Volume 5, Issue 11

ISSN 1942-9673

Volume 5, Issue 11

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Editor-In-Chief Volume 5, Issue 11

Dr. Danka Radulovic, University of Belgrade, Serbia

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Editor’s Message I am glad to present Volume 5, Issue 11 of the International Journal of Social Health Information Management (IJSHIM). The papers offer great intellectual contributions and epitomize our focus on broadening intellectual resources, understanding, development and exchange of ideas among global research professionals. The goal of the International Journal of Social Health Information Management (IJSHIM) is to provide contemporary information to the business, government, and academic communities by helping to promote the interdisciplinary exchange of ideas on a global scale. IJSHIM seeks international input in all aspects of the Journal, including content, authorship of papers, readership, paper reviews, and Executive Editorial Board Membership.

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Reviewers Task Panel and Executive Editorial Board

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Dr. Robin Latimer Dr. Reza Vaghefi Lamar University, USA University of North Florida, USA Dr. William Root Dr. Jeffrey Siekpe Augusta State University, USA Tennessee State University, USA Dr. Michael Alexander Dr. Greg Gibbs University of Arkansas at Monticello, USA St. Bonaventure University, USA Dr. Kehinde Alebiosu Dr. Mike Rippy Olabisi Onabanjo University, Nigeria Troy University, USA Dr. Gina Pipoli de Azambuja Dr. Steven Watts Universidad de Pacifico, Peru Pepperdine University, USA Dr. Andy Ju An Wang Dr. Ada Anyamene Southern Polytechnic State University, USA Nnamdi Azikiwe University, Nigeria Ms. Alison Duggins Dr. Nancy Miller Vanderbilt University, USA Governors State University, USA Dr. Dobrivoje Radovanovic Dr. David F. Summers University of Belgrade, Serbia University of Houston-Victoria, USA Dr. George Romeo Dr. Robert Kitahara Rowan University, USA Troy University – Southeast Region, USA Dr. Natalie Weathers Dr. Brandon Hamilton Philadelphia University, USA Hamilton's Solutions, USA Dr. Linwei Niu Dr. William Cheng Claflin University, USA Troy University, USA Dr. Nesa L’Abbe Wu Dr. Taida Kelly Eastern Michigan University, USA Governors State University, USA Dr. Shahrina Mohd Nordin Dr. Denise de la Rosa Universiti Technologi PETRONAS, Malaysia Grand Valley State University, USA Dr. Kathleen Quinn Dr. Kimberly Johnson Louisiana State University, USA Auburn University Montgomery, USA Dr. Josephine Ebomoyi Dr. Sameer Vaidya Northwestern Memorial Hospital, USA Texas Wesleyan University, USA Dr. Douglas Main Dr. Pamela Guimond Eastern New Mexico University, USA Governors State University, USA Dr. Sonya Webb Dr. Vivian Kirby Montgomery Public Schools, USA Kennesaw State University, USA

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Dr. Jay Sexton Dr. Kiattisak Phongkusolchit Tennessee State University, USA University of Tennessee at Martin, USA Ms. Lauren Colline Razzore Dr. Yvette Bolen William Paterson University, USA Athens State University, USA Dr. Frank Elston Dr. Chrisila Pettey Metropolitan State College of Denver, USA Middle Tennessee State University, USA Dr. Barbara Fralinger Dr. Catherine Matos Rowan University, USA Clayton State University, USA Dr. José Villacís González Dr. Sue-Jen Lin University San Pablo-CEU, Spain I-Shou University, Taiwan Dr. Yajni Warnapala Dr. Zulkipli Ghazali Roger Williams University, USA Universiti Teknologi PETRONAS, Malaysia Dr. Zufni Yehiya Dr. Rena Ellzy Tree Foundation, London, USA Tennessee State University, USA Dr. Reza Shafiezadehgarousi Dr. Wendy Cowan Azad University, Iran Athens State University, USA Mrs. Ghada Mahdi Dr. Ron Sardessai University of South Dakota, USA University of Houston-Victoria, USA Dr. Ralph Butler Dr. Jasmin Hyunju Kwon Middle Tennessee State University, USA Middle Tennessee State University, USA Dr. Jakir Hossen Dr. Ronald Mano Multimedia University, Malaysia Weber State University, USA Dr. William Howard Kazarian Dr. David Hansen Hawaii Pacific University, USA Texas Southern University, USA Mr. David Battista Dr. Nan Chuan Chen Kennesaw State University, USA Meiho institute of Technology, Taiwan Dr. Juss Eyanson Dr. Edgar Ferrer Azusa Pacific University, USA Turabo University, USA Dr. Marisra Baramichai Dr. Jose Gerardo Martinez Martinez University of the Thai Chamber of Commerce, Thailand Universidad de Puerto Rico, USA Dr. Frank Tsui Dr. Jeffrey Campbell Southern Polytechnic State University, USA Stephen F. Austin State University, USA Dr. Hetal Jasani Dr. Mary Hudachek-Buswell Northern Kentucky University, USA Clayton State University, USA Reviewers Task Panel and Executive Editorial Board (Continued)

Dr. Lee Pickler Dr. Carl Pfaffenberg Nova Southeastern University, USA University of Tennessee, USA Dr. Michael Jones Dr. Laura Hansen-Brown University of Wollongong, Australia Webster University, USA Dr. Mohammed Halib Dr. Penn Wu Universiti Teknologi PETRONAS, Malaysia Cypress College, USA Dr. Jiekwan Kim Dr. Reed Geertsen Changwon National University, Korea Utah State University, USA Dr. Youngjin Park Dr. Francis Daniel Inpack Global Inc., Korea Tennessee State University, USA Dr. Scott Norman Dr. Gulshan Kumar Azusa Pacific University, USA Global B-School, India Dr. Christopher Brown Mr. Fong-Woon Lai University of North Florida, USA Universiti Teknologi PETRONAS, Malaysia Dr. Norma Ortiz Dr. Arthur Shriberg University of Puerto Rico-Mayagüez Campus, USA Xavier University, USA Dr. Carol Costello Dr. Tanti Irawati Muchlis University of Tennessee, USA Widyatama University, Indonesia Dr. Manfred Maute Dr. Ramon Gomez York University, Canada Florida International University, USA Dr. Agnes Gathumbi Dr. Retta Guy Kenyatta University, Kenya Tennessee State University, USA Dr. Joseph Armour Dr. Ruben Gely University of Houston – Victoria, USA International Insurance Center – Puerto Rico, USA Dr. Marcelline Fusilier Dr. Gary Clark Northwestern State University of Louisiana, USA Saginaw Valley State University, USA Dr. Chunxing Fan Dr. Ronald Salazar Tennessee State University, USA University of Houston- Victoria, USA Mr. Andrew Leidner Dr. Valbona Bejleri Texas A&M University - College Station, USA University of the District of Columbia, USA Dr. Michael Lau Dr. Madison Holloway Sam Houston State University, USA Metropolitan State College of Denver, USA Dr. Jack Elson Dr. Jun Yang TUI University, USA The University of Mississippi, USA

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Dr. Siva Somasundaram Dr. Medha Talpade University of Houston-Victoria, USA Clark Atlanta University, USA Dr. Tiffany Jordan Prof. Lana Brackett Nova University, USA Roger Williams University, USA Dr. M. N. Tripathi Dr. Kelly Waters Xavier Institute of Management – Bhubaneswar, India University of South Carolina Upstate, USA Dr. Marcia Lamkin Dr. Mark Crowley University of North Florida, USA Bridgewater State College, USA Dr. Jason Caudill Dr. L. Murphy Smith Carson-Newman College, USA Murray State University, USA Dr. Yuxia Zhao Dr. Carrie Hurst Shandong Administration Institute, China Tennessee State University, USA Dr. Katherine Taken Smith Dr. Vojko Potocan Murray State University, USA University of Maribor, Slovenia Mr. Jesse Cox Dr. Richard Douglass Metropolitan State College of Denver, USA Eastern Michigan University, USA and Ashesi University, Ghana

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TABLE OF CONTENT

MEDICAL IDENTITY THEFT: CONSEQUENCES, FREQUENCY, AND THE IMPLICATION OF ELECTRONIC HEALTH RECORDS AND DATA BREACHES Chlotia P. Garrison and O. Guy Posey ...... 1

MULTICULTURAL MARKETING AND CONSUMER WELL-BEING IN UNDERSERVED HISPANIC NEIGHBORHOODS Ruth Chavez, Madison Holloway and Rocio Perez ...... 18

ETHNIC DIFFERENCES IN THE NUTRITIONAL STATUS OF NIGERIAN RURAL HAUSA AND YORUBA SCHOOL-AGE CHILDREN AND THE ROLE OF BIO- FORTIFICATION TO ALLEVIATE PROTEIN ENERGY MALNUTRITION E. William Ebomoyi and Josephine I Ebomoyi ...... 32

DIABETES: AN EDUCATIONAL OPPORTUNITY Anita King and Maureen Biggs ...... 45

EFFECTS OF A TEN-WEEK COLLEGE-BASED PHYSICAL ACTIVITY PROGRAM ON FOUR HEALTH-RELATED FITNESS COMPONENTS Abdelhadi Halawa ...... 53

ELECTRONIC COMMUNICATIONS AND UNINTENTIONAL SEXUAL HARASSMENT Keith T. Crowe and Madison Holloway ...... 63

C. P. Garrison and O. G. Posey IJSHIM - Volume 5, Issue 11 (2012), pp. 1-17

Full Article Available Online at: Intellectbase and EBSCOhost │ IJSHIM is indexed with Cabell’s, JournalSeek, etc.

International Journal of Social Health Information Management

MEDICAL IDENTITY THEFT: CONSEQUENCES, FREQUENCY, AND THE IMPLICATION OF ELECTRONIC HEALTH RECORDS AND DATA BREACHES

Chlotia P. Garrison1 and O. Guy Posey2 1Winthrop University, USA and 2Alabama A&M University, USA

ABSTRACT hile much attention and research has focused on financial identity theft, much less research has been devoted to medical identity theft. The average per W incident cost of medical identity theft is over $20,000; this amount is well above the average for other types of identity theft. Medical identity theft has many of the same consequences as financial identity theft but also has unique and potentially life threatening consequences. Medical identity theft can negatively impact a person’s physical health in addition to its negative financial impact. This research investigates the frequency of medical identity theft, the use of electronic health records and the prevalence and types of data breaches of personal identifying information by healthcare providers. This research found that the percent of medical identity theft incidents is low as a part of the overall identity theft problem; however, the incidence of medical identity theft is increasing. Secondly, the analysis found many healthcare providers do not have proper security measures in place to properly protect health records even among those that have implemented electronic health records. Thirdly, an analysis of data breaches by healthcare providers reveals that data breaches are not decreasing, and are most often caused by lost, discarded, or stolen portable devices.

Keywords: Medical Identity Theft, Identity Theft, Data Breaches, Electronic Health Records, Electronic Medical Records, Security, Data Security, Personal Identifying Information, Personal Identifiable Information, Personally Identifiable Information, Personally Identifying Information.

INTRODUCTION In 2011, according to Javelin Strategy & Research, over 11 million Americans were victims of identity fraud, an increase of 13 percent over the previous year. The financial loss was similar to the $20 billion loss of 2010 (Javelin, 2011-1; Javelin, 2012). Identity theft as defined by the Consumer Sentinel occurs when someone obtains your personal identifying information with the intent to commit fraud or theft (FTC, 2011). Javelin Strategy & Research defines identity fraud as the misuse of illegally obtained personal information for financial gain (Javelin, 2011-

Medical Identity Theft: Consequences, Frequency, and the Implication of Electronic Health Records and Data Breaches

1). Personal identifying information includes social security number, financial information such as credit card and bank account numbers, and insurance information.

A growing form of identity theft is medical identity theft. According to a 2010 study by the Ponemon Institute, 5.8% of American adults (over 13.9 million) have been medical identity theft victims. These thefts had an average per incident loss of more than $20,000. The study also found that 29% of victims are not aware of the theft until more than a year later and 75% of victims experience difficulty in resolving issues relating to the medical identity theft (Creditinfocenter.com, 2011). Medical identity theft has multiple but similar definitions. The Federal Trade Commission (FTC) defines medical identity theft as using stolen personal information to obtain medical services or goods or to make false insurance claims (FTC, nd). The Healthcare Information and Management Systems Society (HIMSS) provides global leadership in the optimal use of information technology (IT) and management systems for the improvement of healthcare (HIMSS, nd). In the HIMSS annual security survey report, the definition of medical identity theft includes the FTC definition and is extended to include cases where an “individual’s beneficiary information is used to submit false claims in such a manner that an individual’s medical record or insurance standing is corrupted, potentially impacting patient care” (HIMSS, 2010). In an environmental scan conducted by Booz Allen Hamilton for the Office of the National Coordinator (ONC) for Health Information Technology medical identity theft is defined as the misuse of another person’s personal identifying information to obtain or bill for medical goods or services (Booz Allen Hamilton, 2008). This definition expands on the other definitions in that it is intended to include misuse with or without the person’s consent or knowledge. The Identity Theft Resource Center (ITRC) is a non-profit organization that provides victim support and consumer education relative to identity theft. The ITRC defines three categories of medical identity theft: Financial – an individual is billed for medical services provided to someone else using the individual’s information; Criminal – an individual is held responsible for the criminal behavior of another; and Government Benefit Fraud - someone receives the government benefits of another individual (ITRC, 2010-1). This research is intended to increase awareness of the problem and character of medical identity theft thereby aiding in its reduction. This paper analyzes the consequences and frequency of medical identity theft, reviews electronic health records and finally investigates data breaches of personal identifying information by healthcare providers as potential sources of medical identity theft.

CONSEQUENCES Medical identity theft includes the adverse impact of general identity theft as well as additional unique negative consequences. Victims of medical identity theft may experience financial loss. Javelin Strategy & Research documented in its 2011 Identity Fraud Survey that the cost of identity fraud is increasing even though the median cost to the victim is $0. The median cost to the victim is $0 because most banks now offer zero-liability fraud protection (Javelin, 2011-1). Financial loss is increasing because the cost includes lost work time and according to the Javelin study (Javelin, 2011-1) the fraud is more difficult to detect and resolve, increasing the length of time to repair the victim’s credit following identity fraud. Just the process of reporting

C. P. Garrison and O. G. Posey IJSHIM - Volume 5, Issue 11 (2012), pp. 1-17 and obtaining a response from the creditor or provider involved can take from 30 to 90 days (Fair Isaac Corporation 2011). Financial loss also includes the cost a victim may incur as a result of hiring a company to help correct fraud related issues, or paying for medical services and goods not received. Medical identity theft can lead to inaccuracies in a victim’s medical files. These inaccuracies could lead to errors in medical diagnosis, denial of coverage by insurance companies because of a non-existent precondition, and inappropriate or faulty prescriptions.

