Massage therapist Esther Sager will present Reiki: A Vibrational Alternative, 6:30 to 8 p.m. Tuesday, July 8, at the Ephrata Health Pavilion, 175 Martin Ave.

Reiki is a hands-on energy discipline.

The free program is sponsored by Ephrata Community Hospital’s Center for Women’s Health.

Registration is required. Call 721-5750.

The nonprofit St. Joseph Health Ministries recently delivered thank-you floral bouquets to some 200 members of the Lancaster County Dental Society.

Grin Grams plays off the name of the ministry’s children’s oral- health initiative, Brush. Brush. Smile!

Royer’s Flowers, which has five Lancaster County stores, provided the bouquets.

Originally published by The Beat.

(c) 2008 Intelligencer Journal. Provided by ProQuest Information and Learning. All rights Reserved.

By Gillissen, Adrian

To the Editor: I read with interest the article by Dr. Wedzicha and colleagues (1) wherein the authors compared clinical efficacy of a 104-week treatment with salmeterol/fluticasone propionate fixed combination (SFC) with a treatment with tiotropium bromide in chronic obstructive pulmonary disease (COPD). However, a few important aspects regarding the severity of COPD in the recruited patients and the interpretation of the results merit further attention.

First, the authors included COPD patients with a postbronchodilator FEV^sub 1^

Finally, the authors rightfully make a very careful statement about the reduction in mortality in the SFC group compared with tiotropium bromide, since mortality was not a prespecified efficacy endpoint. Therefore, no measures were taken to confirm primary causes of death by an independent clinical endpoint committee (1). It is, however, encouraging to recognize that both treatment regimens resulted in an all-cause mortality which was considerably lower (3-6% in 2 yr) than that reported across all groups of the TORCH trial (12.6-15.2% in 3 yr) (3). This is particularly interesting, since the patient population in the INSPIRE study had more severe COPD than that in TORCH (1, 3)

In summary, the real “unexpected finding” of this study is that SFC and tiotropium were equally efficacious with respect to the primary endpoint of exacerbations. This result is even more interesting in a patient population where guidelines recommend that long-acting bronchodilation should be complemented with an inhaled corticosteroid.

Conflict of Interest Statement: A.G. has received fees for advisory board activities from GlaxoSmithKline (GSK) ($10,500 in 2005, $8,500 in 2006, $9,100 in 2007) and Boehringer Ingelheim ($3,000 in 2005, $3,000 in 2006, $2,700 in 2007); he has received lecture fees from GSK ($7,500 in 2005, $8,000 in 2006, $9,200 in 2007), Boehringer Ingelheim ($2,000 in 2005, $3,500 in 2006, $330 in 2007), and Pfizer ($500 in 2006, $750 in 2007); he has received industry-sponsored grants from Boehringer Ingelheim ($97,000 in 2006 and 2007).

References

1. Wedzicha JA, Calverley PMA, Seemungal TA, Hagan G, Ansari Z, Stockley RA; for the INSPIRE Investigators. The prevention of chronic obstructive pulmonary disease exacerbations by salmeterol/ fluticasone propionate or tiotropium bromide. Am J Respir Crit Care Med 2008;177:19-26.

2. Seemungal T, Stockley R, Calverley P, Hagan G, Wedzicha JA. Investigating new standards for prophylaxis in reduction of exacerbations: the INSPIRE study methodology. COPD 2007;4:177-183.

3. Calverley PMA, Anderson JA, Celli B, Ferguson GT, Jenkins C, Jones PW, Yates JC, Vestbo J; for the TORCH Investigators. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med 2007;356:775-789.

ADRIAN GILLISSEN

St. George Medical Center

Robert-Koch-Hospital

Leipzig, Germany

Copyright American Thoracic Society Jul 1, 2008

(c) 2008 American Journal of Respiratory and Critical Care Medicine. Provided by ProQuest Information and Learning. All rights Reserved.

By Lordly, Daphne Taper, Janette

Changing demographics in aging place new demands on dieticians related to education and subsequent employment. This study presents data from a survey illuminating dietitians’ perceptions concerning the acquisition of entry-level clinical competence within a single practice setting. A purposive sample consisting of recent, employed internship graduates (n = 8) and internship supervisors (n = 6) from both long-term and active care settings completed a survey and was interviewed. While initial analysis suggested there were perceived risks and benefits associated with receiving clinical training exclusively in either of the environments, a more disturbing finding was a pervasive attitude indicating long-term care dietitian roles and training were devaluated. Thematic analysis indicated that issues related to career commitment, skill development, and philosophy of care were barriers to viewing training or working in long-term care as comparable to training or working in active care environments. Attitudes expressed were based on assumptions that could be clarified through increased education and communication, leading to a greater understanding of dietitian roles. Individual and professional efforts must be directed at creating a professional culture that fosters the valuing of all practice areas and the recognition of unique, rather than inferior, skills, knowledge, attitudes, and behaviors that support those environments. J Allied Health 2008; 37:78-81. THE AGE STRUCTURE of the population of Canada has been changing gradually over the past century. Statistical projections suggest that the percentage of older Canadians will reach 27% by 2031.1 An aging population has many social implications, including a tremendous impact on the health care system and the nutrition services it provides.2 Similar data from the United States indicate an expected doubling of the population age 65 years or older by 2030.3 As the population of North America ages, the need for dietitians to work with this segment of the population is increasing.

A need for increased internship placements for clinical training of dietetic students has led to the exploration of long-term care (LTC) settings as potential sites for such training.4

As faculty members with experience in internship and also in the area of aging, we conducted a study with professional dietitians and recent interns, now employed, to examine their perceptions of the possible risks and benefits of attaining clinical competencies through an LTC setting. The overall findings suggested that entry- level clinical competence is attainable in an LTC environment. However, a negative attitude toward dietitians trained and/or working in LTC surfaced.

Our findings provide an important, although disturbing, insight into negative attitudes among current professionals toward those working in LTC settings and toward the possible use of such settings as internship placements for the clinical training of future dietitians. They point to a need to examine and question the value we place on the elderly and those professionals who care for them. Thus, the purpose of this study was to explore the assumptions concerning the devaluation of LTC dietitians and training sites that emerged during our initial investigation.

Methods

PARTICIPANTS

In Canada, integrated interns complete their practical professional experience in conjunction with their undergraduate degree. A purposive sample was recruited from one such program. The sample consisted of recent, now employed, program graduates who had received clinical training in either an active care (AC) (n = 4) or an LTC (n = 4) setting and intern supervisors who currently were working in either setting (AC, n = 3; LTC, n = 3). This sampling ensured a cross section of experiences from specific practice areas would be captured. All individuals who were approached agreed to participate. Ethics approval was obtained through the University Research Ethics Board. Informed consent was provided by each participant.

DATA

Data, collected in two stages, were part of a larger mixedmethods study exploring the acquisition of entry-level clinical competence within a single practice environment.5 Respondents first completed a mailed questionnaire developed by one of the researchers that was based on Dietitians of Canada entry-level competency statements.6 These statements represent the knowledge, skill, and behavior necessary for entry-level dietetic practice and address six areas, including assessment (7 questions), planning (6 questions), implementation (4 questions), evaluation (5 questions), professional practice (9 questions), and communication (14 questions). The questionnaire was pilot tested for face and content validity by a small group of dietetic interns and revised to reflect their comments. Each competency statement was listed. Participants were asked in which environments the various Dietitians of Canada competencies could be developed and which competencies were thought to be transferable from LTC to AC and vice versa. Space was left for additional comments. A sample question is shown in Table 1.

All questionnaires that were administered were completed and returned. Subsequently, individual interviews, conducted in person or by telephone by a trained research assistant, provided an opportunity to confirm and expand on respondent questionnaire responses and to gather qualitative data regarding respondent thoughts on the acquisition of clinical skills. The tape-recorded interviews were transcribed and thematically analyzed7 with the assistance of Data Management Software QSR N6 (The Praxis Group, Calgary, AB). The questionnaire responses were manually tabulated and frequencies established. Qualitative comments collected were independently analyzed for emerging themes and collaboratively discussed to reach agreement on final coding by both the researchers and the research assistant.8 Member checking of survey comments by respondents, ongoing discussion with the researchers and the assistant, and detailed documentation of methods and interpretations both to minimize researcher bias and to provide an audit trail contributed to data trustworthiness.7,9,10

The themes that emerged in relation to the risks and benefits of receiving clinical training in either setting included issues around philosophy of care, approach to practice, attitude, working environment, depth and breadth of experience, relationships (both client and professional), practice outcomes, and employment opportunities. During this initial risk/benefit analysis, several assumptions surfaced that indicated an undervaluing of the LTC environment and LTC dietitians. Thus, a second level of thematic data analysis was completed to explore these apparent negative assumptions and is reported in this article. Themes were not predetermined; rather, they emerged from the data. Selected respondent quotes are included for illustration.

Results

The devaluing of the LTC practice environment and dietitians appeared to be built on a number of interrelated assumptions that served to position the LTC training environment and dietitians as “less than” the AC environment and dietitians. While all interns receive a comprehensive approach to dietetic education,6 based on entry-level competency statements, complemented by a view to lifelong learning, respondents differentiated experiences by practice area. This tendency is supported by an attitude that devalues LTC. Results suggest that perhaps there is not enough cross- communication between AC dietitians and LTC dietitians for them to fully understand and appreciate what the other does in their respective positions. Career commitment, skill development, and philosophy of care emerged as themes related to the devaluation of LTC roles and are discussed in the following text.

CAREER COMMITMENT

Respondents suggested that individuals who chose to work in an LTC environment did so with a lesser level of commitment. Several quotes supported this assumption: “. . . with clinical dietitians in my experience, there’s a perception that if you work in LTC, it’s not a serious career choice. Like that’s someone who didn’t really want to work but they wanted to get out of the house might choose.””I sometimes perceive in students, they sort of like, well that’s [LTC] kind of a second choice.””Some people would take a LTC position … filling in the gap until they got what they really wanted.”

SKILL DEVELOPMENT

The value that is placed on the experiences of AC dietitians seems to be centered on their technical skills; the value of the experiences of LTC dietitians appears to be centered on their interpersonal skills. It was suggested that AC allowed for a vast quantity of data assessment in a short period and provided more technical challenges. In comparison, LTC fostered an understanding of quality of life and provided more human psychosocial challenges. Even though LTC dietitians were acknowledged to have “maybe stronger interpersonal skills . . . greater patience . . . better skills at working on an interdisciplinary or multidisciplinary team,” it was felt that the knowledge deficit on the technical aspects would be a major barrier to their employment in AC. Interestingly, respondents did not view a lack of interpersonal or social skills as a barrier to working in LTC. These results suggest there are differences in the amount of value that is placed on these respective skill sets. PHILOSOPHY OF CARE

There are diverging philosophies of care that exist between AC and LTC; AC tends to focus on immediate care based on the generation of laboratory values and facts intended on extending life, whereas LTC focuses on quality of life based on a more holistic assessment of the client. It would appear that such a holistic approach is devalued. As one individual pointed out “the philosophy of care in LTC has an emphasis on quality of life, maintenance, and a dietary emphasis on enjoyment and pleasure . . . versus being therapeutically correct.” This philosophy of care may mean that the role of the dietitian is “sort of looking after … a caregiver kind of role.” Another respondent did worry though that “the danger in AC is that people could be reduced to a set of lab values and the humanity is lost.” Such concerns seemed to be explained or dismissed by the fact that more “down time” in LTC allowed dietitians to focus on “extras” of patient care. Practicing within a distinct philosophy of care may contribute to assumptions about practice, both one’s own and others.

These differences in career commitment, skill development, and philosophy of care ought to be viewed as appropriate and valued responses to very different work environments. Assumptions contribute to the attitudes AC and LTC dietitians share toward one another’s practice. The relationship between the attitudes and the values placed on AC and LTC experiences may be cyclical in nature in that as the attitudes are formed and acted on, values are shaped and formed; as the values are shaped, attitudes develop. One respondent admitted, “stereotypes are very different than the realities in most cases. But people base things on stereotypes.”

Discussion

The generation and perpetuation of negative stereotypes about older adults and the aging process is well documented in Western culture.11-15 Such negative stereotypes marginalize the elderly population within our youth/younger adult-centered society.

Studies indicate that the attitudes of many students concerning older adults are consistent with negative aging stereotypes.16-18 Even with changing demographics, students training for health care professions (nursing, medicine, and social work) did not consider work with older adults to be a high priority and ranked caring for older adults as their least preferred choice of practice setting.19 Social work students have been shown to have negative attitudes toward older adults and their service providers, which negatively impact the choice of geriatric social work as a desired area of practice among undergraduate social work students.20 Kaempfer et al.21 report that dietetics students had a low knowledge about aging and neutral attitudes toward older adults. When asked which of 10 age groups they preferred to work with, respondents ranked the three oldest age groups (65 to 74 yrs, 75 to 84 yrs, 85 yrs and older) lowest.

Current undergraduate preparation may include geriatric nutrition as an elective22 with limited coverage in other applicable required courses (i.e., life cycle nutrition), representing a small proportion of overall dietetics training. Geriatric exposure within internship is not mandatory; however, students may choose such an experience. The majority of our students opt for internship in AC environments. The current positioning of geriatrics in both the undergraduate and internship programs may not foster an appreciation of this area of study as a desirable choice.

While evidence indicates that negative attitudes held by health professionals about the elderly adversely influence the quality of services provided,23 there is a lack of research describing how current professionals view their colleagues who have chosen to work with the elderly population. It is possible that negative stereotypes also carry over to this group of professionals. Worldwide, informal caregiving by family and friends is the predominant form of care to seniors as they age.11 It is possible that individuals providing care services in LTC settings are simply viewed as an extension of this informal, rather than professional, caregiving. Negative attitudes about geriatric/gerontology professionals and practice settings may mean that students will be less interested in working with older adults despite the dramatic increase in size and needs of the older population. This could have detrimental consequences for the increasing demand for professionals in this area and negatively impact the nutritional health of the elderly.

Given the pervasiveness of negative stereotypes about aging in our society, future research must be designed to focus on factors that enable individuals to overcome such stereotypes. Additional training may be a first step toward a more age-sensitive health care system either through inclusion of information on aging and exposure to geriatric/ gerontology professionals in university curricula or continuing education opportunities. Cohen et al.20 have demonstrated the positive effect of focus groups to deconstruct negative attitudes and replace them with more positive and accurate information about older adults. When students’ misconceptions about older adults were confronted, they became more interested in choosing geriatric social work as a career option. Kaempfer et al.21 also suggest that more aging education in dietetics curricula could improve student attitudes. It would be hoped that aging education provided by knowledgeable and experienced professionals would help to eliminate stereotypes and increase respect for LTC professionals and the practice areas in which they work.

Conclusions

Although the results of this study cannot be generalized due to the small sample recruited from a single internship program, they do suggest the need to further investigate existing perceptions related to career commitment, skill development, and philosophy of care held by current practitioners. Our results may reflect the experiences, academic and internship, available through this program. However, current training is based on Dietitians of Canada accreditation standards, which are nationally applied. As dietetic professionals, we need to be cognizant that ageism, as constructed by and within our society, may shape professional opinion and bias professionals as they evaluate training programs and formulate hiring policies.

Individual and professional efforts must be directed toward creating a professional culture that fosters the valuing of all practice areas and the recognition of the development of unique, rather than inferior, skills, knowledge, attitudes, and behaviors that support those environments. Increased communication may lead to a greater understanding and appreciation of dietitian roles.

REFERENCES

1. Statistics Canada: Annual demographic statistics. Ottawa, Ontario, Canada: Statistics Canada; 1999.

2. Health Canada: Healthy aging: nutrition and healthy aging. Ottawa, Ontario, Canada: Health Canada; 2002.

3. U.S. Bureau of the Census: Population projections of the United States by age, sex, race and Hispanic origin: 1995-2050. Available at: http://www.census.gov/prod/1/pop/p25-1130/ p251130.pdf. Accessed June 27, 2006.

4. Molag M: Developing gerontology focused internship in British Columbia. Practice 2001; 15:1-5.

5. Lordly D, Taper J: Gaining entry-level clinical competence outside of the acute-care setting. Can J Diet Pract Res 2008; 69:32- 36.

6. Dietitians of Canada: Dietetic internship Program Procedures Manual. Toronto, Ontario, Canada: Dietitians of Canada; 1997.

7. Morse J, Field P: Qualitative Research Methods for Health Professionals. London, England: Sage; 1995.

8. Lincoln Y, Guba E: Naturalistic Inquiry. Newburg Park, CA: Sage; 1985.

9. Guba E: Criteria for assessing the trustworthiness of naturalistic inquiries. Educ Commun Technol 1981; 29:75-91.

10. Guba E, Lincoln Y: Fourth Generation Evaluation. London, England: Sage; 1989.

11. Chappell N : Correcting cross cultural stereotypes: aging in Shanghai and Canada. J Cross-Cui Gerentol 2003; 18:127-147.

12. Fiske S: Stereotyping, prejudice and discrimination. In: Gilbert DT, ed. The Handbook of Social Psychology. Volume 2. 4th ed. New York: McGraw Hill; 1998:pp 357-411.

13. Cuddy A, Fisk S: Doddering but dear: process, content and function in stereotyping of older persons. In: Nelson TD, ed. Ageism: Stereotyping and Prejudice Against Older Persons. Cambridge, MA: MIT Press; 2002:pp 3-26.

14. Cohen H: Developing media literacy skills to challenge television’s portrayal of older women. Educ Genrontol 2002; 28:599- 620.

15. Harwood J: “SHARP” Lurking incoherence in a television portrayal of an older adult. J Lang Social Psychol 2002; 19:110- 140.

16. Hawkins M: College students attitudes toward elderly persons. Educ Gerontol 1996; 22:271-279.

17. Tan P, Hawkins M, Ryan E: Baccalaureate social work student attitudes toward older adults. J Bacc Soc Work 2001; 6:45-56.

18. Gellis Z, Sherman S, Lawrence F: First year graduate social work students knowledge and attitude towards older adults. Educ Gerontol 2003; 29:1-16.

19. Carmel S, Civikel J, Galinksy D: Changes in knowledge attitudes, and work preferences following courses in gerontology among medical, nursing and social work students. Educ Gerontol 1992; 18:239-342.

20. Cohen H, Sandel M, Thomas C, et al: Using focus groups as an educational methodology: deconstructing stereotypes and social work practice misconceptions concerning aging and older adults. Educ Gerontol 2004; 30:329-346.

21. Kaempfer D, Wellman N1 Humburg S: Dietetics students low knowledge, attitudes, and work preferences toward older adults indicate need for improved education about aging. J Am Diet Assoc 2002; 102:197-202.

22. Mount Saint Vincent University academic calendar 2006-2007. Available at: http://www.msvu.ca. Accessed April 26, 2007. 23. Palmore E: Ageism Negative and Positive. New York, NY: Springer; 1999.

Daphne Lordly, EdD(c), MA, PDt

Janette Taper, PhD

Dr. Lordly is Associate Professor and Dr. Taper is Professor, Department of Applied Human Nutrition, Mount Saint Vincent University, Halifax, Nova Scotia, Canada.

Received October 11, 2006; revision accepted June 28, 2007.

Address correspondence and reprint requests to: Daphne Lordly, EdD(c), MA, PDt, Department of Applied Human Nutrition, Mount Saint Vincent University, Halifax, Nova Scotia B3M 2J6, Canada. Tel 902- 457-6259; fax 902-457-6134; e-mail [email protected].

Copyright Association of Schools of Allied Health Professions Summer 2008

(c) 2008 Journal of Allied Health. Provided by ProQuest Information and Learning. All rights Reserved.

By Lyons, Kevin J

This issue will be my last as Editor of the Journal of Allied Health. When my term ends this month, I will have served as Editor for 10 years, which will be the longest tenure of any editor of the Journal. It has been a great ride. When I first assumed the job, my greatest concern was whether I would be able to maintain the work of previous Editors in building our Journal. I hope I have succeeded. It has been an interesting time and one that has been very fulfilling to me, both professionally as well as personally. I have watched the Journal grow over the years as we have moved from a publication with national visibility to one with international scope, as now an average of 20% of our submission come from outside the United States. The number of submissions continues to increase and today averages close to 80 per year, and this number continues to grow. Along with that, our acceptance rate of approximately 60% for Original Articles makes us comparable to other quality journals. We have been able to do this while still maintaining opportunities through Research Notes and Potential Patterns for novice researchers to gain exposure to scholarship and experience in publishing.

None of this growth would have been possible without the strong contributions of a number of people who rarely get the acknowledgments that they deserve. My heartfelt thanks go out to Mary Mullison, who was my first Editorial Assistant; Lisa Marzucco, my right-hand person for more years than she will admit, who stepped in when Mary left; Jessica Kaplowitz, who became Managing Editor when we moved our operations to an electronic format and made the transition seamless; Tom Elwood, who contributed many ideas that kept the Journal up with the times; and Mike Bokulich, who stepped in as our publisher when our original publisher, Hanley & Belfus, was sold. A special thank you also goes out to the many Editorial Board members and peer reviewers who have done a superb job, not only in reviewing manuscripts but also in working to make them better.

My very best wishes go out to Tom Elwood, as he becomes the seventh editor of the Journal in July. I cannot think of a better person to uphold the standards that the Journal has maintained over the years. I look forward to watching our Journal continue to grow and prosper.

As we move forward, the terms of many on the Editorial Board are expiring. If you would like to recommend anyone, please let Tom know.

This summer issue contains six Original Articles and three Commentaries. The online e-supplement contains three Research Notes, a Potential Pattern, and another of our International Features. In keeping with policy, the article from this issue available for a free download is “Training for Interdisciplinary Health Research: Defining the Required Competencies,” by Kristine Gebbie, Benjamin Mason Meier, Suzanne Bakken, Olveen Carrasquillo, Allan Formicola, Sally Aboelela, Sherry Glied, and Elaine Larson.

Interdisciplinary approaches to health care are fast becoming recognized as an important way to address many health conditions. It is generally accepted that effective interdisciplinary approaches require collaborative teamwork from those participating. However, little is known about the competencies required to be successful when working in teams. Kristine Gebbie and her research group report the results of their Delphi study that was designed to identify these competencies. The Delphi panel, comprised of interdisciplinary researchers, was able to identify and reach consensus on 17 competencies believed to be necessary for interdisciplinary collaboration.

In another study exploring interdisciplinary or interprofessional approaches, Jennifer Furze and her colleagues assessed the impact of an interprofessional, community-based project with older adults on the attitudes of students from four health professions. Using the Interdisciplinary Education Perception Scale and Survey of Attitudes on Aging Scale, they investigated whether participation in the project produced changes in the attitudes of students from nursing, occupational therapy, physical therapy, and pharmacy. Statistically significant improvements were found in some of the professions in their attitudes on aging and in an increased respect toward other health care professions

Issues related to caring for older adults also formed the topic of another study, this time in dietetics. Lordly and Taper conducted a mixed method study of dieticians’ perceptions concerning the acquisition of entry-level competence if they received training exclusively in a long-term care setting as compared to an active care setting. They used survey data and in-depth interviews of internship graduates and supervisors from both settings. They found that while there were both positive and negatives associated with training exclusively in one of the settings, thematic analysis revealed that more negative attitudes were associated with training in a long-term care setting in terms of skill acquisition.

The implementation of best practice guidelines can be problematic if these guidelines are not accepted by those who are most closely involved in their implementation. Dana Lawrence and his colleagues reference a case in the chiropractic profession where disagreement regarding the value of a set of clinical guidelines resulted in enough opposition to render the guidelines useless. To understand how better to approach implementation, they conducted a focus group of leaders in the profession, for the purpose of identifying, from these leaders, the variables that must be considered in implementing best practice guidelines. The authors found that implementation needs to be accepted system-wide and that multifaceted strategies must be used to disseminated them.

The question of why students attend college and continue to pursue their education is one that has not been studied extensively. Determining the type of motivation of allied health students may have an influence on the way that these students practice and the type of motivating environment they create for their clients. Ballmann and Mueller studied a convenience sample of over 220 upper- class and graduate allied health students, using the Academic Motivation Scale to identify the reasons that these students are attending college. The results allowed them to identify several key reasons why students continue in their academic program. The authors suggest that if allied health programs provide their students with an educational environment that supports self-determination, this may result in those students’ providing the same type of environment for their clients upon graduation.

Identifying the variables that are the best predictors of success in academic programs is an ongoing process. Multiple preadmission variables, including personal interviews, are often used to decide which students to admit into allied health programs. However, the evidence for the success of any of these variables, particularly personal interviews, is conflicting. Hollman and his research team conducted a retrospective study to determine inter-rater reliability on the behavioral interview in physical therapy for assessing future performance and to calculate the ability of commonly used admissions variables to predict success on the physical therapy licensing examination (NPTE). They found evidence to support the utility of the behavioral interview and verbal subscale of the GRE to predict performance on the NPTE.

Abundant evidence suggests that quality health care can be severely compromised by workforce shortages. As a result, workforce planning requires that attention be paid to a number of variables, such as ways to improve retention, in addition to strategies for recruitment. Betty Rambur and her team conducted a statewide study to investigate job satisfaction, intention to leave current position, intention to leave ones’ profession, and the reason for such intentions, in four professions-medical laboratorians, respiratory therapists, radiographers, and registered nurses. They found that while members of these professions had a relatively high level of satisfaction, over 20% in each profession were somewhat or very likely to leave their positions in the next 12 months. These seemingly contradictory findings are discussed, as are implications for future workforce policy.

Students with disabilities are enrolling in health care education programs in increasing numbers. These students pose potential issues for educators and administrators, such as academic adjustment, required services, and the need for auxiliary aids. With the exception of the medical and nursing literature, there is limited information addressing these issues. It is important to understand the impact of the law on education programs and on the rights of these students. In the first Commentary, Katherine Newsham reviews the case law and legislation as it applies to students with disability.

Direct-to-consumer (DTC) advertising by pharmaceutical companies has become more prevalent in recent years, a trend that presents both positive and negative consequences for consumers’ health. In the second Commentary, Isaac Montoya and his colleagues present an overview of DTC advertising and discuss the implications for physicians, pharmacists, consumers, and insurers.

Finally, there appears to be an upsurge in behaviors antithetical to academic integrity by students in many colleges and universities. Ken Randall and his team describe how students and faculty in one occupational therapy and physical therapy program went about formulating and refining an honor statement and a process for addressing issues related to academic integrity. The online e- supplement contains three Research Notes and one Potential Pattern. In the first Research Note, Diane Wyatt and her team present the results of their work investigating the development of process for criminal background checks, which are now required at most universities. In the second, Debbie MacLellan and Daphne Lordly discuss the influence of preceptors on the socialization of dietetic students. In the third, Gary Blau and his research team present the results of their research on professionally related differences among a group of laboratory professions. Interdisciplinary teamwork is the topic of the Potential Pattern in this issue: Janet Buelow and her colleagues present the results of a study that was designed to build interdisciplinary teamwork among students using live clinical case simulations. Finally, the International Perspective, by lain Graham, describes the development of higher education for health care professionals in Europe.

Have a relaxing and enjoyable summer. see you in Baltimore.

KEVIN J. LYONS, PHD, FASAHP

Philadelphia

[email protected]

Copyright Association of Schools of Allied Health Professions Summer 2008

(c) 2008 Journal of Allied Health. Provided by ProQuest Information and Learning. All rights Reserved.

By David Singleton, The Times-Tribune, Scranton, Pa.

Jul. 2–Geisinger South Wilkes-Barre employees who learned last week their jobs will be eliminated in September are now learning something else.

Their skills are in demand.

In newspapers ads this week and a direct mail effort that will follow, Mercy Health Partners is making an aggressive pitch for soon-to-be-displaced nurses and other employees who worked at the hospital when it was known as Mercy Wilkes-Barre to rejoin the Mercy organization.

Other area health care facilities have also been quick to recognize the cutbacks at South Wilkes-Barre as a chance to plug critical staffing holes.

“Given the size of our health care system and the diverse opportunities for professionals and other employees, we would always have openings for talented, experienced people,” said Jim Carmody, vice president of human resources for Wyoming Valley Health Care System.

Geisinger said Thursday it will cut about 400 jobs at South Wilkes-Barre as it restructures services there and at Geisinger Wyoming Valley. Of the jobs that will be eliminated, approximately 170 are in nursing, 100 are technicians or aides, and the rest are support staff and maintenance, Geisinger spokesman Dave Jolley said.

Mercy Health Partners views the shake-up as an opportunity to welcome back former employees dispossessed when Mercy sold the Wilkes-Barre hospital to Geisinger in 2005 but who are still passionate about the Mercy ministry, said John M. Starcher Jr., interim president and CEO.

Between its hospitals in Scranton and Nanticoke, Mercy has more than 100 openings in a variety of positions.

“To the extent we can create a win-win out of this and fill our needs with former Mercy employees, I can’t think of anything better than that,” Mr. Starcher said.

Mercy is sweetening its invitation by offering former employees credit for their previous years of service with the organization, which can affect a worker’s salary, pension, vacation accrual and tuition reimbursement.

Community Medical Center has been in touch with the human resources department at South Wilkes-Barre and “will be working with them in accommodating some of these (displaced) employees,” spokeswoman Jane Gaul said.

Hazleton General Hospital is inviting South Wilkes-Barre workers to an open house July 16. Although the event was scheduled before last week’s announcement, the timing will work out well for the hospital, which has more than 25 open nursing positions, said Jim Edwards, CEO of the Greater Hazleton Health Alliance.

“We are looking at this as an opportunity for us to fill some vacant positions and provide some people who aren’t going to have jobs an opportunity … to join a successful team,” Mr. Edwards said.

Daniel J. West, Ph.D., associate professor and chairman of health administration and human resources at the University of Scranton, said displaced workers whose specialities are in high demand — nurses, pharmacists, physical therapists — will be snatched up quickly.

Others will have a more difficult search for employment, especially at a time when no hospitals in Northeastern Pennsylvania are truly expanding, he said.

Contact the writer: [email protected]

—–

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Centene Corporation (NYSE: CNC) today announced that it has closed the acquisition of Celtic Group, Inc., the parent company of Celtic Insurance Company (“Celtic”), effective July 1, 2008. Concurrent with regulatory approval of the transaction, Centene received regulatory approval from the Illinois Division of Insurance to realize an extraordinary dividend.

Celtic is a national individual health insurance provider that provides high-quality, affordable health insurance to individual customers and their families. This acquisition uniquely positions Centene as a national leader in providing government-sponsored and market-driven solutions to increase access to high-quality, affordable healthcare for all Americans.

Michael F. Neidorff, Chairman and Chief Executive Officer of Centene, stated, “We are very pleased to close on this transaction because Celtic will play an important role in advancing our goal of building a multi-line healthcare enterprise. Celtic positions us to offer a broad range of coverage solutions customized to the unique needs of each state. This acquisition is consistent with our product diversification strategy to add complementary capabilities that allow us to meet the evolving needs of our state customers.”

The transaction is expected to be immaterial to earnings per share in 2008.

About Centene Corporation

Centene Corporation is a leading multi-line healthcare enterprise that provides programs and related services to individuals receiving benefits under Medicaid, including the State Children’s Health Insurance Program (SCHIP), Supplemental Security Income (SSI) and Medicare (Special Needs Plans). The Company operates health plans in Arizona, Georgia, Indiana, New Jersey, Ohio, South Carolina, Texas and Wisconsin. In addition, the Company contracts with other healthcare and commercial organizations to provide specialty services including behavioral health, life and health management, long-term care, managed vision, nurse triage, pharmacy benefits management and treatment compliance. Information regarding Centene is available via the Internet at www.centene.com.

The information provided in this press release contains forward-looking statements that relate to future events and future financial performance of Centene. Subsequent events and developments may cause the Company’s estimates to change. The Company disclaims any obligation to update this forward-looking financial information in the future. Readers are cautioned that matters subject to forward-looking statements involve known and unknown risks and uncertainties, including economic, regulatory, competitive and other factors that may cause Centene’s or its industry’s actual results, levels of activity, performance or achievements to be materially different from any future results, levels of activity, performance or achievements expressed or implied by these forward-looking statements. Actual results may differ from projections or estimates due to a variety of important factors, including Centene’s ability to accurately predict and effectively manage health benefits and other operating expenses, competition, changes in healthcare practices, changes in federal or state laws or regulations, inflation, provider contract changes, new technologies, reduction in provider payments by governmental payors, major epidemics, disasters and numerous other factors affecting the delivery and cost of healthcare. The expiration, cancellation or suspension of Centene’s Medicaid Managed Care contracts by state governments would also negatively affect Centene.

By Wilmes, Barbara Harrington, Lauren; Kohler-Evans, Patty; Sumpter, David

The following paper addresses the responses that the learner has to changes in the learning environment that enhance instruction. While theorists have supported the notion that instruction embedded in sensory-filled, brain-based and hands-on activities, classrooms remain unchanged in many, if not most interactions. What can we do to wake up teachers and administrators to make these modifications? We believe as educators we must “come to our senses” to bring about best quality learning environments. The following section of this paper supports why we have come to the conclusion that sensory and brain based teaching strategies can no longer be left behind. For many years scientists viewed the brain as somewhat inflexible, subject to genetic control. Recent research, however, indicates that the brain is quite adaptable over the individual’s lifespan. Many researchers now consider environmental influences to be more significant than hereditary factors. These findings have considerable implications for educators as they directly affect pedagogical strategies used in the classroom.

Teachers can no longer ignore the findings and implications of brain-based research in the educational environment. The cognitive development of children is affected by a multitude of diverse factors, but educators have been slow to recognize the impact that brain-based research provides in our awareness of the role of the brain in learning. Since the 1960’s, research in this area is more convincingly supporting notions of the increased role of brain activity in learning. Findings suggest that heredity provides 30-60 percent of our brain’s wiring, while 40-70 percent is due to environmental factors (Jensen, 1998). Educators have a significant moral and ethical responsibility for enhancing the lifetime potential of an individual, especially since schools are places that learners reside for an average of six hours, 180 days for 13 years of their lives (Jensen, 1998).

Before teachers begin to incorporate positive changes in the learning environment, negative influences in the learning environment must be altered or removed. If undue stress, for example, is present, brain-based practices will be less successful. Teachers often resort to scolding and threats to motivate students. “Finish your work or else!” or other similar exhortations are often ineffective. Other similar strategies such as finger pointing, humiliation, sarcasm, the use of unrealistic deadlines, and other demeaning methods, also have dubious impact.

The teacher-student relationship which best facilitates learning is characterized by “trust, safety, and mutual respect”(Jensen, 1998). According to Jensen (1998), there is no evidence to suggest that the use of threats effectively meets long-term academic goals. To the contrary, there is substantial evidence to suggest that negative types of stress can prohibit learning. It is believed that such stress causes the “fight or flight” syndrome for many students. Conant (2001) stated that glucose, the fuel of the brain, travels from the center of the brain where reasoning and thought occur and goes to the muscles during stressful situations. For instance, if an instructor reprimands a student in front of the class, this action may trigger the “fight or flight” syndrome.” Once stress or fright develops, it may take some time for the body to recover, making it difficult to breathe normally, much less to learn. While humans use this defense mechanism in life-threatening situations, it can be counterproductive when used in the classroom. Stress hormones can reside in the body at high levels for several days, depending on the severity of the situation. Similar findings suggest that chronic stress in the environment may produce excess glucocorticoids, which are toxic to neurons (Conant, 1988). Once the environment is balanced, educators can begin to manipulate the environment. The following section of the paper will address manipulating the environment to include sensory-filled, brain-based instructional strategies into the classroom to produce more effective learning.

Enhancing the Visual Environment

Brain research demonstrates that human eyes are capable of registering 36,000 visual messages per hour and that over 80 percent of all information that is absorbed by the brain is visual in nature (Optimal Environments, n.d.). Therefore, it is critical that educators consider the significant role visual factors play in learning. There are several brain-based principles that are useful in creating an enriched visual environment involving movement, contrast and color. There are several ways to access the brain’s inherently fast access to these properties. An excerpt from Brain- based learning, (n.d.), published at the Brain Store, a website in conjunction with the Jensen Learning Center, offers the following suggestions for teachers: When speaking to a group, the teacher needs to move around the room, increasing and decreasing distance from the audience. Other strategies include using visual displays to demonstrate content, using authentic objects so that students can feel as well as see them, color code student materials, and turn off the lights momentarily for introspection.

Using Color and Lighting in Instructional Settings

Color in the visual environment is particularly important because of its powerful impact on the brain. Color provides electromagnetic radiations, similar to that produced by x-rays, infrared, and microwaves. Each color has its own wavelength and affects our bodies and brains differently. One study attempted to see if colors in the environment had any influence on children’s learning capacity. Several classrooms with low ceilings were painted in different colors. IQ tests were given before placing students into different colored rooms. Students who were placed in light blue, yellow, yellow-green, and orange environments increased their IQ scores by 12 points on average. Those placed in white, black or brown rooms made lower scores when given new IQ tests (Katt, 1997). Color also effects emotions. In the book, Power of Color, by Morton Walker (1991) the following responses were most common among tests subjects: Red tends to raise blood pressure, pulse rate, respiration, perspiration, and excites brainwaves. It also stimulates appetite, a reason that many restaurants use the color red. Orange is similar to red but less pronounced in its effect. Blue tends to lower blood pressure and pulse rate. Brain waves tend to decline. Blue is considered the most tranquil color. There may be times that a blue environment may be helpful in learning, such as in a classroom with hyperactive students. However, for the regular classroom, blue may be a bit too calming for most students. Green is also a fairly calming color, though less so than blue. It has similar impact on student learning. Yellow is the first color that the brain distinguishes. It is associated with a certain degree of stress and apprehension, yet stimulates a sense of well being and optimism. It could be helpful in goal-setting for students as well as for review activities. Overall, researchers have found that bright colors tend to increase creativity and energy. Dark colors, conversely, lower stress and elicit feelings of peacefulness. The colors yellow, light orange, beige, and offwhite are useful for optimal learning because they seem to stimulate positive feelings (Brain-based learning, n.d.). Researchers have also noted a strong relationship between memory and color. A recent study in Brain- based learning, (n.d.) measured the relative value or verbal cue against color cues in learning memory. In testing memory for verbal cues and memory for colors, learners remember associations with colors more accurately than those with mere black-white patterns. Thus, educators could increase learner’s potential by linking new information to color whenever possible. This strategy if used frequently could enhance learning in the classroom. Writing the featured phoneme or entire words in different colors, for example, may improve reading and spelling abilities by helping the learner effectively visualize the word.

Lighting, like color, can have impact on learning effectiveness. Most studies show that soft, full spectrum lighting is optimal for learning. But in educational classrooms today, standard florescent lighting is the most frequent light source. In one study, the researcher replaced standard florescent bulbs with full spectrum lighting in several elementary classrooms. He observed a 65 % drop in absenteeism among the affected students in Brain-based Learning, (n.d.). In his study of five Canadian schools, Henry (1999) found that natural light is more beneficial than traditional lighting. With daylight, student attendance improved, tooth decay decreased due to Vitamin D exposure, average growth of students was one and a half centimeters more than in classes with artificial light, and scholastic performance increased. Unfortunately, educators have little input into school design including light fixtures. Teachers can help reduce the harmful effects of artificial light by replacing fluorescent light bulbs with indirect and full spectrum lighting, and when possible, and keeping widows uncovered, allowing natural light to filter into their own classrooms. Sounds in the Environment

The hearing environment is also highly important in helping learners achieve maximum capability. What might describe a sound- enriched classroom? Classrooms incorporating brain-based principles involve a great deal of communication. Cooperative learning and real- world applications are crucial to a successful brain-based classroom. According to studies on noise levels, learners have divergent preferences. Some desire complete silence; others may prefer a busy, noisy environment (Brain based learning, n.d.). Instructors should be sensitive to both preferences to ensure optimal learning. Extraneous noise can be very distracting to those who need a quieter environment, while others may feel very productive in this atmosphere. Since many classroom designs have not changed over the past 20 years, those who prefer silence are often “out of luck.” Old air conditioning units and poor acoustics often add to other already existing external noises.

Possible ways teachers can reduce classroom noise include the following:

Place area rugs in discussion areas to soften sound level and movement in classrooms.

Place tennis balls on the legs of chairs preventing them from banging against tables and other chairs.

Keep windows and doors shut.

Place a rubber strip around the door to block hallway noise.

Let students use earplugs to conceal extraneous sound.

Use earphones with tapes for individual learning.

Using Music in Classrooms

Music is an element that may also be heard throughout the day. The role of music in learning is well known. Music “enriches the human intellect and spirit. It can provide solace or joy; it can entertain or educate. And music is a universal language, which helps bind together the human community (Campbell and Brewer, 1998). Music certainly has a unique way of integrating many elements of the brain. It appeals to emotional, cognitive and psychomotor elements of the brain, and several studies show a link between music and increased learning (Brain-based learning, n. d.). Unfortunately, despite the evidence for its value, often music and other art programs around the country have been reduced or cut from the curriculum.

Listening to music engages the entire brain (Jensen, 1998). Furthermore, medical research has shown that the nerves in the ear have more extensive brain connections than any other nerves of the body. Research also indicates that music directly effects pulse rate, blood pressure, the nervous system, and glands of the body (Neuman, n. d.). Music can be used for arousal, as a carrier of words, and as a primer for the brain (Jensen, 1998).

Arousal refers to the increases and decreases of attentional neurotransmitters. The theme from “Rocky” would be an example of “perk-up” music and a soft piano melody would be more relaxing. Soft background music, some studies show, results in substantial improvement in reading comprehension (Jensen, 1998).

Music is used as a carrier when the melody acts as a vehicle for the words. Words of songs are very easily remembered because of this strong musical connection, and, therefore, are often used as educational tools. Toddlers, for example, learn the letters of the alphabet through the familiar “Alphabet Song. Another example of song-based learning is the tune of “Twinkle, Twinkle, Little Star.” All musical songs do not necessarily produce the results educators desire, such as Winston cigarettes and the slogan, “Winston Tastes Good Like a Cigarette Should.” This ad is remembered today even by those who were not smokers, and even though cigarette ads have been missing from media for a number of years (Teacher’s Helper, n. d.). Academic content put with music is powerfully connected to the brain. One of the most powerful ways music enriches the environment is its ability to prime neural pathways. Neurons fire constantly. The difference between “neural chatter” and clear thinking lies in the speed, sequence, and strength of the connection. For this reason, some people are primed by certain types of music to help them get a task completed (Jensen, 1998). Campbell and Brewer (1998) stated that music is recognized as a “vital, easy, and simple tool for dynamic improvement in body and mental awareness.” They further suggest that music can be used in the classroom to accomplish various learning goals including:

creating a relaxing atmosphere, establishing a positive learning style, providing a multi-sensory learning experience that enhances memory, increasing attention by creating a short burst of energizing excitement, developing rapport, providing inspiration, and adding an element of fun.

The Teacher’s Helper (n. d.), an online educational resource, suggests using active concerts where the instructor introduces new learning material to classical music in a theatrical manner. This strategy can deliver 60% of the content in 5 % of the time! What teacher couldn’t use that kind of help in enhancing academic instructional time? The power of music to bring about learning is immense (Newman, n. d.).

What benefits can be found from the use of oral or the use of sound-based methodology in the classroom? Stahl and Yaden (2004) reported strong correlations that involved memory and recall tasks pairing a TV episode and aurally presented stories. Konoid, Juel, Minden-Cupp and McKinnon (2000) found in a longitudinal study of 213 children that oral language development significantly related to growth in phonological awareness in kindergarten children.

Benefits may also be seen when attention is given to oral language skills as they relate to written word knowledge, to comprehension and to phoneme awareness. Thus, it is imperative that teachers consistently schedule adequate time for children to talk, discuss, and for them to hear good oral language models with a widely spoken language vocabulary.

Another method using sound to produce brain activity changes was reported by McCandleiss and Posner (2003) of a study using Fast For Word, a process of rapidly changing auditory information to draw attention to changes in speech streams. This method, using amplification of sounds, has been found to increase brain activity in the posterior areas of the brain that are related to sounding out visual words. It would seem that teachers should use auditory changes in pitch and intensity to enhance children’s reading print for any academic content that may be addressed.

Using the Sense of Smell

Smell is the least obvious of the senses in its value to enrich the learning environment; however, its impact is also powerful. Wallace (2000) cited this quote from Oliver Wendell Holmes, “Memories, imagination, old sentiments and associations are more readily reached through the sense of smell than any other channel.” Scientists now recognize that they only know a fraction about olfaction and its relationship to learning. What they have discovered so far about the nose has practical applications for learning. The use of aromas produces similar effects as music in the learning environment. Both can energize, set or change a mood, relax, reinforce memory, and make the surroundings more pleasant and welcoming (Wallace, 2000).

Obviously, not all aromas produce the same effects. Certain aromas are linked to increased performance. Peppermint and lemon scents are known to energize. One study showed that groups exposed to the aroma of peppermint were able to solve puzzles 30% faster than the unexposed control group (Brain based learning, n. d.). Popcorn and fresh coffee signify a mood change and raise anticipation. Vanilla, chamomile and pine are great for performance jitters before tests to create a relaxing atmosphere. The scent of pine is used to put travelers at ease going through customs at London’s Heathrow Airport (Wallace, 2000).

Educators can reinforce memory by using the same aroma while introducing the information that will be used during the exam. Although the exact mechanism responsible for the effects of odor on memory is not known, memory seems to be enhanced when associated with odor (Lippner, 1999).

Pleasant smells can improve cognitive functioning. When exposed to pleasant odors of powder, spiced apple, and lemon, college students performed word construction and decoding tasks under stressful and no stress environments better than those not exposed to the fragrances. In addition, one study showed that a combination of floral aromas was associated with double the speed of learning (Lippner, 1999). To boost learning in the classroom, educators should use essential oils rather than artificial ones (Wallace, 2000). There are also “scratch and sniff” labels and other scented papers available to help connect learning to aromas. Computer technology has utilized aromatherapy effectively. scented papers available to help connect learning to aromas. Computer technology has utilized aromatherapy effectively. Digital scent technology has made it possible to send and receive “e-smell” messages. Websites now have the capability to release a customized scent (Wallace, 2000). Imagine the possibilities!! Although this technology is not widely available and is rather costly, instructors can very easily, and inexpensively enhance the learning environment using aromas. Furthermore, as an added bonus, the use of aromas can also energize or relax the instructor!

Conclusions

Scientists and educators alike have produced volumes of evidence and studies that demonstrate the significant impact that the environment has on learning. But why are we not putting into practice brain-based environmental strategies when we have evidence that they work? The key to a quality-learning-productive environment is a sensory-rich, brain-based classroom using techniques that include visual, color, music and sound, wide-spectrum lighting and even aromas. As long as the student’s physical needs are met, and the student feels safe and secure in an environment, sensory enrichment really has no limits. We can reduce stress through the use of color by incorporating blues and greens into our classroom walls and floor coverings; using yellow on a bulletin board in the area of the classroom where teachers conference with children to set future goals could produce good benefits; simple changes including changing out light bulbs and using natural lighting has demonstrated many benefits; teaching new information through song and music maximizes the use of teaching time; and incorporating aromas with new learning has been shown to increase recall.

Enriching student learning through using sensory strategies in a brain-based environment is one of the easiest and most rewarding ways for an instructor to begin to improve the learning environment and academic outcomes for all children! Teachers can no longer ignore the significance the sensory environment and to fail to implement the fore mentioned, wellresearched sensory and brain based teaching strategies. We educators must “come to our own senses” and implement the senses through brain-based environments and activities if we are to maximize learning opportunities for children!

References

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BARBARA WILMES, PH. D.

LAUREN HARRINGTON, MASTER’S CANDIDATE

PATTY KOHLER-EVANS, ED. D.

DAVID SUMPTER, PH. D.

University of Central Arkansas,

Conway, Arkansas

Copyright Project Innovation Summer 2008

(c) 2008 Education. Provided by ProQuest Information and Learning. All rights Reserved.

By Mosley, Don C Jr Boyar, Scott L; Carson, Charles M; Pearson, Allison W

Self-efficacy is defined as people’s judgments of their capabilities to organize and execute courses of action required to attain designated types of performances (Bandura, 1986). Self- efficacy perceptions, in concert with self-regulatory behaviors, influence the goals people set, strategies people choose, effort people expend, and perseverance people display (Bandura, 1991). Thus, successful performance requires that a person possess both the appropriate skills and abilities and strong feelings of efficacy (Lent et al., 1994). Past research has established the importance of task, domain-specific, and general self-efficacy in determining human behavior (e.g. Ackerman and Kanfer, 1993; Bono and Colbert, 2005; Erez and Judge, 2001; Judge and Bono, 2001; Judge et al., 2000; Judge et al., 2002; Judge et al., 2004; Judge et al., 2005; Lent et al., 1994; Saks, 1995; Stajkovic and Luthans, 1998), but researchers have issued a call for additional studies to further our understanding of the relationship between domain-specific self- efficacy and a broader array of work processes and outcomes (Harrison et al, 1997). Task and general self-efficacy, while important levels of analyses, do not completely address today’s complex business environments in which employees are continually challenged within their job domains; domain-specific measures allow for a rich, contextualized assessment of individual self-efficacy. Efficient and effective performance across a variety of tasks within a given work domain is necessary in order for individuals to remain viably employed. Multitasking, role, work and family, and stress management are not only challenges for employees, but for human resource professionals and managers as well. Today’s management and staff need tools to assist them in making effective developmental and evaluative decisions.

To date, no measure exists to assess applicants or employees’ perceptions of job self-efficacy within production environments, such as automobile manufacturing, shipbuilding, and computer assembly. Considering recent workforce trends, such as the declining competence of the U.S. labor force, the migration of many highly skilled manufacturing jobs abroad, and the influx of foreign-born workers in the U.S. (Latham, 1998; Mosisa, 2006), developing additional tools to assist organizations’ in managing their human capital seems a worthwhile endeavor. Therefore, in order to contribute to our understanding of the manifestation of individual job self-efficacy in more diverse settings, a production self- efficacy (PSE) scale is developed in our study. Given the fact that very little exploration regarding job applicants’ self-efficacy perceptions and post-hire outcomes has been conducted, we utilized two separate organizations’ staffing processes as a means of developing and assessing the PSE scale for reliability and validity.

Next, we provide an overview of the self-efficacy selection and testing literatures. Then, the Methodology and Results section details our efforts of item generation and purification as well as the respondents and procedures used, and reliability and discriminant validity tests for two samples. The Discussion section addresses study limitations and potential future directions for research, and ends with our conclusions based on the study results.

