtz, & Kimberly Stringer

This research brief provides the evaluation results of a pilot version of the novel health program, En Familia (ENF). The program has two aims. First, through its use by community-based nonprofits, it aims to improve knowledge about key health topics and health literacy skills of Latino families in the United States (U.S). Second, by building knowledge about key health topics and health literacy skills in Latino families, it aims to reduce the health disparities that many Latino families face. To achieve these aims, ENF uses an intergenerational approach that draws on the concept of familism, or the exchange of social support among the generations of a family unit (Ruiz, 2007). In this regard, ENF encourages teens, their parents, and their grandparents to support each other in making healthy choices.

September 2011

Eric C. Twombly, Kristen D. Holtz, Kimberly Stringer, and Louise C. Palmer

Latinos comprise the ethnic group in the United States that is most likely to report no usual source of health care (U.S. Bureau of the Census, 2004). Only 68 percent of Latino children have a regular source of medical care, compared to 90 percent of whites, Asian/Pacific Islanders, and multiracial children (Flores & Tomany-Korman, 2008). This is an important public health problem because lack of care relates to poor health outcomes. That Latinos disproportionately lack access to routine care relates to numerous barriers, such as lack of insurance, language barriers, and fear and mistrust of the health care system (Redes En Acción, 2004). Therefore, to improve Latino health outcomes, methods must be formulated and implemented to overcome barriers and increase access to care.

February 2011

Kristen D. Holtz, Eric C. Twombly, Joshua B. Becker, Arienne S. Wyatt

From August 2010 to February 2011, KDH Research & Communication (KDHRC) conducted a large-scale, multipurpose evaluation of Tier Two’s Tag It, part of the National Youth Anti-Drug Media Campaign (NYADMC). Tag It is a three-session activity designed to be implemented by youth-serving, community-based organizations to raise awareness of positive and negative influences in youths’ lives and foster skills for youth to avoid negative influences like drug use. Tag It aligns with the tenets of the NYADMC’s brand for youth “Above the Influence” (ATI) which, according to campaign documents, positions “above the influence” as the state of being directly opposite of “under the influence” of drugs and alcohol. Tag It fits into the NYADMC’s recently redesigned strategy, referred to as Tier Two, to prevent youth drug abuse by augmenting national-level anti-drug advertising with local partnerships and youth activities.

December 2010

Eric C. Twombly, Arienne S. Wyatt, & Kristen D. Holtz, KDHRC, & Greta K. Tessman, Emerson College

This paper examines the geographical diffusion of prescription drug misuse by teens in the United States and compares it with the geographical diffusion of methamphetamine, marijuana, and alcohol. Currently, there is no systematic evidence of how usage patterns of potentially addictive but licit drugs, such as prescription drugs, geographically diffuse, raising questions of how to best prevent their abuse and treat their consequences. We find evidence that the geographical diffusion of drugs of abuse by teens varies by the drugs’ social acceptability, supply, legal status, and use in medical treatments. We also find that the diffusion of prescription drug misuse among teens fails to resemble the patterns of methamphetamine, marijuana, and alcohol, raising the need for a national prevention effort to stem this growing public health problem.

December 2010

Eric C. Twombly, Kristen D. Holtz, & Alison Daub, KDHRC

This paper reports on data from a population of caregivers of people with Autism Spectrum Disorders (ASD) to examine the extent and motivations for their use of the Internet to obtain information on caregiving. We find considerable interest for Web-based information, but a strong bifurcation among respondents on the preferential type of information. The majority of respondents indicate that Web sites that provide factual information about caregiving are most important. Other respondents see the Internet as a vehicle for social exchanges about ASD. Regardless of their preferred method to consume Web-based information, all respondents reported using Web sites to obtain caregiving information

August 2009

Christine B. Agnew, Eric C.Twombly, & Kristen D. Holtz, KDH Research & Communication

Prescription drug abuse, particularly among teens, has become a major public health problem in the United States. In 2003, roughly 2.3 million teens in the U.S. reported lifetime nonmedical use of a prescription drug (Substance Abuse and Mental Health Services Administration [SAMHSA], 2004). By 2008, the number of teens who reported lifetime nonmedical use of a prescription drug rose to 4.7 million, or one in every five teens in the U.S. (Partnership Attitude Tracking Study [PATS], 2009). What is more, the rapid increase in the rate of prescription drug abuse corresponded to a dramatic growth in related poisoning and deaths among teens (Office of National Drug Control Policy [ONDCP], 2008). Taken together, these factors have raised the attention of public health practitioners and policy makers and created a need for effective prevention messages. A key issue for public officials is to determine what prescription drug prevention messages resonate with teens, because highly resonant messages are more likely to influence intentions to avoid drugs (Harris, 2006). This brief begins to explore that issue.