Medical identity theft in some instances can lead to criminal prosecution, known as criminal medical identity theft. An example of criminal medical identity theft would occur when someone has a child using another person’s identity and the newborn tests positive for illegal drugs or alcohol. According to the US Department of Health and Human Services’ Child Welfare Information Gateway (2009), twelve states and the District of Columbia include prenatal drug exposure as a type of child abuse or neglect. Medical identity theft could also make it difficult for the victim to obtain medical services. These difficulties could occur because of unpaid medical bills and exhausted insurance or government benefits.

Medical identity theft also has consequences for the healthcare provider. According to ONC’s Medical Identity Theft Environmental Scan (Booz Allen Hamilton, 2008), medical identity theft has two primary consequences for health care providers. First, providers may use corrupted health information, thereby compromising patient health. Inappropriate care caused by corrupted health information may lead to lawsuits and victim compensation. Second, medical identity theft creates financial risks. Healthcare providers may have to write-off some or all expenses for services rendered, may incur additional administrative costs identifying and handling false claims, may incur costs identifying third parties that may have received inaccurate information, and may incur costs correcting victims’ health records.

Javelin (2011-2) found that general identity fraud cost small businesses $5 billion and financial institutions lost over $590 million in clients and revenue opportunities over a five-year period. Healthcare providers could experience similar losses. For example, in June 2011, Phoenix, AZ police reported that 128 patients were discovered to have had their medical identities stolen when thousands of dollars in fraudulent charges for medical services were billed to their insurance carriers. Insurance companies were billed for charges for everything from non- performed tests and x-rays to therapy that was never provided. Total losses to ten different insurance companies were approximately $108,000 (Parks, 2010). In addition, medical identity theft could damage a provider’s reputation, causing potential customers to fear their information might be compromised.

FREQUENCY The environmental scan by Booz Allen Hamilton investigated the frequency of medical identity theft and determined that it was unknown (Booz Allen Hamilton, 2008). The data is not being collected to make a definitive determination of its frequency. However, multiple sources confirm that medical identity theft is a growing problem.

Medical Identity Theft: Consequences, Frequency, and the Implication of Electronic Health Records and Data Breaches

The FTC 2006 Identity Theft Survey found that 18% of non-account identity theft was to obtain medical treatment, services or supplies. The study also found that 3% of existing accounts’ misuse involved using personal information fraudulently to obtain medical care and 3% of the misuse of existing accounts was of medical insurance accounts (FTC, 2007). James Quiggle, Director of Communications for the Coalition Against Insurance Fraud states in a 2008 article for the Chicago Tribune that medical identity theft is the fastest growing form of identity theft in America (Booz Allen Hamilton, 2008; Graham, 2008).

The Consumer Sentinel is a database of consumer complaints available exclusively to law enforcement. The Consumer Sentinel publishes an annual report of consumer complaints (FTC, 2012, 2011, 2010, 2009). Medical complaints are included as one of the subcategories of identity theft complaints. Combining information from multiple reports we compared the percentage of total identity thefts with the percentage of medical identity thefts. Table 1 shows the percentage of identity theft complaints in the Consumer Sentinel that were medical. The percentage of medical identity theft complaints remained constant from 2008 through 2010 even though the percentage of all identity theft complaints decreased more than 8% between 2008 and 2010. The percentage of identity theft complaints to total complaints in 2011 decreased by nearly 2% but the percent of medical identity theft complaints decreased by only 0.3%. In 2011, there were 279,156 identity theft complaints and 1,813,080 total consumer complaints (FTC, 2012).

Table 1: Percent of complaints Medical ID ID Theft

complaints complaints 2007 1.6% 24.7% 2008 1.3% 25.7% 2009 1.3% 19.6 2010 1.3% 17.2% 2011 1.0% 15.4% Source: FTC Consumer Sentinel

The latest HIMSS (2011) security survey found that fourteen percent of the 326 healthcare facilities in the study had at least one known case of medical identity theft at their organization. The data was based on responses of information technology and security professionals at organizations that electronically store data. Table 2 presents the percent of organizations for the four years the HIMSS has conducted the study that reported having a case of medical identity theft (HIMSS, 2011, 2010, 2009, 2008). The percent of organizations that report having a case of medical identity theft increased significantly between 2008 and 2009 and remained essentially the same for 2009 and 2010 even as organizations were theoretically improving their security procedures. There was a dramatic drop in reported incidents in 2011. We observe that these percentages could be higher. The percent of respondents that answered don’t know to an incident of medical identity theft was 16% in 2009, 21% in 2010 and 2008,

C. P. Garrison and O. G. Posey IJSHIM - Volume 5, Issue 11 (2012), pp. 1-17 and 20% in 2011 (HIMSS, 2011, 2010, 2009, 2008). The data reported also reveals that 64% of the organizations with a reported incident of medical identity theft had two or more incidents, 23% had four or more, and 6% had more than 10 incidents in 2011. The 2010 HIMSS study found that hospitals are more likely to report having an incident of medical identity theft than medical practices: 38% hospitals versus 17% medical practices (HIMSS, 2010). However, the 2011 study found that corporate entities were more likely to report an incident than medical practices and hospitals: corporate entity 22%, medical practices 15%, and hospitals 12% (HIMSS, 2011).

Table 2: Orgs w/Medical ID Theft incident # Org %Med ID 2008 155 20 2009 196 32 2010 272 31 2011 326 14 Source: HIMSS

In a report by the FBI (2010-1), FBI Special Agent in Charge Lamkin stated in discussing a $4 million Medicare fraud scheme, that sophisticated crime rings often include medical identity theft in their health care fraud schemes. An additional FBI (2010-2) press release cited the arrest of 73 persons including several members of an organized crime ring that involved the theft of $163 million in Medicare and medical identity theft. These FBI examples of medical identity thief included the use of stolen physicians’ identities to file the false claims. In another incident, a Los Angeles woman used the stolen identities of physicians to defraud Medicare of more than $6.2 million (FBI, 2011).

A report by the Department of Justice stated that as the abuse of methamphetamine increases, medical identity theft will likely increase. Methamphetamine abusers may seek treatment for methamphetamine-related illnesses using stolen identities or they may sell identities for others to use and obtain medical treatment, prescriptions, or insurance payments (National Drug Intelligence Center, 2007). A report by the Office for Victims of Crime, a component of the Office of Justice programs, US Department of Justice, stated that medical identity theft is one of two main types of identity theft growth (Office for Victims of Crime, 2010).

ELECTRONIC HEALTH RECORDS In April 2004, President Bush issued an executive order to create a new position in Health and Human Services (HHS) charged with establishing electronic health records for all Americans within 10 years. The president’s 2005 budget proposed $50 million in new grants to support state and local government efforts to develop systems needed for the exchange of medical data and another $50 million for research into how technology could improve healthcare (Healthcare Financial Management, 2004). In 2005, HHS awarded a contract to Certification Commission for Healthcare Information Technology (CCHIT) to develop certification criteria

Medical Identity Theft: Consequences, Frequency, and the Implication of Electronic Health Records and Data Breaches and a certification process to assist healthcare providers in selecting EHR products that meet certain functionality, interoperability and security standards (HHS, 2006). In 2008, HHS announced a five-year demonstration project that would pay providers for using certified electronic health records. Higher payments would go to those that use more technology (Leavitt, 2007; HHS, 2007).

President Obama, in 2009, signed the Health Information Technology for Economic and Clinical Health Act (HITECH), a component of the American Recovery and Reinvestment Act of 2009. HITECH encourages the rapid adoption and meaningful use of electronic health records through Medicare and Medicaid incentive payments to physicians and hospitals (CCHIT, nd; Congressional Budget Office, 2009). In July 2010, the Centers for Medicare and Medicaid Services (CMS) issued the final rule that established requirements for the Medicaid EHR incentive program and defined meaningful use. The Office of the National Coordinator for Health Information Technology (ONC) issued a related final rule the same month for the standards, implementation specifications, and certification of EHRs (CMS, 2010-1; ONC, 2010). The incentives are funded at $22.6 billion for 2011 (HHS, 2011).

According to the Centers for Medicare and Medicaid Services, meaningful use has three main components. The providers must show they are using certified EHR technology, using EHR technology to improve the quality of health care through electronic exchange, and measuring the results (CMS, 2011). In January 2011, the HHS Office of the National Coordinator for Health Information Technology issued a request for comments for stage 2 meaningful use recommendations. The request for comments also provided notice that additional stages would be forthcoming and that meaningful use criteria would be raised beyond those of stage 1 (ONC, 2011, HITPC, 2011). In March 2012, Centers for Medicare & Medicaid Services (CMS), HHS published the Medicare and Medicaid Programs; Electronic Health Record Incentive Program - Stage 2 proposed rules (CMS, 2012-1). Eligibility for the incentive program includes the requirement to provide online access to health information for more than 50% of patients and to successfully transmit multiple types of data on an ongoing basis (CMS, 2012-2).

One of the core criteria of meaningful use is the requirement to protect electronic health records. The stage 1 measure associated with security stated the providers must conduct or review a security risk analysis, implement security updates and correct any identified deficiencies as part of their risk management process (Navigating Cancer, nd; CMS 2010-2). Stage 2 explicitly calls attention to the need to encrypt stored data. The HHS found that nearly 40% of large breaches involved lost or stolen devices that were unencrypted (CMS, 2012-1).

The 2010 HIMSS security study included questions that evaluated the organizations compliance with the meaningful use requirement to protect the security and privacy of electronic health records. The results indicated that one-fourth of the organizations, all of which store data electronically, would not meet the meaningful use requirement. In addition to storing data electronically, 85% of the HIMSS study participants share patient data electronically; 83% of hospitals and 77% of medical practices (HIMSS, 2010). Unfortunately, much of this data is

C. P. Garrison and O. G. Posey IJSHIM - Volume 5, Issue 11 (2012), pp. 1-17 being shared without the proper controls in place to secure the data. This type of activity can lead to identity theft.

The 2011 HIMSS study reported that a separate survey found that only 45% of US hospitals conduct or review a security risk analysis as a part of securing EHRs (HIMSS, 2011, 2011-2). Three-fourths of the 2011 HIMSS security survey respondents reported that their organization does perform a risk assessment to evaluate the risks to patient data. The percent of respondents that conducted a risk assessment has remained constant over the four years the HIMSS has conducted the study. This means one-fourth of the responding organizations are not compliant with meaningful use security measures (HIMSS, 2011).

DATA BREACHES A data breach occurs when personal identifying information such as social security number, credit card numbers, bank account or insurance information becomes publicly available. The information in these breaches could lead to medical identity theft. Javelin Strategy has found through its annual identity fraud surveys that those that receive a data breach notification have a ten times greater risk of becoming a victim of identity theft (Dyke, 2012).

California was the first state to enact a security breach notification law in 2003. As of October 2010, 46 states, the District of Columbia, Puerto Rico and the Virgin Islands require companies to notify affected individuals of a data breach. Only Alabama, Kentucky, New Mexico, and South Dakota have no current laws (National Conference of State Legislatures, 2010; CSO, 2008-1, 2008-2). Many states followed California’s landmark SB1386, which requires companies to notify affected consumers without unreasonable delay (CSO, 2008-2; Deutsch, 2011). Some state laws include civil penalties of between $100 and $500 per violation. For example, Alaska sets a civil penalty of $500 per violation with a cap at $50,000 per incident (Alaska State Legislature, 2008; National Conference of State Legislatures, 2010).

Letters of notification may state only that a breach has occurred and provide some guidance on how to protect oneself. In addition to state laws, federal law may prompt notice of a data breach. Financial institutions subject to the federal Gramm-Leach-Bliley Act must adopt procedures to safeguard customer data. As part of a security plan, financial companies must notify customers when a data breach has occurred or is likely to have occurred (Stevens, 2010; Privacy Rights Clearinghouse, 2011). In addition, HHS requires providers covered by the Health Insurance Portability and Accountability Act (HIPAA) to notify individuals when their health information is breached (OCR, 2009).

Data Breaches - ITRC The Identity Theft Resource Center (ITFC) has been tracking incidences of data breaches since 2005 (ITRC, 2012). The ITRC reports the number of records breached in an incident. A record is the personal identifying information of an individual. An individual could have multiple records in a single breach, particularly if the breach involves multiple companies or if the

Medical Identity Theft: Consequences, Frequency, and the Implication of Electronic Health Records and Data Breaches individual has multiple identifications with a company such as employee and customer. Medical/Healthcare is one of the organization types the ITRC uses to classify the incidents (ITRC, 2012-2). We analyzed the occurrence of data breaches by Medical/Healthcare facilities; data breached by these organizations could be more readily used to commit medical identity theft. Table 3 was created using a four-year period of ITRC data. The number of incidents of Medical/Healthcare data breaches is not consistently decreasing. There was a decrease in incidents in 2009 (65) from 2008 (97), a considerable increase in incidents for 2010 (160) and a decrease in 2011 (86). The percentage of Medical/Healthcare data breaches in 2011 (20.5%) is higher than both 2008 (14.8%) and 2009 (13.1%) though it is lower than in 2010 (24.2%). In addition, the number of records is the largest in 2009 (10,461,818) when the number of incidents was the smallest and the percentage of breached records has increased each year from 2009 through 2011. An incident can breach from 1 record to millions of records.

Table 3: Number of Medical/Healthcare Data Breaches & Percent of Total Data Breaches 2008-2011 Year Incidents % Records % 2011 86 20.5 3,732,071 16.3 2010 160 24.2 1,874,360 11.6 2009 65 13.1 10,461,818 4.7 2008 97 14.8 7,311,833 20.5 Source: ITRC

Tables 4 through 7 present examples of the incidents recorded by the ITRC with a large number of records breached. The incidents placed at risk as many as 2.2 million records with a single incident. Each year, except 2010, had a single incident that breached more than a million records. In 2010, the largest incident breached 800,000 records, a considerable number of records that place many individuals at risk of (medical) identity theft.