Self-efficacy and Selection

Few studies have explored the influence of self-efficacy during recruitment and selection from either the applicants’ or firm’s perspective, but two such recruiting studies focused on job applicants’ self-efficacy beliefs during the re-employment process. One found that for job seekers with initially low self-efficacy beliefs, job search training led to increased job search self- efficacy perceptions, thereby resulting in more intense job search activities (Eden and Aviram, 1993). Unemployed job seekers with high job search motives and strong feelings of search competence also were found to conduct more intense job searches (Wanberg et al., 1999). Lent et al. (1994) developed a theory of career and job interest and choice based on Bandura’s (1986) social cognitive theory and suggested that self-efficacy perceptions and outcome expectancies were directly and indirectly related to the choice of career and job goals. More recent research examined the relationships among applicants’ personalities, biographical backgrounds, interview self-efficacies, and interview successes. The results indicated that interview self-efficacy mediates the relationships among extraversion, conscientiousness, leadership experience and interview performance (Tay et al., 2006). Positive affectivity is another dispositional characteristic that has been found to predict job search clarity over and above conscientiousness and job search self-efficacy (Cote et al, 2006).

Saks (2006) examined the direct and moderating effects of job search self-efficacy on job search behaviors and job search success. Using a sample of recent university graduates, he found that job search self-efficacy significantly predicted interviews, offers, employment status, and person-job (P-J) fit perceptions, as well as moderated the relationship between job offers and employment status. P-J fit perceptions are typically assessed based on two broad definitions: desires/supplies fit and demands/abilities fit (Saks and Ashforth, 1997). Desires/supplies fit relates to an applicant’s or employee’s evaluation of his or her needs and wants compared to what the organization is willing to provide; whereas, the demand/ abilities fit perspective deals with one’s assessment of the organizational demands and one’s abilities to meet those demands. While self-efficacy involves making judgments about capabilities that relate to a task or a set of tasks, these beliefs are not identical to person-job fit perceptions or an objective assessment of one’s skills (e.g., Lent et al., 1986).

Self-efficacy and Testing

Past selection research utilizing self-efficacy generally focused on either the perceived fairness of employment tests based on the organizational justice perspective or the influence of employment- testing self-efficacy on actual test performance (Ackerman and Kanfer, 1993; Gilliland, 1993; Maertz et al, 2005; Ryan et al., 1996). Based on the organizational justice perspective, Ryan et al (1996) explored which factors influenced the perceived fairness of a physical abilities test (PAT) for firefighters. They found that when both previous experience with a specific PAT and self-efficacy were related to a specific PAT, the test was perceived to be job related. Ackerman and Kanfer (1993) examined employmenttesting self-efficacy and test performance by developing a battery of selection instruments, including a measure of self-efficacy, for the job of air traffic controller. The self-report measure of self-efficacy demonstrated discriminant validity and accounted for an additional four percent of the variance of simulation success. However, they used students and trainees in a simulated environment, not actual job applicants.

Previous research suggests that as a result of different experiences, self-efficacy perceptions may differ among demographic groups depending upon the environmental situation (Bandura, 1997; Lent et al, 1994). One study in particular assessed the antecedents and outcomes of self-efficacy during employment testing and found that past experience with employment tests was positively related to testing self-efficacy. However, neither minority status nor being hired by employment tests in the past had an effect. Additionally, testing self-efficacy was positively related to performance on the employment test (Maertz et al., 2005). Using a self-regulatory job- search framework, LaHuis (2005) investigated the influence of applicants’job pursuit intentions and perceived procedural fairness of selection tests. He found that for clerical jobs, job search self- efficacy moderated the relationship between perceived procedural fairness and job pursuit intentions. Alternatively, the relationships among general and specific self-efficacy in a training experience with newly hired recruits has been studied utilizing a pretest-posttest design. The results indicated that pretraining motivation, training self-efficacy, and performance expectancy influence work-specific self-efficacy (Schwoerer et al., 2005).

In summary, previous research has demonstrated that self- efficacy has important implications for organizational recruitment and selection. However, no study is known to examine individual job self-efficacy in a production setting during the organizational staffing process. Thus, we develop and validate the PSE scale utilizing the staffing processes of two separate manufacturing organizations to enhance our understanding of how self-efficacy manifests itself during recruiting and selection.

METHODOLOGY AND RESULTS

Construct Definition, Item Generation and Purification

In developing the PSE measure, we adhered to Churchill’s (1979) scale development process, which suggested a seven-step process for developing stronger multi-item measures. While self-efficacy has been examined as a general personality variable (Chen et al, 2001; Erez and Judge, 2001), a domain-specific construct (Gist and Mitchell, 1992; Goddard, 2002), and a task-specific variable (Harrison et al, 1997; Schyns and von Collani, 2002), we chose to develop a specific, domain-linked, measure of self-efficacy. The domain of interest is manufacturing and production. As suggested by Churchill (1979), we began creating the PSE scale by specifying the domain of the construct and generating sample items. We obtained key job information for production employees by examining job descriptions and interviewing human resource (HR) personnel at three manufacturing facilities in the southeastern United States. HR professionals were asked to provide the key performance criteria for production jobs in each of the plants. Follow-up questions were provided when necessary to further probe the domain of interest. A comparison was made between the interview responses and the job descriptions to ensure accuracy of the data. For example, a particular interview at one location revealed that promoting a positive image of the organization was important. However, the job descriptions, training and evaluation materials, and other interviews did not support this viewpoint. Thus, it was not included for consideration. Ultimately, the information obtained revealed key performance areas, including work quality, production competence, safety, interpersonal relations, and attendance, which were all used to generate the initial set of sample items. The following paragraphs describe our efforts in carrying out the remaining five steps of Churchill’s (1979) measurement development process: data collection, measurement purification, additional data collection, reliability assessment and, lastly, validity assessment. Initially, 37 items were generated. Six Ph.D.s with expertise in human resource management, scale development, and manufacturing, as well as human resource (HR) directors and managers at each location reviewed the items for the purpose of assessing content validity using the job descriptions, performance criteria, and interview data. Based on their comments, 16 items were retained, modified, and assessed for developmental purposes with actual employees in two separate work settings (see Appendix A). Traditional measures (Bandura, 1986) of self-efficacy have assessed both the magnitude and strength of the construct. These measures are two-part assessments with magnitude responses addressing (with a yes or no answer) specific task performance capabilities and strength responses affirming the respondent’s confidence in those capabilities. However, Maurer and Pierce provided support for using Likert-type “scales as an alternative to the traditional format for measuring self-efficacy” (1998: 329). Subsequent researchers (Tucker and McCarthy, 2001; Carlson et al., 2000) have used such scales as a viable means of assessing self-efficacy. Similarly, we have chosen to use a five- point Likert-type scale with the following response items: 1 = not very confident, 2 = 25% confident, 3 = 50% confident, 4 = 75% confident, 5 = extremely confident.

Sample 1

Respondents and Procedures. The sample consisted of job applicants (N = 117) applying to be production employees with a furniture manufacturing company located in the southeastern United States. Each job applicant was asked to participate by filling out the survey, sealing it in the attached envelope, and dropping it in a locked survey collection box. The applicants were told their responses to the survey would not impact the hiring decision and assured that their answers were confidential. A financial incentive was provided for their participation.

The sample consisted of 14% African-Americans, 61% Caucasians, 17% Hispanic-Americans, 3% Asian-Americans, and 5% Native- Americans. Fifty-eight percent of the sample was male, while forty- two percent was female. The majority of the job applicants were under 40 years of age. Eighty percent of the individuals had related job experience. Fourteen percent of the respondents completed elementary school, 69% finished high school, and 17% graduated from college.

Following procedures established by Joreskog (1993), we utilized confirmatory factor analysis (CFA), employing LISREL 8.5 (Joreskog and Sorbom, 1996) to examine the measurement model. The covariance matrix was used as the input for the analysis. The measurement model was estimated using the maximum likelihood function Sigma = Sigma (Theta), where S is the population covariance matrix and Sigma (Theta) is the predicted population Covariance matrix. A variety of fit indices can be utilized to determine how well the actual data fit the proposed model (Joreskog, 1993). Following Hair et al (1998), we based our evaluation on measures of absolute fit, incremental fit, and parsimonious fit. The chi-square statistic, the goodness-of-fit indicator (GFI), and the root mean square residual (RMSEA) are measures of absolute fit which assess to what degree the proposed model predicts the observed covariance matrix. The normed fit index (NFI) represents the incremental fit measure as recommended by Rentier and Bonnett (1980), which compares the proposed model to the null model. We used the adjusted goodness of fit indicator (AGFI), an extension of the GFI, taking into account degrees of freedom, to measure parsimonious fit. Adjusted goodness of fit indicator (AGFI) assesses whether the overall fit of the model is a result of over-fitting the data. Modification indices for both the lambda-X (LX) and thetadelta (TD) matrices were examined for possible cross-loadings and correlated errors.

Careful and systematic analyses of these indices indicated that nine of the 16 items were candidates for removal. However, prior to eliminating any item, the authors carefully considered its relevance to the domain of interest. Only poorly fitting items that were repetitive or theoretically unnecessary were removed. Therefore, the final scale consisted of seven items representing key performance areas. see Table 1 for the items’ standardized path coefficients, descriptive statistics, and correlations. As shown in Table 2, the chi-square of 22.89 with 14 degrees of freedom is non-significant (p = .06), indicating the proposed seven-item model fits the data well. The GFI of .95, the AGFI of .89, the RMSEA of .07, and the NFI of .98 provide support for the seven-item measure of PSE.

Reliability and Discriminant Validity Tests. Cronbach’s alpha was used to evaluate the internal consistency of the items. Alpha scores of .70 or higher are deemed to be acceptable (Nunnally, 1978). The seven-item measure of PSE has an acceptable coefficient alpha of .91.

To assess the PSE scale’s disriminant validity, correlation analysis (Cohen and Cohen, 1975) was performed with Saks and Ashforth’s (1997) four-item measure of personjob fit. The person- job (P-J) fit measure’s response set is a five-point Likert-type scale ranging from I (To a very little extent) to 5 (To a very large extent). The coefficient alpha of .80 for PJ fit was acceptable.

Saks and Ashforth’s (1997) measure includes items that tap into the two broad definitions of P-J fit: desires/supplies fit and demands/abilities fit. While self-efficacy involves making judgments about capabilities that relate to a task or a set of tasks, these beliefs are not identical to personjob fit perceptions or an objective assessment of one’s skills (e.g., Lent et al., 1986). Self- efficacy perceptions are dynamic beliefs that relate to specific performance domains and influence the goals people set, strategies people choose, effort people expend, and perseverance people display (Bandura, 1991). Successful task performance requires that a person possess both the appropriate skill and ability, and a strong feeling of efficacy relating to the task (Lent et al., 1994). Thus, PSE and P-J fit should be related, but different constructs. The correlation between PSE and P-J fit was .39, indicating significant differences exist. In addition, a means difference test was performed to determine whether PSE perceptions differed for those hired verses those not hired and the results showed no significant differences.

Sample 2

Respondents and Procedures. This sample consisted of job applicants applying to be production employees with a different furniture manufacturing company located in the southeastern United States (N = 2,029). The survey procedure was identical to that in sample one. The sample consisted of 41% African-Americans, 53% Caucasians, 3% Hispanic-Americans, 2% Native-Americans, and 1% Asian- Americans and those identifying the other category. The modal age range was the 18-24 category. Seven percent of the sample finished elementary school, 85% completed high school, and 8% graduated from college. Eighty percent of the individuals had related job experience. Females represented 52% of the sample, while males comprised 48 percent.

The statistical procedure was identical to that in sample one. The chisquare is 360.46 with 14 degrees of freedom (p = 0.00). As shown in Table 2, the GFI of .95, the AGFI of .90, the RMSEA of .11, and the NFI of .98 indicate, overall, the unidimensional PSE factor structure fits the data well. see Table 3 for the items’ standardized path coefficients, descriptive statistics and correlations.

Reliability and Discriminant Validity. The statistical procedures were identical to that in sample one. The coefficient alpha for the PSE scale of .89 was found to be acceptable.

Person-Job (PJ) fit was again used to assess the PSE scale’s discriminant validity. The coefficient alpha for P-J fit in this sample was .83. The correlation between the two constructs was .44 (N = 2,028), suggesting distinct constructs.

Exploratory Analysis. The PSE scale was included in a regression analysis with employee job performance as the dependent variable to explore the predictive validity of the measurement instrument. Actual job performance was assessed using employee efficiency rates or scores. Employees’ efficiency rates, which are calculated by the organization, are based on the amount of production achieved by an individual for a given pay period with base rate adjustments to control for pay differentials. An efficiency score of 100% signifies that the production employee is performing at the expected rate given the individual’s job, knowledge, skills, abilities, experiences, etc. Rates below 100% indicate under-performing employees, while rates above 100% represent overachievement. The efficiency scores ranged from 94% to 228%. Employee job performance was obtained directly from the company six weeks after an employee had been hired. Due to certain organizational constraints (i.e., time limitations), the sample size for this analysis is 50. Overall, the results show a positive relationship between pre-hire PSE and post-hire job performance. The t-statistic is 1.81, the unstandardized coefficient and error are 21 and 11.6, respectively, and the standardized regression coefficient is .25. The R-square is .06 and the adjusted R-square is .05. In addition, a means difference test was performed to determine whether PSE perceptions differed for those hired versus those not hired and the results showed no significant differences.

DISCUSSION

The purpose of this research was to develop and validate the PSE measure to be used in the production domain. To this end, the PSE scale was created and tested using two separate manufacturing samples. The overall, incremental, and parsimonious fit statistics calculated with the first sample suggested that production self- efficacy is a seven-item construct. The PSE measure demonstrated reliability and discriminant validity. Once the measure was developed, we reassessed the scale’s properties. The results were quite similar to those in sample 1. Afterwards, we conducted a post- hoc exploratory analysis to test the PSE scale’s predictive validity. While PSE was positively related to employee job performance six weeks after hire, the sample size precluded the determination of a significant relationship.

Therefore, we recommend this measure be used by organizations for developmental, rather than selection, purposes until further validation studies may be conducted. For example, administering the PSE scale to new hires during the early stages of employment may help managers in several ways. If administered during the formal orientation or socialization process, the results could provide managers with areas that they could specifically target for training and developmental activities. Such assessments, and the subsequent discussions that should follow, would allow managers to clarify work expectations to their employees. The PSE scale could also be utilized to assess employee progress following training and developmental activities thereby aiding managers in their continuous improvement efforts. This study is not without limitations. Even though we took great care to assure the applicants of confidentiality, the high mean PSE item scores could be a result of social desirability. Further, the samples were from the same industry, which limits generalizability. The sample size for the performance data collected was rather small; however, it is not uncommon to have small samples when collecting employment data.

Conclusions

While self-efficacy has been associated with job-related processes and outcomes (e.g., Jex and Bliese, 1999; Stajkovic and Luthans, 1998), more research is needed that examines selfefficacy in alternative venues. This exploratory study partially fills this void by examining job self-efficacy in a production context in actual organizations. The PSE scale can be used by researchers and practitioners in die future to assess employees’ efficacy perceptions to further improve organizational processes and outcomes.

Quality is an important aspect of all organizations today. Production employees need to meet quality production standards, detect quality problems and make appropriate changes, while properly maintaining and operating the equipment with which they work. Likewise, with increased litigation arising from workplace accidents, organizations should place a premium on developing safety- conscious employees. The employee’s ability to operate safely also positively impacts the amount of output produced, while reducing the amount of time actually spent on the job. Employees are ultimately evaluated on how well they produce. Organizations prefer to employ productive individuals that maintain an optimal production pace, keep track of daily schedules, show up for work on time, and embrace learning new skills to stay ahead of the competition.

While the results from this study suggest the PSE scale is reliable and valid, future research efforts should utilize this measure in providing further evidence of construct validity. One recommendation is to employ the PSE scale in diverse production settings, such as automobile, food preparation, and technology plant environments. Additionally, given that foreign-born workers contributed to nearly half of the increase in the U.S. labor force during the period of 1996-2000, with the trend continuing (Mosisa, 2006), future research should also investigate the PSE scale’s usefulness in multicultural work environments. Specifically, Latinos and Asians represent the largest percentage of influx in the U.S. labor market (Mosisa, 2006). Therefore, to assist researchers’ efforts, we have developed a Spanish version of the PSE scale (see Appendix B). Two Spanish translators employed the translationback- translation method (Oquendo et al., 2001) to create the Spanish version. One individual translated the English version into Spanish, and the second person conducted a back translation to validate the process. After the process was completed, the translators collaborated to ensure that both versions of the surveys were communicating the same information. It is our intention that the Spanish version of the PSE will assist practitioners and scholars alike in the collection of self-efficacy data from the growing Spanish-speaking production workforce.

The post-hoc exploratory analysis revealed an insignificant but positive relationship between PSE and performance. Thus, future researchers might find it fruitful to examine the predictive validity of the PSE scale utilizing controls, such as experience, with larger samples in diverse settings. Additionally, testing for differences based on race and ethnicity and hiring status would assist in establishing PSE as a selection tool.

In summary, the PSE scale demonstrated high internal consistency estimates and validity for two separate samples in a manufacturing environment. Fit indices were acceptable, providing some evidence of construct validity. Through the scale development and validation offered here we have taken an important step in moving self- efficacy measurement away from the generalized measures of the past towards more relevant, domainspecific measures that will allow for a richer, more contextualized assessment of individual self-efficacy.

Self-efficacy has received increased attention in management; in particular, task and domain-specific self-efficacy perceptions have been found to impact organizational commitment, job satisfaction, stress, and performance. More recently, general self-efficacy (GSE) has been linked with important organizational outcomes. While strides have been made, there continues to be a need to examine the impact of domain-specific perceptions of self-efficacy, especially in the manufacturing sector where developing a competent, efficient workforce is critical for the domestic survival of highly skilled production jobs. To assist organizations in effectively managing their employees, a production self-efficacy (PSE) scale is developed using two separate samples. This seven-item measure demonstrates reliability and discriminant validity. Implications and future research directions are discussed.

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Don C. Mosley, Jr.

Assistant Professor of Management

University of South Alabama

Scott L. Boyar

Assistant Professor of Management and Entrepreneurship

Xavier University

Charles M. Carson

Assistant Professor of Management

Samford University

Allison W. Pearson

Professor of Management and Information Systems

Mississippi State University

APPENDIX A

Initial 16 Items

1. I can make sure that the materials used to make the furniture are of good quality.

2. I am confident that I can meet the physical demands of my job.

3. I am confident that I can correct mistakes in my work.

4. I am confident that I can maintain the equipment that I work with.

5. I can follow all of the safety rules on the job.

6. I am confident that I can show others how to follow safety rules.

7. I am confident that I can follow all other company rules and policies.

8. I can maintain good work relationships.

9. I can get along with other workers.

10. I am confident that I can get along with my boss.

11. I am confident that I can be on time for work.

12. I am confident that I won’t be late to work.

13. I am confident that I won’t be absent from work.

14. I can keep up with my production pace.

15. I am confident that I can read basic schedules for my job.

16. I can learn all of the right parts and materials used in my job.

APPENDIXB

PSE Scale (English version):

1. I am confident that I can meet the physical demands of my job.

2. I am confident that I can correct the mistakes in my work.

3. I am confident that I can maintain the equipment that I work with.

4. I can follow all of the safety rules on the job.

5. I am confident that I won’t be late to work.

6. I can keep up with my production pace.

7. I am confident that I can read basic schedules for my job.

PSE Scale (Spanish version):

1. Estoy seguro que puedo cumplir con las exigencias fisicas de mi trabajo.

2. Estoy seguro que puedo corregir errors en mi trabajo.

3. Estoy seguro que puedo mantener las herramientas y la maquinaria con que trabajo en buen estado.

4. Puedo seguir todas las reglas de seguridad en el trabajo.

5. Estoy seguro que no llegar tarde a trabajar. PORFAVOR, CONTINUE AL RESPALDO DE ESTA HOJA.

6. Puedo mantener mi ritmo de produccin.

7. Estoy seguro que puedo leer horarios y tablas simples en mi trabajo si es necesario.

Copyright Pittsburg State University, Department of Economics Summer 2008

(c) 2008 Journal of Managerial Issues; JMI. Provided by ProQuest Information and Learning. All rights Reserved.

By Miller, Brian K Nicols, Kay McGlashan

Organizational politics are complex phenomena, particularly because their existence is interpreted through the perceptions of individual organizational members. Each individual’s perception of organizational politics (POP) is a function of his or her own particular characteristics, the social relationships that they have developed within the organization, and certain outcomes and consequences such as reward allocations and job attitudes. Ferris, Russ, and Fandt (1989) developed a conceptual framework and working definition of organizational politics that identified antecedents, outcomes, and moderators of POP. They define politics as a “social influence process in which behavior is strategically designed to maximize short-term or long-term self-interest, which is either consistent with or at the expense of others’ interests” (1989: 145). Other researchers have subsequently refined and extended this model (e.g., Ferris et al., 2002; Kacmar et al., 1999; Valle and Perrewe, 2000). These researchers suggest that certain situations in organizations (e.g., those that are ambiguous, uncertain, or subjectively determined) are conducive to political perceptions. Some researchers (e.g., Ferris et al, 1996; Valle and Perrewe, 2000; Vigoda, 2000) have examined the pivotal role of POP as a mediator of the relationship between particular antecedents and outcomes, while others have examined political perceptions as a moderator of workplace phenomena (e.g., Harris et al., 2005; Hochwarter et al., 2000). Antecedents found to be significantly related to POP include hierarchical level (Ferris et al., 1999), feedback (Kacmar et al., 1999), interaction with supervisors (Valle and Perrewe, 2000), and career development opportunities (Kacmar et al., 1999; Parker et al., 1995). Outcomes significantly related to POP include job stress (Kacmar et al., 1999), job involvement (Ferris and Kacmar, 1992), job satisfaction (Ferris et al., 1996), and pay satisfaction (Zhou and Ferris, 1995). Previous research has treated antecedents as independent of one another in empirical testing of the POP model. We believe that it is important to begin to explore the highly interactive nature of antecedent variables commonly included in models of POP, and the transmitted effects of such interactions on outcomes associated with organizational politics. Thus, the purpose of this study is to examine the interactive roles of one type of individual difference, locus of control, and an aspect of one’s relationship with their supervisor, leader-member exchange quality, in the prediction of perceptions of distributive justice, as mediated by POP.

In the following sections, we introduce the theoretical framework associated with our mediated moderation model. First, we introduce our two antecedents, work locus of control and leader-member exchange. Next, we discuss the concept of POP. We then discuss our outcome variable, distributive justice. Lastly, we develop hypotheses in order to test the relationships in our model (see Figure I).

A COGNITIVE SOCIAL LEARNING MODEL OF POLITICAL PERCEPTIONS

According to cognitive social learning (CSL) theory, perception is cognitively constructed and the nature of the relationship between job perceptions and job attitudes is purely one of reciprocity (James and Jones, 1980; James and Tetrick, 1986). An individual makes inferences about events in a social setting based on stimuli that are captured and interpreted individually. Such inferences are then impacted by an individual’s unique characteristics (e.g., personality traits), pre-existing expectations and schemata, attributions, and relationships with others, as well as other influences. Thus, employee perceptions about organizational settings are affected by individual interpretations of a situation, rather than being a function of an objective description of the relevant environment (Fiske and Taylor, 1991). The variables of interest in this study interact within individuals’ socially constructed realities. Work locus of control is one such characteristic that impacts an individual’s interpretation of events. Individuals’ perceptions of organizational politics, judgments about the quality of their relationship with their supervisor, and perceptions regarding distributive justice also result directly from social interaction with others in an organizational setting. This study contributes to our understanding of the social construction of reality by examining the interplay among these variables.

Work Locus of Control

Locus of control grew out of social learning theory (Rotter, 1954), which suggests that reinforcement will strengthen the expectancy that a particular behavior will be followed by that reinforcement in the future. Rotter states that “people . . . have developed generalized expectancies in learning situations in regard to whether or not reinforcement, reward, or success in these situations is dependent upon their own behavior or is controlled by external forces, particularly luck (or) chance” (1966: 25). Thus, individual differences account for much of how we interpret events and the effect of those events upon ourselves. Spector (1982) suggests that locus of control is related to multiple other individual differences such as motivation, effort, satisfaction, perception of the job, and supervisory style. He states that internals tend to believe that they control the work environment, while externals maintain that the environment controls them. Cognitive social learning theory suggests that it is the social milieu that provides context for the interpretation of events and from those events individuals learn and adjust their behavior. Because individual differences like locus of control play such an important role in the interpretation of organizational events, it is likely that persons with an internal locus of control will be more cognizant of potentially disruptive external issues imbedded in politics and justice.

Leader-Member Exchange

Unlike theories of leadership that focus on leader traits and behaviors (Bass, 1990; Mintzberg, 1973), leadermember exchange (LMX) theory suggests that the effectiveness of a supervisor is largely determined by the perception of die quality of die dyadic relationship between leaders/supervisors and members/subordinates (Dansereau et al, 1973; Dansereau et al, 1975; Graen, 1976; Graen and Cashman, 1975). Leader-member exchange suggests that leaders treat members differently and, accordingly, an in-group and an out- group of members are formed. In-group membership is preferred by members, as such affiliation is often associated with preferential treatment and characterized by favorable attitudinal correlates for in-group members. Leader-member exchange is strongly associated with subjective performance ratings from leaders and with member affective states (Gerstner and Day, 1997). Additionally, training interventions where leaders are trained to foster highquality relationships with members have increased member performance ratings and member satisfaction (Graen et al., 1982).

It is the reciprocal nature of leadership in general, and LMX more specifically because of its dyadic premise, that lends itself well to interpretation in a CSL framework. Cognitive social learning theory suggests that individuals learn from their supervisor as part of the organizational milieu in which they find themselves. The high quality relationship of ingroup members with their supervisor reinforces their behavior as the scarce organizational resources which are garnered for these favored subordinates leads to reinterpretation of what it means to be so favored-i.e. lower levels of dysfunctional politics and higher levels of perceived justice.

Perceptions of Organizational Politics

Kacmar and Baron (1999) attribute the beginning of empirical research on micro-level organizational politics to Gandz and Murray (1980). For the remainder of that decade, research waned as struggles to define and operationalize organizational politics ensued. Over time, the conceptualization of organizational politics has been refined as researchers consistently identify organizational politics as something that is usually perceived of negatively, even though some have attempted to reconceptualize the construct as something positive (Ferris et al., 1995).

In the conceptualization of perceptions of organizational politics, it is important to distinguish it more specifically from other politics constructs. Political perceptions are different from political tactics (an increasingly common construct of interest to researchers), which refer to specific behaviors by specific individuals (Zanzi and O’Neill, 2001), rather than the perception of political policies, rules, procedures, and outcomes like those conceptualized as POP. Ferris et al. (2002) differentiate among the constructs of organizational politics, political behavior, and politics perceptions. They state that “political behavior deals with influence attempts that occur at the individual and group level, while organizational politics examines the extent to which such behaviors are pervasive in the work, decision-making, and resource allocation processes within the organization” (2002: 183). Rather than being an objective reality, organizational politics is subjectively perceived by individuals in a workplace (Ferris et al, 1989; Ferris et al, 2002). Much of the research (e.g., Ferris and Kacmar, 1992; Ferris et al., 1996; Kacmar et al, 1999; Valle and Perrewe, 2000) has therefore focused on perceptions of organizational politics, in response to Gandz and Murray (1980) who suggested that the most accurate way to study organizational politics is by measuring individuals’ perceptions about it.

Distributive Justice

We utilized distributive justice perceptions as the outcome in our model. Previous research has demonstrated a significant relationship between distributive justice and organizational politics perceptions (Andrews and Kacmar, 2001; Parker et al, 1995). Organizational justice describes the perception of the fairness of distribution, processes, and personal interactions in the workplace (Colquitt, 2001; Greenberg, 1987). Distributive justice is concerned with the fairness of allocation of rewards and is often seen as the antithesis of organizational politics (Andrews and Kacmar, 2001). The two are inversely related because as individuals perceive that resources are allocated unfairly or without regard for need or merit, they are more likely to perceive that organizational politics is the culprit. Andrews and Kacmar (2001) found evidence of discriminant validity in their confirmatory factor analysis of justice, politics, and perceived organizational support. They suggest that politics and justice are likely to be different constructs, but that they are also moderately inversely related.

Dulebohn (1997) suggests that individuals are motivated to use influence tactics in order to achieve particular goals or objectives. Individuals see political behaviors as instrumental in obtaining outcomes of interest to them. Individuals tend to evaluate processes and outcomes separately (Greenberg, 1990; Tyler, 1994). They attempt to realize more favorable outcomes by influencing processes. A favorable outcome is one that is perceived as beneficial to the recipient’s self-interest (Dulebohn, 1997). Political behavior is specifically defined as a social influence process designed to maximize self-interest (Ferris et al., 1989). As such, individuals’ perceptions of the level of organizational politics at play within their organization pertain to the extent to which others are attempting to “work the system” to their own benefit (which may or may not negatively impact the perceiver’s own outcomes). Some may argue that procedural justice is a more appropriate outcome variable to examine in a model of perceptions of organizational politics, because political behaviors are designed to affect organizational processes in order to influence outcomes. However, we argue that perceptions of distributive justice are a more concrete representation of the success of political behaviors. Political behaviors are specifically used to further individuals’ self-interested outcomes. Individuals’ perceptions of distributive justice answers the “so what” question regarding perceptions of organizational politics-if an individual perceives that organizational politics is operating within the work environment, he/ she will most likely be concerned with how this impacts his/her own self-interested, desired outcomes. Thus, we propose that individuals perceiving a great deal of political behavior within their organizations would perceive that such behaviors affect the fairness of reward outcomes distributed to them.

The Mediating Role of Perceptions of Organizational Politics

We suggest that the effects of leader-member exchange and work locus of control (and their interaction) are transmitted to distributive justice via POP. That is, political perceptions serve to explain haw the antecedents affect the outcome. Thus, to test our model, we examine the mediating role of POP in the relationship between the interaction of work locus of control and leader-member exchange in the prediction of distributive justice. The Baron and Kenny (1986) framework for examining mediation requires that certain preliminary relationships be found (namely that the antecedents are statistically related to both the mediator and the outcome and that the mediator is statistically related to the outcome). Each of these relationships is examined below, and their existence is required before an examination of the mediating influence of POP in these relationships can be undertaken.

Influence of Work Locus of Control on Distributive Justice. Sweeney et al. (1991) found a strong direct linkage between an internal locus of control and perceptions of justice in the workplace. Andrews and Kacmar (2001) found that locus of control was significantly associated with perceptions of distributive justice such that individuals with an external locus of control reflected lower distributive justice ratings than individuals with a more internal locus of control. Persons with an internal locus of control tend to look inward for sources of both their successes and failures. As such, we suggest that they are more likely to be believers in the just world hypothesis (Lerner, 1980) that people get what they deserve in life. They are likely to believe that life in general, and their organization specifically, are both fair. Locus of control is operationalized in this study such that higher values represent more internal locus of control, while lower values represent more external locus of control. Thus,

Hypothesis 1: Work locus of control and distributive justice are positively related.

Influence of Leader-Member Exchange on Distributive Justice. Scandura (1999) suggests that justice perceptions are a result of economic exchanges (i.e., pay increases, promotions) being considered fair or unfair. However, these economic exchanges take place within a larger social context. The leader-member exchange process is a social exchange that affects individual perceptions of the fairness of a particular economic exchange. Vecchio et al (1986) and Manogran et al (1994) found significant positive relationships between distributive justice and leader-member exchange, such that individuals with higher quality relationships with their immediate supervisors perceived higher distributive justice than those individuals with lower quality relationships with their leaders. Andrews and Kacmar (2001) found a non-significant relationship between leader-member exchange and distributive justice. However, Wayne et al. (2002) found a significant positive relationship between LMX and distributive justice.

Out-group members in particular may focus more on distributive justice than in-group members, because the nature of the relationship between the leader and members of the outgroup tend to be more formal and contractual in nature (Liden et al, 1997) and “both parties are more concerned with the flow of tangible resources than with the quality of the relationship” (Davis and Gardner, 2004: 446). Therefore, members with low quality relationships with their leader are likely to have heightened sensitivity to an inequitable distribution of rewards and are likely to perceive low levels of distributive justice. Leader-member exchange quality is measured in this study such that higher values represent higher quality exchange relationships, Thus,

Hypothesis 2: leader-member exchange and distributive justice are positively related.

Interaction of Work Locus of Control and Leader-Member Exchange on Distributive Justice. Kinicki and Vecchio (1994) found a positive relationship between individuals’ internal locus of control and quality of relations developed with their immediate supervisor. Martin et al. (2005) also found a significant positive relationship such that individuals with an internal locus of control perceived higher quality relationships with their supervisors. Thus, locus of control and LMX relationships appear to be significantly interrelated. Our previous discussion of these variables reflects their individual positive relationships with distributive justice. Due to the strong positive association between locus of control and leader-member exchange as well as their individual positive effects on distributive justice demonstrated in previous research, we propose that the two variables will interact in our model, and that the interaction of the two is likely to further positively influence individuals’ interpretation of the fairness of organizational outcomes.

Hypothesis 3: There is an interaction effect between leader- member exchange and work locus of control on distributive justice, such that the highest levels of distributive justice will arise from high levels of leader-member exchange and work locus of control.

Influence of Work Locus of Control on Perceptions of Organizational Politics. Valle and Perrewe (2000) suggest that because individuals with an external locus of control are more likely to perceive that they have little or no control on the events that impact them, they are more likely to perceive high levels of organizational politics. Because politics are frequently construed of as phenomena external to one’s self, CSL theory suggests that the social construction of reality depends at least partly upon one’s attributions of causality and one’s locus of control. That is, as an individual attempts to make sense of his/her organizational environment he/she seeks to attribute causality to these encounters. Attribution theory (Weiner, 1980) and CSL theory suggests that while most observers of these phenomena agree on perceived causality, “in contrast, . . . locus of control posits that stable individual differences among perceivers influence causal inference” (Fiske and Taylor, 1991: 42). With this in mind, we suggest that persons with an internal locus of control would view the organizational political process as something for them to more effectively manage, and that some insufficiency of their own efforts (as opposed to organizational constraints) might have allowed for a greater existence of organizational politics. Hypothesis 4: Work locus of control and perceptions of organizational politics are negatively related.

Influence of Leader-Member Exchange on Perceptions of Organizational Politics. A low quality relationship between member and leader is also likely to result in the member’s perception of higher levels of organizational politics. Because the in-group status defined by LMX suggests that favoritism runs concurrently with such status, members of the outgroup are likely to perceive that politics, as evidenced by the inequitable distribution of rewards without regard for merit, is responsible for their undesirable status. Davis and Gardner (2004) suggest that the quality of the leader-member exchange influences the tone of subordinate reactions to, and interpretations of, perceived political actions. Ferris and Kacmar (1992) and Valle and Perrewe (2000) found direct evidence of a significant inverse relationship between quality of LMX relationship and POP. Individuals with low- quality relationships with their superior may tend to perceive leader favoritism toward in-group members that is based on political factors rather than on objective performance factors (Davis and Gardner, 2004; Kacmar and Ferns, 1991). On the other hand, Andrews and Kacmar (2001) found a positive relationship between leadermember exchange and organizational politics. They posited that ingroup members with higher quality relationships with supervisors may actually be more “in-the-know” about political machinations in their organizations. However, at least three other studies (Ferris and Kacmar, 1992; Kacmar et al, 1999; Valle and Perrewe, 2000) have all found negative correlations between interactionwith-supervisors and POP. Thus, it appears likely that a high quality relationship with one’s supervisor will decrease one’s perceptions of organizational politics.

Hypothesis 5: Leader-member exchange and perceptions of organizational politics are negatively related.

Interaction of Work Locus of Control and Leader-Member Exchange on Perceptions of Organizational Politics. As previously discussed, prior research has demonstrated a positive relationship between locus of control and LMX, such that individuals with more internal locus of control perceive higher quality relationships with their supervisors. Individuals perceive higher levels of organizational politics when they have an external locus of control, and when they perceive low LMX quality. Therefore, we posit that individuals with an internal locus of control combined with perceptions of high quality relationships with their supervisors will likely perceive the lowest levels of organizational politics within their organizations.

Hypothesis 6: There is an interaction effect between leader- member exchange and work locus of control on perceptions of organizational politics, such that the highest levels of perceptions of organizational politics will arise from low levels of leader- member exchange and locus of control.

Mediating Role of Perceptions of Organizational Politics. Perceptions of organizational politics is the central construct in our model. To test our model, we use mediated moderation regression analysis to examine these relationships. We borrow the language of Baron and Kenny (1986) when we suggest that politics is a generative mechanism through which one’s relationship with their supervisor and their perception of their ability to influence events around them is transmitted to, and predicts, their perception of the fairness of organizational rewards.

Hypothesis 7: Perceptions of organizational politics mediates the relationship between work locus of control and distributive justice.

Hypothesis 8: Perceptions of organizational politics mediates the relationship between leader-member exchange and distributive justice.

Hypothesis 9: Perceptions of organizational politics mediates the relationship between the interaction of leader-member exchange and work locus of control with distributive justice.

METHOD

Participants

The participants in this study were full-time employees enrolled in an MBA program at a large state university in the southern United States. Demographic information was gathered via a categorical response sheet. Seventy-eight percent of participants were managers, 67% were male, and the racial breakdown was as follows: 78.0% Caucasian, 10.2% African American, 3.9% Hispanic, 2.4% Asian, and 5.5% Other. Fifty-eight percent were over 35 years of age. Regarding current job tenure, 35% had less than one year, 32% reported between one and five years, 6% had six to 10 years of job tenure, 12% reported 11 to 15 years, and 15% had more than 15 years of current job tenure.

Procedure

Participants were solicited for their voluntary participation in a survey of their organizational experiences, attitudes, and perceptions. One hundred eighty-three surveys were distributed to the participants during class time. They completed the survey on their own time and returned them at the next class meeting. One hundred twenty-five usable surveys were returned. They did not record their name or any identifying information on the survey, and the data were therefore completely anonymous. Extra credit was awarded for participation.

Measures

Perceptions of Organizational Politics. A fifteen-item scale measuring perceptions of organizational politics by Kacmar and Carlson (1997) was used. The scale uses a five-point Likert response anchored by 1 = strongly disagree and 5 = strongly agree. High scores indicate that respondents experience high levels of ambiguity and uncertainty in the workplace and are more likely to encounter favoritism and highly self-interested behavior. Six items were reverse scored. Examples of items include: “People in this organization tend to build themselves up by tearing others down,””Favoritism rather than merit determines who gets ahead around here,” and “Promotions in this department generally go to top performers (reverse scored).” The Cronbach’s alpha for scores on this scale was .89.

Distributive Justice. The six-item Distributive Justice Index by Price and Mueller (1986) was used to assess perceptions of distributive justice. High scores indicate that respondents perceive that they are fairly rewarded by their employer. The scale items use a five-point Likert response anchored by 1 = very unfairly and 5 = very fairly. Examples of items include: “To what extent are you fairly rewarded considering the responsibilities that you have?” and “To what extent are you fairly rewarded for work that you have done well?” The Cronbach’s alpha for scores on this scale was .94.

Work Locus of Control. Spector’s (1988) 16-item Work Locus of Control Scale measured locus of control. Half of the items indicate an internal locus of control, while half indicate an external locus of control and were reverse scored. High scores on the scale therefore indicate an internal work locus of control. A high internal work locus of control suggests that respondents believe that they influence their environment more than their environment influences them and that they have the ability to manipulate events that occur around them. The scale uses a five-point Likert response anchored by 1 = strongly disagree and 5 = strongly agree. Examples of items include “A job is what you make of it,””Making money is primarily a matter of good fortune (reverse scored),” and “Most people are capable of doing their jobs well if they make the effort.” Cronbach’s alpha for scores on this scale was .78.

Leader-Member Exchange. A sevenitem scale by Graen et al. (1982) was administered from the perspective of employees regarding the quality of their relationship with their supervisors. Thus, the subordinate (i.e., member) perspective on the dyadic relationship was the focus in this study. High scores indicate that employees (i.e., members) favorably perceive of their relationship with their supervisor (leader). The scale uses a five-point Likert response anchored by 1 = strongly disagree and 5 = strongly agree. Examples of items include: “I can count on my supervisor to ‘bail me out’ at his or her expense when I really need it,””My immediate supervisor understands my problems and needs,” and “I usually know where I stand with my immediate supervisor.” Cronbach’s alpha for scores on this scale was .93.

Analysis

Multiple regression analysis was used to test our hypotheses. We used the Baron and Kenny (1986) framework for testing for mediation and the suggestions of Muller et al. (2005) to examine mediated moderation. Referring again to our model in Figure I, step one in testing for mediation is to establish the existence of a relationship between the independent variables and their interaction in the prediction of the dependent variable. Step two involves testing for a relationship between the independent variables and their interaction in the prediction of the mediator. If, and only if, steps one and two are satisfied can one proceed to steps three and four. If steps one and two result in non-significant relationships, then the relationships to be mediated do not exist and the analysis should stop there.

Steps three and four are examined in a hierarchical regression where the independent variables and their interaction are entered and then followed by the mediator. If the presence of the mediator in the equation reduces the independent variables or their interaction to non-significance, then there is evidence of full mediation. If the independent variables and their interaction remain significant, but less in magnitude when the mediator is in the equation, then partial mediation exists. Lastly, we centered the independent variables before the interaction term was computed in order to avoid the effects of multicollinearity (Aiken and West, 1991). Sobel Tests

Whereas Baron and Kenny’s (1986) multi-step test for mediation is commonly used by researchers, it only provides a broad characterization of the indirect (i.e., the path from the predictor to the mediator to the criterion) effect by classifying mediation as either full, partial, or none at all. Increasingly, researchers are turning their mediation tests to a single-step procedure that provides a precise measure of the level of statistical significance for the indirect effect of a mediator. For this, MacKinnon et al. (2002) recommend the Sobel (1982) test. The Sobel test uses the standard errors of regression weights and the t-tests of these coefficients to produce a measure interpreted as a Z-score. It should be noted that MacKinnon et al. (1995) consider this test to be very conservative. We conducted Sobel tests using the Aroian (1944) adjustment advocated by Preacher and Leonardelli (2003). The Aroian (1944) adjustment to the test does not assume that the standard errors of the independent variables are exceedingly small, as the original Sobel test does. The Aroian version is an appropriate tool for researchers examining mediation using the Baron and Kenny (1986) framework. The intention of the Sobel test is to provide additional evidence regarding whether the mediator is indeed a generative mechanism by which the influence of the predictor is transmitted to the criterion. With this in mind, we use the Sobel test to provide a precise measure of the likelihood that our mediated effects are truly non-zero in the population to which we hope to generalize.

RESULTS

Correlation Results

We ran two-tailed tests of significance for the relationship between the demographic variables and the focal constructs. See Table 1 for these results. Results revealed that of the demographic variables, tenure (r = -.34, p

Factor Analysis Results

Because each of our variables was collected via self-report in a cross-sectional survey, it is possible that our data may suffer from commonsource, common-method bias (Podsakoff and Organ, 1986). To examine if a four-construct model devoid of nuisance or method factors fit the data, we ran confirmatory factor analysis (CFA) using Lisrel 8.72 software (Joreskog and Sorbom, 2004). This also allowed us to examine whether our respondents conceptualized of the focal constructs in our study as distinct and separate. We examined two models: a one-factor model comprised of all items in all four scales and a four-factor model forcing each item to load on its intended factor. In each model, error variances for the items were not allowed to correlate. If the one-factor model provides a fit of the data that is equivalent to the four-factor model, it would indicate a single underlying latent construct. If the four-factor model should provide the better fit than the one-factor model, then we have evidence that our respondents conceptualize of the constructs in our model as independent and distinct. The Chi-square difference test is used to compare the two models.

The fit statistics for the one-factor model were root mean square error of approximation (RMSEA) of .14, comparative fit index (CFI) of .85, standardized root mean square residual (SRMR) of 0.11, and Chi-square (chi^sup 2^) of 2501.48 (df = 902, p

Regression Results

Because Ferris and colleagues (1989, 2002) suggested that certain demographic characteristics and aspects of work experience would be related to POP, we controlled for age, race, sex, tenure, and hierarchical level in each of our regression models. In step one of the test for mediation, we regressed the dependent variable of distributive justice on the control variables, independent variables, and the interaction term. see Table 2 for these results. The regression resulted in a significant F-score with an R-squared value of .42. The beta weight for work locus of control was significant at .38 (p

In step two of the test for mediation, we regressed POP (our mediator) on the control variables, independent variables, and the interaction term. See Table 3 for these results. The regression resulted in a significant F-score with an R-squared value of .58. The beta weight for work locus of control was significant at-.35 (p

In steps three and four of the test for mediation, we ran a hierarchical regression with distributive justice as the dependent variable, with the control variables and independent variables of work locus of control and leader-member exchange and their interaction entered first, followed hierarchically by the mediator of POP. See Table 4 for these results. The regression resulted in a significant F score with an R-squared value of .51. In the first step of the regression the beta weight for work locus of control was significant at .38 (p

Sobel Test Results

Consistent with the results above, the results of our Sobel tests also suggest that perceptions of politics is a generative mechanism through which the effects of leader-member exchange and work locus of control and their interaction are transmitted to distributive justice perceptions. Our Sobel tests revealed significant indirect effects for each of these three relationships. The Sobel test statistic (interpreted as a Z-test) for work locus of control was 3.38 (p

We found that leader-member exchange, work locus of control, and their interaction are valid predictors of both perceptions of organizational politics (POP) and of distributive justice. Our graph (see Figure H) of the interaction showed support for the relationship between the interactive effects of leader-member exchange and work locus of control in the prediction of distributive justice, and revealed that high levels of the antecedents predict high levels of the outcome. However, our other graph (see Figure III) shows that the highest levels of organizational politics are also perceived when one has a high quality relationship with their supervisor combined with a strong internal work locus of control. This is somewhat unexpected, as most previous research on the main effects of these variables indicates that one would expect low POP when one has a high quality relationship with their supervisor or a strong internal work locus of control.

Our results reflect a mutually reinforcing relationship, in that the interaction between a strong internal work locus of control and high leadermember exchange counter-intuitively predicts high levels of POP. Langfred found this result in his mediated moderation study and referred to it as “too much of a good thing” (2004: 385). Perhaps having a strong internal work locus of control and a great relationship with one’s supervisor is too much of a good thing as well. We suggest that such persons in such situations may have a heightened awareness of organizational politics as a result of the combination of a strong internal locus of control and a good relationship with their supervisor.

Another potential explanation is that these high internals may possibly feel a stronger “frustration effect” of sorts, in that they prefer to think they are in charge of their own fate and have developed positive relations with their supervisors to further their ability to be in control. Yet they may perceive that others’ political behaviors thwart their efforts to be in control, which could cause frustration leading to more negative perceptions of distributive justice. Conversely, strong externals may feel less frustration simply because they do not feel they are in control anyway. Thus, externals may accept negative effects of organizational political behaviors on distributive justice more readily.

At the heart of our study, our mediation tests show that POP partially mediates each of the main effects of work locus of control and leader-member exchange in their relationship with distributive justice, but fully mediates the relationship between the interaction of work locus of control and leader-member exchange in its relationship with distributive justice. Furthermore, our Sobel tests show that the main effects of internal work locus of control and leader-member exchange, and their interaction, are mediated by POP in the prediction of distributive justice. Therefore, we have strong evidence that POP is a generative mechanism through which the relationship between a subordinate and supervisor and the subordinate’s perception that they control the events in which they find themselves are transmitted to, and a predictor of, perceptions of distributive justice. In essence, when one has a good relationship with their supervisor combined with a strong internal work locus of control, they are not necessarily likely to perceive that they are fairly rewarded because they are also likely to perceive higher levels of organizational politics, and we found that perceptions of high levels of politics yields low levels of perceptions of fairness. Thus, political perceptions are so strongly present in the perceptions of those high in leader-member exchange and work locus of control, that because of these political perceptions they may perceive that they are unfairly rewarded.

Limitations

Like many survey-based studies, ours potentially suffers from the fact that our sample size is small, but still above the cutoffs provided by Tabachnik and Fidell (2001) for the interpretation of multiple regression results. A larger sample would have allowed us to include more variables in our analysis which might have alleviated model misspecification. It may also have allowed us to utilize structural equation modeling (SEM) rather than regression analysis. However, in our sample the number of subjects per estimated parameter in our model is below the commonly accepted threshold for SEM of five to ten (Kerlinger, 1986); so SEM was inadvisable for our study. Therefore, we suggest that our use of hierarchical regression analysis and the Baron and Kenny (1986) framework was appropriate.

Managerial Implications

As in previous studies (e.g., Andrews and Kacmar, 2001), our initial correlational analyses (see Table 1) reflect the interrelatedness of the variables in our model. Each of our focal measures was shown to be significantly correlated with one another. In our full model, we found that those with the high internal locus of control combined with the high quality relationship with one’s supervisor actually increases, rather than reduces, individuals’ perceptions that organizational politics are at play in their organizations. Perhaps such high internals with high quality relationships with their supervisors may feel more cognizant of their political system, and may feel greater frustration that they are unable to utilize their strong sense of control and relationship with the boss to impact their organizational rewards as effectively as they would wish to.

Our study’s use of the cognitive social learning (CSL) framework provides some context for understanding the complex dynamics of the workplace. Specifically, as managers seek to foster high quality relationships with their subordinates (as they usually should), they should recognize that subordinates with strong feelings regarding their own ability to manipulate their work experiences may become so in tune with organizational dynamics that by nature of their relationship with their supervisor they are also more aware of organizational politics. This may in turn affect individuals’ perceptions regarding the fairness of the organization’s reward system.

This study examines the mediating influence of perceptions of organizational politics in the relationship between the interactive effects of work locus of control and leader-member exchange on distributive justice. We use the tests for mediation described by Baron and Kenny (1986) and amended for mediated moderation by Muller, Judd, and Yzerbyt (2005). We found that the perception of organizational politics partially mediates the relationships between work locus of control and leader-member exchange with distributive justice. We also found that the perception of organizational politics fully mediates the interaction of work locus of control and leader-member exchange in the prediction of distributive justice. Our results suggest that organizational politics acts as a generative mechanism through which the interaction of one’s relationship with their supervisor and their perception of their own ability to influence events around them is transmitted to their perception of the fairness of organizational rewards.

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Brian K. Miller

Assistant Professor of Management

Texas State University

Kay McGlashan Nicols

Assistant Professor of Management

Texas State University

Copyright Pittsburg State University, Department of Economics Summer 2008

(c) 2008 Journal of Managerial Issues; JMI. Provided by ProQuest Information and Learning. All rights Reserved.

By Wiener, Josh Doescher, Tabitha

This article identifies the constructs that influence an individual’s intention to save for retirement and discusses how and when these factors can be changed by an agent trying to induce an individual to enroll in a retirement plan, increase his or her contribution to a plan, or purchase a particular retirement product. A broad array of psychological theories is used to develop a series of persuasive communications that can encourage a person to save. In addition, the persuasive communication approach is placed in the broader context of all efforts used to promote retirement savings. Many Americans are not saving enough for their retirement. According to the 2007 Retirement Confidence Survey (Helman, VanDerhei, and Copeland 2007), only 66 percent of workers report that they and/or their spouse have saved money for retirement and only 60 percent report that they are currently saving. Even among those who do save, savings can be insufficient. About half of all workers saving for retirement report that the total value of their investments, excluding their home and their defined benefit plan, was less than $25,000.