August 2009

Eric C. Twombly, Christine B. Agnew, & Kristen D. Holtz, KDHRC

Prescription drug misuse is a major health problem, particularly among teens. A key step in curbing misuse is the development of effective prescription drug prevention messages. This paper explores the elements of prescription drug misuse prevention messages that resonate with teens using data from focus groups with seventh and eighth grade students. In contrast to some previous research, students reported that messages with positive alternatives and refusal skills had little resonance, but scare tactic messages about prescription drug misuse resonated strongly. The data also suggest a substantial difference in message resonance between seventh and eighth grade students. Overall, the findings suggest the need to craft and target different types of messages for prescription drug misuse prevention to targeted teen audiences.

November 2009

Eric C. Twombly, Kimberly A. Stringer, & Kristen D. Holtz, KDHRC

Latinos in the United States face numerous barriers to accessing health care and suffer from relatively low health outcomes. To address these barriers and improve Latinos’ health, community-based nonprofits attempt to use innovative and creative health care delivery methods, including promotores programs. Promotores are community lay health workers, often working through nonprofit organizations, who provide outreach and services to Latinos. Using primary data from a sample of national experts, this paper explores the challenges faced by nonprofits in the implementation of promotores programs. The findings suggest three key implementation problems: the lack of standardized information on promotores programs, labor issues, and organizational costs. The paper concludes with several strategies to addresses these problems.

November 2009

Stephanie N. MacLaverty, Eric C. Twombly, & Kristen D. Holtz, KDHRC

One traditional avenue to developing health literacy is through health educational curriculum in primary and secondary schools. However, recent policy shifts that emphasize core curriculum learning standards decreased the ability of schools to offer health content. Thus, supplementing the core genetics curriculum with health content is a possible approach to increase health literacy in the current educational environment. Qualitative data suggest that control is the primary institutional and instructional barrier to the adoption and use of supplemental genetics educational materials. However, teachers report that supplemental educational materials with specific elements can help minimize this barrier and allow teachers flexibility to maximize the health content they can deliver. But to effectively build health literacy, supplemental materials must relate genetics to personal health. When combined with effective teaching practices, such as inquiry-based activities and content that is adaptable to different levels of student ability, supplemental genetics materials may help minimize barriers and make genetics education an effective conduit to build students’ health and genetic literacy.

July 2008

Kristen D. Holtz, KDH Research & Communication & Eric C. Twombly, Georgia State University

The misuse of prescription drugs by teens in the United States is a growing problem. Results of national surveys of youth drug use report such substantial increases in nonmedical use of prescription drugs that the current generation of youth has been referred to as “Generation Rx” (PDFA, 2005). Although there is basic information on patterns of misuse among teens, there are few systematic analyses of what influences teens’ knowledge about and attitudes towards prescription drugs – key factors for the creation of effective prevention programs – and even less research on methods to curb these increases. To address this information gap, this brief combines multiple bodies of research to construct recommendations to stem the growing problem of prescription drug misuse by teens.

June 2008

Eric C. Twombly, Georgia State University & Kristen D. Holtz, KDH Research & Communication

Research on illicit drug use among elementary school children suggests that usage is high. For example, Wallisch and Liu (1998) report that 36 percent of fourth- through sixth-grade students use alcohol, tobacco, marijuana, or inhalants, and 26 percent had used one or more of these substances in the previous year. That more than one-third of children indicate the use of illicit drugs constitutes a substantial public health problem. Illicit drug use places these children at risk for negative outcomes, such as poor academic performance and increased school dropout rates, early sexual initiation, perpetration of violence, and later substance abuse (Anthony & Petronis, 1995; Gil, Wagner, & Tubman, 2004; Hawkins et al., 1997). What is more, these outcomes produce high societal costs. The cost of illicit drug use, including treatment and healthcare, productivity loss, and costs in the criminal justice system, was estimated at $181 billion in 2002 (Office of National Drug Control Policy, 2004).

May 2008

Kristen D. Holtz, KDH Research & Communication & Eric C. Twombly, Georgia State University

Drug and alcohol use among youth remains at high levels (Johnston et al., 2006), and this issue is a concern for many in the public health community because of the significant economic, social, and personal costs caused by addiction. Because the risk of addiction is highest in people who begin drug use in their youth (Office of Applied Studies, 2004), the National Institute on Drug Abuse and other government agencies suggest that prevention programs should be implemented universally through schools and should target children at early ages. Research suggests that these types of universal prevention efforts will decrease overall youth drug use and the burden of addiction (McBride, 2003).

September 2007

Eric C. Twombly, Georgia State University, Kristen D. Holtz, KDHRC & Greta K. Tessman, Emerson College and Tufts University

Health literacy is defined as the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Healthy People 2010, 2000) and refers to all forms of health promotion communication (CDC, 2005). More than 90 million people in the United States are estimated to have low health literacy (Kirsch, Jungeblut, Jenkins & Kolstad, 1993), and even people with high overall literacy may not understand critical health information if time constraints or stress interfere with their attention or comprehension skills.