Table 4: ITRC 2008 Sample Large Breaches Univ of Utah Hospitals and Clinics 2,200,000 Univ of Miami FL 2,100,000 Medical Excell LLC US 900,000 Univ of FL College of Dentistry FL 330,000 Lifeblood Mid-South TN 321,000 Horizon Blue Cross Blue Shield NJ 300,000 Blue Cross/Blue Shield of GA 202,000 Saint Mary's Regional Med Center NV 128,000 WellPoint US 128,000 Baylor Health Care TX 100,000

C. P. Garrison and O. G. Posey IJSHIM - Volume 5, Issue 11 (2012), pp. 1-17

Table 5: ITRC 2009 Sample Large Breaches Health Net US 1,500,000 Jackson Memorial Hospital FL 200,000 Peninsula Orthopedic Associates MD 100,000

Table 6: ITRC 2010 Sample Large Breaches South Shore Hospital MA 800,000 Millennium Medical Mgt Resources US 180,111 NY’s Lincoln Med & Mental Health C NY 130,495

Table 7: ITRC 2011 Sample Large Breaches Jacobi Medical Center, North Bronx Healthcare Net 1,700,000 Eisenhower Medical Center 514,000 Wellpoint - Anthem 600,000 Seacoast Radiology 231,400 Ankle + Foot Center 156,000

Data Breaches - Privacy Rights Clearinghouse As a result of a large data breach in 2005, the Privacy Rights Clearinghouse (PRC) began tracking data breaches. The PRC (nd) is a nonprofit consumer organization with consumer information and consumer advocacy as its core missions. The PRC seeks to raise consumers’ awareness regarding how technology affects privacy and to empower consumers to take action to control their own personal information.

The ITRC and the PRC data breaches overlap but are not identical. The organizations use the datalossdb, media sources, notification lists from state agencies and information from individuals to compile their lists. We analyzed breaches in the PRC Healthcare-Medical Providers category. Table 8 shows the number of incidents and records for the four-year period, 2008-2011. Both the ITRC and the PRC identify at least 160 incidents in 2010 and more than 1.5 million records at risk of being used for medical identity theft. Both show a decrease in incidents in 2009 but a significant increase in 2010. The PRC identified 3 incidents in 2009 and 2010 with at least 100,000 records, and 8 incidents in 2008 with at least 100,000 records breached. In 2011, there were 8 incidents that breached more than 100,000 records; three of the incidents breached more than 1.5 million records each.

Table 8: # Medical Data Breaches & Percent of Total Data Breaches 2008-2011 Year Incidents % Records % 2011 200 33.84% 7,291,532 23.44% 2010 172 28.81% 2,843,260 23.09% 2009 46 18.33% 2,781,659 1.27% 2008 52 14.69% 5,172,952 10.42% Source PRC

Medical Identity Theft: Consequences, Frequency, and the Implication of Electronic Health Records and Data Breaches

The PRC includes breach descriptions with its tracking. The descriptions vary as to the information contained because of the varying sources and because companies are not mandated to provide specific information. Table 9 depicts three sample large breaches with information gained from the PRC descriptions and original sources.

Table 9: Example PRC Identified Breaches Jacobi Medical Center, North Central Bronx Hospital, Tremont Health Center, and Company Gunhill Health Center Records 1.7 million Information Name, SSN, address, patient health information, and other patient and employee Breached information Current and former patients, staff members and associated employees for a 10 year Who affected period Stolen backup tapes (unencrypted). Stolen from an unsecured and unlocked van during How transport

Company Affinity Health Plan NY Records 409,262 Current and former employees, providers, applicants for jobs, members, and applicants Who affected for coverage How Returned leased copier with un-erased hard drive

Company AvMed Health Plans FL Records 208,000 original figure, 1.2 million updated figure Information Names, addresses, phone numbers, SSN, protected health information Breached Who affected Current and former subscribers How Theft of two company laptops, one not properly protected

Data Breaches by Type As the breach descriptions in Table 9 depict, data breaches have multiple causes. The PRC has classified its breaches into seven types: Unintended disclosure - Sensitive information posted publicly on a website, mishandled or sent to the wrong party via email, fax or mail. Hacking or malware - Electronic entry by an outside party, malware and spyware. Payment Card Fraud - Debit and credit card fraud that is not accomplished via hacking. Insider - Someone with legitimate access intentionally breaches information. Physical - Lost, discarded or stolen non-electronic records, such as paper documents. Portable - Lost, discarded or stolen portable devices. Stationary - Lost, discarded or stolen stationary electronic devices. Unknown or other (PRC, 2011).

Table 10 and Figure 1 present the data breaches by type for a five year-period, 2005-2010. A single factor ANOVA revealed a significant difference in the number of incidents per breach type, P-value of 8.3E-89. The greatest number of breach incidents is the result of compromised

C. P. Garrison and O. G. Posey IJSHIM - Volume 5, Issue 11 (2012), pp. 1-17 portable devices. In this five-year period there were 171 incidents, 41.3%, with over 12 million records compromised by portable devices. The category that is often considered the most dangerous, Hacking, had the least number of incidents other than the 5 incidents in the category Unknown.

Table 10: Medical Data Breaches by Type Incidents Percent Records Percent Portable 171 41.30% 12,129,727 80.02% Physical 73 17.63% 210,936 1.39% Insider 58 14.01% 138,765 0.92% Disclosed 48 11.59% 809,329 5.34% Stationary 40 9.66% 596,141 3.93% Hacking 19 4.59% 1,092,176 7.21% Unknown 5 1.21% 180,500 1.19% Totals 414 100.00% 15,157,574 100.00%

Figure 1: Medical Data Breach Incidents by Type

CONCLUSION The specific number of incidences of medical identity theft is unknown. However, an analysis of multiple sources points to its increase. The federal government is encouraging the use of electronic health records. As more health records are maintained electronically and shared between organizations, the risk of data breaches also increases. According to a survey by Ponemon Institute, 49% of organizations do nothing to protect mobile devices used to collect, store, and transmit protected health information (2011). While hacking incidents of healthcare

Medical Identity Theft: Consequences, Frequency, and the Implication of Electronic Health Records and Data Breaches providers are low compared to other types, 4.59%, the incidents of lost, discarded or stolen records is high, 41.3%. Of particular concern is that these breached data are unencrypted. In addition, based on the data from the HIMSS annual survey, as many as 25% of healthcare facilities do not have proper security measures in place to protect health records. Both the ITRC and the PRC recorded an increase in the number of data breach incidents at Medical/Healthcare facilities in 2010 and an increase in the number of records breached in 2011. The Javelin study and the Consumer Sentinel report an increase in medical identity theft complaints.

These findings suggest the consumer cannot rely completely on businesses to protect them from identity theft. The findings also highlight the need for continued vigilance in monitoring/encouraging/mandating security by businesses that have access to personally identifying information.

Recommendations for Consumers Unlike victims of financial identity theft that have a well laid-out path to restoring and correcting their financial history, victims of medical identity theft often find that there is no clear process for challenging false medical claims or correcting inaccurate medical records. Victims of financial identity theft often discover the fraud early and are assisted by banks and other financial institutions in reporting the fraud to credit reporting agencies. Detecting and correcting medical identity fraud is not as straightforward. There is no central clearinghouse for all medical records equivalent to the credit reporting agencies. Therefore, medical records are likely to be interspersed among several providers. Under HIPAA, if there is an error, victims have the right to request that the records be amended. However, they have the burden of proving that the information is incorrect. In addition, according to the Federal Trade Commission, some providers may not be aware that consumers have the right to receive a copy of their records (FTC, 2010 Facts).

The continued prevalence of data breaches and the potential increase in medical theft suggests limiting the distribution of personal indentifying information. Consumers are advised to limit where and how much information they provide and should ask how businesses protect their information. If a healthcare provider is going out of business, moving, retiring, or changing owners, consumers should find out how information will be transferred or destroyed. Review medical files, insurance statements, health provider bills and credit reports for errors. If consumers discover an error, they should contact the appropriate organization in writing, include any documentation that supports their claim, and request that their records be amended.

Recommendations for Healthcare Providers Just as financial institutions ultimately absorb most out-of-pocket costs, medical providers and insurance companies will likely shoulder much of the cost of medical identity theft. Healthcare providers should ask patients to monitor their ‘explanation of benefits’ and invoices and report

C. P. Garrison and O. G. Posey IJSHIM - Volume 5, Issue 11 (2012), pp. 1-17 any discrepancies. HIPAA gives consumers the right to receive copies of their medical records. Providers should make it easy for patients to review their medical records and should encourage them to report discrepancies.

Healthcare providers should make security of information a priority. In addition to hiring security staff or consultants, train employees on the importance of security and how to recognize medical identity theft and fraud. Many businesses focus on hackers but significant risks exist from non-malicious insiders. The provider should create policies and enforce them. If a patient is a victim of medical identity theft, the originating provider should conduct a review; and should notify anyone that received the patient’s medical information, correct security practices as necessary, conduct training to eliminate deficiencies revealed by a review, provide breach notifications, know and inform the patient of their rights.

HIPAA covered entities have several requirements that may help reduce medical identity theft. HIPAA requires that covered entities follow national standards for the security of electronic health information (Miller School of Medicine, University of Miami, 2011). In addition, the Privacy Rule requires covered entities to verify the identity of anyone requesting protected health information. Covered entities also must include reasonable measures to protect health information such as training employees on how to handle, dispose, and keep health information safe (FTC, 2011, Medical). HIPAA covered entities are also required to notify affected individuals when a breach of protected information occurs (HHS, nd-HITECH; HHS, 2009).

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Medical Identity Theft: Consequences, Frequency, and the Implication of Electronic Health Records and Data Breaches

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Medical Identity Theft: Consequences, Frequency, and the Implication of Electronic Health Records and Data Breaches

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Privacy Rights Clearinghouse (2011) Financial Privacy FAQ, accessed online: https://www.pri vacyrights.org/fs/fs24d-FinancialFAQ.htm#19 Privacy Rights Clearinghouse (n.d.) About the Privacy Rights Clearinghouse, accessed online: http://www.privacyrights.org/about_us.htm Stevens, G. (2010) Federal Information Security and Data Breach Notification Laws, Congressional Research Service, accessed online: http://books.google.com/books?hl=en &lr=&id=BYNd1MkVNMYC&oi=fnd&pg=PA1&dq=State+Breach+Disclosure+Laws&ots=O- TPtnIPeE&sig=qK0_VhsGt3JbDBWa86KAEtLyY4E#v=onepage&q=state%20notification&f =false

R. Chavez, M. Holloway and R. Perez IJSHIM - Volume 5, Issue 11 (2012), pp. 18-31

Full Article Available Online at: Intellectbase and EBSCOhost │ IJSHIM is indexed with Cabell’s, JournalSeek, etc.

International Journal of Social Health Information Management

MULTICULTURAL MARKETING AND CONSUMER WELL-BEING IN UNDERSERVED HISPANIC NEIGHBORHOODS

Ruth Chavez1, Madison Holloway2 and Rocio Perez3 1Ethniche, USA, 2Metropolitan State University of Denver, USA and 3Definitive Marketing, USA

ABSTRACT ubstantial evidence suggests inadequate access and consumption of nutritious foods such as fresh fruits and vegetables combined with a poor diet of convenient S processed fast foods lead to obesity and present a myriad of serious health consequences that impair an individual's quality of life. In the United States, the prevalence of obesity and overweight is significantly higher for some racial and ethnic groups. Hispanics and Blacks are disproportionately affected by obesity and its related risk factors (Flegal, Carroll, Ogden & Curtin, 2012). Today, cardiovascular diseases, diabetes, and other chronic diseases are increasing at alarming rates in underserved consumer populations such as racial and ethnic residents of low income neighborhoods. It is also evident that mainstream food marketing practices have only exacerbated the nation's epidemic health problem by intentionally targeting these vulnerable populations. Yet public policy concern and academic inquiry has been remarkable slow to address the subject of health disparities as it relates to predatory advertising and marketing promotion. Concerned about the health and economic costs of obesity, The Institute of Medicine (IOM) in 2012, assessed the influence of marketing within the food and beverage industry. Multicultural marketing, the IOM concluded, is a high priority for this industry because ethnic consumers segments are growing, their buying power is increasing and there has been an increase in their cumulative lifetime spending potential (Grier, 2012). Furthermore, Hispanic and Black children have significantly higher media use and exposure than their non-Hispanic white peers (Rideout, 2012). Youth and children are readily influenced by the media and may not have fully developed cognitive decision skills to decipher fact from fiction. To address the problem of inadequate access to healthy food in consumer constrained neighborhoods, community-based interventions are emerging to alleviate the impact on vulnerable populations. Increasing neighborhood corner store participation in improving access to fruits and vegetables is proving to be a promising approach to promoting consumer well-being. This article describes such a multicultural intervention as part of a broader Healthy Corner Store Initiative (HCSI) designed to address the lack of commercial grocery stores in low-income urban neighborhoods. The intervention incorporates both service and experiential student learning in multicultural marketing education through an academic-community partnership. Along with implications of reducing health disparities within

R. Chavez, M. Holloway and R. Perez IJSHIM - Volume 5, Issue 11 (2012), pp. 18-31 these neighborhoods, this paper underscores the importance of embedding cultural competence in multicultural marketing practice and education.

Keywords: Multicultural Marketing, Hispanics, Consumer Well Being, Food Deserts, Academic-Community Partnerships, Deliberative Democracy Marketing, Cultural Competence, Consumer Behavior, Service and Experiential Learning.

INTRODUCTION Marketing has played an important role in the determination of quality of life as consumers are affected directly and indirectly by marketing factors, such as product quality and safety, price, product availability, distribution, and promotion, etc. For food products, such impact could be even more obvious as research has documented how the marketing of these products has affected general health of consumers. Considerable attention has been given to the importance and effect of nutrition information, health claims, and food labeling (Andrews, Netemeyer and Burton, 1998 & 2009; Golodner, 1993; Ippolito and Mathios, 1993; Nestle, 2002).

One of the urgent issues found in the cumulative research evidence points to the effect of food marketing on obesity in the U.S. (Crister, 2003; Ford and Calfee, 2005; Moore, 2007; Seiders and Petty, 2004 &, 2007). More alarming is the effect on children as childhood obesity has become a serious social and public policy issue and many children are victims of food marketing by major food companies and restaurants (Descrochers and Holt, 2007; Nestle, 2006; Robinson, Bloom and Lurie, 2005). Research also shows a significant disparity between well-to-do consumers and disadvantaged consumers (Teisl, Levy and Derby, 1999); between socioeconomic groups (Brinberg and Axelson, 2002; Mathios, 1996), and between ethnic groups (Grier, Mensinger, Huang, Kumanyika & Stettler, 2007). Among ethnic groups, Hispanic and Black populations have been reported being insidiously targeted by food marketers due to their higher level of media exposure and increased population growth. Consequently, both populations are most likely to be negatively affected by obesity-causing food products (Ogden, Carroll, Curtin, McDowell, Tabak & Flegal, 2012). Recent studies suggest that obesity and other dietary related diseases such as type II diabetes are directly related to the food environment found in low-income communities (Gittelsohn and Sharma, 2009; McKinnon, Reedy, Morrissette, Lytle & Yaroch, 2009, Wilkie, 2007a). As obesity and related chronic diseases in the U.S. reach epidemic proportions, there is unprecedented opportunity for marketing to positively influence public policy and change, by becoming a major contributor in accelerating obesity prevention and advancing consumer well being.