Because this problem has been well known for many years, both private agents and public policy makers have made numerous efforts to increase the extent to which American workers save for retirement. Basically, two broad approaches, the first structural and the second involving communication, have been used to do this.

Structural approaches attempt to change the conditions under which people save. For example, policy makers can alter the financial conditions associated with retirement saving (e.g., enhance tax benefits or raise retirement plan contribution limits), while employers can rework plan design (e.g., institute matching, enrollment by default, or automatic contribution increases). In contrast, communication approaches focus on changing both workers’ knowledge and their perceptions. The former occurs through education (e.g., teaching the fundamentals of investing); the latter occurs through persuasion (e.g., creating normative pressures or enhancing the perceived importance of one’s retirement years).

Past policy efforts have focused on structural changes and on education. For example, the most recent effort, the Pension Protection Act of 2006, contains several favorable retirement savings measures, including allowing employers to offer automatic enrollment plans as the default and permitting plan providers to offer certain investment advice without running afoul of advisor conflicts of interest. However, 42 percent of all working-age wage and salary employees do not work for an employer or union that sponsors a retirement plan (Copeland 2006) and therefore will not be affected by either of these changes. Moreover, these changes may not be sufficient even among workers who have access to employer- sponsored plans. A recent study by VanDerhei (2007) suggests that automatic enrollment will not be a magic bullet: although replacement rates (the percent of final salary that is replaced in retirement) will increase, they will still be below the traditional minimum recommended replacement level of 70 percent.1 In addition, some experts doubt that automatic enrollment plans (even for new employees) will rapidly diffuse (Laise 2007).2 The effects of the educational change (investment counseling) are also problematic: despite some successes, the impact of past employee educational programs on participation and contribution rates has been disappointing (Benartzi and Thaler 2007). Thus, the evidence suggests that although these structural and educational efforts have been and are valuable, there is a need to do more.

In this article, we focus on the role that can be played by persuasive communications. To depict the role of persuasive communications, we use a policy framework. The framework is constructed from the point of view of an agent who is trying to get an individual to join a retirement savings program (e.g., a 401(k) plan), increase his or her level of contribution to such a program, or make a discrete savings decision (e.g., buy an individual retirement account [IRA]). The likelihood a person will act is strongly influenced by two factors, intentions and inertia/ procrastination. Because there is a very rich literature on the role inertia/procrastination plays in the decision to save (see Appendix 1), the focus in this article, and in our framework, is on intentions.

More specifically, the article identifies the factors that influence an individual’s intent to save and provides guidance regarding how and when these factors can be changed by persuasive communications. In addition, the article places the persuasive communications approach in the broader context of all efforts being used to promote retirement savings.

INTENTIONS OVERVIEW

A person’s intention to save for retirement is a conscious decision to engage in a savings action. In a host of psychological models, for example, social cognitive learning (Bandura 1986), reasoned action/planned behavior/trying/goal directed (Bagozzi 1992), and protection motivation/health belief (Tanner, Hunt, and Eppright 1991), the likelihood a person engages in a particular behavior is an increasing function of the strength of his intention to act. In our model, a person may have a strong transient intention that reflects little cognition. This transient desire is viewed as an intention because it can be influenced by many of the same constructs that can influence a more enduring intention.

An agent seeking to alter a person’s intention to save can take an action that attempts to change a person’s perceptions of the following constructs: his perceived ability to save, the benefits associated with saving, his concerns about the future, and the costs associated with saving (Figure 1). The first construct, a person’s perception of his ability, has both an actual and a subjective dimension. In other words, a person may over- or underestimate his true or actual ability. The second construct is more straightforward: the primary types of benefits are short-term benefits (e.g., matching dollars or normative pressures), having a higher retirement income due to earning a higher real rate of return and having greater hope. The third construct is concerns. Both hopes, which indirectly affect intentions through their impact on benefits, and concerns, which directly affect intentions, are determined by how the agent frames the long-term consequences from saving. These consequences can be framed as either hopes (e.g., how having more money during retirement will make one’s life better) or concerns (e.g., how additional retirement income is needed to stave off dire consequences). When a positive (hope) frame is employed, the agent’s action simply enhances the benefits associated with saving. When a negative (concern) frame is employed, the agent’s action has the potential to set in motion a much more complex set of psychological responses. Finally, the last construct, the cost of saving, depends on both the opportunity cost of the dollars put into a savings instrument and the deprivation associated with the value of these dollars.

Changing these constructs will influence a person’s intention to save. First, increasing one’s ability to save will increase the likelihood of saving as long as the benefits outweigh the costs. Second, increasing the benefits associated with saving will have a positive effect on the likelihood a person will save as long as a person thinks that he has the ability to save. Third, increasing concerns can either increase or decrease the likelihood a person will save: if a person thinks that he is capable of taking actions that will save him from an awful fate, then enhancing concerns will motivate a person to save; however, if he does not feel capable, enhancing concerns can reduce the likelihood of both current and future savings behaviors. In other words, when perceived ability is too low, a persuasive message that emphasizes concerns (e.g., a classic fear appeal) can be counterproductive. Finally, increasing the costs associated with savings will reduce the likelihood a person will act.

The remainder of this article examines these constructs in detail. Each section begins with a discussion of the basic theories behind the construct and their application to retirement savings and includes empirical evidence supporting the theories’ relevance to retirement savings. The section then turns to the type or types of approaches-structural changes, education, and persuasive communications-that can be used to encourage individuals to save for retirement.

PERCEIVED ABILITY

One version or another of perceived ability plays a critical role in many psychological theories. In each theory, the construct has a somewhat unique definition and, in many cases, is given a theory- specific name. We use the language of Bagozzi (1992) in which perceived ability is synonymous with his term goal efficacy.

Bagozzi created the term goal efficacy to capture two distinct versions of efficacy: the self-efficacy dimension denoted by perceived behavioral control in the theory of planned behavior and the response efficacy dimension denoted by success and failure expectancies in the theory of trying. Goal efficacy is therefore a person’s perception of the likelihood that she will reach a goal if she tries (Bagozzi 1992; Bagozzi and Edwards 1998). It includes a person’s appraisal of both her ability to perform the instrumental act (self-efficacy) and her estimate of the likelihood that if she performs the act she will achieve the goal (response efficacy). There is considerable empirical support for the hypothesis that the strength of a person’s intention to act is a positive function of his degree of self- and/or response efficacy. This holds whether the action is framed as gaining a personal benefit (Bagozzi 1992; Bandura 1986), reducing a threat (Tanner, Hunt, and Eppright 1991), or obeying a norm (Schwartz 1977). In all cases, there is a boundary condition: a person must think that the positive consequences of acting outweigh the costs.

In all theories that include a self-efficacy construct, for example, trying (Bagozzi 1992), normative behavior (Schwartz 1977), and protection motivation (Tanner, Hunt, and Eppright 1991), very low levels of self-efficacy do more than simply reduce the likelihood of acting. When the action is viewed as producing a benefit or obeying a norm, self-efficacy plays a gatekeeping role. If a person’s level of self-efficacy is so low that she does not think she is capable of engaging in an act, then she will not even try. In other words, when self-efficacy is low, increasing the benefits from acting will not result in a higher likelihood of acting. When the action is viewed as reducing a threat, both self- and response efficacy determine whether increasing the threat level leads to a higher or lower likelihood of acting. If either self- efficacy or response efficacy is too low, then increasing the threat level can reduce the likelihood a person will act now or in the future.

Although saving has not been one of the behaviors empirically studied, the argument that efficacy will influence savings behavior is consistent with two empirical findings. First, Farkas and Johnson (1994) and Public Agenda (1995) find a positive association between 401(k) participation and thinking that it is easy to save for one’s retirement. Since assessment of task difficulty is a proxy for self- efficacy (Bandura 1986), this finding suggests that individuals with higher levels of self-efficacy (in terms of saving for retirement) are more likely to participate in 401 (k) plans. Second, Public Agenda (1995) finds a positive relationship between 401(k) plan participation and confidence that one will reach one’s retirement goals. Being confident of reaching one’s retirement goals can be thought of as a proxy for response efficacy.

There are two primary ways of influencing a person’s level of goal efficacy (i.e., perceived ability). The first is to increase the individual’s actual ability to perform and accomplish critical tasks; the second is to increase the individual’s subjective judgment of her ability to perform and accomplish these tasks given her current skill/knowledge base.

Increasing Actual Ability

Behavioral economists argue that most people lack the computational ability and knowledge needed to solve the dynamic optimization problem that the standard neoclassical theory of savings assumes people act as if they solve (Benartzi and Thaler 2007). In particular, behavioral economists recognize it is difficult to (1) calculate how much money one needs to accumulate in order to be able to have a comfortable retirement, (2) calculate how much one must save on a monthly basis in order to reach this financial goal, and (3) decide how to invest this money. Their claims are consistent with numerous studies reporting that most Americans know very little about calculating retirement needs (Yakoboski and Dickemper 1997), investing (Public Agenda 1995), or even when they will retire (Employee Benefit Research Institute 2000). The standard approach is to deal with knowledge problems through education. Several studies have found that providing educational materials and seminars has a positive impact on participation in employer-sponsored retirement plans (Conte 1998; Yakoboski, Ostuw, and Hicks 1998). For example, 73 percent of those who have received educational materials from their employer have begun to save for their retirement as compared to 57 percent of those who have not received such material (Yakoboski, Ostuw, and Hicks 1998). However, as noted by Benartzi and Thaler (2007), many educational efforts have been disappointing.

A second point made by the behavioral economists is that people lack the willpower required to forgo consumption and save on a regular basis (Benartzi and Thaler 2007). Economists have long recognized that a key reason people fail to save is that they lack self-control. For example, in 1930, Fisher argued that people failed to save because they were “impatient”; some of the characteristics that led to impatience were “weak will,””habits of spending freely,” and “slavish following of whims of fashion” (Wameryd 1990). A long-standing structural solution to the self-control problem is to provide plans that allow a person to make a single one-time commitment to enroll in an automatic salary deduction plan, for example, a 401(k) or 403(b) plan. This type of precommitment strategy imposes a constraint on future behavior, thereby enhancing a person’s willpower because the sacrifice is made before the source of short-term gratification is truly encountered. The strongest evidence supporting this view is from empirical studies which find that although providing workers with 401(k) plans increases savings, changing the level of the employer match does not (e.g., Papke and Poterba 1995). In other words, these studies suggest that some workers may be responding to the availability of a 401(k) plan and not simply to the financial benefit.

Recently, there have been a number of innovative structural changes that jointly address the cognitive ability and willpower barriers (see Benartzi and Thaler 2007, for a detailed discussion). The changes include quick enrollment (a person can enroll and accept a preset contribution level and investment strategy by simply checking a box), enrollment by default (if a worker does nothing, she is automatically enrolled), and automatic escalation (the percentage of a person’s income allocated to a retirement fund automatically increases over time). Early evidence finds that these structural changes can be very effective. For example, one study found that implementing quick enrollment for new employees increased plan participation from 5 to 19 percent after one month and from 10 to 35 percent after four months. When all nonparticipating employees were given the quick enrollment option, about 25 percent of these employees joined a plan, and consequently, the overall participation rate rose from 54 to 66 percent (Beshears et al. 2006). Not surprisingly, the power of automatic enrollment has been even more dramatic. For example, Madrian and Shea (2001 ) found that with automatic enrollment, the level of participation by new hires at a large financial services company rose from 49 to 86 percent. While these structural changes appear promising, it should be noted that they are not a panacea: as mentioned in the introduction, not all workers are covered by a pension plan and not all workers can be expected to adopt plans with these features.

Increasing Subjective Assessment of Ability

A second way of enhancing goal efficacy is to use persuasive communications to increase the individual’s subjective judgment of her ability to perform and accomplish certain tasks given her current skill/knowledge base. A person’s subjective assessment of her ability is strongly influenced by four factors: effective attainment, vicarious experience, persuasive messages, and heuristics and biases. Through using marketing strategies and tactics to influence these factors, it is possible to alter an individual’s assessment of her ability, thereby influencing either self-efficacy or goal efficacy. (Response efficacy will not be independently affected.) The type of efficacy affected will depend on whether the person is led to think in terms of the instrumental act (e.g., can I save) or the goal (e.g., if I try, will I be able maintain my current lifestyle during my retirement years). The remainder of this section discusses the four determinants of subjective judgment and the appropriate marketing strategies for manipulating them.

Because a person’s level of efficacy will be higher if she can recall situations where she successfully performed a similar task, one way of enhancing an individual’s assessment of her ability to perform a task is through effective attainment, that is, past successful performance of a similar task. When applied to the issue of saving for retirement, this suggests a footin-the-door communications strategy. This strategy entails encouraging nonsavers to begin saving small amounts of money on a regular basis and then, over time, encouraging them to increase their level of saving. Because saving at a low amount is very similar to saving at a somewhat higher amount, a foot-in-the-door approach will enhance a person’s perception of her ability to save enough to meet her retirement needs. Note that this strategy is contrary to the current practice of relying on financial planning tools that identify the level at which a person must save to reach her retirement goal. The level of saving identified by a retirement planning tool can be so high so that it may well appear to be an impossible task to a nonsaver.

A second way of increasing a person’s judgment of his ability to accomplish a task (and hence her efficacy) is through vicarious experience, that is, observing similar individuals succeeding at a task. In the context of saving for retirement, this suggests the value of communicating how others with similar jobs, employers, and life circumstances are saving. This positive bandwagon approach is contrary to the current emphasis on how, because most workers are not saving enough to meet their retirement needs, there is a national savings crisis. The emphasis on a current crisis serves to undercut a person’s perception of her efficacy because it is communicating that similar people are not succeeding at the retirement task. A third approach to boosting an individual’s perception of her ability to successfully perform is through persuasive messages. A person’s level of efficacy can be influenced by messages, which communicate that she is capable of meeting her objectives. For example, when applied to retirement savings, this suggests using messages that convey confidence in the individual’s ability to save enough money to reach either her retirement goal (goal efficacy) or some smaller sum, such as the amount matched by her employer (self-efficacy). The positive, optimistic orientation suggested by this tactic is contrary to the crisis orientation exhibited by much of the existing promotional material. However, it is consistent with the current use of persuasive messages that emphasize the magic of compounding.

A fourth approach is to exploit the heuristics and biases people use when making judgments under uncertainty (see Kahneman, Slovic, and Tversky 1982, for a comprehensive review). For example, the availability heuristic means that a person will think an event is more likely if it is easy for her to recall salient examples. The belief in small numbers means that a prediction can be based on very little data. The representativeness heuristic means that irrelevant data are used when predictions are made. Put together, they suggest that if communications can lead a person to easily recall a small number of very salient examples of people “like herself” who successfully saved for their retirement, she will think that she is more able to save.

BENEFITS

The act of saving for retirement may produce benefits that can be enjoyed either immediately and/or during the retirement years. The short-term benefits consist of the short-term monetary rewards from savings (e.g., tax deferral) as well as the short-term nonmonetary rewards (e.g., gaining the approval of others). The retirement period benefits are the future additional utility gained from saving current income, that is, when a person saves a dollar, he augments his future retirement income and gains some level of future additional utility from this augmentation. In our framework, the impact of increased savings on one’s future income is influenced by the rate of return, and the impact of changing one’s future income on the benefits produced by saving is influenced by one’s hopes. In this section, we focus on how a policy maker can try to augment each of these potential benefits. In essence, four types of action can be taken: provide a short-term monetary reward from saving, provide a short-term nonmonetary reward from saving, increase the anticipated rate of return, and increase hopes by increasing the importance of a positively framed future.

Short-Term Financial Benefits

Behavioral economists argue that a person will be motivated to save by the opportunity to gain short-term financial benefits, such as the tax savings and employer matching dollars associated with some retirement plans (Thaler 1994). Prior research clearly supports the idea that a person is more likely to select a savings instrument that provides a short-term reward over one that does not (Thaler 1994). Feenberg and Skinner (1989) find that, holding all else constant, people who have to write a check to the Internal Revenue Service on April 15 are more likely to invest in an IRA than those who do not have to write a check. In addition, a number of companies have reported that the introduction and promotion of a matching program led to a significant increase in participation by younger, less-educated employees in the company’s retirement program (Conte 1998). However, there is no conclusive evidence that these financial incentives will increase a person’s overall level of retirement savings (see the debate between Engen, Gale, and Scholz 1996 and Poterba, Venti, and Wise 1996).

Short-Term Nonmonetary Benefits

The primary potential source of nonmonetary benefits from saving (at least for people who currently are not savers) is norms. There are four types of norms: societal, personal, injunctive social, and descriptive. Each is discussed in more detail below.

Societal Norms

A societal norm is a belief shared by most members of a social system about what constitutes good or bad behavior (Schwartz 1977). A societal norm (such as the belief that one should save for retirement) has an indirect, rather than direct, impact on behavior. It can only influence behavior to the extent that it is internalized, that is, becomes a personal norm.

Personal Norms

A personal norm is a self-based standard of expectation for behavior that flows from one’s internalized values; it is enforced through the anticipation of self-enhancement or self-depreciation (Cialdini, Kallgren, and Reno 1991; Schwartz 1977). The specific personal norm that a person applies in response to a given problem is, in most instances, constructed by drawing on the societal norms he has internalized in the past and on the values that stem from his unique history, for example, the individual’s upbringing (Schwartz 1977).

Personal norms must be activated to influence behavior (Cialdini, Kallgren, and Reno 1991). In other words, the person must consciously think about how the norm is relevant to a specific situation before the norm will have an impact. According to Schwartz’s (1977) theory of altruism, the likelihood of this occurring is a positive function of both the individual’s ascription of responsibility and his awareness of the consequences of acting.

Schwartz’s model can be applied to the retirement savings decision. An individual’s upbringing, coupled with the societal belief that people should save for their retirement, creates the following personal norm: “I should save for my retirement.” The individual recognizes that if he does not save for his retirement, he will not have a satisfactory retirement standard of living. He takes on the following ascription of responsibility: “I am responsible for my own retirement standard of living.” He is also aware of the consequences of retirement plan participation: “If I participate, I can have a satisfactory retirement standard of living.” Together his personal norm, his ascription of responsibility, and his awareness of the consequences of acting motivate him to participate in a retirement plan. All three elements must be present. A personal norm will not be activated unless a person has both a feeling of responsibility and an awareness of the consequences.

There is some empirical evidence supporting the potential power of personal norms to motivate saving. A nationally representative survey of working-age individuals found a strong association between saying that the statement “I learned the importance of saving money as a child” described them “very well” and actual retirement savings behavior, that is, having an IRA, being enrolled in a 401(k) plan, or having at least $50,000 in retirement savings (Farkas, Bers, and Duffett 1997). Since norms are learned during childhood, this suggests a positive link between possessing a personal norm that enjoins saving and saving for one’s retirement.

Second, there is a strong relationship between an individual’s level of retirement savings and his or her belief that individuals, not the government or employers, should take the greatest share of responsibility for ensuring that they have an adequate income in their retirement. About 60 percent of those surveyed said that an individual had the greatest level of responsibility; however, 79 percent of those with savings more than $50,000 chose individual responsibility as compared with about 53 percent of those with savings less than $50,000 (Public Agenda 1995).

Because influencing personal norms is a very difficult task, agents seeking to promote retirement savings in the near term should focus their efforts on activating latent norms, that is, on increasing a person’s ascription of responsibility for his own retirement and on enhancing his awareness of the consequences of saving. Statements from public officials and educational materials emphasizing that retirees cannot count on social security will enhance a person’s ascription of responsibility, while the tactics that can enhance a person’s perception of his goal efficacy (e.g., effective attainment, vicarious experience, persuasive messages, and heuristics) will increase his awareness of the consequences.

A reasonable long-term goal would be to significantly increase the proportion of the population holding a strong personal norm that enjoins saving. Current efforts to create and deliver savings programs to elementary and middle school students are a step in this direction.

Injunctive Social Norms

An injunctive social norm refers to a person’s perception of what relevant others expect him to do. These people are most often friends, family, and coworkers. Their influence flows through a person’s desire to avoid social sanctions and gain social rewards (Cialdini, Kallgren, and Reno 1991). Numerous studies have found support for the hypothesis that injunctive social norms can have some impact on a person’s behavioral intentions and behavior (Sheppard, Hartwick, and Warshaw 1988).

Prior research suggests that injunctive social norms have the potential to motivate savings behavior. A survey by Fidelity Institutional Retirement Services found that 31 percent of the employees who chose not to participate in a 401(k) plan cited the outside influence of friends and family as a reason (Williamson 1996). In addition, Yakoboski, Ostuw, and Hicks (1998) report that when workers who save for retirement were asked what had motivated them, 55 percent said that advice from friends or family had provided at least some motivation. For this reason, agents who want to encourage participation in retirement plans may find it fruitful to communicate with the friends and families of their employees. This approach has been used in other contexts by using mail to reach spouses, using school programs to reach children, and encouraging people (including coworkers) who are engaging in desired behavior to talk to those who are not. In a broad sense, a person’s retirement plan participation decision is not purely a private decision, but rather one that is subject to social influences. The final norm expands on this point.

Descriptive Norms

A descriptive norm is the belief that one should imitate the behavior of others. The power of descriptive norms is one of the most widely held tenets in psychology (Cialdini, Kallgren, and Reno 1991; Larimer et al. 2004). Numerous studies have found that people will imitate the behavior of others under a wide range of conditions. The power of descriptive norms was first recognized in situations in which individuals were in personal contact with one another (Cialdini, Kallgren, and Reno 1991). However, the power of descriptive norms has also been confirmed in situations where a person is simply made aware of how others have acted (e.g., Cialdini, Kallgren, and Reno 1991; Wiener and Doescher 1994).

Cialdini, Kallgren, and Reno (1991, p. 263) argue that a key reason for the power of descriptive norms is that people use a simple information processing rule of “if everyone is doing or thinking or believing it, it must be a sensible thing to do, or think, and believe.” The term “everyone” refers to all individuals who are in similar circumstances regarding the behavior in question. Similarity is a matter of degree; it can reflect physical proximity, common resources, common demographics, and so forth. A key point is that because the information processing rule is so simple, a person may imitate the behavior of others without consciously realizing that he is doing so.

A study by Duflo and Saez (2002) provides some evidence to support our contention that descriptive norms can be used to motivate retirement behavior. They studied plan participation at 11 libraries of a major university and found that participation rates ranged from 14 to 73 percent. They conclude that since the effect of the specific library a person works at is significant, even when factors such as age and tenure structure are controlled for, their study supports the hypothesis that peer influences are an important determinant of savings decisions.

One important implication of these propositions is that many of the current print promotional materials distributed by the leading preretirement savings organizations may be counterproductive. In their effort to communicate that there is a national savings problem, the pamphlets emphasize the extent to which people are neither saving nor participating in 401(k) plans. The descriptive norm literature suggests that many workers will respond to this communication by reasoning “If other workers aren’t participating, I won’t either.”

Fortunately, there are many social marketing strategies that exploit the power of descriptive norms. Their common trait is that they take the tactic of continually communicating how many people (like the target market) are planning to engage in, or are already engaging in, the behavior being promoted. For example, a small company could follow this strategy by emphasizing how similar companies have very high 401(k) participation rates. Large companies can begin their promotional efforts by expending a high level of promotional resources on a small segment of workers and then running a less resource-intensive communication effort trumpeting how a particular plant or work unit has achieved a very high participation rate. At a broader level, promotional material could emphasize how the number of workers participating in 401(k) plans has been increasing rapidly over the past decade.

In conclusion, because descriptive norms are so powerful, they are an unavoidable element of any strategy to increase retirement plan participation. If the strategy focuses on the empty glass (the coverage problems faced by American workers), the strategy will inhibit participation. If the strategy focuses on the full glass (examples of how workers are participating), the strategy will motivate. Finally, if the strategy is silent, then workers will imitate their friends and coworkers: if participation among their friends and coworkers is high, they will participate; if participation is low, they will not.

Rate of Return

Both Browning and Lusardi (1996) and Thaler (1994) conclude that increasing the real after-tax rate of return can have an ambiguous effect on savings. The theoretical reason in the neoclassical lifecycle savings model for the ambiguity is that while a higher rate of return increases the returns from saving, it reduces the amount of saving required to achieve any given level of retirement income (Thaler 1994). Thaler’s (1994, p. 186) carefully worded summary of the empirical evidence is that most studies are “unable to reject the hypothesis that the elasticity of personal saving with respect to the interest rate is zero.”

Although neither theory nor empirical work provides a sound basis for predicting how a change in the rate of return will influence a person’s intention to save (Browning and Lusardi 1996; Thaler 1994), there is widespread agreement that many savers invest their money poorly (Benartzi and Thaler 2007). In other words, the rate of return these savers earn is lower than the rate of return they could earn if they invested their money differently. To address this problem, employers can provide investment education, allow plan providers to offer face-to-face personally tailored investment advice, limit investment options to a small number of truly appropriate plans, and offer a truly appropriate default plan.

Hopes

A person’s hopes for retirement will be influenced by the extent to which he is aware of the positive aspects of leading a good retirement and the length of time he must wait before he enjoys his golden years. A person’s awareness reflects both how tangible retirement is to him and how connected the idea of retirement is with his basic psychological needs; these ideas, and their associated marketing strategies, are discussed in the next two sections. In the third section, we discuss the role of time and, in particular, how marketing strategies can lessen the degree to which one’s hopes for retirement are discounted.

Tangibility

The tangibility, to an individual, of his retirement refers to that individual’s perceptions of the tangible, concrete outcomes he may experience during his retirement years. (Outcomes that are not tangible or concrete are conceptualized as fulfilling basic psychological needs or being tied to abstract goals and are discussed later.)

The concept of tangibility is based on both basic attitude theory and information processing theories of attribute importance and memory. Specifically, the tangibility of one’s retirement is an increasing function of the number of concrete outcomes a person associates with retirement, his subjective evaluation of these outcomes, the degree to which he has allocated attention to these outcomes, and his assessment of the likelihood of experiencing these outcomes. These outcomes may be based on anything from sober analysis to dreams or fantasies. Greater tangibility leads to greater hopes and so increases the value of any increase in one’s retirement income.

The characteristics of both retirement and retirement plan products (e.g., 401(k) plans and IRAs) are such that we can presuppose that many people will have problems identifying the tangible outcomes. This is because, for many people, both retirement lifestyle and retirement products are innovative products: they cannot be tried, are very complex, do not fit one’s current lifestyle, and are not associated with a well-developed product- class knowledge structure (see Gatignon and Robertson 1985 for a discussion of innovative products).

The supposition that many people cannot identify the tangible outcomes associated with retirement is consistent with empirical findings. Based on a series of focus groups and surveys, Farkas and Johnson (1994, p. 13) conclude that a key reason many people do not prepare for their retirement is that most people just do not think about it very often, that is, “it may be on their radar screen, but just barely.” For example, in one survey, 35 percent said they never or rarely thought about retirement (and this question was ninth in a series of questions about retirement). Not surprisingly, there is a connection between thinking about retirement and savings behavior; for example, 41 percent of all individuals who said they never thought about retirement have no retirement investments or savings.

When taken together, the concept of tangibility, the product innovation literature, and the empirical studies of retirement combine to identify a key marketing task: agents seeking to encourage retirement savings must effectively communicate how saving for retirement will lead to positive tangible outcomes. The most straightforward (and generic) approach to enhancing the value of an unknown outcome is to communicate concrete consequences.

Although for marketers this task is obvious, its implications for current policy are significant. A major current public education effort is the publication and distribution of millions of pamphlets such as “Choose to Save” and “Ballpark Estimate” by the Department of Labor and American Savings Education Council (see American Savings Education Council 2007). These efforts presume that people are motivated to have enough funds to support a good retirement and focus on informing people (1) that to have a good retirement, they will need 70 to 90 percent of their preretirement income level, (2) that most people are not on track to reach this goal, and (3) how much they will need to save to reach this goal. These pamphlets reflect the underlying assumption of the prosavings community that the key to motivating people is to teach them what they need to do to save enough for their retirement. In other words, there is no recognition that marketing stimuli must be used to transform a vague notion that retirement is important into a set of tangible outcomes. Basic Psychological Needs

Both the means-end (Reynolds and Gutman 1988) and the hierarchy of goals (Bagozzi and Edwards 1998) literatures reach a common conclusion that a person is more likely to engage in an action if the outcomes of the action are linked to basic psychological needs, such as self-esteem, security, and social approval. In the context of retirement savings, this implies that the hopes an individual has for his retirement will be influenced by the extent to which he links reaching his retirement goal with fulfilling these needs.

Both theories postulate, and empirical work confirms, that typically the links between basic psychological needs and product or services are latent. In other words, people are unaware of the links unless a researcher probes or a persuasive communication activates. Persuasive communications activate latent links by making the link very salient. For this type of persuasive communication to work, the receiver must be involved, that is, have a high degree of interest in either the product being promoted or the promotional message itself.

Due to the low utilitarian and hedonic benefits associated with the act of saving for retirement (by nonsavers), it can be expected that, despite the actual importance of retirement, some people will process as if it were a low-involvement product. However, research by Maclnnis, Moorman, and Jaworski (1991) suggests that properly executed communications should be able to stimulate the processing of a retirement message and thus overcome the problem of low involvement.

Persuasive communications should therefore attempt to activate the latent links that exist between basic psychological needs and retirement by using the tactics suggested by Maclnnis, Moorman, and Jaworski, for example, the use of unusual formats, attention- attracting pictures, strong associations between the product and the affect-laden visual images, emotional appeals, and spokespeople who are either celebrities or someone with whom the message receiver can identify. For example, showing grandparents having a good time with their grandchildren is an example of using an affect-laden visual image to activate the latent psychological link between the retirement and the importance of family.

Time and Discounting

Finally, a person’s hopes for retirement will be influenced by time. The longer one must wait for a future benefit, the less it will be worth in the present, that is, future outcomes are discounted. This idea is a key element of the neoclassical theory of saving and is consistent with numerous studies that have found a strong positive relationship between an employee’s age and the degree to which he or she saves for retirement (Andrews 1992; Yakoboski and VanDerhei 1996).

Two approaches can be used to understand why people discount the future. The first is that there are personality differences, that is, different people have different internal rates of discount. Although empirically supported (Lin and Mowen 1994), this idea does not lead to direct policy recommendations since policies cannot alter personality traits. A second approach is more diffuse, but more promising in terms of identifying actions a policy maker can take.

Specifically, marketing scholars have investigated related issues, such as the effect of self-referencing anticipatory visualization on the formation of mental representations (Krishnamurthy and Sujan 1999), the link between mental representations of future outcomes and both brand attitudes and purchase intentions (Krishnamurthy and Sujan 1999), the traits associated with ability to delay gratification (Lin and Mowen 1994), and the relationship between visualization and purchase intentions (Hoch and Loewenstein 1991; Krishnamurthy and Sujan 1999; Maclnnis and Price 1987). These lines of research suggest a reason why future events are discounted.

Because a person’s vision of the future is constructed from available data, mental representations will become less and less detailed as one moves farther into the future and toward life situations more removed from one’s present state (Krishnamurthy and Sujan 1999). Moreover, numerous studies find that there is a positive association between the richness of one’s mental representation and the attitudes and intentions. Based on these ideas, we conclude that future events are discounted due to the inability of a person to form a rich mental representation.

A person’s mental representation can include both verbal propositions, such as those that directly contribute to tangibility, and sensory associations, such as visual images (Maclnnis and Price 1987). Two streams of research suggest that a dearth of sensory associations will lead to extensive discounting. One line consistently finds an association between a person’s ability to envision the future and his ability to delay gratification (Lin and Mowen 1994). The second line of research reports that the attractiveness of a future experience, measured by attitudes and intentions, is associated with the extent to which a person can form a concrete, self-referencing, visual image of the experience (Hoch and Loewenstein 1991; Krishnamurthy and Sujan 1999; MacInnis and Price 1987).

Both early economic reasoning and current focus group research support the argument that an inability to envision the future leads to excessive discounting and discourages people from saving. Over 100 years ago, von Bohm-Bawerk argued that people do not save because “Future goods are less clearly perceived than present goods … [in part due to a] … lack of imagination and ability to understand” (Warneryd 1990, p. 50). In addition, one of the more robust findings of a series of focus groups was that savers were far more likely to imagine retirement life than nonsavers. For example, a young Atlanta woman said, “It’s a real fun thing for us to imagine our retirement-we don’t sit around and bite our nails. We know exactly what we’re gonna do, how much we’re gonna have, what a typical day’s going to be” (Farkas and Johnson 1994, p. 17).

The above findings suggest that the degree to which retirement is discounted can be influenced by marketing communications. This stands in sharp contrast to the economists’ assumption that the degree to which a person discounts retirement income is solely a function of time and his internal rate of discount. Specifically, the extent to which people discount retirement can be limited by communications that are self-referencing and that are capable of inducing the receiver to imagine rich (i.e., visualized, concrete) retirement-related experiences. Since almost all potential savers will neither naturally allocate very high levels of attention to processing the retirement communications nor have strong pre- existing associations with retirement, we would recommend the use of communications that are both visual and filled with contextual detail (see Keller and Block 1997).

CONCERNS

A person’s concerns capture all the negative thoughts she might have about the retirement years. Concerns come into play when a policy maker tries to motivate a person to save by emphasizing the dire consequences of not having sufficient income during the retirement years. A person’s concerns can be enhanced by messages that make the future bad state more tangible, more connected to psychological needs, and more sensory rich. In other words, the tactics for increasing the salience of a future state work whether the future state is good (hope) or bad (concern). The critical issue for a policy maker is to identify when a strategy emphasizing concerns should be employed.

Tanner, Hunt, and Eppright’s (1991) protection motivation model depicts how people respond to threats. A threat can evoke two responses. First, a person can engage in a coping response that will reduce the feeling of threat. Second, she can feel fear.

There are two types of coping responses: adaptive (i.e., an action that reduces the actual threat level) and maladaptive (i.e., a response, which can be cognitive, that lessens the feeling of fear without reducing the actual threat level). When the concern is associated with having too little income during one’s retirement, the adaptive response is to save money. The maladaptive response is to come up with an excuse, for example, “why worry about retirement- everyone in my family dies young.”

Whether or not an adaptive or maladaptive response is followed depends on the individual’s level of coping appraisal, that is, the extent to which a person (1) is aware of an action she can take that will remove the threat and (2) feels capable of engaging in that action. If the answer to both is yes, there will be an adaptive response. If the answer to one or both is no, there will be a maladaptive response. As a result, the effect of threats on willingness to save will be positive or negative depending on coping appraisal.

Consequently, messages raising concerns should be used only under certain conditions: (1) when the target market has a pre-existing high level of coping appraisal or when the message also contains a sufficiently strong efficacy message to concurrently create a high enough level of coping appraisal, (2) when the message will not significantly spill over into low coping appraisal markets, and (3) when the individuals who are being exposed to the message do not have a history of rejecting similar messages. In other words, fear appeals should not be used to encourage retirement plan participation for middle-aged and older people who have very few retirement assets. COSTS

People can incur two types of costs when saving for retirement. First is the conventional opportunity cost, which is the loss of utility equal to the level of utility that would have been gained if the money had been used to purchase the next best alternative. This cost depends on factors such as one’s tastes, income, number of dependents, and stage of the lifecycle. The second cost is deprivation, that is, the cost generated when saving leads to a negative discrepancy between one’s current position and a reference value. Because the factors that influence opportunity costs are not themselves policy levers, this section deals solely with deprivation.

Deprivation

Numerous social science theories postulate that individuals feel deprived if their current level of material well-being declines (see Hoch and Loewenstein 1991, for detailed references). In the context of retirement savings, there are two major sources of deprivation: a reduction in one’s standard of living and the framing of saving so that it appears to be a loss.

Deprivation Due to a Reduction of Current Standard of Living

The unwillingness of individuals to reduce their current standard of living has long been recognized by economists concerned with savings behavior (Wameryd 1990). Duesenberry (1967, p. 85), for example, argues that the reason savings rates are so much lower for families that have experienced a recent decline in income relative to those who have not is that there is a fundamental psychological postulate that “it is harder for a family to reduce its expenditures from a high level than for a family to refrain from making these expenditures in the first place.”

Because individuals will resist reducing their current standard of living, the timing of retirement plan participation requests may play a critical role in determining the extent to which people will participate in a plan. For example, if the opportunity to participate in a 401(k) plan is presented when a salary increase is being received, then it is less likely the person will have to actually reduce his current standard of living to participate. Likewise, the SMART plan feature, which automatically escalates a person’s contribution whenever he receives a raise, is perfectly designed to minimize the individual’s sense of deprivation.

Deprivation Due to Framing

A person’s sense of deprivation and hence willingness to save can be influenced by the way in which the saving opportunity is phrased. One of the most pervasive findings in the psychological decision- making literature is that if an outcome is labeled a loss, a person will think of it as a loss, associate it with deprivation, and seek to avoid it (see Kahneman, Slovic, and Tversky 1982).

The issue of phrasing is relevant because currently some 401(k) participants are asked to sign up for a “salary reduction plan.” Because this phrasing forces them to think of the contribution as a loss, they will be less likely to participate. It would be far better to avoid the term “salary reduction” and refer to the plans using either neutral or positive phrasing, for example, 401(k) plan or tax deferral plan.

A second application of framing draws on the mental accounting literature (Thaler 1994). If a person is asked to take money out of his income stream or another savings account, then he is clearly making a sacrifice. However, if the money is a “windfall” and has not yet been assigned a mental account, then putting it into saving does not require reducing another account. By allowing individuals to purchase an IRA with their tax refund, the 2006 Pension Protection Act allows people to save without incurring deprivation. In addition, since this is additional money, there will not be any deprivation due to a reduction in one’s standard of living.

SUMMARY AND CONCLUSIONS

This article identifies the constructs that influence an individual’s intention to save and discusses how and when these factors can be changed by an agent trying to induce an individual to enroll in a retirement plan, increase his or her contribution to a plan, or purchase a particular retirement product. In addition to placing existing efforts (primarily structural and educational approaches) into context, the article explores a third approach- persuasive communications-that has received far less attention from private agents, public policy makers, and scholars. These persuasive communication strategies encompass both approaches that agents should follow and approaches that agents should not follow to encourage retirement savings.

For the most part, the recommended persuasive communications influence a person’s subjective assessment of his ability to save, his perception of the short-term nonmonetary benefits associated with the act of saving, and the degree of importance or utility associated with consequences experienced during his retirement years (i.e., hopes and concerns). They can be roughly categorized into five main themes.

Theme 1: Be Positive

The overall theme of preretirement communications should change from one emphasizing crisis/doom (focusing on the failure of people to save) to one emphasizing bandwagon/hope (focusing on how people are saving). Emphasizing the positive will enhance perceived ability and exploit the power of descriptive norms. Note that crisis/doom is the frame typically used by organizations attempting to influence public policy by influencing public opinion. What prosavings advocates need to recognize is that communications that may motivate a person to support government policies supportive of retirement may well diminish the same person’s personal willingness to save. In addition to reducing perceived ability and reversing the impact of descriptive norms, the “government action is needed due to the crisis” message can both create fear and reduce an individual’s sense of personal responsibility.

Theme 2: Be Rich in Imagery and Detail

Prosavings communications need to be rich in imagery and focus on the concrete needs and script-based outcomes of meeting one’s retirement objectives. seeing the value of how one can meet abstract higher-order goals in concrete terms will enhance the value of having additional income during retirement. To the extent that messages can present positive pictures and stories of people similar to the target market, it is likely that future outcomes will be more highly valued. In addition to employing this approach in prosavings communications, prosavings advocates should consider imitating the public health advocates. Over the past decade, public health advocates have been working with the television networks to insert prohealthy behavior messages into story lines. The analogy is for prosavings advocates to begin to work with the mass media to insert the theme that one who has saved can live a good life.

Theme 3: Do Not Ask People to Do Too Much

Savings opportunities need to be structured (in terms of initial requested action, financial information provided, wording, and timing) to maximize the likelihood of enrollment, even if the plan is not optimal. For many people, moving from their current level to an optimal level is too daunting a task. If too much is required to reach a goal and failure to reach the goal is framed as failure, then a person may simply do nothing. Automatic escalation may overcome this problem. However, if this feature is not present, promoting savings becomes a continuous process. Once a worker is enrolled in a plan, the task becomes one of continually seeking to influence him to increase his contribution level. Continuous marketing is consistent with the argument that a person should be led to think about the retirement period consequences of saving in terms of positive, concrete images, rather than in terms of achieving a given replacement ratio. Because imagery is open ended, a person who is saving will not be able to assume that since he enrolled in a plan that promises to produce a given replacement level, he now needs to do nothing more.

Theme 4: Use Social and Normative Pressures

The social/normative benefits of saving (e.g., what others are doing, peer pressure, impact on one’s family) should be emphasized, as opposed to casting the decision to save as a purely individual decision. This approach may be well suited for trying to get young people to save. Retirement is so far off in the future that strong, positive imagery; financial incentives; and perceived goal efficacy may not be enough to overcome the negative effect of discounting. Because the benefits produced by norms come from engaging in the behavior rather than the material consequences of engaging, they cannot be discounted and at the same time closely fit the experiential orientation of modern young people. In essence, we are suggesting that agents trying to promote retirement savings use messages that psychologically mirror the messages used by other marketers who are targeting young adults. Specific messages could include: do what others are doing (descriptive norms), gain approval from one’s friends (injunctive social norm), and feel good about one’s self for just doing it (personal norm).

Theme 5: Do Different Things to Different People

Segmentation should be used to identify both the messages that certain groups should and should not get. The groups can be defined in three potential ways. First, a group can be defined, as in the previous example, in demographic terms. Next, a group can be defined in terms of its current retirement savings status. For example, because both fear appeals and retirement worksheets can either encourage more saving by people who see themselves as being clearly capable reaching a goal set by a financial expert or discourage saving by people who do not see themselves as being capable, sending different messages to each segment may be appropriate. Finally, a group can be defined in terms of the structural features of its retirement plan, for example, automatic enrollment. It may well be that employees who are automatically enrolled in a plan should receive very little in the way of retirement education or promotion. This seemingly odd suggestion is based on the contrast in enrollment rates between plans offering automatic enrollment (do nothing) and quick enrollment (check a box). The finding that participation rates are so much higher in automatic enrollment plans suggests that many employees are enrolling without consciously thinking about retirement. If this is the case, an employer using an automatic enrollment plan might be wise to avoid actions that could encourage a prospective enrollee to think about saving for his retirement. In conclusion, persuasive messages can be an effective means of encouraging individuals to save for their retirement. Using persuasive messages complements, both past and current structural and education approaches. Certainly, both the old (e.g., matching, precommitment, and tax deferral) and the new (e.g., automatic enrollment and quick enrollment) structural approaches are beneficial and hopefully will rapidly diffuse. In addition, conventional investor education programs, which help make workers more knowledgeable and more effective savers, are valuable tools in the fight to bring retirement income security to Americans. However, as long as the structural programs are neither fully subsidized by the government nor mandated at either the individual level (like social security) or the employer level (like health care in Massachusetts) and as long as workers lack confidence in their ability to save, there will be a need to encourage individuals to willingly choose to put money aside for their retirement. Therefore, one arrow in the quiver of those seeking to induce people to save should be persuasive communications.

1. VanDerhei estimates all that if employers who currently offer 401(k) plans offered automatic enrollment plans with a six percent contribution level and a lifecycle investment feature as the defaults, the median replacement rates would range from 52 percent for the lowest-income quartile of workers to 67 percent for the highest.

2. If more people participate in a plan which features employer matching, then employers must pay more in matching contributions. Some experts argue that, for this reason, the ability of automatic enrollment plans to achieve very high participation levels will work against their adoption.

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By Pratt, Cornelius B

[P]eople have a responsibility to tackle this issue at an individual level, [even though] a large majority also sees a need for government to play some role in helping individuals accomplish those goals. – Trust for America’s Health (2007, p. 85)

But personal responsibility is not a free pass for corporate irresponsibility. It is easier to just say no when you aren’t being manipulated and marketed to say yes.

– Goodman (2003, p. A21)

Government agencies, foundations, and businesses use public- education and social-marketing campaigns to motivate the nation toward having better health through, among other things, healthful- eating habits and active lifestyles. Some of those efforts, however, have had modest successes. This article presents seven ground rules – or principles – that can improve the effectiveness of campaigns aimed at shrinking bulging waistlines. But the limits of such principles must be stated at the outset: Because social, interpersonal, community, and ecological factors influence health behaviors (Glanz, Rimer, & Lewis, 2002), well-crafted messages can help health communicators meet their campaign objectives only to the degree that those factors enable. Thus, on the one hand, a confluence of environmental and physiological factors inherently negates the effects of weight-management campaigns. Economics and social-psychological factors (e.g., cost of energy-dense foods, social networks, and interpersonal communication), on the other hand, affect the success of message themes, particularly those on intractable U.S. health issues such as excess weight gain and obesity. Consequently, even when well-crafted messages influence peoples’ nutrition and exercise regimens, they do not necessarily result in meeting overall campaign objectives.

Situation Analysis

On August 21, 2007, the U.S. Department of Health and Human Services (DHHS), one of several federal agencies that are tackling the overweight and obesity crisis that afflicts 66 percent of the U.S. population, announced the establishment of the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, as a follow-up to its earlier initiative, Healthy People 2010. Less than a week later, a nonprofit organization, Trust for America’s Health (TFAH), announced in a report, the fourth in a series aptly titled “F as in Fat,” disturbing, yet predictable, findings indicating that our national battle against the bulge has yet again earned a failing grade and implying that the efficacy of many government programs and initiatives on obesity and overweight may be in question (Trust for America’s, 2007).

Who’s to blame? Are we, as individuals, doing our level best to reverse the obesity trend in the United States – or are we placing much of that responsibility on organizations? On October 19, 2005, the U.S. House of Representatives answered yes to the latter question by passing the Personal Responsibility in Food Consumption Act, which bars frivolous lawsuits on excess weight gain or obesity allegedly attributed to consumption of restaurant food. That bill failed to become law.

According to TFAH’s 2004 report on obesity, it had been viewed traditionally and exclusively as an individual problem; however, the report recommended that “the best way to achieve real, sustainable behavior change is through a combination of education plus community, state, and federal policies and programs that support individual action” (Trust for America’s, 2004, p. 4, emphasis added). And such programs inarguably run the gamut: the U.S. Food and Drug Administration, for example, in August 2003, set up an Obesity Working Group, which had policies on the labeling practices of food manufacturers, on having food manufacturers provide accurate information on serving sizes and calories count, on spreading the message that calories count, and on requiring restaurants to provide more nutritional information to consumers (Trust for America’s, 2004).

Also, DHHS’s Healthy People 2010 stated that health education should include information about the consequences of unhealthful diet and of inadequate physical activity. And, for at least a decade, a welter of similar government initiatives had been marshaled to boot: the Center for Nutrition Policy and Promotion’s Dietary Guidelines for Americans 2005; the Federal Trade Commission’s consumer guides on obesity that included Consumer Alert! Paunch Lines: The Skinny on Dieting; Setting Goals for Weight Loss; Pump Fiction: Tips for Buying Exercise Equipment; Tipping the Scales? Weight-Loss Ads Found Heavy on Deception; and The Facts About Weight Loss Products and Programs. All those public-education materials had long been touted as having the potential to alleviate overweight as a public-health challenge.

How much impact have those programs alone had on overweight and obesity in the United States? Because of the complexity of factors that affect the maintenance of healthy weight, singular national effect of those programs is not known. What is known, however, is that an increase in adult obesity rates occurred in 31 states in 2006, with 22 such states having an increase for the second year in a row (Trust for America’s, 2007). Between 1980 and 2004, childhood obesity rate more than tripled, a rate that former U.S. Surgeon General Richard H. Carmona (The Obesity Crisis, 2003, [para] 21) attributed to two fundamental reasons: “Too many of our children are eating too much and moving too little.” And those trends occurred despite massive, concerted efforts by government, corporate, and interest groups to stem the tide of a health problem that 85 percent of respondents in a TFAH survey believe “has reached epidemic proportions in the United States” (Trust for America’s, 2007, p. 85).

Widely implemented education and publicawareness campaigns have been key elements in those efforts. But such institutional efforts have their limitations, as some outcomes of persuasive campaigns tell us. Let’s look at the Reagan administration’s much-vaunted “Just Say No” (to drugs) campaign, which was launched in the 1980s, grounded in social inoculation theory, and cost more than $929 million. Its results indicated an increase in youths’ using drugs, an outcome Andreasen (1995) described as a boomerang effect and Rains and Turner (2004) as a reactance toward a campaign.

It is, therefore, the purpose of this article to present seven ground rules – or principles – for developing message themes (and slogans) on excess weight-gain prevention and reduction within the framework of personal responsibility for one’s physical health that is, such messages must be personalized to emphasize the self, even as health-care institutions, organizations and businesses do their part to enable the nation meet its health goals. In essence, then, governments, foundations, and businesses can provide only part- answers to a vexing health issue, leaving some of that responsibility to the individual. Granted, that view is consistent with that of U.S. adults: “Americans see a role for government in helping to turn awareness into action, particularly in the form of helping to provide strategies to increase physical activity and maintain a healthier diet in people’s daily lives” (TFAH, 2007, p. 88). Therefore, the rest of this article is premised on the notion that, while there is “a role for government in helping to turn awareness into action,” an emphasis on individual efforts is required in a renewed attempt to wrestle a national health epidemic. Thus, as the epigraphs that introduce this article suggest, responsibility for the effectiveness of health-communication campaigns on weight management is twofold: that of the individual and of the organization.

Organizational and Individual Responses

A good number of U.S. organizations increasingly acknowledge the value of a healthy workforce. And some are questioning the economic rationale of focusing on profits to the detriment of the consumer. Perhaps in the same breath, foodand drinks-manufacturing and marketing companies are tinkering with their products and their marketing messages, demonstrating some level of responsibility for the nation’s healthful – or unhealthful – eating habits (e.g., Adams, 2007). Inarguably, some of that corporate action was a response to litigation brought against the food industry: McDonald’s settled for $12 million a lawsuit that alleged that it had failed to disclose its use of beef fat in its French fries; DeConna Ice Cream Company settled for $1.2 million a claim that it had understated fat and calorie content in a brand of its product, as did Robert’s American Gourmet Foods for $4 million; and Kraft agreed to remove trans fats, which it had not disclosed, from its Oreo cookies (Zernike, 2003).

A landmark agreement announced May 3, 2006, is yet another of a flurry of strategic attempts by advocates of healthful-eating habits to battle the obesity epidemic. On that day, some of the largest marketers of carbonated drinks – American Beverage Association, Cadbury Schweppes, CocaCola and Pepsi-Cola – agreed to sell only water, unsweetened juice, and low-fat milk in U.S. elementary and middle schools.