November 2007

Eric C. Twombly, Georgia State University & Kristen D. Holtz, KDH Research & Communication

The use of illicit drugs, including alcohol, tobacco, and other substances, among children and youth is a considerable public health and public policy issue, not only because of alarming rates of usage, but also because of the deleterious effects that illicit drugs can have on individual users and their communities. Research on usage, for example, suggests that roughly two in five eighth graders nationally have used alcohol, while one in five have used an illicit drug (Johnston et al., 2006). What is more, youth who use illicit drugs have a higher risk for negative outcomes than those who refrain from illicit drug use. These outcomes, including poor academic performance and higher school dropout rates (Windle & Wiesner, 2004), perpetration of violence (U.S. DHHS, 2001), and later substance abuse and dependence (Gil et al., 2004), create considerable economic and social consequences, including treatment costs and lost economic productivity.

August 2007

Kristen D. Holtz, KDHRC & Eric C. Twombly, Georgia State University

Drug and alcohol use among youth remains at pervasively high levels, but students are receiving less school-based prevention. Infusing health information into core curricula may be a valuable prevention approach. Therefore, behavior change theory was used to develop a science education curriculum on drugs for fourth- and fifth-grade students, which was then evaluated using a pretest/posttest quasi-experimental design. Exposure to the curriculum was associated with a change in knowledge; other characteristics like grade level also played a role. More positive attitudes toward science at pretest predicted greater knowledge change, and students who knew less at the start showed a greater change in knowledge. Results of this evaluation may support the efficacy of the curriculum and the utility of combining behavior change theory with educational approaches.

August 2007

Kristen D. Holtz, KDHRC & Greta K. Tessman, Emerson College and Tufts University

This study examines the impact of a video-based intervention to increase children’s knowledge and positive attitudes toward a peer with Tourette Syndrome (TS). TS, a neurological disorder characterized by verbal and motor tics, is a confusing and potentially stigmatizing disorder. Although symptoms wax and wane over the life span, TS typically begins in childhood and peaks at puberty. The available literature suggests that individuals with TS are at risk for social rejection; because TS is primarily a childhood disorder, many of the social adjustment problems experienced by individuals with the disorder have their roots in negative childhood experiences in the classroom.

An intervention was developed and evaluated using a pretest, posttest control group study. Children exposed to the intervention video showed greater changes in knowledge, positive attitudes, and behavioral intentions than a control group. Such interventions may have potential to improve social outcomes for children with differences.

August 2007

Eric C. Twombly, Georgia State University, Kristen D. Holtz, KDHRC & Greta K. Tessman, Emerson College and Tufts University

This paper reports on the development and evaluation of a science education-based multimedia prevention curriculum on drugs of abuse. The evaluation used a pretest/post-test quasiexperimental design in which sixth, seventh and eighth-grade students in the treatment group (N=611) were exposed to the curriculum and those in the control group (N=731) were not. Eight charter schools in four states participated. Descriptive and multivariate approaches were used to analyze data from knowledge and attitude measures. The findings suggest that the multimedia approach significantly improved knowledge about drugs of abuse in the treatment group, providing preliminary support for the approach of using multimedia science education as a health education and prevention tool in schools.

August 2007

Eric C. Twombly, Georgia State University, Kristen D. Holtz, KDHRC & Greta K. Tessman, Emerson College and Tufts University Working Paper 07-004

Science literacy is critical for civil society, and attitudes toward science in school have been found to be strong predictors of achievement. Science literacy is of particular concern for the field of substance abuse research. This paper reports the results of an evaluation of a science education curriculum for late elementary school students on drugs of abuse and explores the role that attitudes toward science and attitudes towards drugs played in predicting student outcomes. The main finding is that students with positive attitudes toward science before the implementation of the curriculum tend to show greater acquisition of knowledge. In contrast, students with less protective attitudes toward drugs were found to show greater knowledge acquisition. This study suggests that the development of new pedagogical methods to improve science achievement by identifying and intervening with students who may have more negative attitudes toward science, prior to the implementation of core content, may have value.

December 2006

Kristen D. Holtz, KDHRC & Sid J. Schneider, Westat

A peer-education videotape was developed for elementary school classes with a student with Tourette Syndrome, a chronic, frequently stigmatizing tic disorder. Triads consisting of a child with Tourette Syndrome, the child’s parent, and the child’s teacher were randomly assigned to either an intervention or control group. The triads completed sets of instruments three times, over five weeks. Only the intervention group received the videotape, as part of a classroom presentation between the first and second data collection times. The results indicated that the triads in both groups perceived gradual improvements in the children’s social adjustment. The intervention and control groups, however, also differed in several respects. In the intervention group, the parents reported that their children acquired more friends following the classroom presentation. The children, however, reported having fewer friends at school, less athletic competence, and worse physical appearance. The implications of the results for peer-education interventions are discussed.

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