Facing an obesity epidemic due in part to profit maximization food marketing practices, a community health initiative was developed and implemented by a public health agency to make healthy food alternatives, such as fruits and vegetables available to food desert (defined by the U.S. government a low income. communities with limited access to a supermarket or large grocery store) neighborhood areas. The public health agency is a part of an integrated healthcare system that is the primary public healthcare safety net organization for an urban city

Multicultural Marketing and Consumer Well-Being in Underserved Hispanic Neighborhoods in the Southwest United States. The urban public health agency initiated a number of programs and collaborative efforts to better serve vulnerable populations.

The primary aim of the initiative discussed in this article was to modify food purchase and consumption patterns and to enhance consumer well-being by increasing exposure and availability of alternative healthier products through multiple interventions to create a sustainable and beneficial marketing environment for both stores and shoppers. The present article describes a multicultural marketing intervention as part of a broader Healthy Corner Stores Initiative (HCSI) designed to address that lack of commercial grocery stores in low- income urban neighborhoods. The intervention incorporates student service learning in multicultural marketing education through an academic-community partnership. The paper underscores the importance of embedding cultural competence (e.g. culture and language appropriate promotional material) into multicultural marketing and offers suggestions and implications for future academic and community-based collaborative strategic alliances.

A MULTICULTURAL SOCIETY Multicultural America has prompted scholars and practitioners to explore a new set of marketing opportunities. The multicultural boom is creating profound changes in social and marketing priorities affecting our society. More than ever, minority growth rates and spending power are capturing the attention of marketers. Fostering cultural competence (awareness and responsibility) within organizations has now become a critical imperative to responsibly serve ethnic consumer markets. These recent statistics from the U.S. Census Bureau (Humes, Jones and Ramirez, 2011), and other secondary sources substantiate the relevance of these emerging markets:

 The combined Hispanic, Asian American and African American population growth represents approximately 88 percent of the growth in the last 11 years.  In 2010, there were nearly 51 million Hispanic residents in the United States, accounting for more than half - nearly 52 percent - of the population growth in the last decade.  By the year 2016 the U.S. ethnic composition will represent over half of the overall population.  Aggregate consumer spending for 2012 was estimated to be approximately $538 billion for Hispanics, $437 billion for African Americans and $253 billion for Asian Americans and Pacific Islanders (Melgoza, 2012).  Due in part to larger family household size, Hispanic consumer spending is more than the average household in the food and apparel category (Melgoza, 2011).

The data above indicates that multicultural America represents significant opportunities for marketers. As the population in the United States becomes ever more diverse, there are unprecedented opportunities to increase understanding of the needs of a multicultural marketplace and foster the appropriate responsible relationship between major social issues and consumer behavior strategies.

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DISPARITIES OF OBESITY AND HISPANICS Obesity surreptitiously represents one of the most urgent health threats as well as one of the leading causes of morbidity and mortality throughout the world. In a global marketplace where many people die each day from nutrition deprivation related causes, problems associated with excess weight are often overlooked. Yet, in the United States, racial and ethnic differences in health outcomes are emerging as indisputable disparities. As the Hispanic population within the U.S. represents the highest growth ethnic group with a large number of newly arrived immigrants often at lower socioeconomic ladders, below average education, and above average household size, the high prevalence of obesity for this segment is particularly disconcerting.

Given that low fruit and vegetable consumption is an important risk factor, substantial evidence-based research demonstrates that low-income consumers living in poor food environments disproportionately bear the burden of higher rates of chronic disease and other health disparities (Hall, Moore, Harper and Lynch, 2009). According to the Center for Disease Control (2009), during 2006-2008, obesity prevalence was 21% higher for Hispanics, compared to their non-Hispanic white counterparts. The latest data from the National Health and Nutrition Examination Surveys during 1999-2010, indicates that Hispanics continue to be at greater risk for obesity. Among adults aged 20 or older, the combined prevalence of obesity and being overweight was nearly 79 percent for Hispanics as compared to about 67 percent for non-Hispanic whites (Flegal et al., 2012). This epidemic also applies to children and adolescents. Among children and adolescents aged 2 through 19, nearly 39 percent of Hispanics were either obese or overweight compared with almost 26 percent for non-Hispanic whites (Ogden et al., 2012). These racial and ethnic health disparities take a toll on the entire household. Hispanic children and youth are particularly vulnerable exhibiting disproportionately higher childhood hunger and food insecurity than their non-Hispanic white peers (Johnson, 2008). Hence, effective strategies and policies that promote healthy eating and active lifestyles are needed for this to change.

As mentioned earlier, Hispanic consumers are heavily influenced by the media and many are not making health appropriate food choices. Furthermore, low-income Hispanic residents are often underserved by mainstream grocery chains and rely on neighborhood corner stores to provide basic daily grocery needs. Such corner stores fail to provide enough healthy food alternatives, partially because they are often restrained by space and economies of scale. Consequently, many opt to carry high-margin, heavily advertised processed food and limit the availability of healthy alternatives.

In resolving the problem of inadequate access to healthy food in consumer constrained neighborhood environments, public and private entities have considered community-based interventions to alleviate the impact on underserved populations. Health promotion requires multiple levels of influence to develop and implement effective interventions. As researchers are discovering, consumer attitudes and behaviors are often a function of the environment. While individual and situational variables also play an important role, the neighborhood food

Multicultural Marketing and Consumer Well-Being in Underserved Hispanic Neighborhoods environment is the focus of this article. Building adequate capacity in small neighborhood corner stores could be a promising intervention to bringing positive change the food environment of these communities. With the right intervention program, neighborhood communities could simultaneously sustain business performance and promote consumer well- being. Moreover, Braveman (2006) suggests that health disparities can also be shaped by public policy in order to mitigate health risks for economically disadvantaged social groups.

THE ROLE OF MARKETING AND EXPLICIT DIMENSIONS OF CONSUMER WELL-BEING: AN EMERGING DELIBERATE DEMOCRACY APPROACH Both past and present marketing interests and the field of consumer behavior in particular, has derived benefit from a continuously improved understanding of consumer well-being. Various theories have contributed to marketing knowledge about consumer-well being (See Sirgy, 2008 for an extensive review). Although the development of a consumer well-being approach to marketing may have been impeded by the discipline's earlier economic traditions of production, distribution and institutional organizational management, additional concerns of marketing, inevitably require more consideration for consumer and societal issues. Pancer and Handelman (2012) trace the defining impact of macro-economic theory on marketing, concluding that consumer sovereignty and choice, wherein, the welfare of society accrues the most benefit when consumers can decide what is best for their own well being continues to be an important part of present-day marketing thought.

Similarly Peterson (2006), in the marketing orientation conceptual framework, suggests fundamental dimensions of consumer quality of life are related to choices for goods, the cultural context, and physical environment. Scholars and practitioners share a common belief that the positive effect on business profitability and sustainability is derived from a market orientation that delivers customer value. To date marketing orientation studies of small businesses in underserved ethnic consumer neighborhoods are sparse. With an important social issue, such as obesity among vulnerable populations, it is necessary to incorporate social responsibility into market orientation to achieve the desired effects of delivering superior customer value. Furthermore, it is essential for consumer demand to be sufficiently strong in order for businesses (e.g. local corner stores) to be sustainable. By creating or increasing a desirable demand with intervening product exposure and availability, the connection between business enterprise and an overall sustainable neighborhood market environment emerges as value-based marketing.

Although space does not permit a thorough discussion of the historical evolution of marketing and its relationship to society, it is worth mentioning that the traditional dominant view is well characterized by an organizational function perspective (See Pancer and Handelman, 2012 and Wilkie and Moore, 1999 & 2003 for comprehensive reviews). While marketing as an organizational function remains the dominant approach, greater interest in societal issues and consumer well being is emerging. Wilkie (2005) points out in the Journal of Marketing, "I assert that it is time for a new marketing academic summit, perhaps as a task force on thought development, with the goal of enhancing the participation in and quality of marketing

R. Chavez, M. Holloway and R. Perez IJSHIM - Volume 5, Issue 11 (2012), pp. 18-31 scholarship. In addition to addressing what should be studied and how, I suggest that serious attention should be given to how research quality of life can be improved "(p. 10). Later, Wilkie (2007b) once again advances the plea to the American Marketing Association to enlarge the definition of marketing beyond an organizational function view. In a subsequent 2007 issue of the Journal of Public Policy and Marketing, devoted to childhood obesity, a number of others provide support for his argument (Lusch, 2007; Sheth and Uslay, 2007; Wilkie and Moore, 2007; Zinkhan and Williams, 2007). The improved version by the American Marketing Association defines marketing as…“the activity, set of institutions, and processes for creating, communicating, delivering, and exchanging offerings that have value for customers, clients, partners, and society at large” (Approved October 2007). The new definition incorporates "society at large" and is both social and managerial in nature and broadens the field for the inclusion of consumer well being.

The “Deliberative Democracy Marketing Orientation” is an innovative and inclusive community- based marketing approach that engages multiple participants (e.g. local schools, and universities, local organizations, consumers, public agencies, private enterprise, the media and public policy makers) as key stakeholders to take part in resolving issues that affect their local communities. In this new formulation, multiple stakeholders take part in the marketing function. Ozanne and her colleagues (Ozanne, Corus and Saatcioglu, 2009) introduced this emerging marketing paradigm in order to account for the interplay between business, policy and consumer interests. Distinct from "Social Marketing", where downstream and upstream strategies attempt to change human behavior through traditional marketing techniques, the deliberative democracy approach is specifically designed to engage all stakeholders as equal participants in the marketing decision making process.

The multicultural marketing intervention discussed in this article is consistent with the deliberative democracy approach in that is attempts to build interdependence among various stakeholders to achieve a fundamental goal of helping neighborhood deserts become more sustainable.

A HEALTHY CORNER STORES INITIATIVE (HCSI) HCSI was a community driven intervention based on an earlier comprehensive needs assessment of underserved neighborhoods. In response to the issues and problems identified in the assessment, a community wide strategy was developed to address the needs of the defined neighborhoods. Access to healthy food was identified as a top priority for the residents of the selected neighborhoods who live in a food desert without a major supermarket or grocery store to meet their basic needs. As has already been mentioned, the term “food desert” describes neighborhoods and communities that have limited access to affordable and nutritious foods. In the United States, those who live in urban and rural low-income neighborhoods are less likely to have access to supermarkets or grocery stores that provide healthy food choices (Whitacre, Tsai and Mulligan, 2009).

Multicultural Marketing and Consumer Well-Being in Underserved Hispanic Neighborhoods

Using a deliberative democracy orientation, the initiative was designed to provide coaching and outreach to store owners in order to create a sustainable community model and enhance consumer well-being. The program sought to increase the consumption of healthy fruits and vegetables by the low-income residents while increasing business performance of the corner stores. To increase consumers' consumption of fruits and vegetables, the initiative built relationships with the participating corner stores, distributors, as well as the local community. As store space was limited, the corner store owners were given incentives in the form of a free supply of fruits and vegetables in exchange for shelf space allocated for such products. With greater exposure to healthy alternatives consumers would increasingly modify their purchases to include fruits and vegetable. As intake of healthy food alternatives was built into consumer routine purchases, incentives for stores would gradually decrease to a sustainable level.

The HCSI utilized multiple channels to increase demand, sales, and consumption of fruits and vegetables. The effort included community-wide marketing and promotion strategies utilizing school nutrition programs, health clinics, community organizations, city agencies, local media and an academic partnership to help integrate and reinforce the message that healthy food can be accessible and available locally.

Cultural competence was a critical part of this initiative in that the majority of the store owners were Koreans serving a predominately Hispanic consumer base. The multicultural marketing agency assisted storeowners with coordination of price, product placement and the promotional elements of the community-based strategy. In the course of this initiative a partnership was established between the multicultural agency and a marketing faculty member at a local college. The college is in an urban setting and situated near the neighborhood corner stores. Students who attend are from the greater metropolitan area, the majority of who typically continue to reside in the state after graduation. As such, the college places emphasis on service and experiential community-based learning. The next section discusses the partnership and its impact on the local community and student learning.

THE ACADEMIC-COMMUNITY PARTNERSHIP The multicultural marketing agency provided culturally competent marketing and program assistance for the Healthy Corner Stores Initiative. Representative community outcomes over the period were as follows:

 Increased understanding by store owners of product placement, marketing, purchasing, and media as it relates to the sale of fruits and vegetables.  The hosting of culturally appropriate seasonal open house events as well as the creation and distribution of promotional materials.  Increased understanding by consumers of the importance of the consumption of fruits and vegetables.

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The marketing faculty member provided culturally competent research dissemination strategies and multicultural education. Indicative student learning outcomes over the period were as follows:

 Increased understanding of marketing theory and practice within a multicultural context.  Community service to both corner store owners and consumers through the development and implementation of culturally relevant promotional strategies and tactics.  Client-based experiences and practice in communicating orally and in writing, marketing strategies and decisions using appropriate technologies.

The multicultural marketing agency principal and academic faculty partner implemented culturally appropriate strategies to reach three specific neighborhood stores and the respective consumers in the community. Through the partnership, they met with funding source representatives, community organizations, corner store owners and the local district councilman, to better understand the needs of consumers from various stakeholder perspectives. Informal interviews were conducted with consumers at the corner stores to inform each phase of the multicultural marketing intervention. Experiential and service learning projects were assigned to students and various sessions were facilitated by the partnership to educate the students on how marketers and companies impact the community as a whole - especially the most vulnerable members of the community. Cultural competence education was provided to students, along with consumer related learning. Understanding consumption as a function of ethnicity was a core element of the learning objectives. Working together the consultant and faculty member provided a level of awareness for the students to include in their future work. Figure 1 below presents a high level overview of the key HCSI stakeholders including the role of the academic partner and students.

Approach To build on a participative multicultural marketing strategy, an academic-community partnership was established. Students developed civic engagement team projects to promote health and well-being. The marketing faculty member and multicultural marketing agency principal jointly guided students on best practices in working with underrepresented communities to leverage the potential of these communities to take responsibility for their own health. At the onset the creative agency principal advised students about guidelines, requirements and the expected outcomes for every phase of the project. Students were expected to learn and apply multicultural marketing concepts and principles. Through a multiphase approach students developed and implemented culturally relevant promotional strategies and tactics.