Just months earlier, a group of intrepid fourthand fifth-graders at North Side Elementary School, in Fort Lauderdale, Florida, refused to sell unhealthful snacks to raise funds for their trip to Washington, D.C., and Williamsburg, Virginia. They viewed as unconscionable the sale of sugared, high-calorie snacks because they had been taught at school to abstain from eating those same products. And, three years earlier, California had become the first state in the nation to ban carbonated beverages from cafeteria menus from elementary through junior high school. And high-school cafeterias are only now increasingly giving healthful food choices a much-needed boost.

Health Risks and Business Interests

The clinical implications of food choices for a nation’s health are far-reaching: they contribute in disparate ways to overweight and obesity in children and adults. In 2003-2004, 35 percent of U.S. children were overweight or at risk for overweight, and 66 percent of U.S. adults were overweight or obese (Ogden et al., 2006). Obese U.S. children and adolescents have increased risks for cardiovascular diseases and comorbidities such as Type 2 diabetes, hypertension, and dyslipidemia (Daniels, 2001). Among adults, obesity contributes to cardiovascular disease mortality and to a smorgasbord of diseases, including kidney disease, diabetes, stroke, and cancer (e.g., Flegal, Graubard, Williamson, & Gail, 2007; Friedrich, 2003).

Overweight and obesity also nave economic implications: they result in increases in medical expenses, in absenteeism, and in health-care costs (Finkelstein, Fiebelkorn, & Wang, 2005). Overweight and obese workers are significantly more likely than their normal-weight counterparts to report health-related lost productive time (Ricci & Chee, 2005); poor work ability (Laitinen, Nayha, & Kujala, 2005); disability (Burton, Chen, Schultz, & Edington, 1998); and lost workdays (Burton, Chen, Schultz, & Edington, 1998; Wolf & Colditz, 1998). Such issues provide the impetus to several major U.S. companies – e.g., Coors Brewing Company, Hershey Food Corporation, Kimberly-Clark, and Sprint – to develop worksite wellness programs (Anderson & Kaczmarek, 2004; Zernike, 2003).

The major culprits of much of the nation’s overweight and obesity problem are excess caloric intake and physical inactivity. Americans eat at least one meal out of the home each day. Reported eating at fast-food restaurants has been associated with poorer eating and exercise habits and with higher body mass index Geffrey, Baxter, McGuire, & Linde, 2006a, 2006b). Other studies associate the Circean lures and the use of fast-food restaurants (Maddock, 2004), which, incidentally, tend to cluster around schools and expose students to poor-quality food environments (Austin et al., 2005), with the frequency of consuming restaurant foods and having higher intakes of calories (McCrory et al., 1999; Paeratakul, Ferdinand, Champagne, Ryan, & Bray, 2003); with high-fat, high-sugar food choices and inverse associations with healthful foods such as fruit, vegetables and whole grains (Bowman & Vinyard, 2004; French, Harnack, & Jeffery, 2000; French, Story, Neumark-Sztainer, Fulkerson, & Hannan, 2001); and with the consumption of fast food that has had an adverse effect on dietary quality of children and adolescents aged 4 to 19 (Bowman, Gortmaker, Ebbeling, Pereira, & Ludwig, 2004). Consequently, the U.S. Department of Agriculture designed a Healthy Eating Index (HEI) to help the U.S. public better understand the quality of diet that it consumes. HEI has 10 components, each of which identifies an aspect of a healthful diet, based on the agency’s Food Guide Pyramid and its dietary guidelines (U.S. Department of Health, 2005). An HEI score of 81 or higher indicates a good diet; a score from 51 to 80 indicates a need for dietary improvement; a score lower than 51 indicates a poor diet. The mean score for the U.S. population indicates a need for dietary improvement.

Seven Ground Rules

I present seven ground rules to help organizations develop key messages for motivating audiences to respond to their risk for overweight and obesity. I developed those rules by analyzing campaign messages that were either effective in meeting their goals or that failed to reach them. A key strength of major overweight and obesity campaigns in the United States is that they all subscribe to the cumulative-effects theory: complementary campaign themes are not only repeated over time but are placed in a variety of media, public and interactive outlets. But most such campaigns have limitations; hence, the proposed ground rules.

1. Be attentive. This is the first rule of every successful campaign. We should listen more carefully to what participants tell us in depth interviews, focus groups, pretest message research, pilot tests or other forms of messageevaluation programs. That way, a planner learns firsthand audience reactions, perspectives, and interpretations that could be brought to bear on campaign messages and slogans, sidestepping pitfalls and limitations that typically result from unexpected outcomes of campaigns improvidently rolled out, as was the case of the “Just Say No” campaign. The contractors who helped develop that campaign on behalf of the federal government had evidence of a vetting process, but the scientific rigor and disinterestedness of its planning phase left a lot to be desired. Regardless of how much scientific evidence one has accumulated during planning, art still has a fundamental role in testing copy: one still needs to listen to one’s gut.

2. Be personal. Because individual responsibility is a crucial element in health maintenance, it is important that key messages be replete with personal pronouns: “you,””your,””my.” The point here is to encourage audiences in a succinct way to understand their individual stake in the message and to embrace it. NIH’s “We Can! [Ways to Enhance Children’s Activity and Nutrition]” and Nevada’s Clark County’s “Healthy Eating and Physical Activity Campaign” illustrate the effectiveness of personalization.

3. Be selective. Organizations have a responsibility to help people make wise food choices and engage in physical activity. It is an individual’s responsibility to develop healthful-eating habits by, for example, consuming five or more servings of fruits and vegetables per day, while acknowledging that total calories consumed count. As noted in a preceding paragraph, research links fast-food consumption to obesity (e.g., Mancino, Lin, & Ballenger, 2004), which is further exacerbated by the limited nutritional information that is available to patrons of restaurants and fast-food chains. Granted, this consideration is undermined by realities that low- income households tend to have less access to high-quality foods than middle- and upper-income households (Moore & Diez Rous, 2006; Zenk, et al., 2005). Low-income neighborhoods tend to have a significantly higher concentration of fast-food chains than middle- and upper-income neighborhoods (Block, Scribner, & DeSalvo, 2004; Horowitz, Colson, Herbert, & Lancaster, 2004; Zenk et al., 2005).

4. Be casual. People are responsible for taking mini-steps as a complement to an exercise regimen that requires more frequent physical activity. Wellness programs tend to overemphasize a routine – that is, setting aside 30 or so minutes for a workout; rather, messages will be more beneficial to the public if they focus on the small steps that we can take toward becoming active. An illustration: Granville C. Coggs is an 82-year-old radiologist (and exercise aficionado) who uses the slightest of opportunities to burn calories. At his workplace, he parks his car some 440 yards from the main entrance to his office building. Why? Because he sees that distance as yet another opportunity to maintain his level of physical activity by running into and out of his building. While running through the grounds or parking lot of an office building might be a risky activity, walking longer distances from parking areas to a place of appointment is a passive mini-step toward being in frequent motion and moving toward better physical health. In 2005 and 2007, Dr. Coggs won gold medals in the 400- and 1,500-meter races in his age bracket at the Texas State Senior Games; in 2006, he won a gold in the 400-meter and a silver in the 1,500-meter competitions.

Organizations contribute to such small efforts in the workplace. Cars are banned from Sprint’s 200-acre headquarters in Overland Park, Kansas, forcing employees to park in garages as far away as one-half mile from their offices, where they are also encouraged to use the stairs, not elevators, between floors (Zernike, 2003).

5. Be active. People are responsible for having an active lifestyle. The “Verb: It’s what you do” campaign that the Centers for Disease Control and Prevention hoped will help children ages 9 to 13 become physically active did not even use the active verb. Parts of that campaign, reported to have cost nearly $190 million, raised questions about its efficacy, resulting in the Bush administration’s withholding funding from the campaign in its second year. Consider, for example, one of its abstruse, albeit personal, messages: “Everywhere you go, everywhere you look, there are verbs out there just waiting for you to get into.” Simple exhortations that start with a personal pronoun coupled with an active verb as in “you exercise daily,””you play often””you swim weekly,””you run every day,””you jump rope frequently,””you skate with friends,” or “you walk every day” could have been much more communicative to campaign audience.

Minnesota’s activity-packed “do” campaign, launched in Duluth and in Minneapolis-St. Paul in November 2004 by BlueCross BlueShield of Minnesota and by the American Heart Association, is an exemplar of a long-range persuasive, multimedia effort to encourage adult Minnesotans to “grove your body every day” by adding physical activity to their daily routines at work, at home, at play. This physical-activity campaign, part of a four-goal “Prevention Minnesota” effort, uses television commercials (and a theme song), billboards, street media, and transit ads to drive home its messages, in which are embedded simple auxiliary verbs to motivate audiences into action: do bike, do canoe, do dance, do garden, do hike, do hopscotch, do move, do shovel, do skate, do sled, do walk. The campaign’s two television commercials show a heavy-set middle- age man “do dance” in one and “do walk” in the other; in both, the man shakes his body vigorously and rhythmically to a theme song, “Move Something.” The campaign is being expanded to other major cities in Minnesota, where the mass media, community involvement, point-of-decision prompts (e.g., use stairs, skip this bus stop for the next one down the block) have raised public awareness of the campaign. (Another facet of “Prevention Minnesota” focuses on healthful eating.) Granted, studies have shown that neighborhood safety, walkability and disorder are related to the frequency of outdoor physical activity (e.g., Burdette & Whitaker, 2004; Burdette & Whitaker, 2005; Burdette, Wadden, & Whitaker, 2006; Miles, in press); and that dimensions of the built environment (land use, access to public transit and population density) are significantly inversely associated with body size, while controlling for the potentially confounding effects of demographic factors (Rundle et al., 2007). But U.S. city roads are generally more conducive to driving than to walking, biking, or weaning the public from motorized vehicles – unlike, say, in European cities such as Amsterdam and Paris, where bicyclists tend to have better advantages in road use and where wider sidewalks and more tree-lined streets give pedestrians additional reasons to be outdoors and to be physically active. (Paris’s Mayor Bertrand Delanoe has pledged to reform the city’s transportation system by, among other things, eliminating motorized traffic in parts of the city and reducing the city’s car traffic by 40 percent.) Consequently, a good number of residents of U.S. cities often fail to take advantage of available neighborhood walkways to engage in some regular exercise: walk to a nearby convenience store or to a public facility, and reduce particulate pollution as they become healthier.

6. Be sparing. Audiences’ compliance is enhanced by messages that are clear, simple, tailored and actionable. Marketers and advertisers, on the one hand, understand full well that information clutter is dysfunctional, in that it leads to consumer skepticism toward the message; to viewer opposition, hostility and resentment toward, and defiance of, the message; and to message avoidance strategies (Goldman & Papson, 1994, 1996; Mendoza, 1999; Speck & Elliott, 1997). Rumbo (2002), on the other hand, argues that marketers can convert the subculture of consumer resistance movements into a strategic advantage – one that capitalizes on both consumerism and on marketers’ insights on the lived experiences of ahti-consumerist groups.

In both situations, tailored messages delivered through appropriate channels should convey to audiences that engaging in two major activities eating healthfully and exercising regularly – in small steps can contribute to expected outcomes. Personalized nutrition-only campaigns such as “TrEAT Yourself Well” indicated the effectiveness of focused campaigns in promoting healthful dining (Acharya, Patterson, Hill, Schmitz, & Bohm, 2006), as did the “5 A Day” in promoting consumption of fruits and vegetables (Centers for Disease Control, 2005). Similarly, nutrition-cum-physical-activity campaigns (e.g., “California Project LEAN [Leaders Encouraging Activity and Nutrition] and the NIH’s “We Can!”) are examples of such focused attempts by campaign planners to zero in on one or two expected outcomes, without taxing the cognitive and behavioral limits of their audiences.

But message themes must be actionable for audiences, a principle on which parts of Nevada’s “Healthy Eating and Physical Activity Campaign” fall short. The reason: Its “Walk Around Nevada,” introduced June 2006 as an online program to increase physical activity, may not sit well with people without easy access to such technology, which, in any event, encourages sedentary behavior. The program’s paper alternative for those without online access may not have the same cachet as that associated with entering one’s activity online and may also be so cumbersome that it further discourages disadvantaged residents who are already struggling with a health challenge. Likewise, simplicity in message themes was also lost in “Calories Count,” a nutrition-awareness campaign at the University of California, Los Angeles. Its key messages are buried in a ponderous, text-heavy tutorial on one’s daily calorie needs for a healthy body weight, making audience’s message comprehension and compliance challenging in their own right.

Similarly, elements of “What Moves U,” a national campaign launched October 2006 by the National Football League and the American Heart Association to encourage physical activity among youths are text-heavy and also have Web-based activities (contests and games), which can inadvertently encourage physical inactivity.

7. Be credible. Audiences comply more when information is inarguably and demonstrably accurate. Message themes must be unassailably factual, a consideration that was lost on both the American Dairy Association and the National Dairy Council whose “3- A-Day of Dairy” campaign morphed into a “Healthy Weight With Dairy.” Launched in January 2003, “3-A-Day of Dairy” was a nutrition-based, award-winning campaign aimed at encouraging the public to consume calcium (in milk, cheese and yogurt) for stronger bones and healthier bodies.

Beginning September 2004, however, the campaign was expanded to include a link among dairy consumption, weight loss and weight management, a link so tenuous and controversial that it stoked the ire of an activist group, Physicians Committee for Responsible Medicine (PCRM), which petitioned the Federal Trade Commission (FTC) in 2004 to halt the campaign. A fact sheet distributed in that campaign stated in part that for “adults needing to lose weight, a growing body of research shows that enjoying 3 servings of dairy a day as part of a reduced calorie weight-loss plan can help them achieve better results, when it comes to trimming the waistline, than just cutting calories alone and consuming little or no dairy.” Thus the campaign had television, print and radio commercials with slogans such as “Milk your diet. Lose weight” (from the National Fluid Milk Processor Promotion Board); “3-a-day. Burn more fat, lose weight” (from the National Dairy Promotion and Research Board); and “More Yummy…Less Tummy.” The dairy industry had relied on results that indicated significant positive relationships between dairy consumption and weight loss (Zemel, Thompson, Milstead, Morris, & Campbell, 2004). Those findings were challenged (e.g., Barr, 2003; Lanou, 2005). In May 2007, the FTC axed the campaign, opening the flood gates to further criticism of the industry’s intentions. Absent conclusive evidence on an association, the dairy industry charged ahead to extend its “Healthy Weight With Dairy” campaign toward accomplishing goals that had earlier been deemed questionable, if not controversial.

At its inception, the U.S. government’s cancer-prevention campaign, “5 A Day,” promoted consuming five or more servings of fruits and vegetables daily. Later food research interpreted that consumption as a tool for weight management. While there are reasons for promoting consumption of fruits and vegetables as a useful strategy for preventing overweight, evidence is sparse to support the association between fruit and vegetable consumption and weight (Sherry, 2005).

Conclusion

Communication campaigns – e.g., “TrEAT Yourself Well” and “We Can!” – are a standard response to the epidemic of overweight and obesity in the United States. But most such campaigns are not demonstrably guided by all the seven ground rules this article proposes as guideposts for planners of weight-management communications. Does such absence explain the nation’s failure to rein in its increasing overweight and obesity rates? We don’t know.

What we do know, however, is that health campaigns whose message themes and slogans reflect the hallmarks identified in this article tend to meet their objectives and to have better audience reception. And the campaigns tend to subscribe to the notion that their effectiveness lies at two levels that of the individual and of the organization. To the degree that campaign themes collectively reflect those ground rules, as well as the dual responsibilities of the individual and the organization for combating the epidemic, it is likely that the latter will be much better contained, if not reversed. Failing that, the epidemic could morph into a permanent fixture on the nation’s health landscape, where there is only spotty evidence of success. To avert such an outcome, then, there is an urgent need for a national campaign on overweight and obesity that involves both a commitment from and a partnership among government agencies, foundations, and businesses.

References Available Upon Request

…an increase in adult obesity rates occurred in 31 states in 2006…

…responsibility…of weight management…that of the individual and the organization.

…some of the largest marketers of carbonated drinks…agreed to sell only water, unsweetened juice, and low-fat milk in U.S. elementary and middle schools.

…obesity contributes to… a smorgasbord of diseases…

We should listen more carefully to what participants tell us…

Wellness programs tend to overemphasize a routine…

…ads to drive home its messages, in which are embedded simple auxiliary verbs to motivate audiences into action…

…information clutter is dysfunctional… …to encourage physical activity among youths are text heavy and also have web- based activities… which can inadvertently encourage physical inactivity.

…evidence is sparse to support the association between fruit and vegetable consumption and weight…

Cornelius B. Pratt (Ph.D., University of Minnesota at Twin Cities, 1981; APR, 1983) is a contributing editor of PRQ and a professor at Temple University School of Communications and Theater. Before joining the Temple faculty in 2006, he served for nearly six years in the U.S. Department of Agriculture, in Washington, D.C., and for 11 years on the faculty at Michigan State University. His research interests include health-care delivery and global and strategic communication. E-mail: [email protected]; telephone: (215) 204-3214.

Copyright Public Relations Quarterly 2008

(c) 2008 Public Relations Quarterly. Provided by ProQuest Information and Learning. All rights Reserved.

By Currie, Donya

Health departments, schools, communities hold events Health advocates nationwide submitted details of their events to The Nation’s Health in April, an alphabetical summary of which follows.

PUBLIC HEALTH ADVOCATES across the nation highlighted the connection between climate change and public health during National Public Health Week with community cleanups, light bulb swaps, tree plantings and other activities.

The University of Alabama, Birmingham, School of Public Health held many events during National Public Health Week, including an “Amazing Public Health Race,” to increase community awareness of public health and how it impacts everyone. Five teams from the community participated in a competition to learn about public , health and apply that knowledge while navigating a “public health course” throughout the BIRMINGHAM, ALA., area. Other activities included an APHA membership drive, an outdoor “Green Fest” that brought together vendors from across the city to teach about ways to be environmentally friendly, bingo night at Birmingham AIDS Outreach and a walk across campus to clean up litter and promote physical activity. A representative from CoolPeopleCare, an online destination for activists, spoke on how to help change the world by doing things that take less than five minutes.

In JEFFERSON COUNTY, ALA., during National Public Health Week, the Jefferson County Department of Health hosted vehicle emission inspections and issued daily educational bulletins for all employees to increase understanding of climate change and what residents can do to help stem adverse health effects. The health department hosted a Community Partner Awards Ceremony at the Birmingham Museum of Art to recognize local organizations, schools and restaurants for their work to promote and protect the health of Jefferson County residents.

Also in Jefferson County, Project Homeless Connect delivered services to almost 530 participants, and the health department’s Dental Mobile Clinic performed 112 tooth extractions and provided vouchers for future dental care. Social workers and disease control staff referred clients to primary care clinics and offered education on prevention and treatment of sexually transmitted diseases and tuberculosis. Volunteers wore bright red T-shirts emblazoned with the Association of Schools of Public Health slogan, “This is Public Health,” an outreach effort sponsored by the University of Alabama at Birmingham School of Public Health.

The county’s Health Action Partnership hosted the first Health Action Summit during the week, an event featuring talks on climate change and culminating with the release of “Our Community Roadmap to Health,” which is available at www.jcdh.org.

In Arizona, the Kayenta Public Health Nursing Program in KAYENTA, ARIZ., linked with several programs that are part of the Navajo Nation Division of Health to hold community events throughout National Public Health Week. The week began with a trash pickup, where more than two truckloads of garbage were cleaned from clinic grounds. Staff members planned two “Reduce, Reuse, Recycle” fairs held at local chapter houses that featured exhibits demonstrating creative recycling suggestions. Some of those included sewing handbags, potholders and laundry bags from used denim jeans, weaving with yarn from recycled sweaters, making tablecloths from cloth flour bags, crafting pinatas made with recycled newspapers and making rugs and ropes from hay baling twine.

On Wednesday, filmmaker Jeff Spitz screened his documentary “The Return of Navajo Boy,” which features the true story of a Navajo family and the hardship caused due to uranium mining near their home. The week culminated with a public health staff gathering and cookout on Friday.

The Public Health Association at the University of California in IRVINE, CALIE, started National Public Health Week by staffing a booth at the university’s club fair on April 5. The booth included an exhibit on climate change, organic “Focus the Nation” T-shirts and free books on careers in public health. The association hosted a free showing of the environmental film “An Inconvenient Truth” and a guest speaker discussed issues in health and the environment.

The Public Health Association’s club meeting on April 9 featured a guest speaker panel on graduate school programs at three area schools. An improv game fundraiser called Comedy Sportz raised money for local charities, and the end of the week was marked by a tree- planting event on campus.

At the Orange County Health Care Agency in ORANGE COUNTY, CALIE, the week began with a mini health and educational fair, where community members and staff could learn about programs and services that work to improve and maintain the health and well-being of county residents. Attendees received tote bags containing information on climate change and tips on being part of the solution through everyday activities such as recycling and energy conservation. More than 300 people attended.

Other activities included daily e-mails to staff with general public health tips and a series of community education and outreach events throughout the county at family resource, youth and senior centers.

The agency also took the opportunity to recognize public health staff at its “Celebration of Excellence in Public Health” on April 9. The event featured a presentation of a Public Health Week resolution by the chair of the Orange County Board of Supervisors, presentation of the Gerald A. Wagner Health Education Award and recognition of public health’s “Everyday Heroes.”

The California Department of Public Health in SACRAMENTO, CALIF., introduced members of the new Public Health Advisory Committee and launched California’s Public Health Week to coincide with National Public Health Week. The committee will advise the health department’s director on policies to improve the health and safety of Californians. The committee will also identify emerging public health issues and assist with ways to improve public health.

California Gov. Arnold Schwarzenegger issued a Public Health Week proclamation, and many members of the state public health community took the Healthy Climate Pledge committing to make changes in their lives to improve the health of the climate. Some examples include reducing carbon emissions during a daily work commute, recycling at home and work, and eating more locally grown produce.

Fitness was the focus of National Public Health Week for the County of SAN BERNARDINO, CALIF., Department of Public Health.

The health department hosted a fitness walk around the government center that included display booths, a raffle and giveaways. About 150 residents attended the event, which included participation by local health organizations, businesses and Loma Linda University. Fitness walk activities were designed to promote physical activity and healthy eating habits and an environment that supports such behaviors.

A week before National Public Health Week officially began, advocates in SHERMAN OAKS, CALIF., hosted a two-site “Peace Day” as part of the Anti-Violence Campaign of the International Health and Epidemiology Research Center. The day marked the 14th annual antiviolence gathering for the local Iranian community, and tens of thousands turned out to show their support.

As part of the day, children were asked to turn in toy guns and violent video games and received a certificate and reward in return. The toy weapons were turned into art, which was displayed alongside professional artists’ work with anti-violence themes. More on the ongoing antiviolence campaign is available at www.irol.com/avc.

The Public Health Branch of the Mendocino County Health and Human Services Agency in UKIAH, CALIF., drew attention to climate change by engaging the community in National Public Health Week activities.

The week’s events included a screening of “An Inconvenient Truth,” release of a community health status report and presentation to the local Board of Supervisors, an awards and tea ceremony, and brown bag lunch lectures on climate change and greenhouse gas reduction.

Health workers also submitted four articles to their local paper, the Ukiah Daily Journal, highlighting climate change issues.

At the University of Colorado in DENVER, COLO., more than 100 health scientists, public health directors, local practitioners and public health graduate students attended a special preventive medicine grand rounds symposium titled “Healthy Climate, Healthy People: One Community at a Time.” Presenters included State Rep. Randy Fischer, who provided a legislative perspective on climate action and policy as well as a forecast for future debates on energy and health.

Several public health graduate students, along with representatives from the nonprofit organization Groundwork Denver Inc., distributed pledges to reduce greenhouse gas emissions. More than 70 participants filled out the pledges.

Students also organized a new student action committee – Health Professionals for Social and Environmental Responsibility – to guide the campus toward more sustainable practices. Grand rounds participants were treated to a lunch featuring locally grown produce and received a compact fluorescent light bulb and vegetable and herb seed packets. The Wallingford Health Department in WALLINGFORD, CONN., sponsored a lunch and learn program on state issues surrounding global warming. A short film was presented about global warming’s impacts on the state. A question-and-answer session followed the film screening at the Wallingford Public Library.

The Department of Epidemiology and Public Health at the University of Miami Miller School of Medicine in MIAMI, FLA., cosponsored the “Global Climate Change and Your Health Symposium” with the Health Foundation of South Florida. The symposium worked to disseminate the latest findings on the connection between climate change and health, to highlight how climate change effects extend from south Florida to Latin America and the Caribbean and beyond, and to demonstrate how interdisciplinary approaches are essential when it comes to addressing climate change and health.

The day-long symposium featured an interdisciplinary panel with scholars from across the university as well as local policymakers. Presentations touched on topics such as climate change projections, dengue fever in the Americas, heat and human health, and the politics and political impacts of climate change in the Americas. The day closed with a showing of the film “One Water,” which explores the global crisis of water scarcity, contamination and safety.

The Florida Department of Health in TALLAHASSEE, FLA., hosted an event at the state Capitol to raise awareness about programs provided by the agency. The Division of Environmental Health handed out magnets from the Food and Waterborne Illness Program as well as coffee table books from the Florida Environmental Public Health Tracking Program.

Students, faculty and staff at the University of South Florida’s College of Public Health in TAMPA, FLA., collaborated with a number of community partners in planning and implementing an array of educational, research and service activities during National Public Health Week. Those activities included two community health fairs, one targeting a rural Hispanic population and the other targeting urban black residents. At both events, students helped with bicycle helmet fittings, safety and nutrition education, fitness and handwashing games for children, among other activities. At a health education fair at a local middle school, students led their own health education stations on safety, nutrition, infection control and global health. The week’s events also included a blood drive and the annual university Health Service Corps picnic for patients and caregivers staying at the American Cancer Society’s Benjamin Mendick Hope Lodge.

A number of seminars included a special World Health Day showing of the documentary “Too hot Not to Handle,” focusing on climate change. An annual awards ceremony featured many student research and scholarship awards. The Public Health Student Association held an ice cream social combined with a fitness information station and a college-wide silent auction and talent show raised more than $2,100 to benefit Fundacion Familia Sana, a nonprofit organization serving women and families in Tampa, the Dominican Republic and Venezuela.

The Centers for Disease Control and Prevention in ATLANTA, GA., spearheaded several National Public Health Week activities. They included the development of five climate change and health e-cards, the launch of a new CDC Web site devoted to the topic of climate change and health at www.cdc. gov/climatechange, development and distribution of a special edition of the CDC Partners Newsletter and placement of National Public Health Week content on CDC’s MySpace page.

The agency also created a podcast titled “Health Marketing Matters” and hosted employee activities at CDC headquarters, such as a “lunch and learn” series on topics relating to climate change and health.

Students and administrators at the Rollins School of Public Health at Emory University in ATLANTA, GA., embraced the National Public Health Week theme by scheduling an entire week of events aimed at raising awareness of climate change.

Coordinated by 10 student groups, the week’s events included panel discussions, movie screenings, lectures, displays and a scavenger hunt. The week kicked off with a volunteer day, during which 40 students worked in the community to plant wildflowers, restore trails and create paintings at local hospitals. The week was dubbed “Alternate Transportation Week,” and students, faculty and staff were encouraged to take environmentally friendly transportation to school. About 450 people signed a pledge to use alternate transportation.

“Overall, the week represented unprecedented collaboration among student organizations at the Rollins School of Public Health, and fully engaged the campus community in a discussion of climate change as a public health issue,” according to a summary provided by student leaders.

For more information, visit www.sph.emory.edu/ NPHW.

In DEKALB COUNTY, GA., the Board of Health supported National Public Health Week by creating educational posters addressing air pollution, heat and its impact on health, how to prepare for and respond to a severe storm and how the local community can help reduce the impact of climate change. The posters were on display at all five of the Dekalb County Board of Health centers.

The board also hosted a program from the National Weather Service in Atlanta called “Sky Warn,” which teaches how to identify certain types of severe weather.

The Indiana University School of Medicine Department of Public Health and the Indiana Mid-America Public Health Training Center held a National Public Health Week conference on April 8 in INDIANAPOLIS, IND. Concurrent sessions examined topics such as grant writing, public health and climate change, sustainable partnerships, action steps to address climate change and federal climate change legislation. The closing session highlighted leadership skills every public health professional needs to effectively create change.

Recorded presentations, handouts and a searchable database of research related to climate change and produced by the school’s faculty are available at www.publichealth connect.org.

The public health nursing faculty at Purdue University School of Nursing in WEST LAFAYETTE, IND., challenged students and faculty to focus on climate change and health with a variety of activities. An informational poster was displayed throughout the week, along with a cow statue to suggest people eat less red meat. Cloth shopping bags were distributed to encourage waste reduction. Faculty members said they believe students were encouraged to make long-lasting changes to address the problem of climate change and ill health.

National Public Health Week in KANSAS CITY, KAN., was extra- celebratory this year, as the Johnson County Health Department also marked its 65th year of service. Started in 1943 with just five employees, the health department has grown to a staff of 119.

The Johnson County Health Department provided a week’s worth of activities to commemorate the events, including a workshop on public health accreditation and a presentation by the chair of the Johnson County Board of County Commissioners. The health department also handed out reusable grocery bags in exchange for donations to a local food pantry.

The Johnson County activities concluded with a regional legislative forum sponsored by the health department, Kansas Public Health Association and Kansas Department of Health and Environment. The forum included discussions with legislators on health reform and recommendations from the Kansas Health Policy Authority as well as materials from APHA’s Get Ready campaign.

The Lawrence-Douglas County Health Department in LAWRENCE, KAN., presented the first Kay Kent Excellence in Public Health Service Award, which is given to an outstanding public health employee, during National Public Health Week. Other activities included a lunch presentation for health department staff on organic gardening, during which the winner of an environmental health quiz was rewarded with two free movie tickets.

The Kansas Public Health Association in TOPEKA, KAN., celebrated National Public Health Week with statewide legislative health forums to help educate the public about health reform and pandemic preparedness. The forums were held in 15 cities across the state and allowed legislators to update their constituents about health reform in the 2008 state legislative session. The Kansas Department of Health and Environment presented information on the state’s pandemic preparedness, and information was distributed on APHA’s Get Ready campaign as well as on how individuals, families and organizations can plan for emergencies. Each forum concluded with a question-and- answer session. The public health association also hosted a public health open house in Wichita during this year’s National Public Health Week.

The University of Louisville School of Public Health and Information Sciences in LOUISVILLE, KY., observed National Public Health Week with a variety of activities, including a roundtable discussion on climate change and its risks for the public’s health locally, nationally and internationally. A middle school essay contest for grades six, seven and eight focused on the question “What would my life be like without clean, running water?” Forty students from three Kentucky schools participated, and the winning entries as well as more information are available at http:// louisville. edu/sphis/news-and-events/ 2008-middle-school- essaycontest.html. Students with winning essays received a framed certificate and cash prize during an April 15 awards ceremony at a University of Louisville baseball game.

Hundreds of students stopped by the This is Public Health booths hosted on campus during the week. The booths displayed pictures of public health in the community and brochures about careers in public health. Student volunteers also used giveaways to encourage healthy habits among visitors, such as drinking enough water and using hand sanitizers. Support for the week’s activities came from the Association of Schools of Public Health. Staff at the ANNE ARUNDEL COUNTY, MD., Department of Health celebrated National Public Health Week by holding an Employees Nature Walk. The health department also had displays at county public libraries on the environment and health.

The Johns Hopkins Bloomberg School of Public Health in BALTIMORE, MD., celebrated National Public Health Week both on campus and in the community. To promote the climate change theme, students helped prepare a community garden with a local organization called Civic Works. The garden will be supported by a local church and maintained by children from the local, urban neighborhood and will be used as a tool to teach about nutrition, healthy eating and sustainable gardening.

A public health themed film festival on campus, sponsored by APHA’s Student Assembly and many student groups, featured films on public health topics such as climate change, suicide and adolescent health. The week culminated with a showing of the film “Desire,” which explores adolescent desires and sexuality across socioeconomic strata, and a discussion with the movie’s creator, Julie Gustafson.

In BALTIMORE, MD., Nurses for Global Health at the University of Maryland School of Nursing chose global warming as the focus of their National Public Health Week activities.

The students sponsored a half-day program on the role the health sector can play in improving health effects of climate change. Speakers at the seminar raised awareness of the health risks posed by increased heat and changes in the food supply and highlighted the possibility that global warming will create refugees. The event also stressed the role that nurses can play in addressing climate change through leadership and advocacy.

Participants in the program signed a pledge to change their behaviors to improve health outcomes from climate change.

The consulting firm 3P Strategies Inc., in BOWIE, MD., conducted eight public education sessions April 6-18 to reach community-based organizations and students with information on the influence of climate change and conflict on poverty in Somalia. Session attendees received templates on how to contact members of Congress and the United Nations to urge them to take a leadership role to end the crisis in Africa.

At St. Mary’s College of Maryland in ST. MARY’S CITY, MD., three student leaders accepted Public Health Heroes Awards from the St. Mary’s County Health Department during National Public Health Week. In recognition for contributing to the betterment of public health through environmental activism on campus, the students received the honors on behalf of the 300-member Student Environmental Action Coalition. The club works year-round to bring community and media attention to the problem of global warming and has been instrumental in supporting the installation of a geothermal energy system in the college’s River Center and in efforts to reduce waste and improve recycling on campus.

Earlier in the week, college representatives joined county students of all ages for a reading of a proclamation on environmental health at a St. Mary’s County Commission meeting.

The ninth annual Earth Day Charles River Cleanup in BOSTON, MASS., was held on April 26, when more than 2,500 volunteers and community leaders joined forces to clean up the banks of the 80- mile river. The event kicked off at the Hatch Shell on the Charles River Esplanade with scores of volunteers, including local schoolchildren, college students, and church and civic groups, to pick up trash and debris from the river’s banks. The event was organized by the Charles River Watershed Association with assistance from the Esplanade Association, Charles River Conservancy, state Sen. Steven Tolman, the city of Newton, the Trustees of Reservations, Emerald Necklace Conservancy and the Massachusetts Department of Conservation and Recreation.

At Central Michigan University in MOUNT PLEASANT, MICH., the health sciences class “Methods of Community Health Education” hosted a National Public Health Week presentation on what climate change is, the importance of preventing climate change and ways to help at the community level. Students created an informational brochure, drafted a news release and placed a message on the scrolling marquee in the school’s Health Professions Building. Posters were displayed throughout the building highlighting primary prevention messages during the week.

Staff at the St. Paul-Ramsey County Department of Public Health in ST. PAUL, MINN., marked the week by making a commitment to take action to lessen the human impact on the global climate. Events included a documentary film, a poster display and two presentations on climate change by invited keynote speakers. As part of the week, staff also signed a pledge committing to take small steps to make changes in their lifestyles and help lessen causes of climate change.

More than 40 students, faculty and community members participated in a seminar on climate change and public health at the University of Southern Mississippi in HATTIESBURG, MISS., on April 9. The program was held in honor of both National Public Health Week and National Area Health Education Center Week and was sponsored by the Mississippi Public Health Association and the Southern Area Health Education Center. The seminar included information on environmental health issues in Bangladesh, such as the need for clean, safe water.

Several local exhibitors were on hand at the seminar to provide information, including the Mississippi Public Health Association and the Southern Mississippi Sierra Club.

Student research projects on topics such as global warming and vector-borne diseases also were presented.

The City of St. Louis Department of Health in ST. LOUIS, MO., issued a proclamation for National Public Health Week that established the week in the city and encouraged people to “be prepared, eat differently, travel differently, green your work and green your home.” The department awarded the first Public Health Week Business Awards to five local businesses that help protect the environment by encouraging emergency preparedness, alternative ways to travel, the consumption of locally grown foods and reducing or reusing materials in the workplace and at home. The department also posted ideas on preparedness and decreasing the effects of climate change on its Web site at http:// stlouis.missouri.org/city gov/ health.

In MISSOURI, Gov. Matt Blunt signed a proclamation designating April 7-13 as National Public Health Week in the state. Missouri Public Health Association leaders were on hand to receive the proclamation.

The Montana Public Health Association in FORSYTH, MONT., partnered with the Pew Environmental Group to bring a message of conservation and consideration to the residents of Montana during National Public Health Week. It was the first collaboration between the two agencies and was fostered by M+R Strategic Services.

Montana Public Health Association President Ginger Roll wrote a guest editorial that was published April 12 in the Billings Gazette that drew attention to the issue of climate change and health. She outlined the devastating effect climate change is having on the world’s population in terms of heat stroke, hypothermia, asthma, cardiovascular and pulmonary illnesses, gastrointestinal illnesses and deaths.

The Lincoln County Public Health Department’s Office of Emergency Preparedness and Infectious Diseases in LIBBY, MONT., emphasized personal preparedness and National Public Health Week at a “Road to Health” fair hosted by the local hospital on April 5. The health department’s booth featured a contest to win a fully stocked disaster supply kit, free “How Prepared is Your Family for a Disaster?” computer CDs and “Be Ready, Be Safe” magnets.

The University of Medicine and Dentistry of New Jersey and the New Jersey Public Health Association kicked off the week with the 13th annual Public Health Symposium in PISCATAWAY, N.J., on April 7th with a theme of “Aging, Growth and Renewal: Public Health in New Jersey in the 21st Century.” Attendees included public health students, faculty, staff, alumni, and federal, state and local public health professionals.

The keynote speaker addressed the public health accomplishments in the state within the past 10 years, current public health issues and priorities, public health work force development issues and global warming.

A panel discussion focused on current and future public health work force development in New Jersey. Poster presentations covered a variety of public health topics, from prostate cancer prevention to effects of stress on health to bilingual asthma education for Hispanic adults and children.

Seven high school students received awards for their development of a public health club in the New Brunswick Health Sciences Technology High School. The club is designed to increase awareness of the professional field of public health and encourage students to consider a public health career. Roundtable discussions on public health issues and exhibits by 16 state and local public health organizations, educators and agencies also highlighted the symposium.

The Burlington County Health Department in WESTHAMPTON, N.J., recognized community members for their efforts to combat global climate change and address other environmental health issues. The department recognized the Burlington County Environmental Health Committee, a group of residents formed as a result of an environmental health assessment and with a mission to improve the overall environmental health of the community through education. The Burlington County Board of Chosen Freeholders presented the group with a proclamation to thank them for their work and to recognize National Public Health Week. The Environmental Health Committee kicked off an environmental photo contest titled “An Appreciation of the Environment Where I Live,” and encouraged residents of all ages to submit photos to be displayed at the county’s Earth Fair.

The University of Albany School of Public Health in ALBANY, N.Y., led up to National Public Health Week with an emergency preparedness drill for students that was organized by the school’s Center for Public Health Preparedness.

On April 7, the school hosted Centers for Disease Control and Prevention Director Julie Gerberding, MD, MPH, who gave a presentation on the public health effects of global climate change.

The week’s events also included a book discussion on “The Omnivore’s Dilemma” and film screening of “The 11th Hour” as well as a satellite broadcast of “Alternative Marketing and Messaging to Prepare Vulnerable Populations” presented by the school’s Center for Public Health Preparedness. An internship and career fair gave students an opportunity to speak with public health organizations and agencies seeking interns and soon-to-be graduates.

The Graduate Student Organization also held “penny wars” and raised about $400 for the Northeast Regional Food Bank. As part of the Association of Schools of Public Health grant for the This is Public Health campaign challenge, graduate students gave presentations to local middle and high school health classes and organized a poster session and photo contest for undergraduate students.

The New York Department of Health in ALBANY, N.Y., sponsored activities all during National Public Health Week, starting with a news conference on April 7 at the Capitol where State Health Commissioner Richard F. Daines, MD, unveiled the state’s “Prevention Agenda Toward the Healthiest State.” The agenda is a call to action to local health departments, health care providers, hospitals and other community partners to work together to achieve improved outcomes for New Yorkers. The agenda’s 10 priority areas are access to quality health care; tobacco use; healthy mothers and healthy babies; physical activity and nutrition; intentional and unintentional injury; chronic disease and cancer; infectious disease; healthy environment; community preparedness; and mental health and substance abuse.

During the week, Daines traveled throughout northeast and central New York and the Hudson Valley to showcase the important work done by local health departments and primary care providers and others to promote and protect health.

APHA International Health section chair Samir N. Banoob, MD, DM, DPH, PhD, was invited to two universities to offer National Public Health Week presentations. At the University of Maryland on April 9, he led a panel on global health careers across various professions and gave a presentation on “Global Health: Opportunities and Self- Preparation.” At the University of Albany School of Public Health in ALBANY, N.Y., he gave a presentation at the Global Health Fair on April 11 on “Future of Global Health” and then met with interested faculty, doctorate students and residents.

The Institute for Public Health Sciences of Yeshiva University in BRONX, N.Y., held its kick-off event and National Public Health Week celebration by hosting a screening and discussion of the PBS special documentary “Unnatural Causes” on the Einstein campus on April 10.

Public health students from the Mailman School of Public Health at Columbia University in NEW YORK CITY, N.Y., traveled to the “Today Show” to make their voices heard during National Public Health Week.

Sporting public health T-shirts, the students had their photo taken with “Today Show” host Meredith Vieira. They also carried signs and chanted in support of public health. The event was part of the Association of Schools of Public Healths’ This is Public Health campaign, which engaged students around the country in support of public health during National Public Health Week.

“Celebrating Latino Health and Culture!” was held on April 9 at the City University of New York’s Hunter College School of Health Professions in NEW YORK CITY, N.Y. The event kicked off the Latino Health Fellowship Initiative and was open to students, faculty and the community. Highlights included an Argentine tango dance performance, a book presentation, giveaway and screening of the film “Salud!”

The mission of the Hunter College initiative is to provide graduate fellowships to increase representation of Hispanics in the U.S. public health work force, particularly early career professionals who are committed to addressing the health disparities confronted by a large and growing Hispanic population in the United States.

Students, faculty and staff at the University of North Carolina School of Public Health in CHAPEL HILL, N.C., gathered on April 10 to celebrate the week with “Cyclicious: A Celebration of Bicycle Transportation.” Organizers shared popsicles and tips on topics such as bicycle safety, selecting an appropriate bicycle and maintenance strategies. Maps and local experts were also on hand to help attendees find safe routes around the Chapel Hill area. The event culminated with a prize giveaway that included a free bike. Cyclicious was coordinated by the school’s Epidemiology Student Organization with funding from the School of Public Health Office of Student Affairs.

The Graduate Public Health Association and the Department of Public Health Sciences, in conjunction with several other departments at the University of North Carolina at Charlotte celebrated with activities throughout National Public Health Week. On Monday, a lecture on “Good Nutrition and Global Climate Change – Steps We Can All Take” focused on the environmental footprint left by a meat-oriented diet and the environmental challenges in a rapidly developing world. Tuesday’s panel discussion focused on how climate change impacts public health in CHARLOTTE, N.C., and was jointly sponsored with the Mecklenburg County Health Department. Wednesday’s event was a campus cleanup jointly sponsored by the school’s Office of Waste Reduction and Recycling and Keep Mecklenburg Beautiful. Participants collected 2, 425 pounds of trash.

The week’s activities culminated with a screening of “Blue Vinyl,” a movie that searches for answers about the nature of polyvinyl chloride, one of the world’s largest-selling plastics.

Because climate change is intimately connected with animal health, the William Rand Kenan Jr. Library of Veterinary Medicine at the College of Veterinary Medicine at North Carolina State University in RALEIGH, N.C., joined with the university’s libraries to promote National Public Health Week for students and faculty in the graduate veterinary public health program. Materials were displayed near the library’s service desk, and Web and print resources on climate change were highlighted on the library’s blog. Books, along with the April president’s column from The Nation’s Health linking climate change, animal health and human health, remained on display through Earth Day in late April.

At the Southwestern District Health Unit in DICKINSON, N.D., staff focused on how individuals can become healthier while creating a healthier planet. Residents were asked to take a “Healthy Climate Pledge” and to commit to making five small changes in their lives that can have a big impact on both the climate and health.

Other activities included the sixth annual “Take 10 at 2” events that were held at more than 20 area elementary schools within the eight southwestern North Dakota counties of Adams, Billings, Bowman, Dunn, Golden, Valley, Hettinger and Stark. The campaign is designed to have students as well as teachers and school staff participate in 10 minutes of healthy activity at 2 p.m. each day during National Public Health Week and then to continue the healthy activity for the remainder of the year. Each participating school received National Public Health Week posters, “Take 10 at 2” activity sheets and ideas to promote health beyond the week’s festivities.

District-wide activities included free blood pressure screenings at public health offices in Beach, Bowman, Killdeer and Dickinson. Killdeer ‘ and Dickinson also hosted open houses for the public with special health displays and refreshments.

To encourage residents in GRAND FORKS, N.D., to be aware of the connection between the way they lead their lives, their impact on the planet and the planet’s impact on human health, the Grand Forks Public Health Department, University of North Dakota College of Nursing and the local Wal-Mart joined to promote a greener city. A light bulb swap on April 9 allowed residents to bring in a regular light bulb and exchange it for an energy-saving bulb.

Columbus Public Health in COLUMBUS, OHIO, created a week of climate change activities for its more than 500 employees. Each day featured a different theme, and whiteboards were used in place of paper products to publicize the day’s events. The entire campaign, from brainstorming to planning to implementation, used only 12 pieces of paper. Monday featured e-mail instructions for opting out of junk mail lists and credit card offers. On Tuesday, employees purchased 90 reusable shopping bags and on Wednesday, they bought more than 250 compact fluorescent light bulbs at a discount. Thursday focused on transportation, and employees could pick up a map showing restaurants and errand destinations within walking distance of the health department as well as receive information on local bus routes and a carpool sign-up sheet. Friday spotlighted green cleaning with free bottles of homemade, all-purpose cleaner.

Researchers at the Ohio State University College of Public Health in COLUMBUS, OHIO, gathered some of the nation’s top experts in public health and the environment for a Web-based conversation on the current state of the planet’s health. “Converging Environmental Crises” featured more than a dozen health and environmental experts who provided live and recorded presentations on topics such as global warming, overpopulation and energy depletion. Also in Columbus on the Ohio State campus, a panel discussion with state and local leaders was held April 8 with the theme “In Sickness and Wealth.” Sponsored by the College of Public Health, the event was based on the PBS series “Unnatural Causes” and highlighted how people’s work conditions, social status, neighborhood conditions and lack of access to power and resources can affect their health status.

The OHIO Public Health Association sponsored a contest to encourage all health agencies, schools of public health and organizations to help public and local policy-makers understand the important connection between climate change and public health. The Zanesville-Muskingum County Health Department, Mansfield- OntarioRichland County Health Department, Cuyahoga County Board of Health and the Marion City Health Department all participated in the association’s National Public Health Week activities.

The Mansfield-Ontario-Richland County Health Department in MANSFIELD, OHIO, held a Public Health Day celebration breakfast on April 9 to honor local “Friends of Public Health” who have made outstanding contributions to health department programming and public health within the community.

The Marion City Health Department in MARION, OHIO, hosted a “Cool Down, Go Green” recycling event that featured a public collection of paper and phone books for recycling, a tree planting ceremony, kite- and paper-making from recycled paper, a viewing of the children’s movies “FernGully” and “The Lorax,” and global warming coloring activity books with soybased crayons. All participating families received a free tree seedling and learned how the rainforest keeps the planet healthy. Daily letters to the editor on public health topics were published in the Marion Star newspaper based in Marion. Those topics included how individuals can positively impact the environment; being prepared for climate change and natural disasters; breastfeeding as a natural, environmentally friendly behavior; climate change legislation for corn growers; recycling; and global warming.

The Cuyahoga County Board of Health in PARMA, OHIO, partnered with the local YMCA on April 12 to host the fourth annual 5K run and one-mile walk to promote increased physical fitness and healthier lifestyles.

A tree-planting ceremony on April 11 hosted by the Zanesville- Muskingum County Health Department in ZANESVILLE, OHIO, and sponsored by Mission Oaks Foundation raised, awareness about local public health and provided information to community leaders and members about the local impact of climate change. Speakers addressed climate change and community health, and Zanesville’s mayor, Howard Zwelling, presented a proclamation commemorating National Public Health Week.

Health department headquarters staff are planning to keep the National Public Health Week theme alive by putting together a list of recommendations that will make the agency more eco-friendly and help incorporate those changes into each day.

The University of Oklahoma Health Sciences Center College of Public Health in OKLAHOMA CITY, OKLA., hosted public health grand rounds each day during National Public Health Week. At the first grand rounds on Monday, a proclamation from Gov. Brad Henry declaring April 7-11 as Oklahoma Wellness Week was read, encouraging all Oklahomans to work toward improving the health of the state. Presentations throughout the week focused on the Oklahoma City campaign to fight obesity, global health, leadership and uninsurance.

The Oregon Department of Human Services in PORTLAND, ORE., focused on climate change and its impact on health with a series of educational forums and displays in the Portland State Office Building. The department also issued a news release, featuring it on its Web site. Monday featured a “Climate Change and Human Health” panel, Tuesday a speech looked at “Environmental, Economic and Health Benefits of Eating Local Food,” and two speeches on Wednesday touched on the challenge of maintaining water quality and building environments that encourage physical activity and reduce pollution. An interactive discussion on Thursday centered on looking toward the future. Throughout the week, the state office building’s lobby and a large meeting room adjacent to the lobby were filled with exhibits and handouts.

The Oregon Master of Public Health Program, a joint program offered through Oregon Health and Science University, Oregon State University and Portland State University, held its sixth annual Student Symposium during National Public Health Week in PORTLAND, ORE. The symposium’s theme was “A Climate of Change,” and was co- sponsored by the Oregon Public Health Division and the Oregon Public Health Association. Students, faculty and public health practitioners explored various influences on the global climate and such topics as how climate change affects indigenous health and health disparities. The symposium also featured student oral and poster presentations, networking opportunities with groups such as the Oregon Environmental Council and student awards for best poster and oral presentations.

The Department of Public Health and Preventive Medicine at Oregon Health and Science University in PORTLAND, ORE., held a fundraising dinner during National Public Health Week for the Osterud MD/MPH Scholarship. Bruce Goldberg, MD, director of the Oregon Department of Human Services, spoke about the state of public health in Oregon.

The Multnomah County Health Department in PORTLAND, ORE., recognized the contributions of community members who through their work or volunteerism protect and promote the public’s health. Oregon Secretary of State Bill Bradbury, recipient of this year’s John Kitzhaber Public Health Policy Leadership Award, gave a presentation on the ways climate change affects Oregonians.

Areufit Health Services in MALVERN, PA., coordinated the seminar “Climate Change and the Nation’s Health” on April 8. The event, held in West Chester, Pa., featured speakers from diverse disciplines. The day included slides from the movie “An Inconvenient Truth,” an in-depth look at how the changing climate could affect cardiovascular health and heat-related diseases in vulnerable populations, information on air pollution and health, a demonstration on how to reduce carbon footprints by eating fresh local produce, a presentation on infectious diseases, and a video that highlighted how the things consumers buy affect the community and the environment.