Multicultural Marketing and Consumer Well-Being in Underserved Hispanic Neighborhoods

Figure 1: Healthy Corner Stores Initiative Program Structure

Phases of the Community Academic Partnership Phase I Background Research and Analysis:  Conducted a needs assessment of the project to identify purpose and scope.  Strategized on the best course of action and recommendations for Phase II.

Phase II Strategy Stage:  Developed a vision statement for the partnership.  Established priorities and created an action plan.  Co-facilitated student presentations, community partner and key stakeholder meetings.  Guided and assisted in the implementation of the student action plan.  Worked with students to create a multicultural marketing plan, marketing message, and creative work.

Phase III Strategic Assistance:  Developed and presented findings to key stakeholders.  Discussed future opportunities created by the joint strategies.  Examined sales strategies, impact and marketing outcomes.

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 Identified elements of the community-based model for future projects.

LIMITATIONS Three important limitations of the deliberative democracy approach need to be considered. First, given the exploratory nature of the model describe in this article, the findings are limited by the use of qualitative design. Since a distinctive feature of participatory community-based research is to foster the inclusion of numerous stakeholders in support of a common goal, the work described in this paper was intended as an initial step in identifying the potential for possible future studies. Whereas the community-academic alliance resulted in number of early successful outcomes, the partnership also raised significant questions about the appropriate role for students in community participatory work. The general findings suggest that student involvement is largely limited to providing promotional marketing assistance as a part of a class project. Hence, a more sustainable approach for student participation would need to better accommodate the short-term involvement and availability. Third, combining the strengths of quantitative and quantitative methods in future research would inform strategies to better understand and effectively address the complex problems facing underserved vulnerable consumer segments.

RECOMMENDATIONS FOR FUTURE RESEARCH AND PRACTICE Implications for Multicultural Marketing: Practice, Academia and Service Learning Practice The need to improve community and individual consumer well-being continues to be an urgent issue. The stakes are high for all concerned. Given the scope of the problem, consumers in underserved consumer communities face an uncertain future as the burden of economic, education and health disparities continues to place an undue burden on their well-being. From a practitioner's perspective health corner stores initiatives are proving to be powerful tools for community-based interventions. On the one side, consumers must be reached in culturally competent ways and have a voice to co-create healthy solutions in their particular neighborhood environments. On the other hand, value-based partnerships such as the one discussed in this article can make an impact.

Academia Unfortunately, in higher education, racial and ethnic minority issues continue to receive relatively little attention in the study of consumer behavior. For example, a recent comprehensive analysis of major marketing journals found that over a ten year period (1995- 2004), only 2.5 percent of consumer research articles addressed race or ethnicity (Williams, Lee, & Henderson, 2008). Similarly, an earlier review of the literature, Gilly (1993) found that from 1987 to 1992, only one article in the Journal of Consumer Research examined Hispanics and none addressed the needs of African-Americans or Asian-Americans. Such a lack of

Multicultural Marketing and Consumer Well-Being in Underserved Hispanic Neighborhoods education and research is perplexing given that taken individually, or collectively, groups of color represent a lucrative consumer market.

To address this gap marketing curriculum should assign higher priority to the development and delivery of multicultural marketing courses that concentrate on consumer behavior as an expression of race, ethnicity and gender. The course discussed in this article was designed by the marketing faculty partner to cultivate an awareness and appreciation of consumer diversity in the United States. In the multicultural marketing course students develop an understanding of marketing management strategy and practice within a diverse consumer society. As an extension of the social science and marketing literature, the academic-community partnership broadened student knowledge of consumer behavior and well-being in underserved Hispanic neighborhoods.

Service Learning It is important to build rapport with current key stakeholders involved prior to inviting others to participate. Successful service-learning projects include: 1) setting a clear vision with detailed expectations and project outcomes, 2) working with storeowners to participate in service- learning projects, 3) establishing a working relationship with academic partners with clearly defined timelines, roles and responsibilities, 4) create a plan of action with detailed outcomes between academic-community partnerships, 5) co-facilitate sessions with students, 6) review and follow through during the implementation process and 6) at the end of the project: discuss findings and decide on a course of action for future partnership opportunities.

CONCLUSION This preliminary work finds support for future community-based interventions involving local academic institutions as viable partners to address health disparities in underserved communities. As multicultural marketing evolves, academia can effectively play a stronger role in determining the health and well-being of ethnic consumer segments. Moreover, the contribution of marketing in the determination consumer well-being continues to be an intriguing issue that can be further explored. Future work should also examine marketing's detrimental and beneficial impact on vulnerable consumer populations.

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Seiders, K. & Petty, R. D. (2007) Taming the obesity beast: Children, marketing, and public policy considerations, Journal of Public Policy & Marketing, 26 (Fall), pp. 236-242. Sheth, J. N. & Uslay, N. (2007) Implications of the revised definition of marketing: From exchange to value creation, Journal of Public Policy & Marketing, 26 (2), pp. 302-307. Sirgy, M. J. (2008) Ethics and public policy implications of research on consumer well-being, Journal of Public Policy & Marketing, 27 (Fall), pp. 207-212. Teisl, M. F., Levy, A. S. & Derby, B. M. (1999) The Effects of Education and Information Source on Consumer Awareness of Diet-Disease Relationships, Journal of Public Policy & Marketing, 18 (Fall), pp. 197-207. U.S. Census (2008) A More and Older and more Diverse Nation by Midcentury, accessed online November 29, 2009: http://www.census.gov/Press-release/www/releases/archives/ population/012496.html. Whitacre, P. T., Tsai, P. & Mulligan, J. (2009) The Public Health Effects of Food Deserts: Workshop Summary, accessed online August 2009: http://www.nap.edu/catalog/12623. html. IOM (Institute of Medicine) and National Research Council (NRC) Washington, DC: The National Academies Press. Wilkie, M. (2007a) Food access and obesity, Obesity Reviews, 8 (1), pp. 99-107. Wilkie, W. L. (2005) Needed: a larger sense of marketing and scholarship, Journal of Marketing, 69 (October), pp. 8-10. Wilkie, W. L. (2007b) Continuing challenges to scholarly research in marketing, Journal of Public Policy and Marketing, 26(1), pp. 131-134. Wilkie, W. L. & Moore, E. S. (1999) Marketing’s contribution to society, Journal of Marketing, 63 (special issue), pp. 198-218. Wilkie, W. L. & Moore, E. S. (2003) Scholarly Research in Marketing: Exploring the “4 Eras” of Thought Development, Journal of Public Policy & Marketing, 22 (2), pp. 116-146. Wilkie, W. L. & Moore, E. S. (2007) What does the definition of marketing say about us?, Journal of Public Policy & Marketing, 26 (2), pp. 269-276. Williams, J., Lee, W. N. & Henderson, G. (2008) “Diversity Issues in Consumer Psychology,” in Handbook of Consumer Psychology, C. Haugtvedt, F. Kardes and P. Herr (eds.), Mahwah, NJ: Erlbaum. Zinkhan, G. M. & Williams, B. C. (2007) The new American Marketing Association definition of marketing: An alternative assessment, Journal of Public Policy & Marketing, 26 (2), pp. 284-288.

E. W. Ebomoyi and J. I. Ebomoyi IJSHIM - Volume 5, Issue 11 (2012), pp. 32-44

Full Article Available Online at: Intellectbase and EBSCOhost │ IJSHIM is indexed with Cabell’s, JournalSeek, etc.

International Journal of Social Health Information Management

ETHNIC DIFFERENCES IN THE NUTRITIONAL STATUS OF NIGERIAN RURAL HAUSA AND YORUBA SCHOOL-AGE CHILDREN AND THE ROLE OF BIO-FORTIFICATION TO ALLEVIATE PROTEIN ENERGY MALNUTRITION

E. William Ebomoyi1 and Josephine I Ebomoyi2 1Chicago State University, USA and 2Saint Xavier University, USA

ABSTRACT he purpose of this paper was to compare the nutritional status of Hausa and Yoruba children living in rural areas of Kwara State, Nigeria. There were 586 Hausa school- T age children (343 males and 243 females) and 889 Yoruba subjects (615 males and 284 females). The height, weight, triceps and sub scapular skin fold thickness of 1475 children age 1-15 years were measured. The mean height of Hausa and Yoruba female children were below the 5th percentile of the United States NCHS at ages 1-2. At ages 4, 11, 13 and 15 statistically significant differences were observed between the heights of Hausa and Yoruba children (P<0.05). Although Hausa subjects were lighter than the US National Center for Health Statistics (NCHS) data, in eight age groups, significant differences were observed between the weight of Hausa and Yoruba children(P<05). Beyond age 3, the Hausa male children had triceps skin fold thicknesses which were less than those of the Yoruba and the NCHS standard. The body mass index or Quetelet’s index (Weight/height2) identified 50.4% and 68.6% of the Hausa and Yoruba children respectively to be malnourished. In the age of genomic science, the recently developed technology involving bio-fortication can be applied to alleviate the problem of protein energy malnutrition in rural Nigeria.

Keywords: Anthropometric Status, Ethic Differences, Rural Nigerian Children, Hausa, Yoruba, Protein Energy Malnutrition, Bio-Fortification.

INTRODUCTION In most of the developing African nations, protein energy malnutrition (PEM) is a serious public health problem. Many of the research investigators consider PEM as the underlying cause of death among children less than 5 years of age (Jelliffe and Jelliffe, 1989; Creswell and Newman, 1993). In the assessment of PEM scant data exists on rural Nigerian communities because of the predominantly urban-based hospitals and the preponderance of qualified nutritionists, epidemiologists and other medical workforce in the urban areas (Ebomoyi, 1986).

E. W. Ebomoyi and J. I. Ebomoyi IJSHIM - Volume 5, Issue 11 (2012), pp. 32-44

Also, not much effort has been devoted to delineating ecological, genetics and genomics effects on the health of children.

In Nigeria, the dire consequences of PEM are most seriously felt in rural areas where children of different ethnic groups, with distinct feeding patterns, reside. Routinely used anthropometric variables for studying nutritional status of children consist of weight for age, height for age and mid-upper arm circumference for age. Although these anthropometric indices are fraught with minor errors due to inaccurate estimation of age especially in rural areas of developing nations with a very high degree of parental illiteracy, the body mass index (weight/height2), is frequently used as it is independent of age and sensitive in detecting degrees of either malnutrition or obesity in children. A combination of methods such as the inclusion of measurement of skin fold thickness can provide pertinent data on subcutaneous fat which is another indicator of the nutritional status of children as it is closely related to the caloric value of the existing staple diet of the community (Jelliffe and Jelliffe, 1989).

There is no reported study assessing the nutritional status of rural Hausa and Yoruba children in Nigeria. This study was therefore designed to compare the nutritional status of Hausa and Yoruba children living in rural areas of Kwara State - Nigeria by measuring their weight, height, head circumference, chest circumference and mid arm circumference. The subcutaneous fat of the children of the two ethnic groups were compared using the skin-fold thickness of the triceps and sub scapular regions.

The Hausa Ethnic Group The Hausas are migrant traders and butchers trading on beef products and many of them in Kwara State live in Jebba, a rural community about 13 miles from Bode Saadu in Kwara State, Nigeria. Anthropologists categorize the Hausas as dark skin ethnic group of mixed genetic stock. Of the Nigerian population (estimated at over 110 million people), over 23 million of them are the Hausa. Essentially, the Hausa constitute the largest ethnic group in West Africa. Demographic data reveals that thirty percent of all Hausa can be found in the north and northwest regions of Nigeria, in the area described as “Hausa land”. They probably migrated from northern Africa around the Sahara desert where their ancestors may have been driven by the war mongering Barbers who themselves were subjugated by Arab invaders (Online Nigeria, 2011). The urban dwelling Hausas are expert traders and a high proportion of them are Moslems. Those living in rural area keep very small herds of cattle near their settlements. Their diet consists primarily of sorghum, millet, maize, rice as well as dairy products. The Hausa have been involved in long distance trading for many centuries. The majority of the traders exchange gold from the Middle East for leather, crafts, and food.

The Yoruba Ethnic Group The Yoruba live in the Guinea Savannah areas of Kwara State. According to Johnson (1956), the people of Yoruba ethnic stock may have sprung from Mecca. The Yoruba of Nigeria primarily occupy the Southwestern region of the country and the ethnic group constitutes over

Ethnic Differences in the Nutritional Status of Nigerian Rural Hausa and Yoruba School-Age Children and the Role of Bio-Fortification to Alleviate Protein Energy Malnutrition

22% of the total Nigerian population. The Yoruba make up the second largest ethnic group of Nigeria, after the Hausa/Fulani ethnic group. However, Ife in Nigeria is believed to be the home of the Yoruba. Genetically, they have typical Negroid features (Pitsch and Danso, 2011). The main occupation of rural Yoruba is subsistent farming. Small scale animal husbandry is also practiced. Over 90% of the Yoruba included in the study were Moslems. The food crops grown in the area include maize, yams, peanuts, Parkia biglobosa nuts, beans, cowpea, cassava and assorted vegetables.

METHODOLOGY This study is a component of an on-going anthropometric study in rural areas of Kwara State Nigeria. The background of the study was given in previous reports (Ebomoyi, 1986; Ebomoyi, 1987). It was carried out at six selected villages in the Moro local government area. The following villages, Ogun Edun, Elemere and Oluru are occupied by the Yoruba people, though a few pastoral Fulani live in temporary settlements in the neighborhood of such rural communities. Over 90% of Hausa subjects live in Jebba while the majority of the Fulani and Yoruba children were measured at Fati Ajegunle and Bode Saadu (Figure 1).

Five research assistants participated in gathering data by visiting each of the selected villages to enlist parental consent for their children who are less than 15 years of age to participate in the study. We received excellent cooperation. Field workers in conjunction with investigator took and recorded the measurement of subjects after the investigator has trained the field workers about the proficient techniques for measuring height, weight, mid upper-arm circumference, head circumference and chest circumference as described by Jelliffe and Jelliffe (1989).

At a test site in one of the neighboring villages, a pretest and assessment of the effectiveness of the research assistants was carried out. Anthropometric measurements were repeated inter- changeably by the field workers to ascertain inter-field workers precision. These results from the pilot testing were not incorporated in the analysis reported.

The children were weighed while wearing light clothes using a bathroom scale. Standing height was measured using a stadiometer calibrated in centimeters with the child barefoot, heels together and with a gentle upward pressure exerted to the mastoid processes. Mid upper-arm circumference was measured with a tape being placed around the arm without compressing soft tissue midway between the acromial process of the scapular and the olecranon of the left arm, to the nearest 1/10 of a centimeter. Since the bone and skin are hardly affected by malnutrition, measurement of arm circumference which encompasses bone, muscles and sub scapular fat and skin reflect essentially the subcutaneous fat and protein status (Jelliffe and Jelliffe1989).

Head circumference was measured by placing a tape firmly around the head over the occipital prominence and just above the supra orbital ridges. The circumference of the chest was taken by placing a tape firmly around the chest at the level of the nipple (Jelliffe and Jelliffe, 1989). A

E. W. Ebomoyi and J. I. Ebomoyi IJSHIM - Volume 5, Issue 11 (2012), pp. 32-44 high proportion of children had no birth certificate therefore their ages were estimated by using historical calendars. Age was round to the nearest year. From previous pilot studies the estimated ages were quite reliable (Jelliffe and Jelliffe, 1989; Ebomoyi, Wickremansinghe and Cherry, 1991).

Data were analyzed for males and females separately. The mean height, weight and mid upper-arm circumferences were computed and expressed as percentage of NCHS standards. Using the 50th percentile or median of height for age, weight for age and mid upper-arm circumference for age, the mean head and chest circumferences were also computed and compared with NCHS standards. Comparisons were made on the NCHC growth chart grid for males and females. To compare inter-ethnic differences among each sex, an analysis of variance (ANOVA) was performed using the un-weighted means approach. The body mass index computed as the weight/height2 (Quetelet’s index), being age-independent, was reported to be quite sensitive and appropriate for this population (Jelliffe and Jelliffe, 1989). The Quetelet’s index was utilized to classify the children into the three categories of nutritional status which included malnourished (0.00126-0.00138), mild malnutrition (0.00139-0.00156) and adequate nutrition (over 0.00156) (Jelliffe and Jelliffe, 1989, Ebomoyi, 1986, Ebomoyi, 1987).

RESULTS Tables 1-3 present anthropometric data for height, weight and mid-upper arm circumference (MAC) for grouped ages 1-15 years in the Fulani/Hausa and Yoruba children. Sample sizes means, standard deviations, percentages of NCHS standards and results of student Neumann keuls’ tests for height, weight and MAC are reported (Keuls, 1952; Shaffer, 2007). Tables 4 and 5 provide data on mean, (+ SD) for head, and chest circumferences and the “student Neumann Keuls” tests for the children of three ethnic groups. Mean height of children is reported separately for each sex (Table 1).

Based on the “Student Neumann Keuls” test, among the males, the Hausas were the tallest in the ten age groups, intermediate in four and smallest in one. The Yoruba school-age children were shortest in seven age groups, intermediate in eight and tallest in one. With the height measurement expressed as a percentage of the NCHS standard, it was only at age one that the Fulani and Yoruba children exceeded 100% of NCHS standard. In contrast, 42.5% of the Hausa children were in the age groups having mean height which exceeded 100% of the NCHS at ages ranging from one to eleven years.

Among the female subjects, the mean height of the Fulani girls exceeded 100% of the NCHS standards only at age seven; the Hausa female children at ages three and nine and Yoruba children in the age group of 3-5 years. Analysis of variance (ANOVA) test was performed to identify any interaction effects between age and ethnicity. The interaction effects was statistically significant (P<0.001).

Ethnic Differences in the Nutritional Status of Nigerian Rural Hausa and Yoruba School-Age Children and the Role of Bio-Fortification to Alleviate Protein Energy Malnutrition

Table 1: Sample size, mean and standard deviations for height of Fulani/Hausa, and Yoruba children in Nigeria (ages 1-15) Hausa Rural Children Yoruba Rural Children

Mean Height (cm) Mean Height (cm) Sex/Age Mean expressed as % of Mean expressed as % of (years) N (cm) S.D. NCHS standard N (cm) S.D NCHS standard

Males

1 12 83 26.87 111.111 24 75.5 17.93 101.071

2 11 88.4 1.5 101.538 41 77 1.5 88.404

3 24 90.75 6.89 94.531 42 82.22 8.49 85.646

4 27 104.5 8.69 101.162 45 91 6 88.093

5 39 113.41 8.41 101.896 38 103.38 7.63 92.884

6 38 114.33 7.42 97.302 31 109.48 6.78 93.174

7 28 124.63 3.07 100.427 46 117.09 5.89 94.351

8 25 123.4 7.09 94.923 62 123.65 5.95 95.115

9 36 133.8 15.97 98.745 33 126.03 6.64 93.011

10 12 141.11 2.83 100.577 35 131.65 7.63 91.872

11 16 146.83 12.97 101.817 21 132.48 6.41 91.135

12 23 142.67 4.16 95.368 30 139.33 8.55 93.135

13 12 142.5 14.85 94.516 49 138.74 8.3 89.51

14 16 151.5 4.5 93.116 60 144.11 8.5 88.574

15 22 161.5 6.36 96.246 55 157.8 9.71 94.041

Females

1 12 64 39.6 85.679 18 60.5 19.7 80.991

2 12 75.5 13.44 86.682 14 71 15.64 81.515

3 11 103 2.5 107.292 11 103 2.5 107.292

4 22 101.5 6.36 98.257 12 110.33 8.31 106.805

5 14 107.5 5.8 97.995 21 110.24 8.2 100.492

6 16 104.16 9.72 89.871 22 109.73 11.44 94.676

7 16 118.16 7.83 96.615 41 119.78 6.23 97.939

8 26 124.67 7.42 97.398 25 125.68 6.43 98.187

9 11 133 1.8 100.075 15 132 9.28 99.302

10 13 127 23.51 91.631 24 134.86 12.91 97.302

11 15 138 1.5 95.37 16 133.5 9.81 92.26

12 22 143.5 2.5 94.47 11 142.73 7.4 93.963

13 17 152 1.5 96.754 16 145.67 7.97 92.742

14 12 153 2.5 95.865 14 151.5 6.43 94.925

15 14 160 1.5 99.317 24 151.75 4.5 94.196

Table 2 provides the mean weight of children of the two Nigerian ethnic groups compared separately for each sex. An ANOVA test showed statistically significant interaction effects between age and ethnicity ((P<0.001). The mean weights of the Nigeria children of the two ethnic groups were predominantly below 100% of the NCHS standard. In only 11 of the 45 groups (24%) was weight above the NCHS standard. Summarized results of the Neuman Keul’s test are contained in Table 2. An ANOVA test revealed statistically significant interaction effect (P<0.001). On comparing the growth curves of the groups of children to the NCHS

E. W. Ebomoyi and J. I. Ebomoyi IJSHIM - Volume 5, Issue 11 (2012), pp. 32-44 curves, the mean heights of all two female groups was below the third percentile at ages one and six. They paralled the median through the age nine, but dropped thereafter and were near the third percentile at age 15 years.

Table 2: Sample size, mean and standard deviations for weight of Fulani/Hausa, and Yoruba children in Nigeria (ages 1-15) Hausa rural children Yoruba rural children

Mean (cm) Mean (cm) Student Sex/Age Mean expressed as % of Mean expressed as % of Neuman (years) N (cm) S.D. Harvard standard N (cm) S.D Harvard standard Kaul's Test

Males

1 12 8 1.41 80.808 24 7.75 0.96 78.283 F Y H 2 11 13 1.5 104.839 41 9 1.5 72.58 Y F H 3 24 10.28 3.52 70.897 42 13 4.24 89.655 H Y F 4 27 15.83 3.72 92.909 45 14.92 3.37 90.424 Y H F 5 39 14.39 5.19 74.175 38 14.94 3.23 77.01 H Y F 6 38 18.44 3.01 84.201 31 17 6.85 77.626 F Y H 7 28 18.25 3.45 74.408 46 18.8 2.29 76.736 F H Y 8 25 20.09 1.95 73.59 62 20.36 2.69 74.579 H Y F 9 36 29.4 12.48 98.328 33 21.36 2.17 71.438 Y F H 10 12 31.5 3.53 96.626 35 25.76 5.48 79.018 F Y H 11 16 40.67 12.98 115.54 21 26.52 4.82 75.341 Y F H 12 23 31.33 3.06 81.802 30 29.59 8.32 77.256 F Y H 13 12 45.5 3.06 105.45 49 28.68 3.21 67.962 Y F H 14 16 45.1 1.5 92.418 60 34 7.52 69.672 F Y H 15 22 47.1 8.48 86.422 55 37.79 9.47 69.339 F Y H

Females

1 12 6 1.41 60.606 18 6 1.31 60.606 F Y H 2 12 7 1.41 56.452 14 8.75 2.22 70.564 H F Y 3 11 15.14 1.1 104.414 11 15 1.5 103.448 F Y H 4 22 15.5 0.71 93.939 12 16.04 1.6 97.212 F H Y 5 14 19 6.68 101.064 21 18.95 8.23 100.957 F Y H 6 16 18.17 3.76 86.114 22 18.18 2.59 86.161 H Y F 7 16 21.5 3.89 90.717 41 20.56 3.15 86.751 F Y H 8 26 33.17 23.82 126.122 25 24.28 12.2 92.319 F Y H 9 11 28 1.5 96.886 15 25.07 4.9 86.747 F Y H 10 13 34 1.65 106.583 24 27.17 5.76 86.865 F Y H 11 15 34 1.74 95.238 16 28.33 5.16 79.365 F Y H 12 22 38.14 1.5 96.071 11 33.41 5.53 84.156 Y F H 13 17 39.14 2.5 87.071 16 37.17 9.77 82.784 Y F H 14 12 40.14 7.5 81.585 14 40 4.76 81.301 F Y H 15 14 46.14 1.66 89.592 24 42.5 6.13 82.524 F Y H

Hausa males were generally near or above the median through age 11 years when the mean height were between the third and fifth percentile thereafter. The Yoruba were 3rd to 5th percentile beyond the third year.

Ethnic Differences in the Nutritional Status of Nigerian Rural Hausa and Yoruba School-Age Children and the Role of Bio-Fortification to Alleviate Protein Energy Malnutrition

The mean and “Student Neuman keuls” test for arm circumference measurement for Hausa and Yoruba children compared to with the NCHS are summarized in Table 3. All the Yoruba children and 94% of the male groups had arm circumference measurements which were above the NCHS median. An ANOVA procedure showed statistically significant interaction effects between age and ethnicity (F28, 1146=9.54, P<.05). Among the female subjects, 53% of the Hausa groups, and 13% of the Yoruba had MAC measurements which were above the NCHS median.

Table 3: Sample size, mean, standard deviations, and student Newman Keul's test for arm circumference of Hausa and Yoruba children in Nigeria (ages 1-15) Hausa rural children Yoruba rural children

Mean (cm) Mean (cm) Sex/Age Mean Mean N S.D. expressed as % of N S.D expressed as % of (years) (cm) (cm) NCHS standard NCHS standard

Males

1 12 14 1.5 87.5 24 12.75 1.44 79.69

2 11 15 1.2 92.625 41 13 1.5 79.75

3 24 14.87 1.44 91.79 42 15.04 1.25 92.84

4 27 15.92 1.28 94.201 45 14.9 1.28 88.17

5 39 16.5 0.76 97.059 38 15.69 1.2 92.29

6 38 16.28 0.67 94.104 31 15.83 1.13 91.5

7 28 16.38 1.19 92.022 46 15.83 0.97 88.93

8 25 16.6 0.55 89.674 62 16.52 1.21 89.78

9 36 18.8 1.1 98.947 33 16.6 0.95 87.37

10 12 20 1.55 101.523 35 17.81 1.19 90.41

11 16 21.31 3.24 104.561 21 17.89 2.98 88.14

12 23 22 3.05 103.773 30 18.37 1.85 86.65

13 12 22.66 1.41 102.072 40 19.21 1.58 86.53

14 16 24.5 1.77 105.603 60 19.78 1.79 85.26

15 22 25 0.71 100 55 20.2 0.84 80.8

Females

1 12 14 1.2 89.744 18 13.54 1.09 86.795

2 12 14.5 2.8 91.195 14 12.75 1.89 80.189

3 11 15 0.5 94.34 11 15 1.5 94.34

4 22 16.15 0.4 95.562 12 17.33 4.21 103.544

5 14 16.5 4.5 97.633 21 17.5 1.08 102.55

6 16 16.92 1.4 97.804 22 16.25 1.39 93.931

7 16 17.83 2.48 100.169 41 17.73 5.59 99.607

8 26 18.08 1.56 98.261 25 17.22 1.38 93.587

9 11 20.4 1.5 106.806 15 18.2 1.58 95.288

10 13 21.4 2.3 107.538 24 18.46 1.66 92.704

11 15 22.1 1.5 106.763 16 19.17 1.86 92.609

12 22 23.11 1.91 107.488 11 20.05 1.75 93.256

13 17 24.16 2.3 107.857 16 20.37 2.05 90.937

14 12 26.17 2.5 112.802 14 22 1.5 94.83

15 14 28.55 4.56 117.008 24 22.37 1.45 91.68

E. W. Ebomoyi and J. I. Ebomoyi IJSHIM - Volume 5, Issue 11 (2012), pp. 32-44

From Table 4, an analysis of variance (ANOVA) assessment of the head circumference in male subjects revealed statistically significant interaction effects between age and ethnicity (F28, 665+12.08, P<0.05). Table 5, presents the chest circumference by sex and ethnic groups. The interaction between age and ethnicity was statistically significant (F28, 665+21.38, P<0.01).

Table 4: Sample size, mean, standard deviation and student Newman Kaul's test for head circumference of Fulani/Hausa and Yoruba children in Nigeria (Ages 1-15) Hausa rural children Yoruba rural children

Sex/Age Mean Mean Student (years) N (cm) S.D. N (cm) S.D Kaul's Test

Males

1 12 44 1.5 24 37.05 1.72 Y H F

2 11 48 1.66 41 45 1.5 Y H F

3 24 49.5 1.29 42 48.5 0.71 Y H F

4 27 50 1.78 45 50 1.58 Y H F

5 39 52.36 1.25 38 50.38 1.69 Y F H

6 38 52.44 2.79 31 52.08 2.38 F Y H

7 28 52.8 0.84 46 51.79 2.02 F Y H

8 25 52.99 4.22 62 52.36 2 F Y H

9 36 54 1.41 33 53.45 1.38 F Y H

10 12 52.66 2.16 35 52.64 2.28 Y F H

11 16 52.5 3.89 21 52.33 1.36 H Y F

12 23 53.5 2.12 30 51.84 1.99 Y F H

13 12 53.6 2.5 49 53.16 4.46 Y F H

14 16 54.1 1.67 60 53.59 1.46 Y F H

15 22 54.5 1.74 55 53.61 2.3 Y F H

Females

1 12 43 1.6 18 43.06 1.88 F H Y

2 12 44.5 0.71 14 45.75 1.71 F H Y

3 11 52 1.5 11 45.88 1.5 F Y H

4 22 52.1 0.71 12 49.63 2.01 F Y H

5 14 52.75 1.71 21 49.99 3.13 F Y H

6 16 52.66 2.58 22 50.73 2.51 F Y H

7 16 53.33 1.97 41 51.39 1.52 F Y H

8 26 53.5 2.36 25 51.13 1.97 Y F H

9 11 52.06 1.7 15 52.43 1.72 H Y H

10 13 52.66 1.76 24 52.5 1.64 Y F F

11 15 53.8 1.22 16 52.33 2.16 Y F H

12 22 53 1.4 11 52.77 1.4 F Y H

13 17 53.5 1.5 16 53.41 1.02 Y H F

14 12 54 3.6 14 54.5 1.41 H Y F

15 14 56 6.66 24 56 0.58 F Y H

Using the BMI as a measure of nutritional status, the overall data revealed 50.4% and 68.6% of the Hausa and Yoruba children respectively to be malnourished; with a quarter experiencing moderate malnutrition and only one Yoruba two year old with marasmus. Regarding nutritional

Ethnic Differences in the Nutritional Status of Nigerian Rural Hausa and Yoruba School-Age Children and the Role of Bio-Fortification to Alleviate Protein Energy Malnutrition status, there were considerable differences among the two ethnic groups. Among the Yoruba subjects one in two children was mildly malnourished, one in five moderately so, and less than one-third were adequately nourished. One-half of the Hausa children were adequately nourished, with about a quarter each among mildly and moderately malnourished.