The Public Health Management Corporation in PHILADELPHIA, PA., formerly known as the Philadelphia Health Management Corporation, presented “Celebrating Public Health Week: The Role of the Built Environment” on April 9. A guest speaker from Drexel University School of Public Health presented research and led a discussion on global public health issues with a focus on the built environment and climate change. Among the attendees were several students in the Public Health Management Corporation-Drexel Master of Public Health Program Partnership. A luncheon and public health celebration followed the presentation, and a cake commemorated both public health and the birthday of the organization’s chief executive officer.

The University of Pittsburgh Graduate School of Public Health in PITTSBURGH, PA., hosted a range of activities throughout National Public Health Week. During a presentation on “How to Eat Locally and How It Can Benefit Our Climate,” participants learned how buying local foods supports the environment, strengthens the local economy and provides healthier food choices. Graduate school faculty and staff were invited to join a farmto-table delivery program. Another lecture highlighted the local, national and global effects of climate change.

As part of the Association of Schools of Public Health’s This is Public Health campaign challenge, graduate students wrote a successful grant for a photo exhibit titled “Picture This: Public Health in Pittsburgh – A Photovoice Exhibit.” The exhibit was aimed at graduate school faculty, staff, students and local grade school students.

The exhibit demonstrated how public health impacts everyday life in Pittsburgh and featured more than 150 photographs that embodied how people conceptualize public health in their lives and how the world around them affects their health. Participants were asked to incorporate This is Public Health stickers into the photographs, which are online at www.thisispublic health.org.

Students continued their This is Public Health activities by leading activities on the value of public health for elementary school children at the Children’s Museum of Pittsburgh.

The University of Puerto Rico Graduate School of Public Health in RIO PIEDRAS, PUERTO RICO, participated in a National Public Health Week health fair sponsored by the Puerto Rico House of Representatives, distributing information on “What is Public Health?” to legislative leaders and other participants. The This is Public Health project hosted a booth at the fair and handed out public health information as well as information on the graduate school.

Other activities during the week included a photo exhibit that illustrated hardships faced by the homeless and an art exhibit, “Personal Mandalas.” The exhibit showcased paintings made by homeless people. More on the mandala project is available at www. mandala project. org/What/index. html. A panel discussion on April 9 focused on meeting the needs of the homeless population. On April 11, students and faculty provided services to homeless people at the Puerto Rico Medical Center.

The Rhode Island Public Health Association celebrated the week by organizing a meeting at the new headquarters of Save the Bay to view Al Gore’s environmental film “An Inconvenient Truth.” Save the Bay, based in PROVIDENCE, R.I., is a consumer and educational advocacy group that works to bring attention to the value of Narragansett Bay to the people of Rhode Island. The film was preceded by remarks from Lt. Gov. Elizabeth Roberts, who reiterated her commitment to improving health care in the state of Rhode Island and spoke on the importance of highlighting the relationship between the environment and a healthy population.

The event marked the Rhode Island Public Health Association’s first National Public Health Week celebration, but organizers told The Nation’s Health that “the enthusiasm of the participants following the meeting made us confident that it was the first of many such meetings to come.”

Graduate students in the Arnold School of Public Health at the University of South Carolina in COLUMBIA, S.C., used grant money from the Association of Schools of Public Health to create a communications campaign called “This is Public Health: Recycling Counts.” The students launched the campaign at the South Carolina Public Health Association’s Public Health Month kick-off at the South Carolina State Museum, where they distributed recycling bins and educational information. Students also promoted recycling efforts by reaching out to community members at the Richland County Public Library, Southeast Branch, and to university students in the Russell House student center and public health buildings.

Graduate students joined together to develop the campaign concept and write the grant application. The South Carolina Department of Health and Environmental Control provided educational materials for distribution in the community and across campus. Other partners in the effort were the South Carolina Public Health Association, the South Carolina Public Health Consortium, Healthy Carolina and the Southeast Branch of the Richland County Public Library.

The TENNESSEE Public Health Association’s Public Health Week Committee organized activities that were held in counties and cities throughout the state in regional, metro and county health departments, local communities and on the campus of Tennessee State University. Among those activities, Monday, April 7, was designated as “Go Green at the Office” day in each health department. Staff were asked to wear green, and information was displayed in the lobby and waiting room on climate change and its connection to health along with “go green” fact sheets and tips. Monday also featured tree plantings with local youth groups or health councils. Throughout the week, walking programs with staff or community groups illustrated how walking, instead of driving, is good for both health and the planet.

The Affiliate also used funds to purchase water bottles emblazoned with APHAs National Public Health Week logo for distribution throughout the state during the week. The bottles included a “message in a bottle” giving facts on the benefits and importance of recycling, disposable water bottles’ damage to the environment and other facts.

The Chattanooga-Hamilton County Health Department in CHATTANOOGA, TENN., launched a community education campaign and organized several employee activities to help increase awareness of climate change. Those included a climate change logo and slogan design contest as well as a weeklong conservation challenge called “Random Acts of Conservation” that “caught” staff members in the act of conservation. Acts ranged from helping conserve energy by powering down computers at the end of the day to picking up litter and recycling. Eight local environmental agencies provided educational exhibits on topics such as recycling, biking to work, power conservation and air pollution. Friday featured a Public Health Week general assembly with remarks from the county mayor and a video presentation of Melissa Etheridge’s “I Need to Wake Up.”

Anderson County Health Department in CLINTON, TENN., organized an intra-office competition of four teams, challenging them to brainstorm the best ways the health department could become more environmentally friendly. Inspired by the daily APHA e-mails on climate change, each team came up with a plan presented at a healthy potluck lunch at the monthly staff meeting. The department’s recycling program was expanded, a vaccine form was changed from four pages to two and staff are planning a vegetable garden to be tended by volunteers after work, among other ongoing green efforts.

The TENNESSEE State University Department of Health Administration and Health Sciences Student Association, in conjunction with the Tennessee Public Health Association, went green on Monday, distributed reusable water bottles on Tuesday, handed out literature attached to paper straws and natural pencils on Wednesday, sponsored a student-run obesity workshop on Thursday and participated in the Williamson County Health Council’s “Walk Across Williamson” in FRANKLIN, TENN., on Saturday.

At the University of Tennessee in KNOXVILLE, TENN., the graduate public health program hosted a seminar on April 10. Speakers touched on topics such as how climate and environmental factors impact the health of children, adults and food protection, lifestyle choices and the reduction of barriers to child development, and health disparities.

The LAWRENCE COUNTY, TENN., Health Department staff wore green and passed out tip sheets and fact sheets on ways to “go green,” distributed reusable water bottles, wore yellow shirts on Wednesday that read “Keep Lawrence County Green” and planted a tree in front of the department’s building. They posted lists of recycling outlets and provided handouts on 10 steps to help curb global warming, save money and create a safe environment for the future. On Friday, staff wore brown shirts that read “Lawrence County Health Department Caring for Kids” and provided information on sun safety.

Staff at the Mid-Cumberland Regional Health Office in NASHVILLE, TENN., also wore green on Monday, and on Tuesday they collected empty water bottles, provided recycling information and distributed reusable water bottles. Other events included a team relay race and individual walking race, a salad bar luncheon and a group exercise class led by a wellness instructor from the local YMCA.

In WAYNE COUNTY, TENN., staff wore green on Monday and distributed tip sheets and fact sheets on ways to “go green.” They also distributed reusable water bottles on Tuesday, wore yellow on Wednesday and posted lists of recycling outlets. Thursday featured global warming handouts, and staff there also wore brown T-shirts promoting child health and provided information on sun safety on Friday.

The Texas Public Health Journal, published by the Texas Public Health Association in AUSTIN, TEXAS, devoted its spring issue to National Public Health Week. The issue highlighted selected practicum experiences and student project abstracts from a recent public health meeting in Texas. More on the journal is available at www.texaspha.org.

The School of Nursing at the University of Texas at AUSTIN, TEXAS, promoted National Public Health Week with an event in the school lobby on April 9. One student built a sculpture from nonrecyclable trash, and passersby added to the sculpture throughout the day. Information on how to protect the environment and pledges to reduce, reuse and recycle were distributed, and attendees also participated in an environmental health quiz game.

The Texas A&M Health Science Center School of Rural Public Health in COLLEGE STATION, TEXAS, celebrated National Public Health Week with activities such as a fun run, a rural health preparedness training seminar and a research poster presentation. The U.S. Center for Rural Public Health Preparedness presented a multi-day educational seminar as well as a full-day exercise encompassing core competencies of public health preparedness and all-hazards response.

The Houston Department of Health and Human Services and the Texas Public Health Training Center in HOUSTON, TEXAS, sponsored a public health grand rounds on “Climate Change: The Evidence and Impact on Public Health” during National Public Health Week. The seminar is online at www.talho.org.

National Public Health Week festivities in ARLINGTON, VA., included health fairs in three neighborhoods, thanks to work from public health nursing students from George Mason University in Fairfax, Va., local MPH practicum students from Walden University, staff from the Arlington County bureaus of environmental health, family health services and communicable diseases, the Arlington Fire Department, Arlandria’s health center, the Northern Virginia AIDS Ministry, local churches and community centers. Students from the Georgetown University School of Nursing and Health Studies provided a broad range of screening and referral services, fire and water safety education, and health education games and prizes.

In RICHMOND, VA., Virginia Commonwealth University’s School of Public Health, the Virginia Department of Health and the university’s Public Health Alumni Association teamed up with a four- day seminar series on climate change and health during National Public Health Week. The series kicked off with a presentation on the impact of climate change on human health, the scientific consensus on climate change and other related issues. Throughout the week, speeches and panel discussions explored the effects of weather, climate variability and climate change on human health, potential impacts of climate change on public health, the environmental community approach to energy policy, and public health’s role in the changing environment, among other topics relating to this year’s National Public Health Week theme.

The Metropolitan Washington Public Health Association in WASHINGTON, D.C., held its annual conference April 15 with the theme “The Triple Threat: HIV, Substance Use and Mental Illness – Building Public Health Advocacy.” At APHA headquarters in WASHINGTON, D.C., Tuesday, April 8, was “travel differently” during National Public Health Week. Employees were encouraged to leave their cars at home and take public transportation, bike or walk to work. Free Metro fare cards were distributed the previous day. The day also featured a free healthy lunch, games and prizes.

The National Health Museum in WASHINGTON, D.C., prominently featured National Public Health Week on “Access Excellence,” the museum’s award-winning educational Web site, at www.access excellence.org. Web site visitors were alerted to the many ways they can address climate change in their own lives and their communities, and Web resources related to National Public Health Week were available on the site. The museum Web site generates more than 1 million visits monthly.

The American Academy of Pediatrics, headquartered in WASHINGTON, D.C., helped engage its members in National Public Health Week by promoting the event to members through its monthly media mailing, on its Web site and in internal publications.

A pediatrician from the organization also testified before a U.S. House committee on the effects of climate change on child health.

– Denya Currie

The Indiana University School of Medicine Department of Public Health held a conference April 8.

Topics at a conference held in Indianapolis by Indiana University included action steps to address climate change and partnerships.

Students from the University of Alabama at Birmingham meet with city Mayor Larry P. Langford.

A Peace Day was held in Sherman Oaks, Calif., as part of the Anti- Violence Campaign of the International Health and Epidemiology Research Center. Kids were encouraged to turn in their toy guns.

University of Alabama at Birmingham students dean up a sign on a campus road that the Public Health Student Association adopted.

Students stopped by campus booths hosted by the University of Louisville, Ky., School of Public Health and Information Sciences.

Missouri Gov. Matt Blunt signed a health week proclamation.

Students in Louisville, Ky., attracted campus booth visitors with giveaways such as hand sanitizers and drinking water.

Students from Johns Hopkins Bloomberg School of Public Health worked at an urban community garden in Baltimore.

The Lawrence-Douglas County Health Department in Kansas presents its first Kay Kent Excellence in Public Health Service Award.

Visitors interact at the University of Albany, N.Y.’s School of Public Health Internship and Career Day.

The Lincoln County Public Health Department in Libby, Mont., emphasized personal preparedness at a hospital health fair.

About 2,400 pounds of trash were collected by students at the University of North Carolina at Charlotte during a community cleanup.

The Anne Arundel County, Md., Department of Health had environmental-themed displays at county public libraries.

The Kansas Public Health Association held legislative public health forums in 15 cities across the state.

University of South Flonda students in Tampa, Fla., demonstrate the importance of handwashing in preventing infectious diseases at their National Public Health Week booth.

Missouri Public Health Association members join Missouri Gov. Matt Blunt, center, in honoring health.

In Grand Forks, N.D., residents were encouraged to swap their regular light bulbs for more energy-efficient ones on April 9.

The Burlington County, N.J., Health Department recognized community members for their efforts to combat climate change.

Hunter College in New York City, N.Y., highlighted Hispanic health issues and disparities.

University of North Carolina School of Public Health students in Chapel Hill focused on the benefits of bicycle transportation.

Oklahoma leaders held daily grand rounds. From left, Mike Crutcher, Oklahoma’s secretary of health; Jackie Jones, executive director, Turning Point, the United Way of Oklahoma; Oklahoma City Mayor Mick Cornett; Gary Raskob, dean of the University of Oklahoma’s College of Public Health; and Kim Holland, commissioner of the Oklahoma Insurance Department.

New York Health Commissioner Richard Daines, left, takes part in an employee wellness program.

Columbus, Ohio, Public Health spotlighted green cleaning techniques with free bottles of homemade, all-purpose cleaners.

Public health students from the Mailman School of Public Health at Columbia University in New York City traveled to the “Today Show” to make their voices heard during National Public Health Week. The students had their photo taken with “Today Show” host Meredith Vieira, center.

New York health leaders present details of the state’s new tobacco tax increase.

The Zanesville-Muskingum County, Ohio, Health Department held a tree-planting ceremony on April 11 to raise community awareness about health and climate change.

The Oregon Department of Human Services sponsored educational forums, speeches and displays in Portland.

Students at the Rollins School of Public Health at Emory University in Atlanta hosted discussions, lectures, displays and movies.

The Department of Public Health and Preventive Medicine at Oregon Health and Science University held a fundraiser dinner.

The Multnomah County Health Department in Oregon recognized the contributions of community members to protect the health of residents.

The University of Puerto Rico Graduate School of Public Health in Rio Piedras, Puerto Rico, gave out information at a health fair.

Participants in the Marion, Ohio, City Health Department’s community event make kites and paper from recycled materials.

Events held by students at the Rollins School of Public Health at Emory University in Atlanta included a community volunteer day.

The Public Health Management Corporation in Philadelphia honored both the week and a staff birthday.

Students at the University of South Car

By Davis, Coralynn V

Ponds are ubiquitous in the Maithil region of Nepal, and they figure prominently in folk narratives and ceremonial paintings produced by women there. I argue that in Maithil women’s folktales, as in their paintings, the trope of ponds shifts the imaginative register toward women’s perspectives and the importance of women’s knowledge and influence in shaping Maithil society, even as this register shift occurs within plots featuring male protagonists. I argue further that in the absence of a habit of exegesis in their expressive arts, and given the cross-referential, dialogic nature of expressive practices, a methodology that draws into interpretive conversation the multitude of expressive forms exercised by Maithil women enhances analytical access to Maithil women’s collective perspectives on their social and cosmological worlds. Pond Narratives

I arrived in Nepal’s eastern Tarai town of Janakpur at the end of October 2003 to do research on women’s storytelling.1 I had first spent time in the region over a fifteenmonth period in 1994-95, during which I conducted ethnographic research in and around Janakpur. Janakpur is a commercial and pilgrimage center located in the heart of Mithila, a primarily rural region named for the ancient kingdom that flourished in its place. Historically, Mithila has more accurately designated a cultural and linguistic region blending into neighboring regions, rather than a definite political or geographical unit (Henry 1998:415-7; Jain 1995:207).2 Mithila expands to the Himalaya foothills to the north, the Ganges River to the south, and the Gandaki and Kosi Rivers to the west and east, respectively (Burghart 1993; Grierson 1881). (See Figures 1a and 1b.) The region is characterized by village clusters surrounded by irrigated rice fields and dotted with ponds. Ponds are arguably the “single most prominent geological feature” of the Mithila region (Brown 1996:728); certainly, as I discuss at greater length below, ponds are an economically, socially, and cosmologically significant element of the Maithil landscape.

I had decided to rent a room to use as an office space in the upstairs of a building just a five-minute walk from the home of my research assistant, Dollie Sah. The metal wardrobe and the crude wooden bed and table that were provided with the room were indications that it was intended as living space, rather than for the uses to which I would to put it over the next five months: a place for Dollie to transcribe stories undisturbed by household duties and for me to write field notes, begin to work on translations of what would amount to 140 Maithil women’s stories, and find peace and quiet. I had chosen this space over others we had looked at because it was up above the fray of neighborhood life and near to Dollie’s home (enabling her parents to keep a distant eye on their marriage-aged daughter, which made our work together more palatable to them); it had cross-ventilation, and its back windows- screened at my request to keep mosquitoes at bay-looked out on rice fields, as far as the eye could see. It was a place where I could think and breathe.

Directly below the back windows, in a corner of the field that served as a place for cows to graze and for men from the nearby aluminum cookware factory to relieve themselves, was a smallish pond formed at a slight low point in the landscape. One merciful result of this dip in the land was that the water table supported the growth of several shade-providing trees; these in turn kept our office from baking daylong in the relentless sun. When we moved into the room just several weeks after the end of the monsoon season, the pond was full of fresh water that drew cattle and other stray animals to drink and also served as home to small fish and frogs. As the fall and then winter progressed, the pond gradually dried up, drawing herons near to feast on the now more exposed water life and attracting a litter of stray puppies who cooled themselves by rolling and chasing each other in the mud. By March, the pond was completely dry.

Given their ubiquity, it is not surprising that ponds feature in any number of Maithil women’s folk narratives and are a central feature in important ceremonial paintings created by Maithil women. Attention given to ponds in Maithil women’s folklore must be seen within a rich set of discourses on rivers, wells, lakes, and ponds throughout South Asia. In Sanskrit texts, water is imbued with the power to wash away the sins of bathers and bring peace to ancestors, the ashes of whose cremated bodies are immersed in it. Of equal or more relevance here is the association of bodies of water with fecundity and femininity, and the belief that they are residing places for female divinities. Some water spirits are dangerous and have the power to interfere with fertility, cause drownings, or seduce male ascetics (Feldhaus 2000:634). In Maithili, the same word, pokhair, is used for what in English are distinguished (primarily by size) as lakes and ponds. For purposes of consistency in this article, I have chosen the English word “pond” even when the body of water in question seems to be large. In this article, I examine a number of stories in which ponds appear. Drawing on these, as well as on the figure of ponds in Maithil women’s paintings, I argue that ponds serve as a locus in plots for women’s knowing, specifically for the kind of knowing that requires deep wisdom-as in the story below, where insight into emotional landscapes and bodily experiences occurs in the context of patrilineal arranged marriage.

In early December, Dollie and I found ourselves sitting at the edge of the kitchen garden behind the mud-and-thatch home Indu Mishra shares with her husband’s parents and her husband’s brothers’ families. Indu, one of ten Maithil women who joined me in the project of recording folktales and other narratives, launched into the following story, announced by a rhythmic and rhyming riddle.3

The Riddle Story

“Chature chature chaughate, jal nai bore hath, gau swarupe pain pibe, he sakhi ekar kon arth?”4 (Round and round four corners of the pond he walks. He does not dip his hands in the water; he drinks water in the manner of a cow. Hey, friend, what is the meaning of this?) Having repeated the riddle twice, Indu then continued:

Now I will tell its meaning:

There was one person who had become a capable young man in whom a particular girl was very much in love. She wished that the boy she was in love with “be he to whom I shall be married.” But the girl’s mother and father betrothed her to somebody else. Her wedding ceremony completed, the girl was soon to leave for her marital home [in another village] when she called for that person whom she had loved before, in order to meet with him. Sobbing heavily, she said to him, “my love is broken, and I am going with someone else.” Her lover raised his hand and wiped her face like this [demonstrating]. When he did so, then sindur (red vermilion powder) and kohl got on that boy’s hand.5 Then that boy thought, “as long as these remain on my hand, her memory will be with me. Neither will I dip my hands in the water, nor will it be washed away.” Then, with these things still on his hand, that girl left for her marital home, and the boy took leave for his own home.

Walking and walking along the road, that boy became very thirsty. Eventually, he came upon a very large pond, whereupon he thought, “If I scoop the water this way with my hands to drink, then the kohl and sindur will get washed away and my love’s mark will be lost. So no, instead, I will go around all four corners, all four corners of the pond, and if I find a current somewhere, then I will drink the water from it with just my mouth.” So, around the pond he walked. Three or four female friends from the nearby village had also come to the pond, in order to take a bath. They noticed the boy walking around, on all four sides. At one spot where it seemed there was a current, sticking his mouth in like a cow, he began drinking water- just like cows and bulls do. He did not use his hands.

Then those friends who were bathing, they saw that he was sticking his mouth in and drinking [like a cow], despite being human. “Why is he drinking this way, my friend?” That is, “Chature chature chaughate, jal nai bore hath, gau swarupe pain pibe, he sakhi ekar kon arth?” (Round and round all four corners of the pond he walks. He does not dip his hands in the water; he drinks water in the manner of a cow. Hey, girlfriend, what is the meaning of this?) Those friends were talking amongst themselves. Then one of the friends came up with the answer. She understood in her mind that he was in love with someone, and that there was some mark of this on his hands. She told them, “One time when he had become a capable young man, they fell in love. She wept and he wiped her tears, so this is why he does not dip his hands in the water.”

In this and other stories featuring ponds, women have the power to shape the fate of men. Indeed, just as ponds in Maithil women’s ceremonial painting are the symbolic locus of auspicious feminine fertility upon which patrilines are utterly dependent (Brown 1996), in Maithil women’s folktales, ponds are frequently sites for the articulation of women’s insight and agency in plots featuring male protagonists. That is, the trope of ponds shifts the imaginative register toward women’s perspectives and the importance of women’s knowledge and influence in shaping Maithil society. My analysis of metaphoric resonances regarding ponds and women in Maithil culture requires attention to certain epistemological concerns, which in turn suggest a particular interpretive methodology. Given the Maithil cultural context of gendered constraints on speech (delineated below), in the absence of an indigenous habit of direct explication of meaning in expressive arts, and the cross- referential, dialogic nature of such expressive forms within Maithil culture, I contend that a methodology that draws into interpretive conversation the multitude of expressive forms exercised by Maithil women enhances our ability to access those women’s collective perspectives on their social and cosmological worlds.6 In demonstrating this assertion, I begin with the recognition that Maithil women’s stories display “an alternative set of values and attitudes, theories of action other than the official ones” (Ramanujan 1991b:53). While A. K. Ramanujan argued that in South Asia, the “folktale universe (both men’s and women’s tales) itself is in a dialogic relation to the more official mythologies of the culture” (1999:585), folktales, particularly those with women protagonists (and most often told by women), shift the moral universe yet further from dominant representations of reality and morality (Ramanujan 1991b). While Ramanujan identified two contrastive ideal types of South Asian folktales, “male-centered” and “woman-centered,” the tales I examine support the view that, within a single telling, shifts in register may occur, with attendant shifts in perspectival angle.7 Gloria Goodwin Raheja and Ann Grodzins Gold have demonstrated that in Rajasthani women’s gali songs, such a register shift may be marked by the presence of a heron narrator (Raheja and Gold 1994). I contend that a similar alteration in perspective-and, in particular, in understandings of women’s knowledge and effectiveness in putting that knowledge to their own uses-is quietly signaled in Maithil women’s stories by what I am calling “pond-women”: women (or girls) situated in actual physical proximity to or immersed within ponds.

This narrative analysis supports the view that “the subaltern” is located not in individuals or collectives of people who share a unified subjectivity. Rather, the subaltern is enacted through verbal and other practices by interpreting subjects whose lives are constituted through and who continually navigate the interstices of multiple-contextually complementary or contradictory-discourses that, in tension together, constitute the webs of meaning and relation we call culture. In this sense, “the subaltern” refers to perspectives on culture or social relations “that may employ reflexive devises to interrogate or subvert that dominant discourse but that may not necessarily coalesce into a closed, unified, discrete, and knowable totality” (Raheja and Gold 1994:14-5).8

In what follows, I situate Maithil women’s storytelling culturally and politically, including a discussion of the politics of women’s speech, before turning to the centrality of ponds in Maithil society. I then locate my own work in these spheres and situate the present article within that work. Because of space limits, I will present the three additional stories in summary and excerpted form, using the above riddle and those abbreviated tales to support my interpretive claims. My concluding remarks center on the function of the trope of ponds in Maithil women’s tales and paintings, the function of women’s storytelling in Maithil society, and epistemological questions regarding the subalterity of Maithil women.

Maithil Women’s Storytelling: Geo-Cultural Contexts

Until May 2006, Nepal had officially been a Hindu kingdom, despite the wealth of religious variation found among its population. And although Nepal has seen dramatic formal political reform and subsequent turmoil in the past sixteen years, Hindu, high caste, and male citizens are still significantly privileged over their counterparts in myriad formal and informal ways. Some of these privileges, for instance that of inheritance based on gender, have been debated in the courts, and others, especially ethnic and caste privilege, have been fought over in the political and social arenas. Directly and indirectly, state-sponsored Hinduism has treated Nepali women as legal and social dependents, sexual threats to patrilineal integrity, and polluting/polluted entities. The decade-old Maoist insurgency in Nepal, for all its brutality, had taken on these matters of inequality (along with others) in its official platforms and, to a lesser extent, in its organization and infrastructural development. In part as a result of this, the insurgency appeared to have been successful at recruiting many young (especially unmarried) women into its ranks.9

Among Maithil people in the Janakpur area, the above-mentioned constructions of gender pre-date the incorporation of Maithil society into the Nepali state and national society, and the two social formations have been mutually reinforcing in some ways.10 Added to these constructions is the Maithil practice of parda, in local parlance, ghogh tanab (lit., to pull a veil), meaning in this cultural context to draw the trail of one’s sari or shawl over one’s face. The parda system in Mithila most affects behavior of and toward recently married women and quite clearly concerns the assurance of appropriation of these women’s procreative capacities for their husbands’ patrilines. In its ideal form, it entails the social, verbal, and spatial/visual isolation of in-married women from nonhousehold males and from males senior in kinship status to the husbands of those women. Although I have been repeatedly told that the constraints and burdens for daughters-in-law have relaxed somewhat in the current generation, I met women in the mid-1990s who reported that, after marriage, they had not left the household courtyard in more than a decade (except perhaps in order to travel chaperoned to their natal homes) and who had never spoken with their husband’s elder brother, with whom they shared common living space. These practices, particularly those involving space, generally do loosen over the years of an individual’s married life, especially for those women who successfully procreate patrilineally appropriate males (that is, have sons by their husbands). Poorer, lower caste, or less-landed households are generally less capable of enacting this ideal (since, among other things, they need women’s field labor) than are their high caste and better-off counterparts. Those of higher social classes are at once more capable of enacting parda and potentially less dependent financially-but not socially-upon the “chastity” of their women; it is, therefore, difficult to generalize about a direct correlation between social class and parda.11

Women carry particular burdens in regard to family honor that center on sexual propriety and its correlates and that are especially acute in the Maithil cultural context. Pramod Mishra characterizes the situation in the following way:

A man, no matter what he does with his sexuality, remains whole and dynamic, capable of countless renewals, while the woman involved in [elopement across caste and culture] is branded as a “broken egg,” forever rotten and polluting. . . .The metaphor of an egg as a signifier of a high caste Hindu woman, current in Nepali cultural conversation, speaks of the fragile status accorded to a high caste woman in Nepal. And since high caste mores constitute the dominant ideology of the Nepali state, this characterization applies, in various ways, to all Nepali women (the case of the hill tribal and Maithili, Bhojpuri, and Awadhi-speaking Tarai women belong to the two extremes of this situation. In the Tarai case, you trample the egg further and finish it, if it breaks. . . .) (Mishra 1997:345-6)

The practices of parda in Maithil communities are meant to safeguard against such “breakage.”12

While Maithil Brahman males sometimes refer to parda as a valued marker of Maithil culture that distinguishes them from and makes them superior to their pahaDi (hill) counterparts in Nepal, whose cultural traditions they describe as “broken” (bigral), popular feminist, media, and development discourses tend to characterize Nepali Hindu culture and society, and Maithil culture and society especially, as particularly oppressive to women (see Acharya 1981; Acharya and Bennett 1981; and Davis 1999). Both Brahmanic and (women’s) developmentalist portrayals have functioned historically to cloak the existence of other views and practices, such as the strategic behavior of women, culturally and socially specific contradictions and tensions in the gender order, alternative extant gender practices and cultural constructions, nonpatriarchal axes of domination, and nonpatrilineal solidarities, such as those among related and unrelated females and among cross-sex siblings (Davis 2005; Nuckolls 1993; Peterson 1988; Raheja and Gold 1994; Seymour 2002).

Maithil women have harnessed the trope of ponds as one vehicle for the construction of these alternative meanings and practices. In Janakpur and its surrounding villages, ponds play important roles both in everyday life and on special occasions. In Janakpur itself there are to be found twenty-four sacred ponds or “tanks” (sagar). Most significant among these are Dhanush Sagar and Ganga Sagar, both located near to the equally famous Ram Mandir (Rama temple).13 Characteristically, villages in Mithila boast several ponds, each with its own origin story. The ponds serve a number of critical functions for the surrounding human population. They are places for bathing and for washing pots and other items. (See Figure 2.) They may be stocked with fish, which are harvested through the cooperative labor of men of the fishing (mallah) caste, who, standing or swimming in the water, use nets to trap and haul out the fish. In this region, where temperatures can reach over 100 degrees Fahrenheit (38 degrees Celsius) for days on end, young children play at the water’s edge and swim there to cool and refresh themselves. Ponds teem with other forms of life, as well, a point captured by Carolyn Henning Brown in the following passage: These ponds shine under full moons as the many creatures who inhabit them sing lustily throughout unquiet nights. In the heat of May and June, moisture lifts from their surfaces, clogs the air with a humidity that is almost painful to breathe, and covers everyone’s skin with greasy layers of perspiration. To bathe in these ponds or wash large brass trays and pots one must wade into thick oozy mud and stake a territory against the encroaching water lilies with which most Mithila ponds are thickly covered from edge to edge. What lives beneath this covering one can only guess, though some of its inhabitants appear on the walls of the kohbara ghar: fish, turtles, and watersnakes. (Brown 1996:728)

Brown’s interest is in Maithil women’s paintings and, in particular, in the central figure (puren, lit. lotus leaf) in the painting done by high-caste women on the wall of the wedding chamber, or khobara ghar, which is referenced in the folktale called “Dost,” summarized below. According to Brown, the somewhat abstract figure of the puren is, in fact, a pond, and the pond, metaphorically, is the source of auspicious feminine fertility (Brown 1996:729). (See Figure 3.)

Maithil women’s connection to ponds is particularly strong on occasions associated with marriage and fertility. Brown describes the ceremony whereby new brides come to worship the household goddess (kula devi) of their marital home, having grown up worshipping the kula devi of their natal home. In a girl’s natal home, kula devi worship is intended to ensure that she be favorably married; at her marital home, such worship is meant to ensure and enhance suhag-the auspicious state of the woman with a living husband, a state connoting adult female sexuality, with its attendant productive womb, beauty, and adornment. The ceremony in which the bride is introduced to the kula devi of her husband’s family is to take place just a few months after her wedding, when ideally she will have become pregnant. In this ceremony,

the young bride carries the old Gauri betel nut she formerly worshipped in her parent’s kula devi shrine to the edge of the pond in a clay pot balanced on her head. In a little pouch made from a fold of her sari hanging over her womb she carries seven types of grain (“seed”), turmeric (for protection), betel nut (representing the goddess of virgins who brings suhag), and a rupee (for prosperity). Wading into the pond, she allows all these materials to float off while other women call Gauri near by singing songs of the goddess. She then emerges and dresses in an old sari to avoid inauspicious premature enactment of the final life-cycle immersion in the pond at widowhood. At that point all symbols of suhag- vermilion, comb, mirror, and bangles-will be abandoned in the pond. Thus in ritual she performs what she proclaims in art: her auspicious association with the natural fertility of pond life. (Brown 1996:729)

Perhaps the most well-known festival of Mithila, and of Janakpur in particular, is ChhaiTh, the central ritual of which is worship of the sun god, Surya. On the last night of this four-day ritual, female devotees enter ponds at dusk to face the setting sun with baskets of offerings. After the subsequent night spent sitting and singing at the water’s edge, women reenter the pond just before dawn and, remaining otherwise very still but often shivering violently from the cold, again make offerings as the sun rises. (See Figure 4.) Their prayers are meant to extend the lives of their husbands and sons. This is at once meant to ensure the viability of husbands’ lineages and also to enhance women’s own security, as women are structurally dependent for survival and well-being on these affinal kin.

South Asian Women’s Expressive Traditions: Epistemological and Methodological Considerations

Just as with festivals, the gender-inflected nature of folklore is pronounced in South Asia. Prominent South Asia folklorist Susan Wadley goes so far as to suggest that “[e]very piece of folklore is gendered by its performer’s identity, while the content of every item reflects, comments on or challenges the gender constructions of the community and norms of the performer” (Wadley 2000b:241). A fundamental factor in the gendering of South Asian folklore is the separation and difference of men’s and women’s lives (whereby women’s ritual and leisure activities are undertaken in the absence of men), particularly the restrictions on speech and movement enforced through practices of parda. Indeed, most South Asian women (except in very particular, framed contexts) sing and tell stories only in the absence of adult males. (While South Asian historians, linguists, and literary scholars have created a substantial literature on the Mithila region, contemporary Maithil culture and society in Nepal has received very little attention from ethnographers and scholars of women’s verbal expressive forms.)

Following Ramanujan, Wadley notes that women’s folk events in South Asia tend to take place within the house among kin and close neighbors, entail relatively simple speech, and involve tales or songs without named characters. In contrast, male public events are sometimes competitive and tend to involve more formal speech patterns, longer and more complex tales, and narratives filled with named people and places. Furthermore, women’s folklore is thematically centered on issues of intimacy, family relations, and household prosperity, whereas men’s folklore emphasizes broad political themes. As both Wadley and Ramanujan recognize, this conceptual scheme is better characterized as a continuum rather than a duality (Wadley 2000b:241-6). Indeed, in the present article, examples of stories told by women with both named and unnamed characters are presented.

A large literature has developed in the last two decades on South Asian women’s expressive traditions, including song, story, art, and ritual. While some of this work focuses primarily on the ways that dominant (patriarchal) forms and understandings of femininity are reinforced through women’s ritual and religious lives (e.g., Leslie 1989, 1991)-even with “small deviations” (Leslie 1991:3) and in self- serving ways (Pearson 1996)-much of the current literature stresses that South Asian verbal arts constitute a form of discourse in a field of competing discourses and a variety of contexts (e.g., Flueckiger 1996; March 2002; Raheja 2003). These works suggest, for instance, that women’s songs are a place to voice criticism and bawdiness not articulable in everyday speech or in mixed-sex settings (Ahearn 1998; Raheja and Gold 1994; Skinner, Holland, and Adhikari 1994; Srivastava 1991). A number of feminist anthropologists of South Asia have also pointed to such forms of expression as a location for indirect commentary on the singer or teller’s own individual life in contexts where direct speech or other registers of articulation are not possible (e.g., Narayan 1997; Wadley 1994). Raheja and Gold suggest that we understand such articulations not as a form of resistance, subversion, or inversion but as evidence of the coexistence of contradictory perspectives available in differing moral registers (1994; also see Kumar 1994). Thus, what Holland and Skinner (1995) have called cultural “contestation” and “critical commentary,” Raheja and Gold (1994) refer to as cultural “dissensus” (see also Brown 1996). I agree with this latter perspective, for I believe that while Maithil women’s gender-specific moral registers and cosmological perspectives may be less known by others-from their own menfolk to outside observers- they are nonetheless central psychological and social organizing principles in Maithil women’s lives, which coexist in complementarity and tension with other such principles. Outsiders, and folklorists in particular, need to learn to listen differently to access these perspectives (March 2002), and we need to rethink our epistemologies and reshape our methodologies accordingly.14

As a possible result of the degree of separation and difference between male and female life experiences, and despite the fact that Maithil women themselves have few outlets for direct, extrahousehold expression (as compared to their male counterparts as a class), Maithil women have developed a number of expressive traditions, which offer insights into their preoccupations, perspectives, and values and which shed light on the micropolitics of their lives. Within the international community in Nepal (and elsewhere), Maithil women have become known for colorful paintings replete with scenes from great epics of the region, as well as with depictions of their work lives and plants and animals that are integral to their world (Brown 1996; Heinz 2000; Mishra 1997; Singh 2000). Maithil women also tell folk stories. By attending to these women’s stories, one of my aims is to bring these narratives and the lives, perspectives, and insights of the women who tell them to the attention of those for whom their existence, and the value of that existence, is unacknowledged. Attention to women’s tales, in conjunction with the images they paint, can help widen the view of Maithil understandings of gender and culture by revealing perspectives and practices submerged in Maithil Brahmin, masculinist, and development discourses-discourses that Maithil women themselves also “speak” in many contexts.15 In her entry “Folktale” in South Asian Folklore: An Encyclopedia, Wadley designates “folktale” as a term referring to “a variety of oral prose traditions in South Asia, told in prose, not sung, although some folktales may include sung rhymes or verses, usually for special effect.” Thus the conversational speech style of the folkteller distinguishes the folktale, for instance, from the folk epic, which is sung and may include verse (Wadley 2000a:218). In addition to this distinction, I would describe folktales as: fundamentally collective (passed from person to person with plots, structures, and conventional elements relatively intact and with this collective nature recognized by those participating in the telling of the stories; oral, performative, and social) requiring tellers and listeners to be in proximity to one another, this quality being present even if the tales are circulated in other ways, as well; neither officially sanctioned nor the prerogative of any person in particular, though they may be appropriately told only in certain contexts by certain kinds of people; set in time and space neither radically dissociated from the speakers/listeners nor immediately present; intertextual, in the sense that themes and motifs traverse tales and cross between tale genres and other forms of folklore (Wadley 2000a:219; see also below); and functioning in part to communicate information about the nature of life in general, to situate types of people and other things within it, and to entertain.16 As Wadley notes:

Folktales contain cultural wisdom to be passed on to further generations, while being continually responsive to the settings and times in which they are told. They tell of social and cosmological relationships, as they create new relationships between tellers and audiences. Folktales are not necessarily used to teach, but even those told for entertainment often contain biting commentaries on social situations and incorporate and substantiate key cultural beliefs. (Wadley 2000a:218)17

Ram Dayal Rakesh (1996), who has written extensively on Maithil cultural life, has said that the Maithili gloss for folktale is kathapihani and that modern Maithili people often just use the term galp (lit., talk or gossip). The people I know from the area in and around Janakpur usually used the word kissa for folktales, although some were familiar with the more formal term purkhauli katha (ancestral stories), which emphasizes that such stories are passed down through the generations.18

In her work with the storyteller Urmila Devi Sood in Mondays on the Dark Night of the Moon (1997), Kiran Narayan identified two broad genres of stories in this Himachal Pradesh community-those told in relation to annual festivals and those told “on cold winter nights” for purposes of entertainment. Among Maithil women, I have noticed a similar (indigenously recognized) categorization of stories. In most of the tales not associated with female festivals in Mithila-that is, in stories told primarily for entertainment of other women and children-the main protagonists are almost always male, although female characters sometimes have quite active secondary roles. In fact, it is often female characters who launch or redirect the plot in Maithil women’s folktales. I have not found true what Ramanujan argues in his book Folktales from India, that “in women’s folktales women predominate and men are wimps, ruled by mothers, mistresses, wives” (1991a:12). Even in those tales whose main protagonists are women, men are not uniformly, as a class, constitutionally weak or stupid-although some certainly are. In most of the tales I recorded, males are the main protagonists. The most common plot line entails a boy who must go on a journey and through his journeying becomes wiser, wealthier, and wed. But even within these, what Ramanujan would call male-centered tales, women frequently are more than rewards at the end of men’s journeys. Indeed, they may instigate, shape, take part in, and themselves reap the benefits of those journeys. As I suggest below, in particular narrative contexts, female characters in Maithil women’s folktales do seem to have special gendered power of insight, an ability that enables them to assert a positive, often lifesaving effect on men’s lives-and, thereby, their own.

Keeping in mind the politics of gender, the place of ponds, and the role of storytelling in the world of Mithila, let us now turn to the story of two friends, entitled “Dost.” By placing this tale in dialogue with two additional tales, the riddle presented earlier, and painting imagery, I aim to demonstrate that female characters, in their familiarity with and proximity to ponds, acquire special abilities to understand the (sometimes strange) behavior of males and to make self-serving interventions in men’s lives and men’s worlds. A corollary to this assertion is that males cannot “see” within ponds and therefore depend on women to light their way. In this manner, the lines of dependency between men and women are reversed in relation to dominant characterizations.

Of Ponds and Women: Stories, Interpretations, Intertextuality

We are in a village a good hour’s bike ride over dusty, pitted road from Janakpur, sitting in Indu Karna’s family courtyard, a place I first visited in the spring of 1995. Indu, Dollie, and I sit together on a woven straw mat. Indu begins haltingly, embarrassed by the tape recorder and the newness of this work together, which subsequently spanned a number of weeks. It is the month of Kartik (October/November), the festival season when the sun, mercifully, has lost much of the brutalizing intensity it had in the early, postmonsoon period. In the course of the telling of this complex story, Indu’s small son, daughter, and mother-in-law sit down and listen in, occasionally commenting on the plot or some other activity related to their everyday lives.19 “Go ahead,” Dollie encourages, “which story will you tell?””Hmmm, the one about the friends,” Indu decides. “Don’t be shy,” I chip in, as Dollie clicks on the tape recorder. With a giggle and a blush that I interpret as combined self-consciousness and excitement, Indu begins.

“Dost”

Friends, there were two friends.

One was a king’s son, the other was the son of a dewan (man of the ministerial/ military caste). The dewan’s son was married, but his bride was dark-skinned.20 He thought she was ugly, and so he left her, saying to his friend, “Let’s get out of here.” The king’s son had a lot of money and agreed to a journey. That night, the two friends slept in the jungle. During the night a large cobra (naga) came out of the recesses of the jungle, searching for food and lighting its way with an incandescent pearl (mani) it took out from its mouth.21 Setting the pearl down to light the area, it went off in search of food. The king’s son was sleeping, but the dewan’s son lay awake. When the cobra had left, the dewan’s son arose and covered the mani with some horse dung, making the area dark. Without the light, the cobra could not see to hunt, and it died. In the morning the friends went to a nearby pond to wash the horse dung off the mani. As soon as they washed the mani clean, it began to shine, and it illuminated the water. And when it shown down into the water, the two friends saw something like a ladder. Curious, they climbed down the ladder, where they discovered a whole cobra kingdom! In one room of a large house they found a cobra maiden, the dead cobra’s daughter, crying. All other cobras were dead. She explained that her father cobra had bitten one of the other cobras each day, eventually killing them all but her. And now, she feared, it was her turn. The two friends explained where they had come from and started living with the cobra maiden. After some days, the cobra maiden declared her interest in marrying one of the boys and threatened that, if neither of them married her, she would never let them go. Since the dewan’s son was already married, they decided the king’s son should marry the cobra maiden, but only if his parents could be present at the wedding.

In order to send off the dewan’s son to summon the prince’s parents, all three of them came up to the surface from inside the pond, using the mani to light their way. It was the first time the cobra maiden had come to the surface. There she saw the ground, the trees, the green grass-all of which she liked very much. When the dewan’s son went off to get his friend’s parents and the wedding guests and such, the other two descended back into the water. The dewan’s son was gone for several days. Each day the cobra maiden would feed the king’s son and then, telling him to rest, take the mani and come to the surface of the water. The top half of her body would emerge, as she looked around. One day, a boy from another kingdom happened by, saw, and fell in love with the cobra maiden. He vowed to marry her and arranged for her abduction. [. . .]

Meanwhile, the dewan’s son returned with his friend’s parents, but the cobra maiden had left with the mani, and his friend down below could not hear them calling for him. Furious, thinking that it had all been a ruse and that their son had been drowned, the parents threw the dewan’s son in the water. Even so, the dewan’s son vowed to find his friend and take him to his father. He began roaming from village to village, searching for his friends, and eventually came to the village where the cobra maiden had been taken. The cobra maiden had been able cleverly to delay her wedding to her abductor long enough to give time for the dewan’s son to find her. Together, they returned to the pond and were reunited with the king’s son. The three then set off for the king’s son’s home to prepare for the wedding.

Along the way, the king’s son became intensely jealous and untrusting of his friend, accusing him of having designs on his bride-to-be. The king’s son’s behavior was observed by the gods, Bidh and Bidhata, who, in the form of birds, were sitting in a papal tree, observing the scene.22 Bidh (the husband of the deity pair) could see the undeserved mistrust in the king’s son’s heart. He decided that the jealous one was not a good person and had no right to live-especially given how helpful his friend had been to him. [. . .] Bidh and Bidhata engaged in a long conversation about how Bidh planned to kill the king’s son. At each suggestion, Bidhata challenged him to have another plan, in case the previous one did not work. Finally, she asked him what he would do if someone overheard the very conversation they were presently having and used the information to foil Bidh’s murderous attempts at every turn. Bidh replied, “When that person explains how he knew about the plan we have lain and why he then sought to save the king’s son, at the moment he begins to explain, his body will turn to stone. And if it becomes a stone, then that person’s life will be destroyed.”

Then again his wife got worried. “How will his stone body ever come back to life again? It will not be good if his body remains of stone.” The god replied, “Those two, the cobra bride and her groom, when their first child is born, while it still has its placenta [nair purain], if at that time they cut the child’s throat and pour its entire blood on the stone body, then the stone person will come into human form again.” She probed, “Then how will that child come back alive?” To which her husband replied, “The dewan’s son had left his own wife. She was black and ugly. That is why he did not like her, so he abandoned her. Every day his wife gets up at four o’clock in the morning and goes to Girija’s temple.23 She prays to Girija, asking only to be reunited with her husband. She had been living as an ascetic [tapasya], doing this for twelve years. If the king’s son goes to that temple, taking that child’s entire placenta with him, and if he tells his wife that Girija will have an elixir for him, then the child will come alive again.” All this Bidh said, and the dewan’s son heard the entire story. [. . .]

And then everything happened just as the gods discussed. The dewan’s son saved his friend and his friend’s bride at each attempt of Bidh to kill them. Ultimately, the dewan’s son had been hiding in the wedding chamber at night when Bidh, in the form of a serpent, came to kill the king’s son and his cobra bride. When the dewan’s son went to slay the serpent, the couple awoke and caught him, thinking he was a thief. But the dewan’s son began explaining everything to his friend. He showed them all the proof, including half of the serpent’s body. He told them that when he finished the story, his body would turn to stone, and that in order to be freed from stone, they would have to slay their first child with its placenta and bathe him in it. Even as he was telling all this, his body turned into stone.24

Now it came in his friend’s heart that, “My friend has saved me over and over again. It will not do for me to leave him as a stone.” Thus, they started waiting for a baby, determined when the child came to set the dewan’s son free from his stone body. After ten months they had a son. Without removing the placenta, they cut the baby’s throat and bathed the entire stone in the baby’s blood. The dewan’s son came into human form again. He took the baby, with the entire placenta, and he departed for his wife’s place. As usual, she came in the early morning to pray. After praying, she saluted the god, imploring, “Unite me with my husband, oh god!” Then the statue of Girija started laughing. Startled, she asked, “Why have you laughed today?” Lord Girija replied, “What you have been praying for all this time, that person is here today.” Then her husband arrived with that child. Putting the baby down, her husband said: “If you bring this child back to life, then I will accept you [as my wife] and take you with me. If you don’t, I will leave you just as I did before.”

Now, she had been praying to Girija for twelve years. Lord Girija had to listen to her, so she asked him for an elixir, which he gave to her. They sprinkled the elixir on the baby’s body, and he came back to life. The two husbands and wives were united, and the king’s son got his son back, too.

Interior Meanings

The version of “Dost” told by Indu Karna is full of interpretive and analytical possibilities. For instance, one might discuss Maithil stereotypes regarding character differences between kings and their ministers, the relationship between gods and mortals, or the ubiquity of naga in South Asian tales. Likewise, one might engage in structural analysis of the narrative, discuss at length the relevance of extratextual factors such as audience in the meanings of the tale, or consider personal resonances of this tale in Indu’s own life. For present purposes, I wish to focus on patterns in gender-inflected relationships between people and ponds in the narratives.

The plot in “Dost” is driven in part by the murky quality of the pond and the use of the dead king naga’s mani to light the way between the surface (the firmament where the two boys live and roam) and the bottom or underworld (where the naga maiden lives). (See Figure 5.) On the most general level, the underworld/surface division resonates with the highly gendered domestic-intrahousehold and public-extrahousehold spheres of Maithil familial and community life. These gendered spheres are not just “opposed”; ideologically, in parda the feminine interior sphere is encompassed within the masculine exterior/public sphere-just as the pond is a space within the larger landscape across which males may (indeed, are compelled to) travel.25 From a woman’s perspective, the pardalike constraining quality of the topological context of the story is made most evident by the fact that the cobra maiden, once she gets a “taste” for the outer world, seeks to access it again and again. Note that the male friends are not, in mirrorlike fashion, interested in experiencing the beauty of the inner world of the pond once they taste it-after all, everyone in it, save the maiden, is dead. Their goal is to remove the maiden from it and place her inside their own patrilineal, patrilocal world.

The underworld of the pond is a feminine space in another sense, as well. It is a locus or impetus of female knowledge, self- determination, and influence over men. In “Dost,” the cobra maiden proposes and succeeds in getting the marriage she desired and in stalling and evading a second, undesired marriage.26 She succeeds, further, in getting out of the dark interior where she had been trapped by her murderous father and into a prosperous royal family. Along the way, she proves to be a vehicle both for the rift between the royal and ministerial classes upon which her well-being depends and for the healing of that rift.

I will return to the analysis of “Dost” below, but for now it is important to explore how themes similar to those I have been discussing play out in a different tale, the story of two brothers, Sit and Basanta. As with “Dost,” this story was told to me by Indu Karna in the courtyard of her home in November 2003.