Table 5: Sample size, mean, standard deviation and student Newman Keul's test for chest circumference of Fulani/Hausa and Yoruba children in Nigeria (Ages 1-15) Hausa rural children Yoruba rural children

Sex/Age Mean Mean Student (years) N (cm) S.D. N (cm) S.D Keul's Test

Males

1 12 46 1.4 24 40.5 8.51 Y F H

2 11 52 1.5 41 46 1.5 Y H F

3 24 51 2 42 51 1.41 Y F H

4 27 56.83 4.17 45 51.5 1.73 F Y H

5 39 56.14 2.55 38 55.75 4.06 Y F H

6 38 57.28 2.71 31 55 2.65 F Y H

7 28 58.25 1.58 46 58.08 2.97 F Y H

8 25 58.79 3.77 62 58.69 3.15 F Y H

9 36 61.39 7.73 33 61.21 3.76 Y F H

10 12 66.5 3.54 35 63.57 3.83 Y F H

11 16 68.67 5.85 21 64.37 4.23 Y H H

12 23 67.33 1.53 30 65.13 3.37 Y F F

13 12 69.5 10.61 49 66.89 6.05 Y F H

14 16 70.11 1.5 60 66.99 6.5 Y F H

15 22 80.4 4.5 55 67.5 1.5 Y F H

Females

1 12 43 2.83 18 43.25 2.04 H Y F

2 12 51.5 10.61 14 49 6.78 F Y H

3 11 53 1.5 11 53 1.5 F Y H

4 22 54.5 0.71 12 54.96 1.94 H Y F

5 14 57.01 6 21 54.47 3.73 Y F H

6 16 53.17 6.99 22 53.99 3.37 H Y F

7 16 58.33 4.51 41 56.63 3.07 Y F H

8 26 59.5 1.5 25 58.59 5 Y F H

9 11 67 1.4 15 61.9 5 Y F H

10 13 68 6.03 24 64.86 4.69 F Y H

11 15 68.1 1.5 16 61.83 6.49 Y F H

12 22 70 1.9 11 66.41 9.5 Y H F

13 17 72 3.4 16 71.5 6.69 Y H F

14 12 73.5 1.44 14 76 4.55 H F Y

15 14 74.5 2.5 24 80.5 2.38 H F Y

E. W. Ebomoyi and J. I. Ebomoyi IJSHIM - Volume 5, Issue 11 (2012), pp. 32-44

DISCUSSION From the measurement of height, weight, MAC and the Quetelet’s indices among the subjects, children of Hausa ethnic group had the largest anthropometric indices. Specifically male Hausa children had height measurement which was above the median of NCHS standard in seven age groups, while the Yoruba subjects attained this median only in the age groups of 3 through 5. The Hausa females did so sporadically at ages 3 and 7.

On weight measurements, none of the Yoruba male groups attained the NCHS median, although the females did at ages three and five. The Hausa male children at ages two, eleven and thirteen, and the Hausa females at ages three, four, eight and ten years attained the median of the NCHS whereas, none of the male Yoruba age groups attained the NCHC median. We found that 26.1% of the Hausa male children were in groups whose mean MAC measurements exceeded the NCHS median.

Reasons for the ethnic difference can be conjectured. On the one hand, since the majority of the Hausa subjects are children of cow meat sellers, the possibility of their being fed a protein rich diet because of the availability of such protein rich diet is quite high (Owolabi, Mac-Inegite, Olowoniyan and Chindo, 2012, Oninla, Owa, Onayade and Taiwo, 2007). On the other hand, the Yoruba subjects are children born to farmers for whom the high price of protein –rich meat products with vital amino-acids, and rich source of zinc, places them out of reach, and so unfortified sorghum, millet, yams, maize and assorted vegetables constitute the staple foods. Simons (1971) has emphasized in his report, that it is the caloric and protein intakes of only the Hausa that seems to be adequate, based on the United Nations Food and Agricultural Organization (UNFAO) stipulated requirements.

African children of school-age born to the elite class more often than not have anthropometric measurements either similar to or greater than the standards derived from North America and British children. This was found in the first phase of our investigations (Ebomoyi, 1986). In female urban children attending the University of Ilorin, Kwara state, Nigeria elementary school children had mean arm circumference that exceeded 100% of the National Center for Health Statistics (NCHS) median.

Using the Quetelet’s index, 24.4% of Hausa and 19.8% of Yoruba school-age children were in groups classified as moderately malnourished, while 49.7% of Hausa, and 31.4% of Yoruba were at risk of protein energy malnutrition. This study has revealed that children in these rural villages were at risk of protein energy malnutrition. Recent anthropometric studies conducted in Oyo State in Nigeria have confirmed the findings reported here. In the same vein, for ecological reasons, most children in the villages of developing nations are not provided adequate primary health care services, and they consume unclean water. The bulk of staple foods consumed in the area consist of cassava (Manihot esculenta), yam (Dioscorea rotundata), coco yam (Xanthosoma sagittifolium), guinea corn and maize. These food crops are predominantly rich in carbohydrate and due to socio-cultural observances children are not routinely fed on food items rich in protein and vital amino-acids (Ebomoyi, 1986; Ebomoyi, 1987). The observations

Ethnic Differences in the Nutritional Status of Nigerian Rural Hausa and Yoruba School-Age Children and the Role of Bio-Fortification to Alleviate Protein Energy Malnutrition from WHO (2003) have emphasized how malnutrition including overt nutrient deficiencies as well as diet-related chronic diseases account for more deaths than any other etiological agents of mortality and morbidity of over 20 million children worldwide (WHO and FAO, 2003). Furthermore, PEM contributes to increased morbidity and mortality, stunted mental and physical growth, and related national socioeconomic underdevelopment. Kennedy, Natel and Shetty (2003) have accentuated their observations about the impact of micronutrient malnutrition alone which afflicts more than two billion people, mostly among the least- developed nations. Among these resource poor-nations, deficiencies involving Fe, I, Zn, and vitamin A are most prevalent (Kennedy et al., 2003). Worldwide, more than five million childhood mortalities occur from micronutrient malnutrition each year. Leading international experts in economics have identified investing in strategies to reduce malnutrition as the singular most cost-effective investment governments can make (Lancet, 2007).

Role of Bio-Fortification Rebecca Bailey (Bailey, 2007) defined bio-fortification as a method of breeding crops to increase their nutritional value. Bio-fortification is un-identical to ordinary fortification because it focuses on enhancing plant foods and making them more nutritious as the plant grows rather than having nutrients added to the foods when they are being processed. This process is an improvement on the mere fortification adopted when attempting to provide nutrients to the impoverished rural communities, more so as they do not have access to commercially fortified foods (Bailey, 2007). Besides, the process can be carried out through conventional selective breeding or through genetic engineering. Bio-fortification is conceived as the innovative upcoming technique for addressing the protein energy malnutrition problems in many developing nations (Johns and Eyzaguirre, 2007, Bailey, 2007).

Since there are many fruits which can be utilized to supplement the diet of the school-age children in Nigeria, innovative scientific interventions are needed to fortify the following ubiquitous fruits in Nigeria. These fruits include the African pear (Dacryodes edulis), soursop (Anona muricata) pine apples, bananas and the African mangoes (irvingia gabonensis) which are quite nutritious and crops will grow in several rural areas of Nigeria. The examples of other food crops which can be enhanced through bio-fortification are maize, yams, cassava, soybeans, sunflower, sweat potato and tomatoes. Maize is rich in lysine, tryptophan, and protein and phytate, while potato has protein and methionine and tomato is very rich in fats, oil, gamma-linolenic acid, folate and carotenoids, lycopene, beta-carotene, zanthophylis and flavonoid.

Owing to the increased prevalence of PEM and other infections among the Yoruba school-age children, it seems expedient to educate the rural Yoruba farmers and parents about the need to incorporate animal husbandry into their agricultural practices so as to reduce the incidence of protein energy malnutrition. The provision of a balanced diet to school-age children can ameliorate not only their cognitive and physical development but also enhance their resistance against viral and parasitic diseases which are very endemic in rural Nigeria. At the rural

E. W. Ebomoyi and J. I. Ebomoyi IJSHIM - Volume 5, Issue 11 (2012), pp. 32-44 primary health care center in Nigeria, a school lunch program can make significant impact in alleviating the prevalence of nutritional deficiency of school-age children in Nigeria.

ABOUT THE AUTHORS Dr. E. William Ebomoyi is a professor in the Department of Health Studies, College of Health Sciences, Chicago State University, Chicago Illinois and he serves as a Consultant in International Health for the American Public Health Association (APHA). He has published extensively in epidemiologic science, genomics, HIV/AIDS pandemics and sustainable development. He is the author of two books: Community Medicine a global perspective, Belmont Star Press 1998, pp. 1-420 and Globalization Health and Human Rights Dubuque, Iowa Kendall Hunt Press 2011, pp. 1-275 He formerly served as AIR QUALITY COMMISSIONER for the City of Greely, Greeley Colorado, USA.

Dr. Josephine I. Ebomoyi is an adjunct professor of Biology, College of Arts and Sciences, Saint Xavier University, Chicago Illinois She received her post-doctorate certificate from the Center for Teaching and Learning in the West and a Ph.D. in Biological science from the University of Northern Colorado in Greeley Colorado. She continues to serve as an International consultant in setting up public health microbiological laboratories and she has published extensively in medical educational and public health journals.

ACKNOWLEDGMENTS I write to thank Mr. Job Bello of Shao rural community in the Moro-local government area of Kwara State, Nigeria for his commitment in ensuring that this project was completed on schedule. The parents of the project participants played a crucial role in enabling our research team to accomplish this project. The project was fund in part by University of Ilorin Senate Research grant on Primary Health Care and the Welcome Nigeria Fund.

REFERENCES Ashcroft, M. T. & Lovell, H. G. (1964) The heights and weights of Jamaican children of various racial origin, Tropical Geographical Medicine, Volume 4, pp. 346-353. Anonymous (1996) Viewpoint: The optimal breeding strategies to increase the density of promoter compounds and micronutrient minerals in seeds; caution should be used in reducing antinutrients in staple food crops, Micronutrient Agriculture, 1, pp. 20-22. Bailey, R. (2007) ‘Biofortification’ one of the world’s primary foods, accessed online September 12, 2011: http://www.dartmouth.edu/~news/releases/2007/11/19a.html. Bouis, H. E. & Welch, R. C. (2010) Biofortification - A sustainable agricultural strategy for reducing micronutrient malnutrition in the global south, Crop Science, Vol. 50, pp. S20- S32. Ebomoyi, E. W. (1994) Prevalence of Pediculosis Capitis in urban primary school children in Nigeria, Journal of the National Medical Association, 86(11), pp. 861-864.

Ethnic Differences in the Nutritional Status of Nigerian Rural Hausa and Yoruba School-Age Children and the Role of Bio-Fortification to Alleviate Protein Energy Malnutrition

Ebomoyi, E., Parakoyi, B. D. & Omonisi, M. K. (1991) Nutritional status and umbilical hernia in Nigerian school children of different ethnic groups, Journal of the National Medical Association, Vol. 83, pp. 905-909. Ebomoyi, E., Wickremasinghe, A. R. & Cherry, F. F. (1991) Anthropometric indicators of children’s nutrition in two Nigerian communities, Journal of Biosocial Science, Vol. 23, pp. 33-38. Ebomoyi, E. W. & Omonisi, M. K. (1991) Human ecology and behavior in onchocerciasis control in isolated villages of Kwara State, Nigeria, AMBIO A Journal of Human Environment, 20(1), pp. 43-57. Ebomoyi, E. (1988) Nutritional beliefs among rural Nigerian mothers, Ecology of Food and Nutrition: An International Journal, Vol. 22, pp. 43-52. Ebomoyi, E. (1988) Pediculosis capitis among primary school children in urban and rural areas of Kwara State, Nigeria, U. S. Journal of School Health, 58(3), pp. 101-103. Ebomoyi, E. & Adeniyi, J. D. (1987) Promoting primary health care in contiguous urban and rural populations: Nigeria, International quarterly of Community Health Education, 7(4), pp. 353-366. Ebomoyi, E. (1987) Nutritional status and morbidity of children in isolated villages of Kwara State, Nigeria, Ecology of Food and Nutrition: An International journal, 10(1), pp. 15-27. Ebomoyi, E. (1986) A comparative study of the nutritional status of children in urban and rural areas of Kwara State, Nigeria, Ecology of Food and Nutrition: An International Journal, 19(1), pp. 19-30. Jelliffe, D. B. & Jelliffe, E. F. P. (1989) Community nutritional assessment with reference to less technically developed countries, Oxford University Press, pp. 245-350. Johns, T. & Eyzaguirre, P. (2007) Biofortification, biodiversity and diet: A search for complementary applications against poverty and malnutrition, Food Policy, 32, pp. 1-24. Johnson, S (1956) History of the Yoruba from earliest times to the beginning of British protectorate, Lagos, Nigeria government printer, pp. 8-37. Joshua Project (2011) The Hausa of Nigeria ethnic people profile, accessed online September 12, 2011: http://www.joshuaproject.net/people-profile.ph.p?peo3=1207&rog3=NI Kennedy, G., Natel, G. & Shetty, P. (2003) The Scourge of ‘Hidden Hunger’: Global Dimensions of Micronutrient Deficiencies, Food, Nutrition and Agriculture, 32, pp. 8-16. Lancet (Editorial, 2007) Global childhood malnutrition, Lancet, 367, p. 1459. Oninla, S. O., Owa, J. A., Onayade, A. A. & Taiwo, O. (2007) Comparative study of nutritional status of urban and rural Nigeria school children, accessed online April 23, 2012: http://tropej.oxfordjournals.org/content/53/1/39.abstract Owolabi, A. O., Mac-Inegite, J. O., Olowoniyan, F. O. & Chindo, H. O. (2012) A comparative study of the nutritional status of children in villages in northern Nigeria using and not using soya beans, accessed online: Http://www.greenstone.org/greenstone3/nzd1?a=d&d=HAS H0111cf560bae8f7ba06.2.2pp&c=hd&sib Pitsch, A. & Danso, A. (2011) The Yoruba of Nigeria, accessed online September 12, 2011: http//:www.nigerdeltacougress.com/wartitles/yorubas_of_nigeria.htm

A. King and M. Biggs IJSHIM - Volume 5, Issue 11 (2012), pp. 45-52

Full Article Available Online at: Intellectbase and EBSCOhost │ IJSHIM is indexed with Cabell’s, JournalSeek, etc.