“Sit Basanta”

Two brothers, Sit and Basanta, embark on a journey in order to escape the murderous intentions of their step-mother. In the jungle one of the brothers, Basanta, is bitten and killed by a snake. The other, Sit, continues on to another land in search of the things he needs in order to perform the death rites for his brother. Through a series of events, Sit ends up being declared king of that country and forgets about his brother. Meanwhile, ants suck the venom out of Basanta, bringing him back to life, whereupon he heads for what turns out to be the same country in which his brother has become king. A tiger has been ravaging that country, and the queen promises to bestow half the wealth of the kingdom upon anyone who can kill the tiger. Basanta manages to do it, much to the chagrin of a royal guardsman (chowkidar), who has his sights set on getting that wealth. The royal guardsman determines to kill Basanta and claim the reward for himself. After one failed try, he beats up Basanta and dumps him into a large body of water.

Near death, Basanta is inadvertently caught and dragged in by a fisherman’s [mallah’s] net. The fisherman has a daughter who can see what will happen in the future. He marries his daughter to Basanta. One day, when Basanta decides to go fishing, his wife insists, against his protestations, on going with him. Two other men are already fishing, and they begin to flirt with and tease Basanta’s beautiful wife. They decide they want to take her away, and though she protests, they are able to throw Basanta off of his boat and begin to make away in their boat with his wife. She throws a cushion into the water to provide a floatation device for her husband. Basanta subsequently begins to float to the water’s edge, where he is sucked down into a whirlpool. At the bottom of the whirlpool is a princess, bathing with a friend. She proposes marriage to Basanta. He agrees to marry her only if she can find all of his family members. She says she cannot do that, but she has an idea. “Go forward six kilometers, and you will find a temple with a statue. Bow in front of the statue and then go around and stand behind its back.” Basanta does just this, whereupon the statue swallows him. In the statue’s belly, Basanta finds another beautiful princess sleeping on a bed. He notices a small container of vermilion powder on a table by her bedside. Taking a bit in his hand, he is just about to draw it through the part in her hair (thereby marrying her), when she awakes with a start and asks, “Why do you want to marry me?” In response, Basanta tells her the story of his trials and tribulations. Having heard his story, the princess tells him that she has an idea.

They begin to walk along together and eventually reach the land where Basanta’s brother has been made king. Just before entering the village, the princess suggests to Basanta that he disguise himself as a holy man. She sends a message to the royal court, announcing that a holy man has arrived and wishes to tell the story of the two brothers, Sit and Basanta. Upon hearing this, the king is shocked. He calls together all the people of the kingdom, including Sit’s first, second, and third wives. When Basanta spins his story from beginning to end, the king realizes that this holy man is his very own brother and rushes forward to greet him. He also summons the royal guardsman who had lied and has him killed. Following this, the two brothers and their wives gather together at the palace. After a few months more, they return to their home to be reunited with the brothers’ parents, where they all lived happily ever after. Pond- Woman Insight and Agency

One of the most obvious commonalities between “Dost” and “Sit Basanta” is the presence of maidens in the watery underworld and the nature of their encounter with boys who haplessly find themselves down there.27 As in “Dost,” in “Sit Basanta” a princess in the depths proposes marriage. Then she comes up with an idea to help the boy solve his dilemma of finding his way back to his brother and his home. He submits to her instructions, a relinquishing of agency so complete that he is “swallowed up,” whereupon he encounters yet another princess with the insight to bring him still closer to his goal, but in a manner, again, of submission to her authority rather than of understanding or collaboration. As with “Dost,””Sit Basanta” ends in the reuniting of the patrilineal family amidst an abundance in which all three pond-women wives share.28 This ending is made possible through the combined efforts of the three pond- women, efforts that are not, notably, at cross-purposes. (More commonly, cowives are pitted against one another in story plots.)

Of course, the connection of the first of Basanta’s wives with ponds is one of proximity, not interiority: she insists on going in the boat with him. Indeed, even under the intense duress of capture and possible rape at the hands of the other fishermen, this wife throws Basanta a literal life line. While we can infer that the two other women can, figuratively speaking, see beyond their own watery circumstances into Basanta’s courtly world, the first wife is explicitly designated with the ability to “see the future.” Her special knowledge and ability appears to be connected to her willfulness in defiance of her husband’s protestations, which in dominant Maithil discourse would mark her as a bad wife. In other words, because she knows better, because she in fact will save her husband’s life (while risking her own), her self-determination is vindicated.

This special ability of storied girls and women in association with ponds to understand the plights of boys and men is highlighted in an especially explicit form in the story with which I began this article, a story in which a girl bathing at a pond deciphers a boy’s strange behavior and thereby solves a riddle. The telling and solving of riddles is common to many South Asian communities (Badalkhan 2000; Bauman 2004; Bhattarai 2000b), as elsewhere around the world. Here it is male behavior itself (particularly in matters of unsanctioned love) that is marked as a solvable riddle from the female perspective. One additional story involving special insight by a female at the water’s edge affirms this point. Like “Dost,” the story “Barsait” (rain) features relations between people and nagas. This story, however, begins not with a man ridding himself of his undesirable wife but with a mother of seven sons who is cooking at her hearth. Indu Mishra, the Brahman woman who told me this story in December 2003, herself had but one son who, in the course of his still short life, had already been near death from an undiagnosed illness.

“Barsait”

A Brahman woman inadvertently kills all the children of a naga couple by pouring the scalding wastewater of the rice she has been cooking down into their nest hole at the side of her hearth.29 In what ensues, the cobras seek revenge by vowing to bite and kill all of the woman’s sons and their brides on their respective wedding days. [. . .]

After six of her sons and their brides are killed in this manner, the woman decides not to arrange a marriage for her youngest son and instead provisions him for a journey and sends him off with the following curious admonishment: “When you find yourself standing in the shelter of a tree, pull open your umbrella, and when you start walking the hot sun on the road, then fold closed your umbrella. When you wade into the water, then wear your shoes, but when you walk on the road, remove your shoes.” Along the road, the boy comes to a pond, where he sits down in the shade of a pipal tree to rest and, following his mother’s advice, opens his umbrella. And then when he goes to wade across the water, he wears his shoes. Further, when he reaches the other side, he removes his shoes; and when it is sunny, he folds up his umbrella.30

Now, seven laundresses (dhobin) have come to the pond to bathe, and they observe the boy’s strange behavior.31 They ask one another why the boy is acting in such a way, wondering whether he might be crazy. But one washerwoman, Sait Dhobin, a very devout girl, knows everything. She can see what has happened six months into the past and what will happen six months into the future. She says to her friends: “All his brothers have died. When he stands under the pipal tree, he opens his umbrella, lest a snake or insect fall and bite him. And if he puts his feet in the water, something that he cannot see might bite him from below, so he wears shoes. In the road he can see, so he needn’t wear shoes or protect himself from above with his umbrella.”

Sait Dhobin declares that she will marry the seventh son. Before leaving for her new husband’s home, Sait Dhobin requests milk and popped rice (laba) from her mother.32 When they arrive at the location where, with each previous son’s wedding, the naga have bitten and killed the bride and groom, the Sait Dhobin uses the milk and popped rice to entice the naga husband into a trap. She then bribes his wife into agreeing to bring all those killed back to life in exchange for her husband’s release. Sait Dhobin was a great devotee, and this protected her, along with her husband from themselves being bitten.33 Ultimately, all of the sons, along with their wives, are brought back to life and reunited with their mother.

Further Intersections

As in “Dost,” in “Barsait” we find a male in need of feminine “sight”; as in “Sit Basanta,” in “Barsait” we find a male in need of female instruction in order to safely reach his destiny. Indeed, the boy in “Barsait” needs to be told something as basic as when to put on and take off his shoes. (He cannot, after all, “see” in the pond to avoid its dangers.) As in “Sit Basanta,” the female in question in “Barsait” is associated with the water through proximity (bathing) and occupational caste (in this case, she is a dhobin or laundress).34 As in “Dost” and “Sit Basanta,” this maiden decides autonomously whom she will marry and is successful in carrying out her plan. Through her insights and actions, she not only secures herself a husband but also relivens the fraternal (patrilineal) household of which she will become a part, saving the lives of those brothers and their wives while reversing a mother’s sorrow and loss.

Verbal-Visual Reflections: Tacking across Expressive Forms

In order to make a final and very particular point about the ending of “Dost” and the relationship between it, the other stories, and women’s metaphorical connection with ponds, we need to return to Maithil women’s khobar ghar art. Maithil women’s art, Brown asserts, “originated in a conversation among women” (Brown 1996:726), by which she means that the forms found in women’s painting spring from their collective experiences and perspectives. It is certainly the case that, like storytelling, ceremonial painting is something that women do in each other’s company and rarely in the company of men, with each other’s cooperation and participation, and in the spaces (interior to households) most identified with them. As with the narrative genres, Maithil women are not in the habit of creating verbal exegesis on their painting (Brown 1996:726; cf. Narayan 1997).35

Mani Shekhar Singh describes succinctly the uses of Maithil women’s ceremonial painting:

Within the domestic-ritual space, the act of painting or writing (likhiya) sacred diagrams forms part of a series of ritual events that the women perform without the help of ritual specialists. Most of these ceremonial diagrams are painted on the walls of the kohabara ghara, the inner room where rituals associated with the marriage ceremony are performed. It is here that the bridal couple consummates the marriage. Besides the kohabara ghara or the bridal chamber, ceremonial diagrams are also written inside the gosauni ghara, the abode of the family and lineages shrine. Together these two spaces constitute the garbha-griha (literally the womb) of a Maithil home.

Ritual diagrams in the form of aripana are also written on the floor in the inner courtyard (angina) and other sections of the house on each of the celebrations that are a part of the sacraments or rites of passage accompanying a person’s existence, from the womb through adulthood to death. These floor diagrams are also drawn as acts of devotion during the annual festivals, and for monthly and weekly observances (vrata-puja). In each of these cases, the diagram is written either by one woman alone or collectively by groups of women from the same family and/or community directly on the walls and the floors of the house. The performance by these women artists transforms the domestic place into ritual spaces, thereby making it receptive to the sacred. (Singh 2000:411) Using the past tense to indicate the historical depth of these painterly practices (rather than their disappearance), Carolyn Brown Heinz (earlier Carolyn Henning Brown) contextualizes high-caste Maithil women’s painting in regard to the circumscribed power and influence they wield:

Mithila art was imbedded in a social environment in which objects and images had specific powers and functions, and interacting with them changed something: one’s body, one’s future, other people’s responses. As women, the domains in which they could act were limited by purdah, but tremendous powers resided in the household with them. Whether as a daughter worshipping Gauri to bring a husband like Siva, or as a wife worshipping kula devi, the lineage goddess, and incarnating her to bring offspring to her husband’s family, there were powers which women controlled. Mithila arts was a powerful visual discourse of Brahman and Kayastha women; it was reflexive, about themselves, their powers as women, and their mystical connection with the goddesses. (Heinz 2000:404)

With regard to the images painted or drawn on the eastern wall of the bridal chamber known as the kohabar ghar, while Kayasthas refer to these diagrams as kohabara (or khobar), Brahmans refer to the same composite image as purain (puren), which is also the word for placenta.36 According to Singh, among the Karna Kayastha of Mithila (of whom Indu Karna is one), the propitious way to begin the painting is to place a vermilion dot (sindur) at the center of the eastern wall. The first motif-what Singh (2000) identifies as a lotus plant and what Brown (1996) identifies as a pond with lotus plants in it-is then drawn from that center point. An integral feature of this motif is a “central vertical stem (dhar) with a broad base (jari) and a pointed head (muri), the latter being in the form of either a lotus bud or a female face” (Singh 2000: 413-4).37

The Maithil word for the placenta is narpuren (or nairpuren), literally “the lotus leaf of the navel.” When she asked women about the long, pointed object that pierces the ring of the lotuses in puren (usually interpreted by Western observers and their Brahman priest informants as a phallus), Brown reports that they described it as “the stem which roots the lotus leaf to the bottom of the pond” (Brown 1996:729).38 Brown points out that men never see the placenta or the cord attached to the navel of the newborn. Indeed, as I was to find out in my own research, women in Maithil villages give birth in their homes with the assistance of midwives of the chamair caste, who are considered “untouchables.” The blood of birth is considered especially defiling. Men avoid it completely, absenting themselves from the birth process, and the women who encounter it afterwards undergo ritual purification. To Maithil women, Brown argues, the image of the marriage chamber “resembles the lotus leaf and the long stem attached to the bottom of the pond is a metaphorical umbilical cord. In Mithila art that cord . . . is often . . . shown personified with a face; it is not the male phallus, however, but the infant to be born of the marital union depicted there,” just as a new lotus bud rises from the pond bed, breaking the surface to open as a blossom (Brown 1996:729). Drawing on trope theory (Fernandez 1991), Brown argues that Maithil women’s “bodily experiences are projected outward into cultural productions as source domains by which they attempt to grasp crucial but inchoate aspects of human existence” (Brown 1996:732).39

The theory that the central motif of the khobar ghar painting is a pond and that the pond is a source metaphor for women’s fertility is reinforced by the way in which the pictorial surface is filled with local flora and fauna. In Singh’s interpretation,

The view of nature as depicted in the background has its basis in the artists’ understanding of life as growth. Filling the entire pictorial surface with plants and creepers with buds, flowers and fruit in an important sense emphasizes that emptiness is tantamount to infertility or barrenness. It is not surprising that the plants most frequently depicted in both ritual and commodity painting are those that proliferate in water (such as the lotus) or on land (such as betel, banana and bamboo). This is not to suggest, however, that the representation of nature in Maithil arts is conditioned simply by an optical impression of nature’s form. Whenever Maithil painters represent a freely growing lotus creeper (or for that matter any other plant) in their paintings, the intention is not to capture their impression of the transitory shape of a particular lotus but to render the lotus as representing the creative and creating power of nature. (Singh 2000:436-7)

Echoing Singh’s interpretation, Brown describes one particular khobar painting: “every space is occupied by themes drawn from Mithila’s many ponds: birds, fish, leaves, blossoms, ants, worms, snakes, centipedes, turtles, and toads” (1996:719). While not all of the flora and fauna represented are exclusive to pond environs, the preponderance of such life forms is readily apparent, as Figure 3 illustrates.

In “Dost,” two extremely polluting types of substances-those associated with childbirth and death-become the only ones that can negate death itself, turning stone into living, breathing humanity. Only with the placenta still attached is the blood of the baby powerful enough to bring the dewan’s son back alive. It is this very blood of a child who just passed from the womb through the vagina that gives, rather than threatens, life and that has the power to (re)establish social order. Thus, the story ends by coming full circle to the rejected, dark-skinned first wife. While the dewan’s son is repeatedly described as clever and as a devoted friend with a pure heart, we are reminded that his one fault-that he rejected his first wife-is what in fact launches all of his trials, trials that, in the end, return him to her, virtually dead hims

By Dale Quinn, The Arizona Daily Star, Tucson

Jul. 2–More than 60 Pima Health System employees will be laid off at the end of the September because the health-care provider lost its bid to provide services to local Medicaid patients.

Losing its contract with the state’s Medicaid program, called the Arizona Health Care Cost Containment System, or AHCCCS, means Pima Health System will lose 27,000 of its 30,000 acute-care members.

The significant membership reduction means the health-care provider, which is a non-profit arm of Pima County, won’t need to keep all its employees, said Virginia Rountree, deputy director.

For the new fiscal year, which began Tuesday, the county had budgeted 777 full-time-equivalent positions for Pima Health System, Rountree said.

The county decided to reduce the number of full-time-equivalent positions by 187 because of the decrease in acute-care members, a move that will take effect Oct. 1, Rountree said.

Due to budget constraints, only 63 of those positions are currently filled, and it’s those employees who will be laid off at the end of September, Rountree said. The employees were notified of the layoffs late last week, she said.

The layoffs include all levels of positions, including clerical support, member services, accounting staff and nurses, Rountree said.

The county doesn’t offer a severance package, but employees will be paid for vacation time, she said.

No further staff reductions are immediately expected. “At this point in time, this is all the layoffs,” Rountree said.

Though it’s losing 27,000 members, Pima Health System is keeping 590 full-time-equivalent positions because it still has about 4,500 members who get care through its Arizona long-term-care system, which is also through AHCCCS.

“That benefit package is much more comprehensive,” Rountree said. “It requires each member have a case manager and requires more individualized oversight and support of their care needs.”

AHCCCS awarded its latest round of five-year. acute-care-service contracts in mid-May. The services are used by low-income families with children, pregnant women, children and disabled people.

Pima Health System was allowed to keep its members who also qualify for Medicare, which is the federal program that provides health-care assistance to those over 65.

But with that enrollment cap, its acute-care members would plummet from 30,000 to 3,000. Most of those members are in Pima County, but some are in Santa Cruz County.

Pima Health System has challenged the bid process that denied the health-care provider its contract, and AHCCCS notified them there will be a hearing to address its concerns.

A date for that hearing has not been set, Rountree said, but the health-care provider must move forward as if it’s losing its members.

–Contact reporter Dale Quinn at 573-4197 or [email protected].

—–

To see more of The Arizona Daily Star, or to subscribe to the newspaper, go to http://www.azstarnet.com.

Copyright (c) 2008, The Arizona Daily Star, Tucson

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Bayer HealthCare is expanding its commitment to hemophilia with the acquisition of Maxygen’s (NASDAQ:MAXY) hemophilia program assets, including a next-generation recombinant Factor VIIa protein known as MAXY-VII. The lead therapeutic candidate is expected to enter Phase 1 clinical testing in the third quarter of 2008. The total transaction is valued at $90 million upfront with a final, potential milestone payment of $30 million. This agreement includes a license to use Maxygen’s MolecularBreeding(TM) technology, a novel research platform, for exploiting gene targets.

Hemophilia is an inherited bleeding disorder caused by deficient or defective blood coagulation proteins. Roughly 20 to 30 percent of patients with hemophilia develop antibodies – or inhibitors – to current therapies. In these instances a Factor VIIa is used to bypass inhibitors and help these individuals to form clots. MAXY-VII is a next generation Factor VIIa clotting factor that may offer an improved dosing regimen and safety profile. The addition of a development candidate for patients with clotting factor inhibitors could further build Bayer’s leadership position in hemophilia care where it offers the recombinant Factor VIII product, Kogenate(R) (antihemophilic factor (recombinant)). The company has a strong development program dedicated to hemophilia including ongoing clinical investigations into long-acting forms of Kogenate.

“MAXY-VII has the potential to be an important expansion of therapeutic options for people living with hemophilia and we are pleased to add this to our global development portfolio. The agreement fits into our growth strategy for our specialty pharmaceutical business and builds on our expertise in the commercialization and manufacturing of protein therapeutics,” said Dr. Gunnar Riemann, member of the Executive Committee of Bayer HealthCare. “Our scientists are actively collaborating with researchers in academia and biotechnology firms to leverage novel research platforms. Access to Maxygen’s MolecularBreeding(TM) technology provides us with another tool to expand our product pipeline.”

“This agreement allows Maxygen to capture significant value from this preclinical asset, and puts MAXY-VII in the hands of the hemophilia leader,” said Russell Howard, chief executive officer of Maxygen. “MAXY-VII has the potential to become the world’s first approved shuffled protein therapeutic, a milestone that is likely to open up many more opportunities for Maxygen’s technology. Bayer is the ideal company to move the MAXY-VII program toward that goal.”

Bayer also receives a non-exclusive license to use Maxygen’s MolecularBreeding(TM) technology for a broad set of genes for its internal use in its specialty pharmaceutical business. In addition, Bayer receives exclusive rights to use the technology for 30 specified gene targets in areas of strategic business interest. This novel platform allows scientists to exploit gene variation that can result in unique drug targets or novel therapeutic protein candidates.

About MAXY-VII and Hemophilia

MAXY-VII is designed to be an improved Factor VIIa for the treatment of hemophilia patients. Hemophilia is an inherited bleeding disorder characterized by prolonged or spontaneous bleeding, especially into the muscles, joints or internal organs. The disease is caused by deficient or defective blood coagulation proteins, known as factor VIII or IX. The most common form of the disease is hemophilia A, or classic hemophilia, in which the clotting factor VIII is either deficient or defective. Hemophilia B is characterized by deficient or defective factor IX. According to the World Federation of Hemophilia, about 1 in 10,000 people is born with hemophilia A and 1 in 50,000 people is born with hemophilia B. Over time, roughly 20 to 30 percent of patients develop antibodies to these replacement factors (frequently referred to as inhibitors).

About the MolecularBreeding(TM) Directed Evolution Platform

MolecularBreeding(TM), also known as gene shuffling, is an iterative process of recombination and selection. The products of these recombined genes (proteins) are then screened for the targeted drug properties. This novel platform allows scientists to exploit gene variation that can result in unique drug targets or novel therapeutic protein candidates.

About Kogenate(R) FS/KOGENATE(R) Bayer

Kogenate(R) FS (Antihemophilic Factor (Recombinant)) / KOGENATE(R) Bayer (Recombinant Coagulation Factor VIII (octocog alfa)) is a recombinant factor VIII treatment indicated for the treatment of hemophilia A. The safety, efficacy and overall reliability of the Kogenate(R) line of products are based on 20 years of clinical experience. Clinical data shows that Kogenate(R) provided excellent hemostatic control, was well tolerated, and has a proven safety profile in patients with hemophilia A. Kogenate(R) is manufactured at Bayer’s state-of-the-art biotechnology facility in Berkeley, California. The most frequently reported adverse events were local injection site reactions, dizziness and rash. Known intolerance or allergic reactions to constituents of the preparation is a contraindication to the use of Kogenate(R). Known hypersensitivity to mouse or hamster protein may be a contraindication to the use of Kogenate(R).

About Maxygen, Inc.

Maxygen is a biopharmaceutical company focused on developing improved versions of protein drugs. Maxygen looks for opportunities where its proprietary protein modification technologies can address significant therapeutic needs. Maxygen’s approach to drug discovery and development leverages the established development and regulatory paths of approved drugs. www.maxygen.com.

About Bayer HealthCare

The Bayer Group is a global enterprise with core competencies in the fields of health care, nutrition and high-tech materials. Bayer HealthCare, a subsidiary of Bayer AG, is one of the world’s leading, innovative companies in the healthcare and medical products industry and is based in Leverkusen, Germany. The company combines the global activities of the Animal Health, Consumer Care, Diabetes Care and Pharmaceuticals divisions. The pharmaceuticals business operates under the name Bayer Schering Pharma. Bayer HealthCare’s aim is to discover and manufacture products that will improve human and animal health worldwide. Find more information at www.bayerhealthcare.com.

Bayer Schering Pharma is a worldwide leading specialty pharmaceutical company. Its research and business activities are focused on the following areas: Diagnostic Imaging, General Medicine, Specialty Medicine and Women’s Healthcare. With innovative products, Bayer Schering Pharma aims for leading positions in specialized markets worldwide. Using new ideas, Bayer Schering Pharma aims to make a contribution to medical progress and strives to improve the quality of life. Find more information at www.bayerscheringpharma.de.

Forward Looking Statements Disclaimer

This news release contains forward-looking statements regarding agreements between Maxygen and Bayer and about Maxygen’s MAXY-VII program and technology platform, including the potential benefits thereof. These forward-looking statements involve substantial risks and uncertainties, including but not limited to the ability or plans of Bayer to commence or continue the clinical development of MAXY-VII, whether Maxygen will receive any future milestone payments from Bayer related to such development and the timing and status of any such payments. Such statements involve risks and uncertainties that may cause results to differ materially from those set forth in these statements. Additional risk factors are more fully discussed in Maxygen’s Annual Report on Form 10-K for the year ended December 31, 2007, including under the caption “Risk Factors,” and in Maxygen’s other periodic reports filed with the SEC, all of which are available from Maxygen or from the SEC’s website (www.sec.gov). Maxygen disclaims any obligation to update or revise any forward-looking statement contained herein to reflect any change in Maxygen’s expectations with regard thereto or any change in events, conditions or circumstances on which any such statement is based. In addition, important information regarding the material terms and conditions of the agreements between Maxygen and Bayer will be set forth in a Current Report on Form 8-K to be filed by Maxygen with the SEC.

MolecularBreeding and Maxygen are U.S. trademarks of Maxygen, Inc.

By Bushra Baseerat

HYDERABAD: Fed up with unending marital problems, Ayesha Fatima, 25, wanted freedom from the bitter relationship and was toying with the idea of seeking divorce. She was planning to petition the mahila court when a friend of her’s passed on a helpline number.

In a confused state after finding herself on the edge, she dialled the helpline- 66632672. After listening to a soft and soothing voice, Ayesha opened up to an unknown woman at the other end of the line.

She counselled Ayesha Fatima for half an hour. That settled things. She decided to make the first move to end the uneasy relationship and speak to her husband.

The helpline, started by Muslim Girls Association (MGA), a 12- year-old city-based body involved in promoting Islamic education among the community, has given a new hope for many young and just married women to bail them out of suffocating circumstances, be it a family dispute or problems between the couple or adjusting with the husband’s family or the stress arising from bringing up a child.

“With the community straying from the Islamic path, there has been a considerable rise in dowry harassment, maintenance and divorce cases. People are falling prey to material comforts,” Dr Asma Zehra, a medical practitioner and founder-member of the association, told ‘TOI’.

“Hundreds of young girls and women call us with simple problems which they can solve on their own and in turn make things complicated. Reluctance to discuss these issues with their parents further compounds the problem. We counsel around 15 cases a month and clarify their doubts,” she added.

For Afshan Jabeen, an insurance consultant, a minor misunderstanding with her husband took their marital relationship to the verge of breaking. “I got appropriate advice to speak to my husband with a calm mind before taking any decision. It saved my marriage,” Afshan said.

The association is planning to start pre-marital counselling sessions shortly for young Muslim girls so that their queries as to how to behave in different circumstances could be answered.

From career guidance, seminars on various topics, visiting houses to convincing parents to educate their daughters, to undertaking counselling for young girls and distributing educative booklets, the MGA has started a silent revolution.

(c) 2008 The Times of India. Provided by ProQuest Information and Learning. All rights Reserved.

By Vianna Davila, San Jose Mercury News, Calif.

Jul. 1–Stanford University researchers said they are one step closer to accurately predicting if in vitro fertilization will result in pregnancy, according to a study released Tuesday.

The study, published in the Public Library of Science journal, identifies factors that will indicate with 70 percent accuracy the chances of pregnancy after a single round of in vitro fertilization, or IVF.

In vitro fertilization is a process by which eggs and sperm are clinically combined to create viable embryos that are then transferred into the uterus. Nationally, anywhere from 18 to 45 percent of IVF treatments, on women using their own eggs, result in pregnancy, according to the Society for Assisted Reproductive Technology.

Stanford researchers isolated four factors out of 30 to better predict pregnancy outcomes: the total number of embryos developed during fertilization; both the number of fully developed and undeveloped embryos; and a hormone test.

But the scientists’ method only tells parents who’ve already undergone one round of IVF if the treatment likely worked, said Dr. Mylene Yao, the lead researcher on the study and Stanford assistant professor of obstetrics and gynecology. What the method doesn’t predict is the parents’ chances of a pregnancy should they try IVF again, assuming the first attempt failed.

The Stanford researchers analyzed 665 IVF trials conducted at the university in 2005.

The researchers are now analyzing a larger set of birth data from

another study. Both studies will help them develop a method that predicts the odds of a pregnancy, and hopefully a live birth, in subsequent IVF treatments, Yao said.

“Ultimately we want to be able to give patients more personalized and evidence-based information to help them decide whether they want to have IVF treatment if their first one (treatment) does not result in a baby,” Yao said.

For the most part, scientists already know to look at both undeveloped and developed embryos, said Dr. Susan Willman, an endocrinologist with the Reproductive Science Center of the San Francisco Bay Area. What the study does is calculate an actual probability, the first time she had read of one.

The trend in endocrinology research is to develop tests that predict the likelihood of pregnancy before fertility treatments begin, Willman said. Research is also focused on determining which embryos are healthiest to transfer.

Yao emphasized the study is one more way scientists pinpoint when IVF is most likely to work.

Contact Vianna Davila at [email protected] or (408) 920-5064.

—–

To see more of the San Jose Mercury News, or to subscribe to the newspaper, go to http://www.mercurynews.com.

Copyright (c) 2008, San Jose Mercury News, Calif.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

By Rosalie Rayburn Journal Staff Writer

A new clinic slated to open next year will give local veterans im]proved access to health care.

Rio Rancho will be the site for one of 44 new Veterans Administration clinics scheduled to be opened nationwide, according to a news release issued Thursday by Secretary of Veterans Affairs James Peake.

The news release said the Veterans Administration over the next few months will determine the exact location, staffing and services to be offered by the Rio Rancho clinic.

Sen. Pete Domenici, R-N.M., and Rep. Heather Wilson, R-N.M., hailed the news, saying it would bring health services closer to veterans who need them.

“There is an ongoing and growing demand for care among veterans, including those who served in past conflicts and our newest veterans from the conflicts in Iraq and Afghanistan,” Domenici said in a statement e-mailed to the Journal.

Domenici’s e-mail said the clinic is expected to open in the summer of 2009.

“This new facility will help make care more accessible for the thousands of veterans who live in Sandoval County and the surrounding areas,” Wilson said in a statement e-mailed to the Journal on Thursday.

Marla Griffith, president of the Rio Rancho Chapter of the Blue Star Mothers of America, an organization that supports the military, veterans and their families, said the clinic would help meet a big demand for services in the Rio Rancho and surrounding area.

“I think this is an absolutely wonderful thing for Rio Rancho and all the military families in our area,” Griffith said in a phone interview.

The VA determines where to open new clinics based on the distance veterans have to travel to their local hospital or clinic, local demand and the existing local hospital workload, said Floyd Vasquez, public affairs specialist for the New Mexico VA Health Care system.

Vasquez said the Raymond G. Murphy VA Medical Center in Albuquerque is the only VA hospital in New Mexico.

The New Mexico VA system currently operates community-based outpatient clinics in 10 other cities statewide and in Durango, according to its Web site.

Vasquez said the new VA clinic would not be affiliated with the Veteran and Family Support Services project opened last fall at 184 Unser in Rio Rancho.

That clinic was funded through a $570,000 appropriation from the state Legislature. It is operated by Presbyterian Medical Services, a Santa Febased nonprofit that provides medical, dental and behavioral health services statewide, mostly in rural areas.

(c) 2008 Albuquerque Journal. Provided by ProQuest Information and Learning. All rights Reserved.

By Anna Tong, The Lexington Herald-Leader, Ky.

Jul. 1–A medical malpractice case in which an Owingsville woman accused a Lexington gynecologist of unnecessary castration — removing her healthy ovaries — without warning her of the surgery’s consequences went to the jury Tuesday.

The defense argued that the doctor used sound medical judgment.

“He’s done the worst thing a physician can do — he violated her trust,” said Lexington attorney, Sheila Hiestand.

The plaintiff, 38 year-old Connie Grimes, wept quietly after closing arguments, leaning on her husband.

Grimes is one of six women who filed a lawsuit against Dr. Michael Guiler in 2003, saying he performed medically unnecessary oophorectomies. The cases are being tried separately.

Removing a woman’s ovaries results in early menopause and leaves patients at risk for breast cancer, embolisms and dementia because they can no longer produce their own estrogen.

Guiler has previously been in the national spotlight because of other lawsuits filed in 2003 alleging he had branded “UK” — for University of Kentucky, his alma mater — on uteri before he removed them.

Grimes is seeking almost $900,000 in reparations for the aftereffects of what she thinks was an unnecessary oophorectomy. She said that while she signed a consent form, she did not fully understand the consequences of having her ovaries removed at age 31.

In an interview, Grimes said that in 2001, Guiler told her she needed to have a hysterectomy because of painful, heavy periods.

After the surgery, she said Guiler told her husband he had used his medical judgment to additionally remove her ovaries, which were “too far diseased” with endometriosis for her to keep them.

An oophorectomy is considered a last-resort treatment for endometriosis, a disease characterized by tissue growth outside the uterus.

Guiler’s attorney has said the high number of surgeries performed by Guiler is attributable to his being one of the few surgeons to perform laparoscopically assisted vaginal hysterectomies, a less-invasive procedure than a surgical hysterectomy.

However, Hiestand said that there are 14 doctors in a 30-mile radius of Lexington who perform the laparoscopic procedure, and most of them only perform 10 to 12 per year. Guiler, on the other hand, performed 120 in 2001, Hiestand said.

After the ovary removal, Grimes began to suffer from depression, hot flashes, and migraines. She had an active sex life beforehand, but her husband testified that he “felt guilty” when they had sex since the operation.

Guiler’s attorney said that a diagnosis of endometriosis was reasonable, given Grimes’ long-term complaints.

Grimes has had a history of pelvic pain, abnormal bleeding and pain during intercourse.

“Her complaints were consistent with endometriosis,” said Guiler’s attorney, Donald Brown of Louisville. “The only definitive treatment for that is a hysterectomy and oophorectomy.”

Brown maintained that Grimes had discussions with a nurse and Guiler about the surgery, documented by the consent form Grimes signed at Central Baptist Hospital.

Grimes’ complaints of loss of libido and depression, Brown said, are best explained by the “massive amounts of narcotic medication” Grimes took for migraine relief.

The Women’s Care Center at Central Baptist Hospital also is a named plaintiff in the civil suit.

Anna Tong can be reached at (859)231-1301

—–

To see more of the Lexington Herald-Leader, or to subscribe to the newspaper, go to http://www.kentucky.com.

Copyright (c) 2008, The Lexington Herald-Leader, Ky.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Walgreen Co. (NYSE:WAG)(NASDAQ:WAG), through its subsidiary Option Care Enterprises, Inc., has completed its acquisition of CuraScript Infusion Pharmacy, Inc., a wholly-owned subsidiary of Express Scripts, Inc. CuraScript Infusion Pharmacy, based in Louisville, Ky., is one of the nation’s largest providers of infusion services and for nearly 17 years has supported patients who require complex therapies including anti-viral, immune deficiency, inotropic, chemotherapy and pain management treatments. Walgreens acquired each of CuraScript Infusion Pharmacy’s 12 facilities located in Alabama, Indiana, Kentucky, Missouri, Ohio and Tennessee. Terms of the agreement were not disclosed.

Paul Mastrapa, president of Walgreens-OptionCare, said, “This acquisition further expands our national coverage in home infusion services. We now operate more than 100 home infusion locations in 35 states. CuraScript Infusion Pharmacy is highly regarded in the industry for its clinical expertise and commitment to exceptional patient care. We welcome this addition to our infusion pharmacy network and look forward to reaching even more patients with this combined high level of personalized therapy and support.”

Express Scripts, Inc. is retaining ownership of CuraScript Specialty Pharmacy and CuraScript Specialty Distribution.

Walgreens (www.walgreens.com) is the nation’s largest drugstore chain with fiscal 2007 sales of $53.8 billion. The company operates 6,252 drugstores in 49 states, the District of Columbia and Puerto Rico. Walgreens provides the most convenient access to consumer goods and cost-effective health care services in America through its retail drugstores, Walgreens Health Services division and Walgreens Health and Wellness division. Walgreens Health Services assists pharmacy patients and prescription drug and medical plans through Walgreens Health Initiatives Inc. (a pharmacy benefit manager), Walgreens Mail Service Inc., Walgreens Home Care Inc., Walgreens Specialty Pharmacy LLC and SeniorMed LLC (a pharmacy provider to long-term care facilities). Walgreens Health and Wellness division includes Take Care Health Systems, which is comprised of: Take Care Consumer Solutions, managers of 172 convenient care clinics at Walgreens drugstores, and Take Care Employer Solutions, managers of worksite-based health and wellness services at 364 employer campuses.

Valley Presbyterian Hospital (VPH) is pleased to announce the appointment of Don Kreitz as Senior Vice President and Chief Operating Officer, effective August 4.

Kreitz is a dynamic leader with more than 20 years experience in healthcare. Currently, Kreitz serves as Chief Operating Officer at Los Robles Hospital and Medical Center – a 273-bed acute-care facility owned by HCA, Inc. (Hospital Corporation of America). Kreitz has held executive positions at several hospitals in the San Fernando Valley, including Encino-Tarzana Regional Medical Center and West Hills Regional Medical Center.

“We are extremely excited to have Don join our executive team at Valley Presbyterian Hospital,” said VPH President and Chief Executive Officer Albert L. Greene. “We will benefit immensely from his experience and proven record of success. Don has a strong, well-rounded background specializing in strategic planning, program development, managed care, finance and operations. He will play a vital role in Valley Presbyterian’s commitment to providing advanced quality healthcare for our community.”

Kreitz has been credited in his career as a Co-Founder of a privately held company providing independent living, assisted living, specialized dementia care and adult day care for the elderly. As Senior Vice President and Chief Operating Officer of Valley Presbyterian Hospital, Kreitz will have administrative responsibility for day-to-day operations of the hospital.

Kreitz holds a Bachelor of Business Administration Finance from University of Texas, San Antonio, Texas.

About Valley Presbyterian Hospital

Celebrating its 50th Anniversary this year, Valley Presbyterian Hospital is one of the largest acute care hospitals in the San Fernando Valley. The 350-bed facility offers leading-edge technology and medical expertise in maternal and child health, cardiac care, orthopedics, and critical care services. VPH has more than 500 physicians representing virtually every specialty and most sub-specialties. As a non-profit organization, Valley Presbyterian Hospital depends upon charitable support to provide the highest quality healthcare. To find out how you can help, please contact the Foundation Department at (818) 902-2980. For more information, visit our website at: www.valleypres.org.

DR CUNLIFFE is a senior consultant in children’s pain management and anaesthesia, and is regularly called to lecture abroad. She lives in Calderstones and works at Alder Hey.

“It’s a close-up of a hydrangea-type bush in my garden, but partly made up. There’s a lot of pattern and intricacy and colour that you don’t see until you’re close up. Light and shade and how things twist round each other. I say I’m a frustrated Georgia O’Keefe.”

Patience, concentration, and dexterity are skills she came equipped with.

“I have to be fairly precise at what I do, especially if I’m dealing with a baby weighing a kilo and putting a drip into it, or a tube into its lungs,” she says.

“Being an anaesthetist, there’s no doubt that for periods of time it’s very quiet and there’s nothing to do but stay alert. It’s quite a funny speciality, really. You have to have a certain temperament.”

She has also started a clinic for children with chronic pain, from conditions like rheumatoid arthritis or shingles. “People, even doctors, don’t think children can have chronic pain year after year, but they do,” she reflects.

“There’s a bit of stress on some level when you’re actually doing your art and working out how you want everything,” she says. “But it’s nothing like stress at work.”

(c) 2008 Daily Post; Liverpool. Provided by ProQuest Information and Learning. All rights Reserved.

To: NATIONAL EDITORS

Contact: Monica Harris, Project Administrator of Delaware Valley Innovation Network, +1-215-496-8167, [email protected]

PHILADELPHIA, July 1 /PRNewswire-USNewswire/ — The Delaware Valley Innovation Network (DVIN)announced today the award of its first Innovation Investment Grant. The Wistar Institutewill receive $89,000to support the Wistar Biomedical Technician Training (BTT) Program, a two-year workforce development program in biotechnology and biomedical research.

The BTT Program provides Community College of Philadelphia (CCP) students instruction and hands-on experience training while preparing for careers as Biomedical Technicians. We see tremendous value in supporting a pipeline of talented students from the Community College of Philadelphia through real work experience at the Wistar Institute, various industry laboratories and the Fels Institute, said Helen Groft, Project Director of DVIN. These students will be able to jumpstart their careers and employers will have experienced candidates to hire.

The Innovation Investment Award will support the Wistar Institute- CCP partnership and provide training opportunities for 17 first and second year students through CCPs new Center for Science, Engineering and Emerging Technologies. Dr. William Wunner, Director of the Biomedical Technician Training Program said, The BTT program equips promising community college students with a better understanding of cancers, genetics diseases, autoimmune diseases, and a multitude of related conditions that affect human and animal health.

Since 2001, life science companies and affiliated institutions where students participating in the BTT program have included:

— Centocor (Radnor, PA) — Cephalon (West Chester, PA)

— Charles River Laboratories (Malvern, PA)

— GlaxoSmithKline (Collegeville, PA)

— Neose Technologies (Horsham, PA)

— Tengion, Inc. (East Norristown, PA)

— University of the Sciences in Philadelphia (USP)

— Fels Institute of Temple University

The Wistar Institute will be working with DVIN to expand their training program to other community colleges throughout the tri- state region.

About DVIN Innovation Investments

The DVIN Innovation Investment Fund will provide more than $2.4 million in grants over the next three years to support training and capacity building programs for the life science workforce in the Delaware Valley. Eligible applicants for the DVIN Innovation Investments include 501(c)3 non-profit organizations, individual businesses or business partnerships, educational entities, economic development organizations, workforce intermediaries, and community- based organizations.

The next deadline for Innovation Investment proposal submissions is October 1, 2008.

More information about DVIN Innovation Investments, including guidelines, FAQs and upcoming information sessions is available at http://www.delawarevalleyinnovationnetwork.com/dvin/ guidelinesannouncement.htm.

Point of Contact: Jason Maki, Project Coordinator, DVIN 215-496- 8143, [email protected].

About DVIN

The Delaware Valley Innovation Network (DVIN) was formed in 2005 to apply for a Workforce Innovation in Regional Economic Development (WIRED) grant from the U.S. Department of Labor. This unique, collaborative effort was endorsed by the governors of Pennsylvania, New Jersey, and Delaware and created a fourteen-county initiative to strengthen and grow the tri-state regions vibrant life sciences industry and workforce. DVINs mission is to accelerate the transformation of the life sciences industry in the 14-county tri- state region into an internationally recognized center for excellence. DVIN will attract resources to support research, industry and human capital development.For more information, please visit www.delawarevalleyinnovationnetwork.com.

About the Wistar Institute

The Wistar Institute is an international leader in biomedical research with special expertise in cancer research and vaccine development. Founded in 1892 as the first independent nonprofit biomedical research institute in the country, Wistar has long held the prestigious Cancer Center designation from the National Cancer Institute. Discoveries at Wistar led to the creation of the rubella vaccine that eradicated the disease in the United States, human rabies vaccines used worldwide, and a rotavirus vaccine approved in 2006. Today, Wistar is home to preeminent research programs studying skin cancer, lung cancer, and brain tumors. Wistar Institute Vaccine Center scientists are creating new vaccines against pandemic influenza, HIV, and other diseases threatening global health. The Institute works actively to transfer its inventions to the commercial sector to ensure that research advances move from the laboratory to the clinic as quickly as possible. The Wistar Institute: Todays Discoveries – Tomorrows Cures. On the web at www.wistar.org.

SOURCE Delaware Valley Innovation Network

(c) 2008 U.S. Newswire. Provided by ProQuest Information and Learning. All rights Reserved.

WOODCLIFF LAKE, N.J., July 1, 2008 /PRNewswire/ — Eisai Corporation of North America today announced the preliminary efficacy data from a trial initiated in 2002 comparing Dacogen(R) (decitabine) to Best Supportive Care (BSC) in elderly patients with myelodysplastic syndromes (MDS). The data did not demonstrate a statistically significant advantage of Dacogen treatment on median overall survival. However, response rates were similar to those observed in other clinical trials of Dacogen in patients with MDS. In the trial, conducted by the European Organisation for the Research and Treatment of Cancer (EORTC), Dacogen was administered on a three-day dosing schedule. In this study, the number of treatment cycles was limited. MDS is a potentially life-threatening group of bone marrow diseases that limit the production of functional blood cells.

Subsequent to database lock and the completion of data analysis, comprehensive results of the study, including secondary efficacy endpoints and safety data, will be presented by EORTC at an upcoming scientific forum.

Current Development

Eisai plans to submit a supplemental New Drug Application (sNDA) with the U.S. Food and Drug Administration by the end of the fiscal year for a five-day regimen for Dacogen. The sNDA will be based on a North American, multi-center, open-label, single arm Phase II trial (DACO-020) in which patients received Dacogen every day for five days. The regimen was repeated every four weeks with no limit on the number of treatment cycles that patients could receive as long as they received clinical benefit or until their disease progressed. Median survival at the time of data analysis was 19.4 months and the one-year survival rate for patients treated with Dacogen was 66 percent. An overall complete response rate of 32 percent (International Working Group 2006 Criteria) was achieved with the outpatient administration of Dacogen, confirming previously reported response rates in the outpatient setting. The safety profile of this dosing regimen was consistent with what has been previously reported.

Eisai is committed to a clinical development program to optimize the utility of Dacogen for all patients with MDS. Recent studies of hypomethylating agents have suggested that treatment of patients should continue for as long as they receive clinical benefit or until their disease progresses. To advance the understanding of optimal treatment for MDS and related conditions, there are currently more than 30 ongoing trials with Dacogen either as a single agent or in combination with other therapies, including a Phase III survival study in older patients with acute myelogenous leukemia (AML).

Study Design

EORTC-06011: This Phase III open-label, randomized, multi-center, controlled trial evaluated overall survival of patients receiving Dacogen plus BSC versus BSC only. The study involved 233 elderly patients, greater than or equal to 60 years of age, with predominantly high-risk or Intermediate-2 type MDS.

Patients included in the trial had primary or secondary MDS with or without previous therapy with growth factors, immunosuppressive agents or hydroxyurea. In order to participate in the study, patients had to have bone marrow blast counts between 11 and 30 percent. Patients with blast counts below 10 percent were required to have had poor-risk cytogenetics in order to be eligible for randomization.

DACO-020: This is a multi-center, open-label, single arm Phase II study of Dacogen in 99 patients with de novo or secondary MDS. Dacogen was administered daily for five days repeated every four weeks. Patients were greater than or equal to 18 years of age with MDS (de novo or secondary) of any FAB subtype and with an International Prognostic Scoring System score of greater than or equal to 0.5. In order to be included in the cytogenetic analysis, patients must have had abnormal cytogenetics at baseline and adequate cytogenetics data available for at least one post-baseline visit.

About MDS

Myelodysplastic syndromes, or MDS, are a group of diseases of the bone marrow characterized by the production of poorly functioning and immature blood cells. People with MDS may experience a variety of symptoms and complications, including anemia, bleeding, infection, fatigue and weakness. Those patients with high-risk MDS may experience bone marrow failure, which may lead to death from bleeding and infection. Over time, MDS can progress to acute leukemia, or AML. The Aplastic Anemia and MDS International Foundation currently estimates that up to 30,000 new cases of MDS are diagnosed annually in the United States.

About Dacogen(R)

Dacogen(R) (decitabine) for Injection was approved by the U.S. Food and Drug Administration on May 2, 2006, and is indicated for treatment of patients with myelodysplastic syndromes (MDS) including previously treated and untreated, de novo and secondary MDS of all French-American-British (FAB) subtypes (refractory anemia, refractory anemia with ringed sideroblasts, refractory anemia with excess blasts, refractory anemia with excess blasts in transformation, chronic myelomonocytic leukemia), and Intermediate-1, Intermediate-2 and High-Risk International Prognostic Scoring System (IPSS) groups.

Dacogen may cause fetal harm when administered to a pregnant woman. Women of childbearing potential should be advised to avoid becoming pregnant while using Dacogen. Men should be advised not to father a child while receiving treatment with Dacogen and for two months afterwards. The most commonly occurring adverse reactions with Dacogen include neutropenia (90%), thrombocytopenia (89%), anemia (82%), pyrexia (53%), fatigue (48%), nausea (42%), cough (40%), petechiae (39%), constipation (35%), and diarrhea (34%).

   Please visit http://www.dacogen.com/ for full prescribing information.    About Eisai Corporation of North America  

Eisai Corporation of North America is a wholly-owned subsidiary of Eisai Co., Ltd., a research-based human health care (hhc) company that discovers, develops and markets products throughout the world. Eisai focuses its efforts in three therapeutic areas: neurology, gastrointestinal disorders and oncology/critical care.

Eisai Corporation of North America supports the activities of its operating companies in North America, which include: Eisai Research Institute of Boston, Inc., a discovery operation with strong organic chemistry capabilities; Morphotek, Inc., a biopharmaceutical company specializing in the development of therapeutic monoclonal antibodies; Eisai Medical Research Inc., a clinical development group; Eisai Inc., a commercial operation with manufacturing and marketing/sales functions; and Eisai Machinery U.S.A., which markets and maintains pharmaceutical manufacturing machinery.

Eisai Corporation of North America

CONTACT: Media, Judee Shuler of Eisai Inc., +1-201-746-2241; Investors,Bob Laverty of Eisai Corporation of North America, +1-201-746-2265

Web site: http://www.dacogen.com/

HealthPort, a top 30 company in the healthcare information technology industry, announced today the appointment of Mike Labedz as President and CEO. Labedz also serves as President of HealthPort’s parent company, Thurston Group, LLC, and was instrumental in bringing Companion Technologies and SDS together in 2007 to form HealthPort.

“HealthPort is well-positioned to continue growing, thriving and helping an increasing number of healthcare providers increase efficiency and improve quality of care,” says Labedz. “As we embark on a new and exciting era, I’m pleased to lead such a talented team.” Labedz also notes that HealthPort’s former President and CEO, Frank Murphy, “leaves a legacy of high standards, excellent leadership and commitment to our clients.”

Frank Murphy, who served as President and CEO for four years, presided over the successful transition to the company’s new ownership in 2007 and was instrumental in directing the integration of Companion Technologies and SDS. “My pledge to our parent company after the merger took place was to remain President and CEO of HealthPort for one year to ensure a smooth transition for both companies, build a solid leadership team, and secure our technology infrastructure for future growth. At this point, I’m excited to turn the company over to the capable hands and leadership of Mr. Labedz and the remaining team,” states Murphy. Murphy is leaving HealthPort to pursue another executive leadership opportunity, but adds that he strongly believes in the organization’s direction and vision, and feels privileged to have worked with the HealthPort team.

HealthPort’s strategic initiatives for 2008 include a continued focus on excellent customer service; identifying and capitalizing upon both organic growth and acquisition opportunities; and increasing its portfolio of healthcare technology products and services to offer a more integrated, enterprise suite of solutions that improve healthcare business processes, quality of care and financial performance.

About HealthPort

HealthPort combines technology and strategic solutions to continually improve fragmented business processes for the healthcare community. The company offers revenue cycle management, electronic medical record, electronic document management, document conversion and storage services, practice management, release-of-information, and healthcare consulting services. HealthPort is the one-source provider, offering the widest selection of affordable, quality health information products and services in the industry. For more information, visit www.healthport.com or call 800-737-2585.

By MUSSEN, Deidre

THREE INFERTILE women have stunned New Zealand’s maternity sector by breastfeeding their babies despite never giving birth.

One mum has fully breastfed her baby daughter since her surrogate gave birth 17 weeks ago, a second is partially breastfeeding her adopted baby and a third has induced lactation in preparation for her surrogate baby’s birth.

“When my body has let me down for so many years and now it’s able to give life and health to this little girl, it’s pretty incredible really,” says Upper Hutt first-time mum Jacqui Lucas.

Their private lactation consultant, Cheryl Ganly-Lewis of Upper Hutt, said her colleagues were amazed to hear about the three lower North Island women’s cases – all first-time mothers – at a breastfeeding conference in March.

She could find no records of cases in New Zealand when the first woman came to her for help.

She had to turn to the internet, where she discovered a Canadian programme using medications and regularly expressing milk.

It involves taking domperidone, an anti-nausea drug with a side effect of stimulating breast milk production, and progesterone, an oral contraceptive that simulates pregnancy.

The women must also express milk using a breast pump about eight times a day for up to six months before the baby is due, including once at night. All expressed milk is frozen to supplement feeds later if needed. Expressing continues between breastfeeds a few times a day to ensure good supply.

Ganly-Lewis knows of a fourth woman, who has given birth to two babies previously but has just started breastfeeding her third child, born to a surrogate in Auckland about a week ago.

Lucas, 39, says she had never heard of inducing lactation but asked her midwife if she could breastfeed the baby her surrogate, a close work friend, was expecting.

It’s a huge commitment but Lucas was determined.

“If Cheryl had told me I had to express 15 times a day, I would have.”

She and her husband, Jason Foster, childhood sweethearts together for 21 years, have spent the past seven desperately trying to have a family, including four IVF cycles.

“We had got to the stage we had given up because it was too hard emotionally.

“Then out of the blue, my friend offered to be a surrogate.”

She was motivated to breastfeed to improve bonding rather than to meet her baby’s nutritional needs.

Her eyes well with tears as she describes the moment she first fed her newborn daughter, Lily Marie Foster.

“She was popped on my stomach and her head bobbed around a bit and then she latched straight on.

“It was only about 10 minutes after she was born.”

They are so deeply grateful for their surrogate’s gift of life.

And breastfeeding her baby has made the experience even more special.

“When that little girl looks up at me while feeding and smiles, she melts my heart.”

While plenty of people are incredulous at her ability to breastfeed, she downplays the effort it takes.

“It’s just something I have to do because I’m her mum. I have to give her the best start in life.”

——————–

(c) 2008 Sunday Star – Times; Wellington, New Zealand. Provided by ProQuest Information and Learning. All rights Reserved.

NEWPORT NEWS, Va., July 1 /PRNewswire/ — Solis Women’s Health, with eight centers across the Dallas-Fort Worth Metroplex devoted entirely to mammography and breast imaging, announced today that it is adding molecular imaging to the diagnostic tools it has available in its DFW locations. This exciting technology is performed with the Dilon 6800, a high-resolution, small field-of-view gamma camera, optimized to perform Breast-Specific Gamma Imaging (BSGI). It is initially being implemented at Solis’ Central Plano location, with further implementations planned at Solis locations throughout the Metroplex.

BSGI is a molecular breast imaging technique that can see lesions independent of tissue density and discover very early stage cancers. BSGI serves as a complementary diagnostic adjunct procedure to mammography and ultrasound for difficult-to-diagnose patients. With BSGI, the patient receives a pharmaceutical tracing agent that is absorbed by all the cells in the body. Due to their increased rate of metabolic activity, cancerous cells in the breast absorb a greater amount of the tracing agent than normal, healthy cells and generally appear as “hot spots” on the BSGI image.

Solis has been using the Dilon 6800 in its Solis-Bertrand Breast Center in Greensboro, N.C., for over a year. Molecular imaging will be used as a part of Solis’ advanced imaging program for breast diagnosis, which also includes the use of breast MRI, when appropriate.

“BSGI has proven to be an important adjunct to mammography and ultrasound in the diagnosis of breast cancer at the Solis-Bertrand Center, and we are excited to be the first in the Metroplex to offer this important advance in care,” said Brad Hummel, CEO of Solis.

“At Solis our commitment is to the women of our communities, and this commitment extends to selecting technologies that demonstrate diagnostic value in our mission to diagnose cancers when they are small and at their most treatable. We studied the BSGI extensively at our center in Greensboro, and determined that it offered benefits that we needed to bring to the Metroplex,” said Hummel.

Bob Moussa, CEO of Dilon Technologies added, “We are delighted to have an institution as prestigious as Solis Women’s Health include our advanced technology as part of their diagnostic offering. It speaks volumes for their commitment to enhancing the standard of health care in the communities in which they operate. By working closely together, Solis and Dilon will continue to help the fight against cancer.”

About Solis Women’s Health

Solis Women’s Health is a specialized healthcare provider focused exclusively on the screening and diagnosis of breast cancer. Headquartered in Austin, Texas, Solis operates eight north central Texas facilities; the Solis-Bertrand Breast Center in Greensboro, N.C.; Solis-BenOra Imaging in Phoenix, Ariz.; and 10 MedTech Mammography Centers in Phoenix and Tucson, Ariz.; and has several additional sites under development in markets across the United States. Solis provides a complete range of breast health services including screening mammography, diagnostic mammography, computer-aided detection, breast ultrasound, bone densitometry and stereotactic and ultrasound-guided biopsy, breast specific gamma imaging and breast MRI. More information is available at http://www.solishealth.com/.

About Dilon Technologies

Dilon Technologies Inc. is bringing innovative new medical imaging products to market. Dilon’s cornerstone product, the Dilon 6800, is a high-resolution, small field-of-view gamma camera, optimized to perform BSGI, a molecular breast imaging procedure which images the metabolic activity of breast lesions through radiotracer uptake. Many leading medical centers around the country are now offering BSGI to their patients, including: Cornell University Medical Center, New York; George Washington University Medical Center, Washington, D.C.; and The Rose, Houston. For more information on Dilon Technologies please visit http://www.dilon.com/.

Dilon Technologies Inc.

CONTACT: Nancy F. Morter of Dilon Technologies Inc.,+1-757-269-4910, ext. 302, cell, +1-757-589-3914, [email protected]

Web site: http://www.dilon.com/http://www.solishealth.com/

The Doctors Company, a physician-owned medical malpractice insurer, has completed its acquisition of The SCPIE Companies, a major provider of health care liability insurance.

With the addition of more than 8,000 physician policyholders, The Doctors Company now has more than 43,000 physician members, and expands its market share in California to serve 19,000 physicians.

In connection with the closing of the transaction, SCPIE’s common stock is being deregistered with the Securities and Exchange Commission and delisted with the New York Stock Exchange and public trading of SCPIE’s securities has ceased.

SCPIE will function as a wholly owned subsidiary of The Doctors Company and its operations will be merged into the company’s existing operations. The company will maintain a fully staffed, full-service office in Los Angeles.

Richard Anderson, chairman and CEO of The Doctors Company, said: “The combination of SCPIE and The Doctors Company strengthens our ability to deliver on our mission to relentlessly advance, protect and reward the practice of good medicine. We are pleased by the enhanced value that The Doctors Company will be able to offer California physicians, including lower rates, unparalleled service, and outstanding policyholder benefits.”

By SUZY COHEN

Question: I take Nexium for heartburn and enalapril (Vasotec) for blood pressure. I’m losing my hearing and some of my hair. Now I have symptoms of an enlarged prostate so my doctor has prescribed Proscar. Will it interact with the other drugs that I’m already taking? — L.A., Denver

Answer: No, it won’t interact. But I have to tell you, your symptoms sound a lot like zinc deficiency. It used to only occur in underdeveloped countries, but today it occurs in regular folks who take “drug muggers” of zinc (drugs that reduce zinc levels in the body). These include antacids, antibiotics birth control pills, hormone replacement drugs for hot flashes, acid-blocking drugs (Nexium, Prilosec, Tagamet, Zantac, etc), furosemide, Lotensin, Enalapril, Atacand HCT, HCTZ (Hydrochlorothiazide) and cholestyramine (Questran). You take two of these meds.

Telltale signs of deficiency include frequent colds or infections because zinc is necessary to fight the germs. You may have cold hands and feet, foggy thinking, high blood pressure, high cholesterol, brittle nails and worsening vision. You may not hear or smell things as well as you used to and you may be losing your hair. You may have skin problems like acne, psoriasis, eczema, boils or very slow wound healing.

Teenage boys may need a little extra zinc as they go through puberty to ensure fertility and produce healthy sperm in their reproductive years. Zinc is great for skin and it may get those acne breakouts under control. Low zinc can cause stunted growth, learning disabilities and mental retardation in severe cases.

Older men derive the most benefit from zinc because it helps prevent prostatitis, enlarged prostate (BPH), hair loss, hearing loss and high cholesterol. It could spell trouble in the bedroom, too.

Suzy Cohen is the author of “The 24- Hour Pharmacist.” For more information, visit www.DearPharmacist.com

Originally published by SUZY COHEN Dear Pharmacist.

(c) 2008 Tulsa World. Provided by ProQuest Information and Learning. All rights Reserved.

By LISA ADAMS

GETTING married is the best incentive in the world to cut out calorie loaded snacks.

The sheer terror of walking up the aisle in a figure hugging white dress is enough to make most brides to be go all out to drop a dress size in time for their big day. But Scots TV detox queen Amanda Hamilton, 33, who has just got engaged to herboyfriend Crawfurd Hill, 44, is the exception.

The GMTV nutritionist is such a glowing advert for what she preaches she has a perfect figure. That makes shopping for a dress for her winter wedding simpler.

Amanda is sharing her secrets to staying slim in a new book revealing crash diets don’t work.

Amanda says: “The diet industry with fads and calorie counts is part of the problem, not the solution.

“It’s not about losing 10 lbs in 10 days then putting it all back on, plus more. Instead you need life changing weight loss. That means overcoming hidden physical and emotional causes that prevent you from getting the body you want.

“Why not think of the whole of your life as the ‘special event’!”

Here’s our pick of her best advice for shaping up forever.

Life Changing weight loss – three steps to get the body and life you want by Amanda Hamilton and Sandy Newbigging, published by Piatkus is out and costs pounds 12.99.

BEWARE OF SUGAR

Far from being a friend for work, rest and play, for anyone who wants to lose weight sugar is one of the most toxic substances around.

To lose weight give up sugar.

DETOX

Calorie counting is hurtfully deceptive. Calories can be empty and toxic, making you crave more food. They can prevent your body from burning fat and getting rid of fattening chemicals.

Your liver is a major fat burning organ. If it’s too clogged up with toxins from manmade chemicals then it can’t function optimally.

Avoid artificial sweeteners, colourings or preservatives.

MAXIMISE THE NUTRIENTS

Have you binged on lentil soup or over eaten mackerel or salmon? Probably not. When the body is fed real food we feel full because we’ve given our body what it needs to work best.

Small amounts of protein taken with each meal slows down the release of sugar in the body and you feel full longer.

Essential fats in avocados, seeds, nuts, coconuts and oily fish like salmon and mackerel slow down the transit of foods and help absorb nutrients. They’re also needed by the liver to metabolise fat. You need to eat good fat to burn bad fat.

A handful of nuts and seeds as cereal and a yoghurt can provide micro minerals like zinc and selenium that keep cravings at bay.

DRINK MORE PURE WATER

Water helps your body release toxic waste, so take steps to ensure you get the best water possible.

Bottled water is a good option but buy glass because plastic is likely to release chemicals.

Carbonated drinks have carbon dioxide, which leeches calcium from the reserves in the body.

EXERCISE

For optimum weight loss, the best time to exercise is first thing in the morning before breakfast. That’s when insulin levels are lowest and hormone glucagon is highest. Aminimum 30 minutes, three times a week is needed for your body to benefit.

STOP COMFORT EATING

If you notice you’re having a down day instead of reaching for comfort food to bring you back up try healthier ways to lift you. Change posture, facial expression and breathing. Look up, smile, pull shoulders back, puff your chest and breathe deeply.

(c) 2008 Daily Record; Glasgow (UK). Provided by ProQuest Information and Learning. All rights Reserved.

Tenet Healthcare Corporation (NYSE: THC) announced it has reached a settlement with HCP, Inc. (NYSE: HCP), a real estate investment trust based in Long Beach, Calif., that owns seven hospitals leased by Tenet subsidiaries. The agreement will resolve the pending litigation and arbitration proceedings between the two companies, continue or extend the operating leases at four hospitals, and provide notice of non-renewal at two hospitals.

As part of the HCP settlement, a Tenet subsidiary has entered into a definitive agreement with Providence Health & Services – California regarding the 245-bed Tarzana campus of Encino-Tarzana Regional Medical Center in the Los Angeles area. The Tarzana campus is owned by HCP, however, under terms of the agreement, a Tenet subsidiary will acquire the hospital from HCP and simultaneously sell it to Providence Health.

“We are pleased we can bring resolution to the HCP issues,” said Trevor Fetter, Tenet’s chief executive officer and president. “The sale of the Tarzana campus has been four years in the making, and we now have successfully reached an agreement with a qualified operator to continue the important mission of this hospital. The completion of these divestitures and those announced earlier this month will conclude our divestitures in California. We look forward to growing our services and making investments in our remaining hospitals in the state.”

Providence Health is a not-for-profit health care organization with 25 hospitals in five states – Alaska, California, Montana, Oregon and Washington. Providence Health’s California region operates four acute care medical centers in Los Angeles County, as well as more than a dozen outpatient centers, four skilled nursing facilities and a medical foundation. Providence Health has agreed it will continue to operate the Tarzana campus as an acute care hospital and maintain its emergency department. Providence Health also intends to offer employment to substantially all employees in good standing.

Also, as part of the settlement with HCP, Tenet will continue or extend the leases at four hospitals and will not renew the leases at two other hospitals. The HCP-owned hospitals that Tenet will continue to lease and their expiration dates are:

— Frye Regional Medical Center, a 355-bed acute care hospital located in Hickory, N.C.; lease renewed through February 2014 with options to renew through 2039.

— North Fulton Regional Hospital, a 202-bed acute care hospital located in Roswell, Ga.; lease renewed through February 2014 with options to renew through 2039.

— NorthShore Regional Medical Center, a 165-bed acute care hospital located in Slidell, La.; lease expires May 2010 with options to renew through 2040.

— Palm Beach Gardens Medical Center, a 199-bed acute care hospital located in Palm Beach Gardens, Fla.; lease renewed through February 2014 with options to renew through 2039.

The hospitals owned by HCP with leases that will not be renewed are:

— Community Hospital of Los Gatos, a 143-bed acute care hospital located in Los Gatos, Calif.; lease expires May 2009.

— Irvine Regional Hospital and Medical Center, a 176-bed acute care hospital located in Irvine, Calif.; lease expires February 2009.

Stephen L. Newman, M.D., Tenet’s chief operating officer, said, “The age of the physical plant and the requisite capital improvements was a factor in the decision not to renew the lease at Los Gatos, and over the years the economic terms of our lease created barriers to our success at Irvine. Tenet is giving advance notice of its intentions, so that we can work with HCP to transition Irvine and Los Gatos to new operators as soon as they are identified.”

Newman continued, “California remains an important market for us. We have accelerated the implementation of our targeted growth initiatives and are expanding our outpatient footprint there. We remain committed to our core facilities and the communities they serve.”

The definitive agreements are subject to customary regulatory approvals, and the sales are expected to be completed during the third quarter. Financial terms were not disclosed. These transactions will not affect the range of Tenet’s outlook for 2008 and 2009 operating results or cash flow.

Tenet Healthcare Corporation, through its subsidiaries, owns and operates acute care hospitals and related ancillary health care businesses, which include ambulatory surgery centers and diagnostic imaging centers. Tenet is committed to providing high quality care to patients in the communities we serve. Tenet can be found on the World Wide Web at www.tenethealth.com.

Some of the statements in this release may constitute forward-looking statements. Such statements are based on our current expectations and could be affected by numerous factors and are subject to various risks and uncertainties discussed in our filings with the Securities and Exchange Commission, including our annual report on Form 10-K for the year ended Dec. 31, 2007, our quarterly reports on Form 10-Q and periodic reports on Form 8-K. Do not rely on any forward-looking statement, as we cannot predict or control many of the factors that ultimately may affect our ability to achieve the results estimated. We make no promise to update any forward-looking statement, whether as a result of changes in underlying factors, new information, future events or otherwise.

By Dan Roberts

Making love doesn’t just help you feel good. It also burns calories, boosts your immune system – and can even reduce the risk of cancer. By Dan Roberts

IMPROVES SELF-ESTEEM AND MENTAL HEALTH

Boosting self-esteem was one of the 237 reasons people have sex, according to a study conducted last year by researchers from the University of Texas and published in the Archives of Sexual Behavior. This is no surprise to Julia Cole, author of How to Have Great Sex for the Rest of Your Life. She is convinced that a healthy sex life with a loving partner does wonders for the way you feel about yourself. “After a bout of sex the body releases endorphins, which are known as ‘happy chemicals’ because they improve mood,” she says. “Purely from a physical point of view it’s similar to enjoying a good workout or going swimming – but if you’re having sex with someone you love it also makes you feel cared for and promotes self- esteem.”

The proviso, of course, is that if your sexual experiences are unhappy ones, they will have a similarly negative impact upon your psyche. But assuming the sex is good, it is thought to improve body image, as well as reducing anxiety and the incidence of psychiatric illness, depression and suicide. A 2004 study of men from four different cultures found that sexual satisfaction was directly associated with an increased frequency in sexual intercourse, as well as being inversely related to depression.

AIDS SLEEP

During orgasm the body produces oxytocin, which is a hormone linked to a range of positive physical and psychological effects. Chief among these is its beneficial impact on sleep. “There’s no doubt that sex is relaxing and so helps tackle insomnia,” says Dr David Delvin, a GP and specialist in sexual medicine. “Lots of people use sex, whether with a partner or on their own, as a way of getting to sleep. That’s down to the surge in oxytocin during arousal and orgasm, which is a natural sedative.”

This view is backed up by a US study carried out in 2000, which found that 32 per cent of the 1,866 female respondents who reported masturbating in the previous three months did so to help them sleep.

COMBATS STRESS

One of sex’s main health benefits is its positive impact on how we deal with stress. In a study published in the journal Biological Psychology, 24 women and 22 men kept records of their sexual activity. The researchers subjected them to stressful situations, such as public speaking and doing verbal arithmetic. Those who had intercourse had better responses to stressful scenarios than those who had either engaged in other sexual behaviours or abstained altogether.

According to Julia Cole, this could be down to the soothing effect another person’s touch has. She says: “A great deal of research has shown that touch has a naturally calming effect on human beings, whether it’s linked to sex or not. Of course, being touched by someone you care about will double the calming effect.”

Apart from the obviously pleasurable sensation of being touched or stroked, it is thought to have a biochemical effect, reducing the levels of cortisol – the hormone that is secreted when you’re under stress.

BOOSTS IMMUNITY

Having sex once or twice a week has been linked with higher levels of an antibody called immunoglobulin A, or IgA, which can protect you from colds and other sorts of infections. Scientists at Wilkes University in the US tested IgA levels in 112 college students who reported the frequency of their sexual activity. Those students in the “frequent” group had higher levels of IgA than those who were either abstinent or had sex less than once a week.

Paula Hall, a psychosexual therapist with Relate, also thinks that the impact of sex on our general wellbeing helps to boost immunity. “All the psychological benefits have an impact on your physical health, such as your immune system,” she says. “We know that when you’re feeling good about yourself your body fights off illness and disease better – so the healthier we are psychologically and emotionally, the healthier we are physically.”

REDUCES CANCER RISK

Frequent ejaculations may reduce the risk of prostate cancer for men in later life, according to a study by Australian researchers reported in the British Journal of Urology International. When they followed men diagnosed with prostate cancer and those without it, the researchers found that men who had at least five or more ejaculations weekly during their twenties reduced their risk of getting prostate cancer by a third.

“The evidence is good that men who masturbated regularly in the past are less likely to get prostate cancer,” confirms Dr Delvin. “Nobody knows exactly why this is, but it does seem to be pretty cast-iron.”

Research also suggests that regular sexual activity could help women to avoid breast cancer. A study conducted in 1989 examined 146 French women and found a higher risk of breast cancer in those women without sexual partner or who had sex less than once a month.

IMPROVES INTIMACY

Having sex and orgasms is a key part of improving intimacy and ensuring a healthy long-term relationship – which has been linked to a longer lifespan in a number of studies. It’s all down to oxytocin again. “Oxytocin, also called the ‘bonding hormone’, is released when women give birth, so it is part of the bonding process with their baby,” says Julia Cole. “It’s also released in people who are in secure or long-term relationships, as well as during sexual contact. This bonding effect is one of the reasons people continue to have a sexual relationship long after they have ceased to be fertile.”

This was backed up by a study conducted by researchers from the University of Pittsburgh. They evaluated 59 premenopausal women before and after warm contact with their partners ended with hugs. The study found that the more contact the women had, the higher their oxytocin levels were.

And studies in which couples were asked to go without sex for long periods found that their general relationship declined, indicating that sex has a powerful bonding effect for couples. “There’s also the slightly more indefinable feeling that you are thought to be attractive and someone your partner wants to be with and touch,” adds Cole. “That’s very important – often when I see couples who are in trouble they have stopped having sex, and one of them will say their partner no longer thinks of them as attractive.”

EASES PAIN

Sex has been linked with a pain reduction for a wide range of conditions, including lower back pain, migraines, arthritis and premenstrual syndrome symptoms. It’s all down to those hormones again. “Sex increases endorphins, the body’s natural painkillers,” confirms Dr Delvin. “So there is evidence that having sex eases period pain and PMS.”

Oxytocin is also linked with pain relief. In a study published in the Bulletin of Experimental Biology and Medicine, 48 volunteers who inhaled oxytocin vapour and then had their fingers pricked reduced their sensitivity to pain by half.

In 2001, two studies of orgasms and migraine headaches in a woman and man found that orgasm resulted in pain relief. And an earlier study of 83 women who suffered from migraines reported that orgasm resulted in pain relief for more than half of the group. Although this form of pain relief is less reliable and effective than the use of drug therapies, the effects of orgasm as an analgesic are more rapid.

BURNS CALORIES

Sexual activity, like other forms of exercise, burns both calories and fat. Thirty minutes of energetic sex burns 85 calories or more. Although this may not sound like much, it does add up – 42 half-hour sessions will burn 3,570 calories, which is enough to lose a pound. “Sex does burn calories, so it’s comparable to moderate exercise like doing the housework or going swimming,” says Dr Delvin. And it is, clearly, a great deal more fun.

But there is something of a chicken-and-egg element here, because people who lead more active sex lives tend to exercise more regularly and physical exercise improves sexual health. A 1990 study that followed 78 men over a nine-month period found that with consistent aerobic exercise, participants had an increase in frequency of sexual activity, improvement in performance and an increased ability to reach a “satisfying” orgasm.

INCREASES LONGEVITY

One of the most extensive studies into the relationship between sex and mortality was carried out in Caerphilly, South Wales, from 1979 to 1983, with a 10-year follow-up. In the study, 918 men were given a physical examination and asked about their frequency of orgasm. After 10 years it was found that the mortality risk was 50 per cent lower among men who had frequent orgasms – which was defined as two or more per week. The study also found that, even when adjusting for age and other risk factors, frequent intercourse was associated with lower incidence of cardiovascular disease and stroke.

“There has been a great deal of research into whether people in relationships live longer,” adds Paula Hall. “We know that having a strong relationship is a good indicator of longevity – and a healthy sex life is a big part of that.”

(c) 2008 Independent, The; London (UK). Provided by ProQuest Information and Learning. All rights Reserved.

PHILADELPHIA, July 1 /PRNewswire-USNewswire/ — The ABIM Foundation will dedicate its efforts over the next five years to bridging the concepts of medical professionalism and accountability in health care toward the ultimate goal of improving patient care.

In addition, the Foundation announced that officers of its Board of Trustees now include, for the first time, two non-physician leaders whose public perspectives will help guide the Foundation’s work. Glenn Hackbarth, Chair of the Medicare Payment Advisory Commission, and Bruce Bradley, Director of Health Care Strategy and Public Policy for General Motors Corporation, were elected to one-year terms as Vice Chair and Secretary-Treasurer, respectively. John Popovich, Jr., MD, Chair, Department of Medicine, Henry Ford Health System will also begin two years of service as Chair of the ABIM Foundation Board of Trustees.

As a focus for the next five years, the ABIM Foundation’s work will address the 21st century principles outlined in Medical Professionalism in the New Millennium: A Physician Charter developed by the ABIM Foundation, the American College of Physicians Foundation and the European Federation of Internal Medicine. These aspirational principles redefine the role of physicians to include a commitment to quality improvement, a focus on equitable care across all populations, and an obligation to be stewards of scarce medical resources. Download the charter at http://www.abimfoundation.org/PhysicianCharter.

For many physicians, professionalism is a guiding force for quality patient-physician interactions, spurring and inspiring physicians to do their best for their patients. At the same time, many within and outside of the profession believe the concept has been inappropriately used to avoid external oversight.

“There is a growing sense that professionalism has weakened, which has the potential to negatively affect public trust in medicine,” said Christine K. Cassel, MD, president and CEO of ABIM and the ABIM Foundation. “By developing mechanisms to crisply define and support new notions of professionalism, we can better meet the needs of patients and payers for greater accountability.”

Recent research, sponsored by the Institute of Medicine as a Profession, identified notable gaps between the ideals physicians aspire to in the professionalism realm and their practices. The ABIM Foundation aspires to close these gaps by working collaboratively with patients, employers, health plans, physicians and other stakeholders to develop and implement shared expectations about physicians’ roles and responsibilities in the context of a changing health care system.

“The inclusion of non-physicians as Trustees in the Foundation has proven invaluable in helping us define and implement an agenda that is inclusive of all involved in healthcare,” added John Popovich, Jr, MD, Chair of the ABIM Foundation Board of Trustees. “By having Glenn Hackbarth and Bruce Bradley serve as Officers for the Foundation, we will be better able to bridge the divide between the perspectives of physicians on professionalism and payers and patients on accountability.”

An additional focus of the Foundation will be the responsibilities articulated in the Physician Charter focusing on “stewardship of finite resources.” In light of the crisis regarding the cost of health care, the Foundation hopes to play a leadership role in advancing the physician’s ability to effectively steward the health care resources of his or her community.

   The Trustees serving for 2008-2009 are:    --  Chair: John Popovich, Jr., MD - Chair, Department of Medicine, Henry       Ford Health System   --  Vice-Chair: Glenn Hackbarth, JD, MA - Chair, Medicare Payment Advisory       Commission (MedPAC) (Trustee since 2006)   --  Secretary-Treasurer:  Bruce Bradley, MBA - Director, Health Care       Strategy and Public Policy, General Motors Corporation (Trustee since       2003)   --  Richard J. Baron, MD - President, Greenhouse Internists, PC and Chair,       ABIM Board of Directors   --  Troyen A. Brennan, MD, MPH - Executive Vice President and CMO, Aetna,       Inc.   --  Christine K. Cassel, MD - President and CEO, American Board of       Internal Medicine and ABIM Foundation   --  David B. Hellmann, MD - Professor of Medicine and Vice Dean, Johns       Hopkins Bayview Medical Center   --  Holly J. Humphrey, MD - Professor of Medicine and Dean for Medical       Education, Pritzker School of Medicine and the University of Chicago       Hospitals   --  Sheila T. Leatherman, MSW - Research Professor, School of Public       Health, University of North Carolina Judge Institute, University of       Cambridge   --  Deborah Leff, JD - President, Public Welfare Foundation   --  Debra L. Ness, MS - President, National Partnership for Women &       Families   --  Donald E. Wesson, MD - Vice Dean, Texas A&M Health Sciences Center       (Temple Campus)   --  Beverly Woo, MD - Associate Professor of Medicine, Harvard Medical       School    About the ABIM Foundation   

Established in 1999 by the American Board of Internal Medicine (ABIM), which certifies internal medicine physicians and subspecialists, the ABIM Foundation complements ABIM’s work by exploring the issues central to the common purpose of both organizations — to enhance the quality of patient care.

ABIM Foundation

CONTACT: Lori Bookbinder of ABIM Foundation, +1-215-606-4122,[email protected]

Web Site: http://www.abimfoundation.org/

Avid Radiopharmaceuticals, Inc. announced today the appointment of Richard Baron, CPA, to the newly created position of Chief Financial Officer effective June 18, 2008. Mr. Baron brings more than 20 years of financial experience to Avid, most recently serving as the CFO of eResearchTechnology, Inc., a publicly traded, technology-based, clinical research organization. Mr. Baron will report to the President and CEO, Daniel Skovronsky.

“Rick is an accomplished financial leader and we are fortunate to have him join our executive management team as CFO,” said Dr Skovronsky. “Rick’s accomplishments and experience as a CFO and senior manager of several public companies are critical for us as we grow our company in preparation for the Phase III development and eventual commercialization of our products.”

Prior to joining Avid, Mr. Baron was Executive Vice President and CFO of eResearchTechnology, Inc. (Nasdaq: ERES). In addition, he was Vice President and CFO at Animas Corporation, where he played a key role in helping the company through several rounds of financing through its IPO and eventual sale to Johnson & Johnson. Prior to Animas, Mr. Baron held CFO positions at Genex Services and Marsam Pharmaceuticals.

“Avid is developing medical imaging products which have the potential to address important unmet clinical needs in major chronic diseases, such as Alzheimer’s disease, Parkinson’s disease and diabetes.” said Mr. Baron. “I am very excited to be part of this organization and look forward to working with this outstanding management team to move the company to the next level.”

About Avid Radiopharmaceuticals Inc.

Based in Philadelphia, PA, Avid Radiopharmaceuticals Inc. is a leader in the development of products with the potential for earlier and more effective detection, diagnosis and monitoring of brain disorders. The company is a pioneer in the development of molecular imaging agents for Alzheimer’s disease that could lead to earlier diagnosis and better evaluation of drugs designed to prevent or reverse amyloid plaque build-up in the brain. Avid is currently enrolling patients in Phase II clinical studies of its leading (18)F agent, AV-45, for positron emission tomography (PET) imaging of amyloid plaques in Alzheimer’s disease. The company is also currently in Phase I clinical studies of AV-133, the first (18)F radiopharmaceutical for PET imaging of the vesicular monoamine transporter (VMAT2) for detecting neurodegenerative diseases such as Parkinson’s disease (PD) and Dementia with Lewy Bodies (DLB). Recent research has shown that imaging VMAT2 may also be useful in monitoring the functional viability of beta cells of the pancreas, which could improve efforts to diagnose and monitor progression of diabetes mellitus. More information about Avid is available at www.avidrp.com.

HAMILTON, N.J., July 1 /PRNewswire/ — MedAvante, Inc., the leader in centralized psychiatric patient evaluation, announced today that it has closed a $20 million financing by Goldman, Sachs & Co. and Trevi Health Ventures. MedAvante has developed an innovative platform to centralize and calibrate the assessment of patients undergoing treatment in clinical trials in order to more reliably and precisely measure their response to therapies. MedAvante currently provides centralized patient evaluation services to many of the world’s largest pharmaceutical companies with central nervous system drug candidates, and has administered more than 21,000 remote expert assessments for Phase 2 and Phase 3 large pharma studies including acute schizophrenia, major depressive disorder, generalized anxiety disorder, and psychotic depression.

The Company will use the capital to fund the expansion of its existing patient evaluation platform to meet increasing demand from pharmaceutical companies. The capital will also enable MedAvante to apply its platform into new areas of drug development, including monitoring by mental health professionals of potential warning signs for suicide. The U.S. Food and Drug Administration (FDA) is requiring most drugs with centrally acting mechanisms to be assessed for suicidality, regardless of whether the drugs are being developed for neurological or psychiatric indications.

“The investment by Goldman Sachs and Trevi Health gives MedAvante the capital and resources to deliver on our mission of helping the life sciences industry bring better and safer drugs to patients faster,” stated Paul Gilbert, Chief Executive Officer of MedAvante. Gilbert further noted, “Our unique ability to centralize and standardize the assessment of psychiatric patient’s disease severity and progression is transforming clinical trials for psychiatric drugs; we will now be able to bring this same new paradigm to bear in other areas of critical medical need, such as the development of new treatments for Alzheimer’s disease and the assessment of the risk of suicidality for all classes of drugs.”

The former FDA Deputy Commissioner for Medical and Scientific Affairs, Scott Gottlieb, MD, a member of MedAvante’s Board of Directors, commented, “The cost of conducting trials to treat neurological and psychiatric disorders has been increasing rapidly in recent years in large part due to the approaches industry has been using to measure patient response. Larger numbers of patients are being enrolled in psychiatric trials simply because outdated approaches to drug development require more patients to be exposed to an experimental drug to see whether it’s working.” He continued, “MedAvante has pioneered an approach that offers one of the most effective solutions to improving the efficiency and reliability of psychiatric drug development, enabling new treatments to be assessed more efficiently for safety and effectiveness and potentially reach patients sooner and at lower cost.”

Andrew Fink, Managing Director of Trevi Health Ventures, noted, “MedAvante’s solution solves the critical problem of enhancing precision and reliability in central nervous system trials head-on. This capital infusion will enable the company to meet the rapidly expanding demand for more accurate psychiatric assessment. Importantly, MedAvante has demonstrated the ability to deliver centralized ratings with the operational precision and scalability needed to expand globally.”

Walter Greenblatt & Associates served as MedAvante’s exclusive financial advisor in the transaction.

About MedAvante

MedAvante has pioneered and commercialized a solution that addresses one of the global pharmaceutical industry’s most intractable problems: the high rate of uninformative or failed studies. MedAvante provides centralized expert psychological rater services to the pharmaceutical industry using unique methods to systematically remove potential sources of bias and variability from the assessment process. By centralizing assessments with expert, standardized, objective, clinical interviewers over MedAvante’s 2 way real-time high quality video-conferencing, MedAvante makes subjective measures of determining drug efficacy increasingly objective. As a result, it is now possible to increase study power, reduce trial failure rates, and get more effective central nervous system (CNS) drugs to market sooner. MedAvante has administered more than 21,000 remote expert assessments for Phase 2 and Phase 3 large pharma CNS studies. MedAvante employs 73 professionals based in facilities in Hamilton, NJ; Los Angeles, CA and Madison, WI.

About Goldman Sachs

Goldman Sachs is a leading global investment banking, securities and investment management firm that provides a wide range of services worldwide to a substantial and diversified client base that includes corporations, financial institutions, governments and high net worth individuals. Founded in 1869, it is one of the oldest and largest investment banking firms. The firm is headquartered in New York and maintains offices in London, Frankfurt, Tokyo, Hong Kong and other major financial centers around the world.

About Trevi Health Ventures

Trevi Health Ventures is a healthcare investment firm with over $100 million under management. The investment team combines experienced investment professionals and senior-level executives/entrepreneurs with proven track records. Trevi provides development and growth capital for private healthcare companies with emphasis on medical devices, biopharmaceuticals and healthcare services. The firm was founded in 2005 and has offices in New York and London.

About Walter Greenblatt & Associates

Walter Greenblatt & Associates is an investment banking and specialized consulting organization focused on helping healthcare companies succeed through strategic planning, capital raising and mergers and acquisitions. The firm serves biotechnology, healthcare and healthcare services companies from very early stage startups to established public companies.

MedAvante, Inc.

CONTACT: Paul M. Gilbert, Chief Executive Officer of MedAvante, Inc.,+1-609-528-9400, [email protected]

Web site: http://www.medavante.net/

VioQuest Pharmaceuticals (OTCBB: VOQP) today announced the submission of a 510(k) application to the United States Food and Drug Administration (FDA). The application seeks marketing clearance for Xyfid(TM) (1% uracil topical), a topical skin preparation intended to relieve and to manage the burning and itching associated with various dermatoses including atopic dermatitis, irritant contact dermatitis, radiation dermatitis and other dry skin conditions, by maintaining a moist wound and skin environment. If cleared by the FDA, Xyfid(TM) will be the company’s first commercial product.

“The submission of our 510(k) application for Xyfid(TM) marks an important milestone in our company’s history and we look forward to reporting our progress on this and on other fronts in the months ahead,” said Michael D. Becker, president and CEO of VioQuest Pharmaceuticals. “With this submission, we are also well positioned to consider opportunities for partnership or collaboration to support the commercialization strategy for this novel supportive care oncology product candidate.”

About VioQuest Pharmaceuticals

VioQuest Pharmaceuticals is a New Jersey-based biotechnology company dedicated to becoming a recognized leader in the successful development of novel drug therapies targeting both the molecular basis of cancer and side effects of treatment. VioQuest’s oncology portfolio includes: Xyfid(TM) (1% uracil topical), for the treatment of dry skin conditions and to manage the burning and itching associated with various dermatoses; VQD-002 (triciribine phosphate monohydrate), a targeted inhibitor of Akt activation; and Lenocta(TM) (sodium stibogluconate), an inhibitor of certain protein tyrosine phosphatases such as SHP-1, SHP-2, and PTP1B.

Further information about VioQuest can be found at www.vioquestpharm.com.

This press release contains forward-looking statements that involve risks and uncertainties that could cause VioQuest’s actual results and experiences to differ materially from the anticipated results and expectations expressed in these forward-looking statements. These forward-looking statements concern the timing, progress and results of the clinical development, regulatory processes, potential clinical trial initiations of VioQuest’s product candidates, as well as our ability to complete strategic transactions. These statements are often, but not always, made through the use of words or phrases such as anticipates, expects, plans, believes, intends, and similar words or phrases. These statements are based on current expectations, forecasts and assumptions that are subject to risks and uncertainties, which could cause actual outcomes and results to differ materially from these statements. These statements are subject to various risks and uncertainties and include VioQuest’s immediate need for additional capital to cover its current obligations and future operating expenses and fund its clinical development programs, the possibility that the results of clinical trials will not support VioQuest’s claims, the possibility that VioQuest’s development efforts relating to its product candidates will not be successful, the inability to obtain regulatory approval of VioQuest’s product candidates, VioQuest’s reliance on third-party researchers to develop its product candidates, its lack of experience in developing and commercializing pharmaceutical products, and the possibility that its licenses to develop and commercialize its product candidates may be terminated. Additional risks are described in VioQuest’s Annual Report on Form 10-KSB for the year ended December 31, 2007. VioQuest assumes no obligation and does not intend to update these forward-looking statements, except as required by law.

Elixir Pharmaceuticals, Inc., today announced the Company has entered an exclusive license agreement with Boston University to key intellectual property covering discoveries regarding the use of modulators of SIRT1, a member of the sirtuin class of protein deacetylase enzymes. SIRT1 is the human equivalent of Sir2, a gene identified in yeast that has been recognized to play a key role in the control of lifespan, metabolism, resistance to stress and other cellular regulatory pathways. The agreement with Boston University encompasses therapeutic applications for SIRT1 modulators in metabolic diseases, including obesity and diabetes, as well as therapeutic modulation of SIRT1 for anti-angiogenic activity to treat cancer.

“Modulation of SIRT enzymes has attracted considerable attention because of their potential to address a broad range of diseases,” stated Dr. Peter DiStefano, Elixir’s Chief Scientific Officer. “Based on nearly a decade’s-worth of research, Elixir has amassed a broad intellectual property estate, which includes compounds that activate SIRT1 and compounds that inhibit SIRT1. It is an exciting time to be working in SIRT development and we are pleased to have added this intellectual property from Dr. Stephen Farmer’s lab at Boston University to our portfolio.”

Dr. DiStefano continued, “Elixir Pharmaceuticals is a leader in understanding the enzymology and pathway biology of SIRT1. This knowledge is critical for the successful development of best-in-class compounds. In addition, we have a deep knowledge base and expertise in the development of SIRT assays and disease-specific animal models. We supplement this expertise with insights and discoveries from collaborators such as Dr. Farmer at Boston University. This approach has allowed Elixir to build an unparalleled intellectual property estate which includes a broad portfolio of issued and pending patents.”

About Elixir’s Sirtuin Development Program

Building upon the Company’s knowledge of the regulation of aging and metabolism, Elixir Pharmaceuticals has developed a leadership position in the field of sirtuins, or SIRT, a class of seven naturally occurring human enzymes, known to affect the storage and use of energy in cells. Elixir Pharmaceuticals believes that sirtuin modulators, compounds which increase or decrease the activity or the amount of sirtuin enzymes, may have potential clinical utility in numerous, large pharmaceutical markets with unmet medical needs, such as metabolic disease, cancer and neurodegenerative diseases.

Elixir has an extensive sirtuin intellectual property estate which includes know-how and more than 20 patents (pending and issued) related to screening, assays, mechanism/pathway knowledge, and chemical composition of matter and utility claims for sirtuin modulators, including small molecule compounds. In February 2007, Elixir commenced a program with Siena Biotech S.p.A. to collaborate on the optimization, validation and evaluation of Elixir’s SIRT1 inhibitors in Huntington’s disease. Additional, proprietary programs at Elixir are pursuing applications of sirtuin modulators in obesity, diabetes and oncology.

About Elixir Pharmaceuticals

Elixir is a pharmaceutical company focused on the discovery, development and commercialization of novel pharmaceuticals for the treatment of metabolic diseases such as diabetes and obesity. The Company’s scientific founders identified that modulation of specific genes can slow the aging process and increase longevity. Elixir is developing small molecule drugs that mimic these longevity responses, and these drugs will be used to treat a range of age-related diseases, including the major metabolic diseases.

In addition to sirtuin agonists and antagonists, the Company has two late-stage products (Metgluna(TM) and Glinsuna(TM)) for the treatment of type 2 diabetes in a final phase III trial in the U.S., with NDA filing expected in 2009. Further, the Company is developing an oral ghrelin antagonist for the treatment of metabolic disease. Elixir is also developing EX-1314, an oral drug being developed for the treatment of type 1 diabetic gastroparesis.

About Metgluna and Glinsuna

For patients with type 2 diabetes not well controlled on metformin alone, Metgluna will provide additional HbA1c reduction through comprehensive glycemic control via two complementary mechanisms of action. Metgluna is a fixed combination tablet of metformin, which helps control fasting plasma glucose by improving insulin sensitivity, and mitiglinide, a product that mimics the body’s natural response to glucose by producing a rapid and brief burst of insulin when glucose levels begin to rise to provide for better control of post-meal glucose surges.

The companion product Glinsuna has been studied extensively in human clinical studies in the U.S., Europe, Australia and Asia. Clinical trial results, including more than 1,500 patients treated in phase III trials, have demonstrated an excellent safety and efficacy profile for mitiglinide as monotherapy or in combination with metformin. An ongoing phase III clinical study enrolled more than 300 patients across 60 sites in the U.S. and was designed to evaluate the efficacy and safety of Glinsuna in combination with metformin in patients whose blood sugar is not adequately controlled by metformin alone.

Elixir in-licensed North and South American rights to mitiglinide from Kissei Pharmaceuticals. Under the terms of the licensing agreement, Elixir has the right to develop and commercialize mitiglinide and any future product combinations, in the U.S., Canada and Latin America.

About Elixir’s Ghrelin Development Programs

Using structure-assisted drug design, a method of creating chemical compounds based on an understanding of the configuration of the human ghrelin receptor, Elixir has internally discovered and developed a series of potent, small molecule antagonist compounds that block the ghrelin receptor. Oral administration of these compounds in animal models of diet-induced obesity and early diabetes resulted in similarly favorable metabolic effects to those seen in knockout models with respect to improved blood glucose levels, insulin resistance, HbA1c, triglycerides, total cholesterol, liver fat, body weight and white fat when compared to placebo. Elixir is completing selection of a clinical candidate and expects to file an investigational new drug (IND) application with the U.S. Food and Drug Administration (FDA) early in 2009, initiating a phase I clinical trial shortly thereafter.

In addition, the Company has submitted an IND to the FDA for EX-1314, Elixir’s novel oral ghrelin agonist. EX-1314 is being developed for the treatment of chronic gastrointestinal disorders, including gastroparesis, a disorder in which the stomach takes too long to empty its contents. EX-1314 will be developed initially for gastroparesis in patients with type 1 diabetes, which is the most common systemic cause of gastroparesis. Human clinical testing is expected to begin this year.

Military troops are returning from combat zones with mental health issues, and counselors, psychologists, and other mental health professionals feel unprepared. Yet, there are things that every American can do to help. These are among the findings in Joining Forces America, a Capella University-sponsored study of returning servicemembers and mental health professionals.

Servicemembers & mental health professionals agree that troops are reluctant to seek help

Nearly half of servicemembers surveyed (44 percent) said they returned with a mental health condition. But most feel that recognition of a mental health issue isn’t likely to be paired with getting treatment. Nearly two-thirds said their peers would be unlikely to ask for professional help to deal with such issues as depression, post-traumatic stress, or family adjustment.

Mental health professionals had similar concerns. Seventy-two percent of those surveyed indicated they were very concerned about the reluctance of some servicemembers to seek mental health treatment, which was the top-rated concern. Several recent studies support this finding, including the Rand Center’s study, Invisible Wounds: Mental Health and Cognitive Care Needs of America’s Returning Veterans, which indicated that only about half of servicemembers who need mental health treatment actually seek it.

“Soldiers are recognizing they are experiencing post-combat problems, and that’s a good thing,” said Will Wilson, PhD, president-elect of the American Psychological Association’s Society of Military Psychology and faculty chair for Industrial/Organizational Psychology at Capella University. “When I came back from Vietnam and my wife said I was a different person. I didn’t see it. I would never have gone for help on my own,” added the former Green Beret and retired U.S. Army Colonel.

“People want to believe that time will solve the problem, but time solves nothing. We have to take action to help these servicemembers,” Wilson added. “It’s a national responsibility that we all need to address.”

Mental health professionals feel under-prepared, but most are trying to gain knowledge

More than a third (37%) of mental health professionals indicated they felt “not very prepared” to help returning servicemembers with post-combat and re-entry issues. Only 18 percent of mental health professionals said they are “very prepared” to help returning servicemembers Those working at a military base feel much more prepared than their peers in other settings, but even there, less than half feel “very prepared”.

Most mental health professionals indicated that they are already taking some steps to increase their knowledge of post-combat mental health issues. Three-fourths of mental health professionals surveyed indicate they have taken further coursework, read scholarly materials, and/or consulted more experienced practitioners about this subject.

Servicemembers take a more positive view of the mental health community’s preparedness. Fifty-seven percent said the mental health community was at least somewhat prepared to help with post-combat issues, compared to only a third of mental health professionals. Further, among those who sought mental health treatment, 77 percent said the assistance was helpful, with community mental health providers receiving higher rankings than military providers.

“A big part of the challenge in meeting servicemembers’ mental health needs is making sure there are enough qualified professionals to address the need,” said Wilson. “We certainly see Capella as part of that solution. Our online counseling and psychology programs–including the only online CAPREP-accredited master’s-level counseling specializations–make it more feasible to pursue advanced degrees in the mental health field. This is especially true for those who would find it difficult to attend a campus-based school, such as those in the military and people living in rural areas.

“Nonetheless, this study is a wake-up call for Capella and other universities who educate mental health professionals,” said Wilson. “We need to look closely at the special mental health issues of servicemembers and their families to make sure we are meeting the need.”

Replace one mission with another

Servicemembers and mental health professionals agreed on several coping strategies that can help servicemembers adjust to post-combat life. Setting a goal, such as earning a degree or focusing on a new career was the top-ranked strategy by servicemembers, with 87 percent finding this helpful. A similar percentage (88 percent) of mental health professionals said this strategy would be helpful, though their top answer was “keeping in touch with fellow servicemembers who shared similar combat experiences.”

“Our military students tell us that pursing a degree after returning from combat gives them a new mission and focus,” said Nicole Lovald, Capella University’s armed forces & veterans support supervisor, who oversees the team that provides support to the more than 3,700 military-affiliated students enrolled at Capella. “To further support our troops, we are offering 20 new $5,000 scholarships available to veterans, servicemembers, and their immediate family members. This is in addition to five $10,000 Spirit of Capella Scholarships we have available to students who have been injured in Operation Enduring Freedom or Operation Iraqi Freedom.”

Servicemembers welcome help from family and friends but find them unprepared

Support and encouragement from family, friends, co-workers and the community is vital – especially if there is a reluctance to seek professional assistance. Servicemembers, as well as mental health professionals, reacted favorably to suggestions about what friends, neighbors, and others could do to support returning servicemembers.

 Ways for friends, neighbors, and community members to support returning servicemembers ---------------------------------------------------------------------- Mental health Percentage who rated each idea as       Servicemembers' professionals' "very" or "somewhat" helpful              responses      responses ---------------------------------------------------------------------- Respect their personal privacy and the amount of information they do or do not want to share about their combat zone experience                              86%            94% ---------------------------------------------------------------------- Be available to listen or talk when the servicemember or family is ready             82%            98% ---------------------------------------------------------------------- Offer household assistance so servicemembers can focus on themselves       79%            84% ---------------------------------------------------------------------- Express appreciation for the service he/she provided to their country             77%            93% ---------------------------------------------------------------------- Extend invitations to help the servicemember and family reconnect with each other, extended family, neighbors, friends, etc.                     76%            93% ---------------------------------------------------------------------- 

While they appreciate the support, most servicemembers say that neither military families nor the community are well prepared to help them with the transition from combat duty. Only 3% of servicemembers believe that the typical military family is “very prepared” to help servicemembers transition from combat duty, and more than half believe military families are “not at all prepared” to help servicemembers adjust to post-combat life.

Mental health professionals agreed. More than 70 percent of those who have worked with post-combat servicemembers report that military families are typically not prepared to help their servicemember transition back from combat duty.

None of the servicemembers surveyed felt that friends, neighbors, co-workers, etc. were “very prepared” and only 11% felt they were “somewhat prepared” to help servicemembers adjust to post-combat life. More than 80% believe that the broader community support network is typically “not at all prepared” to help servicemembers re-integrate into society after combat.

Capella sponsors online conversation about this issue

To invite further conversation and better understanding of the mental health and re-entry issues of returning troops, Capella University has created an online public forum, joiningforcesamerica.org, where anyone can contribute ideas and suggestions. A summary report of the Joining Forces America study is also available on the site.

About the Joining Forces America study

The study was sponsored by Capella University to explore post-combat mental health and re-entry issues from the perspective of returning servicemembers and the mental health community, and to solicit ideas for what we as a society can do to make post-combat transitions smoother for returning servicemembers. Two separate but similar survey instruments were used, one for servicemembers and one for mental health professionals.

The confidential servicemember survey was conducted online between May 27 and June 4, 2008. The survey group consisted of Capella University adult students who were affiliated with the military, including active servicemembers, veterans, and their immediate family members. Combat zone experience by the individual or an immediate family member was required to participate in the survey. In total, 238 participated as servicemembers/veterans and 11 participated as family members. The sample size of the family members was too small to be statistically reliable and their results are not included in this report. For the purposes of this report, the term “servicemember” is used to report the combined responses of servicemembers and veterans.

The confidential mental health professional survey was conducted online between May 27 and June 8, 2008, among four groups: an online panel of 201 mental health professionals; 29 members of a military psychology online discussion group; 1,064 Capella University adult students and alumni who were enrolled in or graduated from an advanced degree program with a mental health, counseling, or psychology focus; and 37 Capella University psychology and counseling faculty members. The reported results include the responses of the 999 survey participants in these four groups who identified themselves as working mental health professionals.

About Capella University

Founded in 1993, Capella University is an accredited(a), fully online university that offers graduate degree programs in business, information technology, education, human services, psychology, public health, and public safety, and bachelor’s degree programs in business, information technology, and public safety. Within those areas, Capella currently offers 104 graduate and undergraduate specializations and 15 certificate programs. The online university currently serves more than 23,400 students from all 50 states and 45 countries. It is committed to providing high-caliber academic excellence and pursuing balanced business growth. Capella University is a wholly-owned subsidiary of Capella Education Company headquartered in Minneapolis. For more information, please visit www.capella.edu or call 1.888.CAPELLA (227-3552).

Learn more about Capella’s services and scholarship for military-affiliated students: http://www.capella.edu/armedforces or call 1.888.315.8001.

Learn more about Capella’s graduate programs in the fields of counseling and psychology: http://www.capella.edu/mentalhealth.

(a)Capella University is accredited by The Higher Learning Commission and a member of the North Central Association of Colleges and Schools (NCA), www.ncahlc.org.

Capella University, 225 South Sixth Street, Ninth Floor, Minneapolis, MN 55402, 1.888.CAPELLA (227.3552), www.capella.edu.

Additional Findings from Capella University’s Joining Forces America study

Top 5 pieces of advice for returning servicemembers – from their fellow servicemembers

— Be patient – with yourself, your family and others. Adjustment will take time, for all of you.

— Stay connected/keep busy – spend time with family, friends and other servicemembers

— Take care of yourself – seek professional help if needed, or at least indulge yourself in your favorite activities or some much needed time off

— Give yourself credit – remind yourself of the good that has come from your service

— Look to the future – use your experiences to create a good future; set new goals such as a degree or new career.

Selected quotes from survey respondents:

“Life appears to have changed and you no longer think that you are the same person that you were before you left. Give yourself time and you will learn to re-appreciate those things that you appreciated before you left home.” Servicemember

“Do not set your expectations too high. You have changed and so has your family. Let them in and just relax.” Servicemember

“Connect to family, friends, and professionals as soon as possible. Have the strength to ask for help– it is not a weakness.” Servicemember

“Be patient with family, friends, and others. Many civilians do not understand the experiences or emotions involved in combat and they can overwhelm an individual just returning from combat.” Servicemember

“Breathe, you’re home now. Now make everyday count and don’t take anything for granted.” Servicemember

Top 5 ways for neighbors to help a returning servicemember – according to servicemembers

— Offer support & encouragement (sometimes it helps to just listen)

— Respect my privacy (don’t push me to share my time or information if I’m not ready)

— Just say thanks

— Help me reconnect with my family and community (offer invitations, help with chores so I can spend more time with family)

— Act normally (don’t treat me too differently)

Selected quotes from survey respondents:

“(Family and friends) allowed me to ease into non-combatant life by patiently waiting for me to open up. They were not judgmental, they did not blame me for the actions and failures of war. We did not get into political discussions … They welcomed me with open arms and ears.” Servicemember

“Families and friends (need to be educated)on how to be supportive … Too often, while meaning well, family and friends say and do things that exacerbate or alienate the service member further.” Mental health professional

“Sometimes just taking the family’s children for a few hours so the servicemember and spouse can spend time alone is valuable. It’s the little things that speak volumes of genuine care and concern during periods of distress.” Mental health professional

“Try not to constantly ask questions about the experiences. It is a touchy subject. It took me two years to be able to openly speak about the things I saw in combat … However, it always feels good to hear that someone appreciates our service.” Servicemember

“Follow the veteran’s lead–if they want to talk, be there. If they want privacy, allow it and be on the fringes so they know they can approach you if they need or want to.” Servicemember

Top 5 reasons servicemembers didn’t seek assistance for mental health issues

Among servicemembers who said they returned from combat duty with some or serious mental health issues, the top reason for not seeking assistance was their fear that it would have a negative impact on their career.

  ---------------------------------------------------------------------- I was concerned that seeking mental health treatment would have a negative effect on my career.                   53% ---------------------------------------------------------------------- No help was offered to me.                                    35% ---------------------------------------------------------------------- There was no one available with combat experience who could understand what I gone through.                        29% ---------------------------------------------------------------------- I was concerned that friends, family and/or co- workers would lose respect for me                            24% ---------------------------------------------------------------------- I could not get in to see someone when I needed help/too few mental health providers in my community         18% ---------------------------------------------------------------------- 

*Note: Small sample size; based on subgroup that had mental health issues but did not seek help.

Selected quotes from survey respondents:

“I sought psychiatric help, at the beginning of which I asked the doctor whether physician-patient confidentiality protected me if I found it necessary to divulge classified information during a therapy session. The doctor advised me that I was not protected and if I divulged any classified information, he would report me immediately. Suffice it to say that I left the therapy session and never returned, even to this day.” Servicemember

“There aren’t enough mental health professionals around any military base to serve the tens of thousands of combat vets returning.”- Mental health professional

“In my opinion the therapeutic model fails precisely because servicemembers resist therapy due to stigma … I met with members in their homes or recreation areas and not an office, where even the area brings with it stigma and fear of observation.”Mental health professional

Top 3 recommendations from mental health professionals on ways to improve mental health services for servicemembers

 -- Make it easier for servicemembers to seek treatment. -- Reduce wait times and paperwork. -- Provide services at convenient places and times to allow servicemembers to seek care off the military base if they fear the stigma of seeking care through military providers. -- Offer services and support to families of servicemembers. -- Use outreach programs, marketing, and public service announcements to encourage servicemembers to seek mental health treatment or assessment.  -- Offer education and training to improve care and reduce the stigma of treatment -- Increase the number of mental health providers with knowledge of servicemember needs. -- Educate servicemembers and their families on symptoms, coping strategies, and the value of mental health treatment. -- Increase awareness among the general public about military mental health needs.  -- Advocate for better mental health care and access for servicemembers -- Encourage policymakers to increase funding. -- Advocate or support military efforts to reduce the stigma of seeking mental health treatment. 

Selected quotes from survey respondents:

“Mental health workers have seen the writing on the wall ever since September 11th that the trauma of such an event and the war declared will have devastating consequences for servicemen, women and families for years to come.” Mental health professional

“(Mental health professionals need) specific training regarding the military and post-combat issues. Also, normalize the need for mental health treatment – to the military member, their family and friends. In other words, make it clear that counseling is a normal part of the post-combat reintegration process.” Mental health professional

“Everyday” Challenges for Returning Servicemembers

  ---------------------------------------------------------------------- Percentage of servicemembers who                        Those who found this issue                          returned        Those who "somewhat" or "very"                        with          returned difficult after                           physical       with mental returning from                             health          health combat duty                  Total        problems       conditions ---------------------------------------------------------------------- Family issues                 40%            59%             61% ---------------------------------------------------------------------- Marital issues                39%            54%             69% ---------------------------------------------------------------------- Outlook on job/career         35%            54%             67% ---------------------------------------------------------------------- Clarity on future life choices                      32%            48%             65% ---------------------------------------------------------------------- Personal health/injury        28%            67%             65% ---------------------------------------------------------------------- Personal mental health        27%            46%             84% ---------------------------------------------------------------------- Finances                      25%            30%             39% ---------------------------------------------------------------------- Outlook on life               23%            35%             59% ---------------------------------------------------------------------- 

Selected quotes from survey respondents:

“I think it is difficult when a servicemember comes home to fit back in or to find his or her place in family life. People continue to change and life can never go back to the same as when the servicemember left.” – Mental health professional)

“(Returning servicemembers)are emotionally numb and traumatized, and it is extremely difficult for them to come into the ho-hum of everyday life and not go: ‘Wake up people, don’t you know I have lost my buddies, and more are dying every day??? And all you can talk about is what type of outfit you want to wear, or what we are going to have for dinner tonight?” – Mental health professional

“Family counseling is most important to help family understand and adjust to problems and concerns of the service member.” Servicemember

“When the soldier comes home, it is normal for him or her to feel like they are not part of their real family; it is also normal for them to grieve the loss of the combat family – or feel that they want to go back to combat because that is where they were comfortable.”Mental health professional

“The best medicine is listening. And when that doesn’t work, listen again.” Mental health professional

By Shanna Flowers, The Roanoke Times, Va.

Jul. 1–Doing exercises in the middle of the newly renovated YWCA pool Monday morning, Helen Kitts of Vinton was a trouper.

Every time aquatics coordinator Bernetta McGuire called out another exercise routine, Kitts, who turns 82 this month, did them effortlessly.

Until the dastardly leg kicks.

Clasping the edge of the pool, Kitts grimaced the first time as she slowly raised her right leg. She hung in and completed that set of five. Then she soldiered through the next set on her left leg.

They don’t call folks such as Kitts “The Greatest Generation” for nothing.

She was among a group of older women Monday who helped inaugurate the reopening of the therapeutic pool at the YWCA. The heated, 60-foot-by-17-foot pool is the largest aquatic outlet for the elderly and disabled in the Roanoke Valley.

It marked the first day of classes since YWCA officials closed the pool nearly two years ago. Children attending summer school at Fairview, Monterey, Fallon Park, Westside and Fishburn elementary schools will use the pool Monday through Thursday.

“We thought we’d come back,” Kitts said of herself and her classmate Fairy Kesler. Their class targets arthritis sufferers and anyone else looking for a workout easy on the joints.

Kesler, 83, chipped in, “I’m diabetic, and it’s important I exercise. It’s a nice pool, and it’s not so deep.”

With a depth of about 4 feet, the pool — in what is now called the Copenhaver Aquatic Center — is another mechanism by which the YWCA is seeking to raise its profile.

The organization, which has a women’s shelter and offers programs to help women get back on their feet, traditionally has labored in the shadow of the YMCA. The pool is one way for the YW to gain a bigger share of the spotlight.

“Our goal is to work with as many agencies — day cares, schools, camps, different shelters — to better help underserved children and adults,” McGuire said.

The 23-year-old Roanoke native has a degree in sports management from Old Dominion University. She swam competitively for 14 years as a member of the Virginia Gators and received a scholarship to Old Dominion University. She joined the YW staff in February.

Closing the YW pool in November 2006 at the building on Franklin Road and First Street in downtown Roanoke caused a mild hysteria among some of its longtime users.

Officials initially shut the pool because its heater went out. At the same time, the organization was in the midst of reinventing itself by streamlining costs, searching for new funding sources and redefining its priorities to become more relevant to the community.

Last October, the YWCA received a $50,000 gift from the Foundation for Roanoke Valley’s John and Mary Copenhaver Family Fund.

YW Executive Director Melissa Woodson said the gift earmarked $20,000 to renovate the pool facility, including purchasing a heater and repainting the ceiling, which was flaking and falling into the pool.

The pool uses a mixture of chlorine and salt, which is better for the skin, McGuire said. It also allows people with contact lenses to use the pool without discomfort, she added.

Classes are taught during the week, but the pool is available for private party rentals on Saturdays. Renters don’t have to be a YW member. Rates vary slightly, depending on the size of the group.

But Woodson said the organization tried to make the fees competitive with other pools while at the same time setting them at a rate that will sustain the pool operation.

For example, a group of 15 to 20 people using the pool for two hours will pay $100. McGuire said some other pools charge between $75 and $100 for an hour. An individual pool pass is $5, $40 for 10 passes and $70 for 20 passes. Annual memberships are also available.

Most pools have a temperature of about 82 degrees, McGuire said, but the YW pool is heated to 86 degrees.

“It’s considered a therapy pool,” she said.

The water is warm and soothing for elderly and disabled who use the pool for therapeutic purposes.

The temperature also prevents elementary students from shivering when they climb in.

“This is fabulous,” American Red Cross instructor Karol Lurch said Monday after teaching second-graders from Fairview and Fallon Park. “It’s a great teaching pool. They can get their feet on the bottom.” Kitts and Kesler participated in water exercise classes before the pool shut down in 2006. Kesler said she has swum there for 15 years. The women, who looked much younger than their ages, were proof that staying active yields benefits in the later years.

During class, Kesler stood quietly in the second row. She wore an earnest expression as she concentrated on following McGuire’s movements.

When McGuire launched into a move reminiscent of squats, Kesler made it clear that even exercise had its limits.

“I don’t want to get my hair wet,” she said out loud to no one in particular.

Later, she laughed, explaining that getting her hair wet “means I have to wash it.”

At 58, Jennifer McCraw was in the pool trying to rehabilitate after back surgery in December.

“Water’s good for you,” said the former water aerobics teacher. “It takes the pressure off.”

Shanna Flowers’ column appears Sundays, Tuesdays and Thursdays.

—–

To see more of The Roanoke Times, or to subscribe to the newspaper, go to http://www.roanoke.com/.

Copyright (c) 2008, The Roanoke Times, Va.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

By ELIZABETH SIMPSON

Sometimes the secret to losing weight is not a diet or a gym membership or a lean, mean personal trainer.

Your best allies can be the people facing you at the dinner table: your family.

They are so important in the mind of Barbara Benson, who coordinates a weight-management class at Children’s Hospital of The King’s Daughters, she requires a parent to come with youngsters enrolled in the Healthy You class.

“Sometimes there’s an attitude of ‘Here’s my child. Fix him.’ And that doesn’t work.”

Fitness instructors, too, say a commitment on the part of other family members – whether it’s a parent or a spouse or a sibling – can be the make-or-break factor in a person’s drive to become fit.

That’s because being healthy is a goal that depends not just on what you do at the gym but on the way you eat and live once you get home.

Three local families shared their experiences of making lifestyle changes together. Elderd Sauls is both partner and drill sergeant when she and her 9-year-old daughter, Shanice Morgan, go to the Greenbrier Family YMCA in Chesapeake.

“Ten minutes,” she told Shanice as the two pumped stationary bikes next to one another.

“I can’t do that much,” Shanice said.

“Yes, you can,” Elderd responded, wiping her own brow with a towel.

Sauls had known for a while that her daughter needed help losing weight, so together the single mother and her daughter joined the Y.

“She wanted to do it,” said Elderd, who’s 46. “I told her I would be there to support her.”

An instructor there hooked them up with the 10-week Healthy You weight-management class at Children’s Hospital.

They took the class together in February and March and learned about exercise and nutrition, and the different lifestyle changes they needed to make.

They started swimming together at the Y and going for walks. They cut out a lot of fast food, and Elderd began using brown rice instead of white and offering more fruit and vegetables.

Once the class was over, they began participating in the Greenbrier Family Y’s six-month follow-up program. Twice a week, they exercise together on stationary bikes and weight machines and then attend a one-hour class where they learn about health tips and different exercise strategies.

Fitness instructor Vanessa Faircloth sets up goals for each of the class members, like moving from 10 push-ups to 12, or completing a one-mile walk in ever-decreasing amounts of time, so it’s not all focused on weight loss.

Faircloth said parents aren’t required to come, but most of them do. “If the parent puts forth the effort, it encourages the kids more,” she said. “Not just exercising, but changing the way they eat.’

Benson, coordinator of the hospital’s Healthy You class, said the majority of the parents of children in the classes are also overweight.

Parents will often use euphemisms to describe their children: husky or big-boned or chunky.

“You have to look it squarely and say, ‘This is a problem,’

” Benson said.

The No. 1 mark of success? Parents who make a lifestyle change with the child.

Benson sometimes meets her class members in the lobby of the Y the first night they attend to say, “You can do this,” because gyms can be intimidating.

“They think everyone at the Y is fit, but that’s not true.”

One evening last week, Elderd and Shanice followed a biking and weight training session with a game in the Y’s Interactive Zone. They each took a yellow foam “noodle” and stood at the ready in front of two wall-sized panels with lights that blinked on and off.

When a light blinked on, they hit it with their noodles or kicked it with their feet to gain points.

Mom was getting ahead. 100, 200, 300.

“I call time out,” Shanice said.

But mom didn’t let up,

“Keep going,” she said, dodging from one end of the panel to the other with her noodle to collect more points.

And Shanice did, stretching up to hit her own noodle on a light panel.

Since the first of the year, Shanice has lost 21 pounds, her mother 15.

Does Shanice like working out with her mom?

“Sometimes. And sometimes not,” she said with a wry smile.

Her mother laughed.

“You enjoy time with your child,” she said. “You get to be healthy together.” By Elizabeth Simpson

The Virginian-Pilot

Sometimes the secret to losing weight is not a diet or a gym membership or a lean, mean personal trainer.

Your best allies can be the people facing you at the dinner table: your family.

They are so important in the mind of Barbara Benson, who coordinates a weight-management class at Children’s Hospital of The King’s Daughters, she requires a parent to come with youngsters enrolled in the “Healthy You” class.

“Sometimes there’s an attitude of ‘Here’s my child. Fix him.’ And that doesn’t work.”

Fitness instructors, too, say that a commitment on the part of other family members – whether it’s a parent or a spouse or a sibling – can be the make-or-break factor in a person’s drive to become fit.

That’s because being healthy is a goal that depends not just on what you do at the gym, but the way you eat and live once you get home.

Three local families shared their experiences of making lifestyle changes together:

—

The Lawson family:

The Gonzales family:

Elderd Sauls and Shanice Morgan:

The Gonzales family With plenty of prompting from Mom, the whole family – including daughter Jennifer, above – finally got into the act last year, exercising together and upgrading their diets. The Lawson family Michael Lawson first noticed the Carrollton gym and suggested his wife and son work out there. After shedding more than 100 pounds among them, they’re now inspiring others to lose weight. game on Making exercise fun is a key ingredient to success. Shanice Morgan, 9, jokes with her mother, Elderd Sauls, while they get ready to work out at the Greenbrier Family YMCA in Chesapeake. the program

For additional information regarding Healthy You, the CHKD weight- management program, contact Barbara Benson at (757) 668-7035 or [email protected].

weight-gain causes

* Doing activities that require little physical movement such as watching TV and playing computer and video games.

* Eating junk food frequently.

* Constant snacking.

* Too little exercise.

* Eating fast foods frequently.

* Drinking too much soda and fruit juice.

be a role model

* Make healthy selections for meals served at home, as well as when eating out.

* Choose healthy snacks and beverages.

* Make healthy food choices available.

* Keep precut vegetables, such as carrots, celery and broccoli, in plastic bags in the refrigerator.

* Keep fresh fruits available for snacks.

* Make healthy foods look appetizing.

* Serve water instead of soda, fruit juice or powdered drinks.

* Stay positive.

For additional information regarding Healthy You, the CHKD weight- management program, contact Barbara Benson at (757) 668-7035 or [email protected].

Common causes of weight gain:

Doing activities that require little physical movement such as watching TV, and playing computer and video games.

Eating junk food frequently.

Constant snacking.

Too little exercise.

Eating fast foods frequently.

Drinking too much soda and fruit juice.

Being a good role model:

Make healthy food choices for yourself and let your child know why you made those selections.

Make healthy selections for meals served at home, as well as when eating out.

Encourage the family to become involved in a healthy eating plan.

Choose healthy snacks and beverages.

Make healthy food choices available.

Keep precut vegetables, such as carrots, celery and broccoli in plastic bags in the refrigerator.

Keep fresh fruits available for snacks.

Make healthy foods look appetizing.

Serve water instead of soda, fruit juice, or powdered drinks.

Substitute non-fat ices, juice popsicles, or frozen yogurt for ice cream, cake, or cookie snacks.

Substitute skim or 1 percent milk for whole or 2 percent milk if your child is 2 years or older. Infants less than one year of age need to continue with breast feeding or infant formula.

Stay positive.

Include your children when shopping for groceries. Invite them to make healthy choices.

Read labels with your child to determine fat and calorie content.

Use positive statements to encourage your child to eat healthy.

Avoid using food as a reward or a bribe to change behaviors. Instead offer stickers, special outings.

Source: Children’s Hospital of The King’s Daughters

Family fitness tips from “Shape Up America!”

Buy toys or equipment that promote physical activity.

Select fitness-oriented gifts with the person’s skills and interests in mind.

Limit time spent watching television programs, videotapes, and playing computer games.

Use physical activity, like a trip to the ice-skating rink, as a reward rather than food.

Include grandparents, other relatives, and friends whenever possible.

Spend as much time outdoors as possible.

Schedule regular time throughout the week for physical activity.

Take turns picking an activity for the family to do as a group each week.

Start a log of daily fitness activities for each family member.

Adapt activities to suit those with special needs or preferences.

Check out parks, bike trails, hiking trails, tennis courts, swimming pools, near your home.

Rake leaves, and jump in them.

Dig and plant in the garden. Help everyone plant their own vegetables, fruits and flowers.

Chop and stack wood.

Take a long walk or jog on the beach.

Canoe or raft for an afternoon.

Take a nature hike.

Try kite flying, or miniature golf.

Go camping where you can pitch a tent, gather firewood, fish, bike, and walk.

Visit farms to pick strawberries, peaches, and apples.

Run, jog, and walk in a family treasure hunt.

Play backyard sports: basketball, softball, volleyball, and tetherball.

Take the family pet for a walk or jog.

Enter and walk in holiday parades, ethnic festivals, and charity fund raisers.

Adopt a highway, park, or beach, and keep it clean.

Enter a “Fun Run” or a “Bike-a-Thon.”

Originally published by BY ELIZABETH SIMPSON | THE VIRGINIAN-PILOT.

(c) 2008 Virginian – Pilot. Provided by ProQuest Information and Learning. All rights Reserved.

By Melissa McEver, The Brownsville Herald, Texas

Jul. 1–Doctors have received a temporary reprieve from a 10.6 percent cut in their Medicare payments that was supposed to go into effect today.

The Centers for Medicare and Medicaid Services, at the request of the Bush administration, will wait 10 days before paying any new Medicare claims, giving Congress a chance to take up the issue of Medicare payments when it resumes session next week.

Reimbursements to doctors for treating Medicare patients are scheduled to decrease automatically under a federal formula that ties doctors’ Medicare payments to the economy.

In recent years, Congress has frozen these cuts to Medicare payments at the last minute. But last week, the U.S. Senate rejected a bill that would have stopped the cuts.

Congress could still freeze those cuts retroactively after today, but regardless, these last-minute actions are only a temporary fix, said Dr. Linda Villarreal, an Edinburg internist and member of Texas Medical Association’s Legislative Council.

“These are just patches on a bigger problem … which is the archaic (Medicare) formula,” Villarreal said.

The 10-day delay in claims processing will be tough on Rio Grande Valley doctors, who rely heavily on Medicare and Medicaid payments, Villarreal said.

“When they delay payments for 10 days, you’re looking at three to four weeks of no cash flow, and that can be pretty devastating,” she said.

Dr. Lorenzo Pelly, a Brownsville internist, agreed.

“It puts a strain on physicians’ practices,” Pelly said. “And patients don’t wait, vendors don’t wait … we still have to pay our gasoline bills and everything else.”

CMS officials said the delay would help prevent any disruption in reimbursements to doctors if Congress later decides to stop the cuts.

Villarreal said she hoped Congress would take the additional time to think about the effect these sweeping cuts could have on Medicare patients, who might lose access to their doctors if they stop accepting Medicare.

“Maybe they’ll realize what our plight is, and that it’s a question of keeping our offices open,” she said.

—–

To see more of The Brownsville Herald, or to subscribe to the newspaper, go to http://www.brownsvilleherald.com.

Copyright (c) 2008, The Brownsville Herald, Texas

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Beijing has invested 29 million yuan (4.1 million U.S. dollars) in an emergency reserve of drugs and medical equipment for the Olympic Games, a leading pharmaceutical executive said on Monday.

Chen Jisheng, chairman of Beijing Pharmaceutical Co., Ltd., the sole drug and medical equipment distributor and retailer for the Olympics, said the stockpile would be kept for public health emergencies.

“The medicine we kept is mainly of common use, such as antibiotics and antidotes,” Chen said.

The amount was “enough for a moderate public incident”, but she would not provide the specific amount of the drugs.

“It’s difficult to estimate how much will be needed in a sudden emergency,” she said.

At the company’s storehouse, cordons had been put around shelves with packages of protective clothing, masks and glucose and sodium chloride solution, reminding staff those products were not for commercial distribution.

The special store was prepared at the beginning of the year, said Chen.

Emergency plans have been made to ensure the purchase and supply of medicines if the whole city ran out of supplies.

Chen said her company had reached agreements with firms in Tianjin, Shanghai and Guangzhou to transfer supplies to Beijing if needed.

“We have prepared three times the amount of medicines needed by 10,800 people in a month, which was estimated according to on the experience of previous Games,” said Dai Jianping, head of anti- doping, pharmaceuticals and public health at the Beijing Organizing Committee for the Olympic Games (BOCOG).

Meanwhile, each batch and variety of medicine went through strict safety checks and had detailed records that could be traced back in case of quality problems, said Chen.

Beijing has set up 200 medical stations covering all the Olympic venues, while more than 190 ambulances will be on standby. In addition, 22 hospitals have been designated to serve athletes, volunteers and Games staff.

By Chauvin, Alyssa Rupley, Laurel; Meyers, Katie; Johnson, Kristin; Eason, Jane

Research Corner INTRODUCTION

In today’s medical system, limited resources are available for patient care. For this reason, it is important to evaluate the outcomes of various interventions to ensure that patients are receiving the most efficient and best available care. Recently, clinicians and payers are recognizing that physiological measures do not necessarily relate to function, and functional outcomes need to be measured independently.1-3 Measuring health related quality of life (HRQL) is one method of evaluating functional outcomes. HRQL is commonly assessed through self or interviewer administered questionnaires, and may be discriminative (evaluating cross- sectional differences between patients at a single point in time) or evaluative (measuring longitudinal changes within patients over a period of time).1 For a HRQL instrument to be effective and useful it must be valid, reliable, responsive, and interpretable.4 In general, disease specific measures of HRQL are more responsive than generic tools and may have more face validity to both the patient and clinician.1-5

The Chronic Respiratory Disease Questionnaire (CRQ) is the most commonly used disease specific measurement tool to assess HRQL in patients with chronic respiratory disease.5 The developers suggest that this tool be used to evaluate the effects of treatment in clinical trials as well as in clinical practice.2 As it is so widely used, it is important to understand the psychometric properties of this tool in order to truly understand its effectiveness and practical application. This paper describes the current research regarding the reliability, validity, responsiveness, minimally clinical important difference, and suggested use of the Chronic Respiratory Disease Questionnaire in clinical practice.

DEVELOPMENT OF THE CRQ

The original version of the CRQ was developed in 1987 by Guyatt et al2 and followed Kirshner and Guyatt’s 7 principles of questionnaire development.6 Items believed to be important to patients with chronic respiratory disease were selected through a process that included reviewing the current literature, consulting with clinical respiratory specialists, and interviewing patients.2 Subsequent item-selectionquestionnaires and patient interviews were completed. Based on these interviews, items were rated on their importance and grouped into 1 of 4 categories: dyspnea, fatigue, emotional function, and mastery, or a feeling of control over the disease. Items within the dyspnea domain varied extensively, so the developers of the tool individualized this section, requesting patients to determine the 5 most important activities in their life that are affected by dyspnea. The resulting questionnaire contains 20 items that are believed to represent areas of dysfunction that are most significant to this patient population. All questions were pretested to finalize structure and wording. Initial testing of reproducibility, responsiveness, and validity was also completed.

Subsequent versions of the test have been developed to improve time and ease of administration. All subsequent versions were developed in coordination with the original author,7,8 and psychometric properties were evaluated and compared to the original CRQ. According to the office of the developer (written communication, October, 2007) there are currently 4 different formats of the CRQ available for clinical use: the original interviewer administered CRQ, an interviewer administered CRQ with a standardized dyspnea domain (CRQ-IAS), a self-administered CRQ with a standardized dyspnea domain (CRQ-SAS), and the self-administered CRQ with an individualized dyspnea domain (CRQ-SAI). The use of any format of the CRQ does require a license agreement.

INTENDED POPULATION

The CRQ was developed to assess quality of life in patients with chronic respiratory disease, including COPD of longer than 3 months and other disease processes that lead to chronic airflow limitations.2 Airflow limitation is defined as FEV^sub 1^ less than 80% of predicted value and FVC less than 70% of predicted value,9 though typical patients measured with this tool tend to have FEV^sub 1^ between 40% and 65% of predicted value and FEV/FVC ratios less than 60% of predicted value.3-10 The age of the targeted patient population varies, but typically patients with chronic respiratory disease are older. In studies of the CRQ, mean patient age has typically been reported around 67 years;3,11,12 however, patients as young as 35 have been studied.13 The patient population targeted by this test typically experiences pulmonary symptoms, such as shortness of breath (SOB) and fatigue, with mild physical activity.3

TEST ADMINISTRATION

The CRQ is valuable as a HRQL tool because it incorporates patient perceptions of both physical and emotional health.2 Four aspects of HRQL are evaluated: dyspnea, fatigue, emotional function, and mastery. Each domain includes 4 to 7 items, with each item graded on 7-point Likert scale; item scores within a domain are summated to provide a total score for each domain.2-14-15 Higher scores indicate better HRQL. The 4 domains are scored separately and can illustrate changes in individual domains of HRQL.16 The developers do not recommend using a full test score as a means of comparison.

The original interviewer administered CRQ requires 20 to 25 minutes for the first administration and 10 to 15 minutes for each follow up visit.217 The time required for administration is thought to be a major disadvantage to the CRQ.7 In the individualized dyspnea domain, the interviewer guides the patient to elicit the 5 most important activities during which they have experienced SOB in the past 2 weeks. The patient is prompted with a list of 25 common activities such as “taking care of your basic needs (bathing, showering, eating, or dressing)” if they cannot identify 5 on their own.2 The remaining 3 domains are all standardized. According to the office of the developer, (written communication, October, 2007) using the CRQ-IAS, in which the dyspnea section is also standardized, reduces the administration time to 8 minutes.

The self administered CRQ is a written version of the tool that the patient completes independently; the wording, content, structure and scoring are exactly consistent with the original version.7,8 The office of the developer reported that the self administered CRQ significantly decreased the time taken to complete the questionnaire (written communication, October, 2007). Furthermore, with a standardized dyspnea scale, the time to complete the questionnaire ranged from 5 to 8 minutes.7

RELIABILITY

In order for a test to be useful in the clinic, the instrument must be consistent in its measurements. Reliability, or reproducibility, can be determined in 3 ways: intra-rater, inter- rater, and test-retest.18 The evidence has generally shown the CRQ to be a reliable and reproducible tool for measuring HRQL; however, only test-retest reliability has been addressed; intra-rater and inter-rater reliability were not discussed in the available literature.

Test-retest reliability of the CRQ has been found to be high. Guyatt et al2 the authors of the CRQ, established the test-retest reliability of the tool prior to its release. They administered the questionnaire 6 times in a 2-week interval to 25 patients with stable COPD. They found that mean scores were similar in all 4 domains over all administrations, and there did not appear to be a tendency for either improvement or decline. The coefficients of variation were reported as 6% for the dyspnea domain, 9% for fatigue and emotional function domains, and 12% for mastery domain. From these results, the researchers concluded that the CRQ has excellent reliability. Martin11 found high test-retest reliability for only 3 of the 4 domains of the CRQ. Pearson correlation coefficients were used to determine consistency over time of both individual item scores and domain total scores. High reliability was found for the domains of dyspnea, mastery, and emotional functioning with scores as follows: dyspnea (r =0.90); emotional function (r =0.84); and mastery (r =0.68). The fatigue domain was not found to be reliable and had an insignificant correlation (r = 0.20). Individual item scores were examined using the Kendall tau correlation coefficient. In the dyspnea and mastery domains, only one item was found to lack significant correlation over time. In the emotional function domain, 2 of the 7 items were found to lack significant correlation. In the fatigue domain, which was not reliable as a whole, 3 of the 4 individual items showed insignificant correlation. Harper et al13 also examined CRQ measurements in clinically stable patients over time. He found no evidence of bias in either the initial 6 month period or a second 6 month period. Lower correlation scores were noted in the second 6 month period; however, they were not significant enough to indicate that bias existed between assessments. Wijkstra et al10 used the Spearman-Brown reliability coefficient (p) to determine test-retest reliability with rho >0.7 considered reliable. The researchers found that the domains of fatigue, mastery, and emotional function produced high test-retest reliability scores, ranging from rho = 0.90-0.93; whereas, the dyspnea domain produced a moderate test-retest reliability score of rho = 0.73. Many studies reported internal consistency of the questionnaire to be high over all domains3,9,13,19 with Cronbach’s alpha coefficients ranging from 0.64 to 0.94. Wijkstra et al10 found that the internal consistency of the dyspnea domain to be much lower than the other 3. Internal consistency was determined using Cronbach’s alpha with a significance level set at alpha= 0.7. Scores were reported as ranging from alpha = 0.71 to alpha = 0.88 over 2 administrations for the fatigue, emotion, and mastery domains. The internal consistency of the dyspnea domain was reported as alpha = 0.51 and alpha = 0.53 for the first and second administrations, respectively, indicating a low internal consistency most likely due to the individualized aspect of this domain. Harper et al13 directly contradicted this finding by reporting that “the internal consistency of the dyspnea domain was as high as that of the other domains of the CRQ.”13

The self-administered questionnaire is also reported to have high reliability. Williams et al7 examined both the short term and long term test-retest reliability of the self-reported version and found that there was no statistically significant and/or clinically important difference in either the short or long term reliability between the two administrations of the questionnaire in any of the 4 domains. ICCs of short term reliability ranged from 0.83-0.95 and ICCs of 0.83 – 0.90 were reported for long term test-retest reliability.7

Available literature has repeatedly illustrated the ability of the CRQ to generate results that are reproducible in a variety of settings. This degree of test-retest reliability has been shown for both the individualized and standardized forms of the CRQ. The limited availability of literature regarding intra-rater and inter- rater reliability indicates the need for further research in these areas.

VALIDITY

In order for a questionnaire to be considered practical, it must assess what it claims to measure. The evidence has shown that the CRQ is a valid tool to assess health related quality of life in patients with chronic respiratory disease. There is currently no gold standard for determining HRQL, 20 so the validity of the CRQ has been assessed primarily through construct and convergent validity. Construct validity refers to an instrument’s ability to measure the constructs, or abstract concepts, that it intends to measure.18 Construct validity is supported when convergent validity is present, ie, when significantly correlated results are obtained by instruments that are believed to measure the same underlying constructs. Construct validity was maximized during the original development of the questionnaire by using a multistep process to determine and incorporate the significant aspects of HRQL that are affected by pulmonary disease.2 It was determined that the constructs of dyspnea, emotion, mastery, and fatigue encompassed the key aspects of HRQL in this population.2

To determine convergent validity, the CRQ was compared with various other tools that measure HRQL. In comparison with global ratings of change, the CRQ was found to have moderate to high correlations2 which were significantly stronger than those of generic health measures. Guyatt et al21 determined that the CRQ dyspnea domain had a correlation of 0.61 with the global rating of dyspnea, while the fatigue domain had a correlation of 0.53 with the global rating of emotions. Both the mastery and emotional domains were found to be moderately correlated with the global rating of dyspnea with r values of 0.57 and 0.46 respectively. Guyatt et al2 reported that each of the CRQ domains was more closely correlated to the Transitional Dyspnea Index (TDI) than any other HRQL instrument that was studied. Functional measures were also well correlated with CRQ change scores. Singh et al5 reported improvements in the treadmill endurance test were correlated to improvements in the CRQ total score and improvements in the domain scores of dyspnea, fatigue, and mastery. Fatigue domain scores also improved as shuttle walk test scores improved. Six minute walk test scores, however, were found to be only weakly correlated with all domains of the CRQ.21

Many studies have examined the correlation between CRQ scores and the physiologic factors believed to contribute to dysfunction in patients with pulmonary disease. The majority of physiologic factors, including FVC, FEV^sub 1^, FEV/FVC and pack years, were found to have weak or no correlation with CRQ scores;9,19,22 however, Hajiro et al19 found the dyspnea domain to be significantly correlated with FVC (r=0.25) and Shawn et al14 found moderate correlation with FEV^sub 1^. Guyatt20 completed a study focusing solely on the dyspnea domain and found a stronger correlation with “spirometry, walk test scores, dyspnea following the walk test, and global ratings of dyspnea than either the oxygen cost diagram or the medical research council dyspnea questionnaire.” The author concluded that these results suggest the CRQ is more valid than other instruments in assessing the extent of dyspnea during activities of daily life. With the domains of emotion and mastery, the CRQ places a strong emphasis on psychologic status as a component of HRQL. Hajiro et al9 examined this construct and found that anxiety has a higher coefficient of determination in the CRQ than in other measures (CRQ R^sup 2^ =0.22, SCRQ R^sup 2^ = 0.13).

The most common HRQL tool studied against the CRQ was the St. George’s Respiratory Questionnaire (SGRQ). Many studies found strong correlations between the change in scores of the CRQ and the SGRQ. Correlations of 0.72, 0.74, -0.63, and 0.88 have been reported.3,9,19,23 Hajiro et al9 also found strong correlations between the CRQ and the Breathing Problems Questionnaire (BPQ) (r=0.75). The CRQ also correlates well with generic measures. Wijkstra10 determined that significant correlations exist between the CRQ fatigue domain and the depression and somatisation domain of the Symptom Checklist 90 (SCL-90). Other domains of the CRQ including emotion and mastery significantly correlated with somatisation, anxiety, and depression domains of the SCL-90. Tsukino et al22 found the CRQ to be significantly correlated with the Nottingham Health Profile (NHP) with correlations ranging from 0.42 to 0.67. However, correlations between the CRQ and other specific measures of pulmonary disease were found to be significantly higher than correlations with generic measures.21

With the development of the self-administered CRQ, validity of the newer instrument was established by comparing it to the gold standard of the original version. Validity was determined to be strong; no statistically significant difference between the 2 instruments was found in the fatigue and mastery domains, and the small mean differences found in the dyspnea (0.36, p=.006) and emotional domains (0.22, p=0.04) were clinically insignificant. Although the authors determined that the self-administered version of the CRQ perceives analogous levels of mastery, emotional function, and fatigue, they state that the different versions of the test should not be used interchangeably.7 The self-administered version of the test was also compared to the SGRQ and generic measures of health status in a study by Schunemann et al,8 and moderate to high correlations were found both cross- sectionally and longitudinally with change scores.

The validity of the CRQ is strengthened by the study performed by Shawn et al14 which found statistically significant differences in CRQ scores between patients who had a relapse of their pulmonary condition and those who did not. Further, Harper et al13 reported that CRQ scores remained stable over time in clinically stable patients while CRQ scores improved in patients who were expected to have clinical improvements. There was good agreement between the predicted and actual correlations in both these cases. In a study by Redelmeier et al,24 CRQ score differences were also found to be moderately correlated with subjective comparison ratings made by patients regarding themselves and others.

The evidence has shown the CRQ to be a valid test of HRQL, with moderate to strong correlations with global ratings as well as both generic and disease specific convergent measures. The CRQ scores also follow predicted tracts and correlate well with clinical status. The fact that correlations with physiologic measures are not strong suggests that HRQL instruments such as the CRQ may provide additional information that should be used alongside physiologic tests in determining the health status of a patient.

RESPONSIVENESS

Another important characteristic of an assessment tool is its ability to detect change. Knowledge of an outcome measure’s sensitivity to change is crucial. When less responsive tools are used, it is likely that the treatment effects can be underestimated. The CRQ has been consistently shown to be one of the most responsive tools in measuring pulmonary HRQL and is able to detect small changes in HRQL reported by patients.15The high sensitivity of the CRQ is attributed to the ability to assess impairments outside pulmonary symptoms.23 In the initial psychometric evaluation of the CRQ, Guyatt et al2 performed 2 separate responsiveness studies to ensure the tool’s sensitivity. In both studies, the CRQ was used to evaluate patients who were predicted to improve with initiation or modification of treatment. In the first assessment, the tool was administered to 13 patients all diagnosed with chronic lung disease and the patients were then reassessed 2 to 6 weeks later after treatment had been initiated. The developers found that the CRQ scores at the follow-up assessment were, to a large extent, better than at the initial distribution of the questionnaire, even though spirometry values were only slightly improved. This indicates that the CRQ was able to detect the change in patient condition that occurred with treatment. In the second responsiveness assessment, the developers administered the CRQ in conjunction with other questionnaires. Twenty-eight patients with chronic lung disease received initial and follow-up questionnaires 2 weeks later after treatment had been initiated. Again, considerable improvements in the scores were seen in all domains of the original version. Cuyatt’s study illustrates that the CRQ has adequate responsiveness to detect highly significant differences, even within small numbers of subjects. Many studies have compared the responsiveness of the CRQ to that of other measures of HRQL. Consistently, the CRQ has been shown to be more responsive than other measures. Guyatt et al2 found that the CRQ has similar responsiveness to the Transitional Dyspnea Index and superior responsiveness to the Rand dyspnea questionnaire, the oxygen cost diagram, and the Rand physical and emotional function questionnaires. When compared to other tests, such as the Nottingham Health Profile (NHP)22 and the St. George’s Respiratory Questionnaire (SGRQ),9,23,25 the CRQ was found to be more sensitive in detecting change. In fact, Guyatt et al20 demonstrated that the dyspnea domain of the CRQ was the only HRQL instrument that showed statistically significant responsiveness when tested over 2 known interventions in reducing dyspnea in day-to-day activities. Rutten-van Molken et al3 found that both the SGRQ and the CRQ were statistically significant in detecting changes within subjects; however, the CRQ was able to detect changes in the health status of the patient that the SGRQ could not pick up. The total domain and the emotion domain scores were determined to be the most responsive to these changes. Puhan et al12 used standardized response means (SRMs) to assess the responsiveness of the CRQ opposed to the t-test because it is independent of sample size. In comparison to the other domains, the dyspnea domain had larger SRMs indicating that this individual dyspnea domain was more responsive than the other domains, and the standardized dyspnea domain was determined to be more responsive than the preference-based and generic tools that were also assessed in the study.

The CRQ was also evaluated to determine if it could detect short- term changes in dyspnea following an acute exacerbation of COPD. Aaron et al14 used the responsiveness statistic to assess the sensitivity. If the score is > 1.5, a tool is considered highly responsive.14 Analysis of the data revealed the following results: 2.2 for dyspnea, 4.1 for fatigue, 2.5 for emotion, and 4.2 for mastery. From these results, the researchers concluded that the CRQ was responsive across all domains for detecting short-term changes.

The self-administered CRQ is shown to have more sensitivity when compared to the interviewer-administered CRQ, most likely due to lower baseline scores for the CRQ-SR. These lower baseline scores and greater sensitivity of the self-report questionnaire can be attributed to the fact that patients are more likely to report the severity of the impairment when asked to fill out the questionnaire in private, as opposed to being asked by the interviewer. Williams et al25 used standardized response means to assess the sensitivity and also found the CRQ-SR to be highly sensitive across all domains of the questionnaire indicating that it is able to detect changes following a treatment program. Schunemann et al8 performed a similar procedure using a t-test to determine the responsiveness of the CRQ- SR by comparing it to the CRQ-IL. They also found that the baseline scores for the self-reported test were significantly lower across all domains than for the interviewer-administered questionnaire. Following treatment, CRQ-SA change scores tended to be larger than CRQ-IA scores, however, these differences were not found to be statistically significant.

MINIMALLY CLINICALLY IMPORTANT DIFFERENCE

In the clinic, it is not only necessary to measure outcomes of treatment regarding the intervention process, but it is also essential to measure the extent to which the patient feels the treatment has influenced their condition and quality of life. Minimally clinically important difference (MCID) is a resource available to gauge if a patient deems intervention effective or not. The MCID is defined as “the smallest difference in a score in a domain of interest that patients perceive as beneficial and that would mandate, in the absence of side-effects, a change in the patient’s management.”27 In health care especially, the MCID is imperative to recognize, because the goal of most medical treatment is to improve a patient’s quality of life, alleviate their symptoms, and improve their functional status.15 The only way to determine if the work of health care professionals is valuable to the patient is to determine measurements such as the MCID. This property can also aid researchers when gathering resources to conduct studies by enabling them to calculate appropriate sample sizes. Other useful means of the measure are interpreting studies that show significant findings and improvement of expressing results.24

Jaeschke et al28 established a report using data from three separate studies to determine the MCID of the CRQ by comparing it to global ratings of change (CROC). The 3 studies included: 31 patients participating in an inpatient pulmonary rehabilitation program, a trial examining effects of inhaled salbutamol and oral theophylline in 24 patients, and a trial of digoxin in 20 patients with heart failure. After their second visit, patients from each study were asked to report global ratings of change in shortness of breath on daily activities, level of fatigue, and emotional status. Responses were based on a 7-point Likert scale ranging from 7, “a very great deal worse,” to a 1, which was “almost the same, hardly any worse at all” and these CROC responses were compared to change in scores of the CRQ. The MCID of the CRQ was consistently around 0.5 per question with a 0.43 on the dyspnea domain, 0.64 for fatigue, and 0.49 for emotional function. A mean change per question of 0.81 to 0.96 indicates a moderate effect and a large effect is indicated by a change of 0.86 to 1.47 per question.

Redelmeier et al24 conducted a study using the CRQ to determine if a new method they developed to estimate the MCID compared to the MCID results of the traditional method. The conventional method of determining the MCID relies on the patient’s report as to the degree of change they have experienced in comparison to themselves; whereas, the method by Redelmeier et al24 requires the patient to report the status of their condition in comparison to other patients with the same condition. One hundred twelve patients participated in the study. Considering all of the domains with the exception of the Dyspnea scale, the MCID for the CRQ was found to be 0.53 per question. When all 4 of the domains were included, the MCID was 0.42 per question. The researchers estimated that on average, scores on the CRQ needed to change by about 0.5 per question for the patient to determine an important difference. This is consistent with the MCID reported by Jaeschke et al28 using the conventional approach. Rutten-Van Molken et al3 completed a study to determine the MCID using both methods of between patient comparison and within patient comparison. He also found that the MCID correlated with a change of 0.5 per item score.

Wyrwich et al15 used triangulation methods to identify clinically important differences based on both patient and primary care provider (PCP) perceived differences. The study considered the opinions of an expert panel of physicians, patients with COPD, and their primary care physicians (PCPs). Patients were administered the CRQ before pulmonary rehab and again every 2 months after baseline. The PCPs assessed the patients at baseline and at all follow-up visits throughout the year. They were also contacted following each office visit. The researchers found that according to the patient, a 1-2 point decrease in a specific domain score of the CRQ reflected small declines in HRQL, and that according to both patients and PCPs, a 1-5 point increase on the domain scores of the CRQ reflected a small, but clinically important improvement in HRQL. The expert panel recommended that MCID be associated with a change greater than 2 points in the domain score. In general, patient determined clinically important differences were associated with smaller changes in CRQ domain scores than those determined by the expert panel and PCPs. Results of the study reflected a disagreement between patients, primary care physicians, and experts’ opinions of clinically important change in individual patients.

Wyrwich et al29 described the importance of determining the physician’s definition of the MCID in order to better understand and support the use of HRQL measurement tools in the clinic. A 9 person expert panel was created to attempt to determine the MCID from the physician’s point of view regarding the CRQ and SF-36 HRQL outcome tools. Using 2 rounds of the Delphi method, one in person meeting and a repetitive enhancement process for circulating and correcting the final report, they were able to determine the values of change for each domain that would result in a small, moderate, and large MCID. The following results were reported: for the dyspnea domain, which contains 5 items, 3,6, and 9 point changes in the scores indicate a small, moderate, and large change respectively; for the fatigue domain, which contains 4 items, 2, 4, and 6 point changes in the scores indicate a small, moderate, and large change respectively; for the emotional function domain, which has 7 items, 5, 10, and 15 point changes in the scores indicate a small, moderate, and large change respectively; and finally for the mastery domain, which has 4 items, 3, 6, and 9 point changes in the scores indicate a small, moderate, and large change respectively. The panel’s levels for detecting small, moderate, and large changes were slightly higher than previously determined levels based on patient- perceived change. SUGGESTED USE

The developers suggest that the CRQ be used both in clinical research and in clinical practice to monitor changes in HRQL in patients with chronic respiratory disease. In order to ensure that reliability across clinics is preserved, the health care profession should come to an agreement on the process of administration. Important considerations for questionnaires such as CRQ include the ease and cost of administration. The CRQ requires a licensing agreement as well as a significant time commitment for administration. The newer version of the CRQ, the self administered standardized CRQ-SAS, reduces the need for resources and time in the clinic.8 The interview administered CRQ may take as long as 30 minutes to complete for the initial interview, while the CRQ-SAS takes only 5 to 10 minutes and can be given to the patient to do at home. This may also increase the chances of the patient answering more honestly.26 Another aspect to consider is that 3 months of treatment, which is often typical in clinical situations, may not be sufficient time for patients with COPD to recognize an improvement or decline in their condition. Also, in this specific patient population, improvements in breathlessness or exercise tolerance may not be noticed since these patients are accustomed to avoiding activities that stimulate these symptoms. This may be a factor to consider when administering the CRQ.3

Current evidence suggests that the CRQ is one of the instruments of choice to measure HRQL in patients with COPD and that condition specific questionnaires such as the CRQ are very feasible for use in an outpatient setting. It is known that mortality risk is not associated with the CRQ,30 however, CRQ change scores associated with clinically important differences may be used to highlight significant changes in function and HRQL. These changes might be missed if physiological measures are used alone. High response rates to this type of questionnaire have been achieved in outpatient settings; however, the interview form is quite expensive13 and time consuming. It is recommended that both general and condition specific HRQL questionnaires be administered alongside physiologic tests since each of these contribute unique information regarding disease state and quality of life.22

CONCLUSION

The Chronic Respiratory Disease Questionnaire has been supported in the evidence to be one of the most optimal instruments to measure HRQL in patients with chronic respiratory disease. It has high internal consistency and test-retest reliability, as well as moderate to strong construct and convergent validity. It correlates well with other disease specific and generic measures of HRQL as well as with global ratings of change. It is not strongly correlated with physiologic measures related to dyspnea, indicating the need to administer HRQL tools alongside physiologic measures in order to gain the full picture of the patient’s disease state. The CRQ exhibits responsiveness that is as good or superior to all other measures looked at, and it is able to detect significant differences even in small populations. This is most likely due to the fact that it includes domains of both physical and emotional health. Patient determined minimal clinically important differences typically are associated with smaller change scores than physician or expert determined MCIDs, but in general small clinically important changes are associated with score differences of 0.5 per item.

In the clinic, the CRQ should be used alongside physiologic tests and generic measures of health related quality of life to provide a complete picture of the patient’s health status. Limitations to its use in the clinic might include cost and the time required for administration. The self-administered version may assist with the latter as it is associated with greatly decreased administration time. This review has found that until a gold standard of HRQL assessment is developed, the CRQ is an optimal tool to utilize in determining HRQL in patients with chronic respiratory disease.

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Alyssa Chauvin, SPT, BS; Laurel Rupley, SPT, BS; Katie Meyers, SPT, BS; Kristin Johnson, SPT, BS; Jane Eason, PT, PhD

Department of Physical Therapy, Louisiana State University Health Sciences Center, New Orleans, LA

Address correspondence to: Jane Eason, LSUHSC, Department of Physical Therapy, 1900 Gravier Street, New Orleans, LA 701 U Ph: 504- 568-4288 (jeason@lsuhsc. edu).

Copyright Cardiopulmonary Physical Therapy Journal Jun 2008

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