International Journal of Social Health Information Management

DIABETES: AN EDUCATIONAL OPPORTUNITY

Anita King and Maureen Biggs University of South Alabama, USA

ABSTRACT he burden of care for the diabetic patient on existing resource funds is an emerging health care issue due to the increasing global incidence of this chronic illness. T Implementing evidence-based practice with a theoretical framework as a foundation of care provides a guideline for a collaborative quality initiative. This paper describes a call to action to provide a quality improvement project that would satisfy the needs of patients with diabetes, the local community, and the organization involved in the planned innovation. The pilot project developed after completing a thorough assessment of the needs of the stakeholders, a comprehensive review of the literature, and a collaborative effort to provide a quality improvement plan. The outcome data is useful in the development of future initiatives that address the issue of diabetes self-management skills in an effort to improve lifestyle choices, readiness to learn, and self-efficacy so that an improvement in health is realized by the patient with chronic illness. Management of resource funds by providing patient centered, timely, effective, and efficient care resulting in healthier outcomes is a challenge for the future in health care.

Keywords: Self-Management, Diabetic Group Education, Chronic Illness Care, Freire’s Theory of Pedagogy, Access to Care, IOM Aims.

INTRODUCTION Statistics regarding the number of patients with diabetes demonstrate the urgent need to provide quality care for these chronically ill patients. Diabetes is a global concern encompassing nearly a quarter of a billion people (World Health Organization, 2011). Now imagine a health care system where innovative leaders engage stakeholders to translate evidence into practice. Apply that innovative practice to the most vulnerable population of patients with diabetes as they experience hospitalization for the multitude of co-morbidities relative to the disease process. The article describes one such population and the change initiative developed to address the needs of this health care issue found throughout the world.

Diabetes: An Educational Opportunity

BACKGROUND The purpose of the project was to improve access to care for patients with diabetes after hospitalization by the provision of free monthly diabetes educational classes at the hospital under the guidance of a certified diabetic educator (CDE). Standards of care in the management of patients with diabetes include assessing the quality of life, providing self- management education, and lowering the HgbA1C level to less than 7.0 (Executive Summary, 2008). The provision of education is an important component of diabetic care noted as well by the U.S. Department of Health and Human Services (2008), particularly with the timely utilization of a CDE. The provision of timely care for the project also included the initiation of chronic illness care into the acute hospital setting and the initiation of hospital staff nurses into the educational setting.

In addition to meeting the Institute of Medicine (IOM) aim for timely care, the project also provided an opportunity to develop patient centered care through the determination of and provision for each patient’s readiness to learn and educational needs. The project also provided the opportunity for efficient care through the enhancement of patient’s self- management skills in a cost-effective manner. Effective care was the fourth IOM aim for the project with the opportunity to improve lifestyle choices, improve access to chronic illness care, and improve the health of patients with diabetes.

PROJECT DESCRIPTION Needs Assessment The objective of the project’s design was to improve access to chronic illness care for patients with diabetes after admission and subsequent discharge from Hood Memorial Hospital, a critical access facility committed to providing quality care in the small rural community of Amite, Louisiana. Addressing the gap in quality care through changes in the provision of care for patients with chronic illness adds value to the system (Wagner et al., 2001). In order to identify a gap in quality care, a needs assessment was performed initially using qualitative and quantitative data. Information on the organization’s admissions among the diabetic population confirmed an average of one-third, or 20 of the 60 annual diabetic admissions were patients from the author’s practice. Restrictions on length of stay criteria led to a loss of 20% of reimbursement dollars estimated as a $7,000 loss for the hospital for the 20 patients admitted with diabetes in the year prior to the project.

An assessment of the organization’s nursing staff through the Assessment of Primary Care Resources and Supports for Chronic Disease Self Management (PCRS) questionnaire demonstrated little or no organizational support for chronic illness care (Robert Wood Johnson Foundation, 2006). The mission and goals of the organization provide for a team approach in the provision of cost effective care. An ensuing discussion of the findings at the monthly nursing staff meeting assisted in the development of plans for strategies to initiate improvements and engaged the staff stakeholders in the project. The strategies discussed addressed cost effective care through a decrease in length of stay with minimal expenditures

A. King and M. Biggs IJSHIM - Volume 5, Issue 11 (2012), pp. 45-52 by utilizing free or low cost resources for the educational needs of patients with diabetes. The strategies to involve the staff, patients, and community in the educational project with organizational support represented an effective team approach.

A review of the data for the 20 patients with diabetes admitted to the hospital for the year prior to the project noted that eleven of the patients represented the population of interest for the project. The eleven patients satisfied the inclusion criteria of type 2 diabetes, non-pregnant adults without mental illness, ambulatory, self-care, and living in the community. All of the patients demonstrated a deficit in self-management knowledge, had poorly controlled diabetes, or were responsible for a loss of reimbursement dollars through prolonged hospitalization.

Evidentiary Summary While the needs assessment identified a gap in quality care among hospitalized patients with diabetes, an executable work plan is required to provide a valued outcome (Harris, Roussel, Walters, & Dearman, 2011). A review of the literature pertaining to the comprehensive overview of the project revealed two Level I studies and one Level II-2 study supporting the intervention of class instruction in self-management skills for patients with diabetes (Castillo, et al., 2010; Davies et al., 2008; Ridgeway et al., 1999). Support for self-management training for health improvement is supported in two Level I studies (Norris, Engelgau, & Narayan, 2001; Norris, Lau, & Smith, 2002). There were two Level I studies supporting the process of a group setting for the education (Deakin, McShane, Cain, & Williams, 2005; Sarkadi & Rosenqvist, 2004). Additionally, two Level II-2 studies support patient activation to learn as an important part of HbA1C improvement potential (Peterson & Hughes, 2002; Sarkadi, Veg, & Rosenqvist, 2005). A review of the literature supported an improvement in areas associated with diabetes self-management by providing group education. The anticipated response for the project designed to improve access to care was to provide the patients with diabetes with class instruction, to disseminate an array of self-management skills, to promote an improvement in health, and to decrease length of hospitalization for an improvement in reimbursement dollars for the organization.

Intervention The intervention phase began with the approval of the organization’s administration and Internal Review Board for the University of South Alabama. Patients with diabetes received a recommendation upon discharge from the hospital to attend a diabetic class provided monthly at the hospital by a CDE. Recruitment and consent occurred for all patients satisfying the inclusion criteria in the first six weeks of the project. Upon consent, each patient underwent an assessment through the Readiness for Change, Self-Efficacy, and Lifestyle questionnaires along with baseline HbA1C levels (Robert Wood Johnson Foundation, 2005a; 2005b; 2004). The data revealed deficits for all of the patients in self-efficacy, lifestyle choices, and educational level. HbA1C levels were above 7.0 for five of the six patients, and only one of the six patients had attended a class provided by a CDE at any time in the past.

Diabetes: An Educational Opportunity

Susan Holden, R.N., CDE, the Executive Director of the Louisiana Diabetes Foundation began providing monthly classes at the hospital. For the next 14 weeks, each month revealed formative data collected in the form of attendance records, expenditures for the classes, and reimbursement savings for the hospital. Telephone contact for the patients occurred at least one time throughout the 14 weeks to obtain feedback on the class instruction while the nursing staff discussed the project at each monthly staff meeting. Discussions of barriers to care and strategies to overcome the barriers created a decision point in the project. Two revisions were made with an inclusion of Jennifer Marine, MS, RD, LDN, CDE to provide a dietician CDE in addition to the registered nurse CDE, and to provide class instruction at a variety of times including morning, afternoon, and evening. One revision was made to ensure sustainability through the certification of at least one of the staff nurses to provide class instruction for diabetic education should a CDE not be available for a monthly class.

THEORETICAL FRAMEWORK The educational component of the practice project lends itself to the works of theorist Paulo Freire, a Brazilian educationalist with innovative ideas that have influenced and inspired global informal education in the twentieth century (Bartlett, 2005). Freire’s Theory of Pedagogy emphasized respectful dialogue between teacher and student, informed action that enhances the community, the development of student consciousness in order to transform reality, utilizing situational experience of the students as an educational approach, and educator humility to demonstrate a willingness to learn from the student (Smith, 1997, 2002). In conducting a preliminary needs assessment, baseline data on the educational needs, health, and lifestyle of the patients, and performing revisions to meet additional needs of the patients determined through feedback during the intervention phase, the project utilized Freire’s approach to enhance the attainment of valuable outcomes.

FINDINGS At the conclusion of the project, four of the six patients returned to repeat the Self-Efficacy, Lifestyle, and Readiness for Change questionnaires while the nursing staff repeated the PCRS questionnaire with improvements in responses for all of the tools. Appendix A provides a graph of the data on the four questionnaire outcomes. Three of the six patients attended a class while one of the patients requested and received individual education through home health care. Four of the six patients provided a repeat HbA1C level with all four patients exhibiting an improvement. Appendix B provides a graph of the data for the changes in HbA1C levels. Although the organization realized a decrease in reimbursement losses from 20% to 14% for reimbursements received for any of the initial six patients with hospitalizations during the project, the dollar value for the savings was less than the expenditures for the monthly class educational intervention. Appendix C provides a graph comparing the monthly expenditures and savings realized by the project.

When determining the success or failure of the project with the outcome data, the primary concern for success is the demonstration of patient improvement through an interest in chronic

A. King and M. Biggs IJSHIM - Volume 5, Issue 11 (2012), pp. 45-52 illness self-management with a meaningful improvement in health (DiCenso, Guyatt, & Ciliska, 2005). The outcome data with a comparison of the positive outcomes for the patient parameters with one negative outcome and one positive outcome for the financial parameters presents a mixed response. However, a determination of overall success or failure for the project is in favor of positive findings.

CONCLUSION Discussion The project purpose to improve access to care for patients with diabetes following hospitalization through class instruction followed the guidelines of the IOM in providing timely, patient centered, efficient and effective care. Using information from a needs assessment was essential to the identification of a gap in quality care at the patient, community, and organizational level. The development of an executable work plan based on a comprehensive literature review and Freire’s work provided the necessary evidence-based practice guidelines for the intervention.

Recruitment and assessment of all patients meeting inclusion criteria occurred at the inception of the project’s intervention phase. Monthly classes ensued with a collection of data throughout the project to evaluate the process. The process evaluation data led to revisions, and the project continued for a total timeframe of five months. A repetition of the same tools utilized at the beginning of the project occurred upon completion of the project for a comparison of data to determine outcomes. All patient parameters demonstrated improvement in outcomes, while financial parameters demonstrated a mixture of gains and losses for the organization.

Future Implications The clinical relevance of the project primarily focuses on the improvements in health and self- management skills for patients with diabetes. The project demonstrated support for the use of CDEs with group education to provide a valuable asset in the care of patients with diabetes. Further attention is required for the expenditures necessary to provide education to determine strategies to overcome the barrier of costs outdistancing savings for the organization. Engaging the acute care organization in chronic illness care as an education source for the patient with diabetes is an important component of success for the future of health care.

REFERENCES Bartlett, L. (2005) Dialogue, knowledge, and teacher-student relations: Freirean pedagogy in theory and practice, Comparative Education Review, 49, pp. 344-364, accessed online: http:// www.tc.columbia.edu/faculty/bartlett/publications/pdf/49_3cer.pdf Castillo, A., Giachello, A., Bates, R., Concha, J., Ramirez, V., Sanchez, C., Pinsker, E. & Arrom, J. (2010) Community-based diabetes education for Latinos: The diabetes empowerment education program, The Diabetes Educator, 36(4), pp. 586 - 594, doi: 10.1177/0145721710371524

Diabetes: An Educational Opportunity

Davies, M. J., Heller, S., Skinner, T.C., Campbell, M.J., Carey, M.E., Cradock, S., Dallosso, H. M., Daly, H., Doherty, Y., Eaton, S., Fox, C., Oliver, L., Rantell, K., Rayman, G. & Khunti, K. (2008) Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: Cluster randomized controlled trial, British Medical Journal, 336(7642), pp. 491 – 495, doi: 10.1136/bmj.39474.922025.BE Deakin, T. A., McShane, C. E., Cade, J. E. & Williams, R. (2005) Group based training for self- management strategies in people with type 2 diabetes mellitus, Cochrane Database of Systematic Reviews, 2, doi: 10.1002/14651858.CD003417.pub2. DiCenso, A., Guyatt, G. & Ciliska, D. (2005) Evidence-based nursing, St. Louis, MO: Elsevier Mosby. Executive summary: Standards of medical care in diabetes – 2008. (2008) Diabetes Care, 31, S5-S11, doi: 10.2337/dc08-S005 Harris, J. L., Roussel, L., Walters, S. E. & Dearman, C. (2011) Project planning and management, Sudbury, MA: Jones & Bartlett Learning. Norris, S. L., Engelgau, M. M. & Venkat Narayan, K. M. (2001) Effectiveness of self- management training in type 2 diabetes, Diabetes Care, 24(3), 561-587. Retrieved from: http://www.care.diabetesjournals.org/ Norris, S. L., Lau, J. & Smith, S. J. (2002) Self-management education for adults with type 2 diabetes, Diabetes Care, 25(7), pp. 1159-1171, Retrieved from: http://www.care.diabete sjournals.org/ Peterson, K. A. & Hughes, M. (2002) Readiness to change and clinical success in a diabetes educational program, Journal of the American Board of Family Practice, 15(4), pp. 266- 271, accessed online: http://www.journalseek.net/cgi-bin/journalseek/journalsearch.cgi?fiel d=issn&query=0893-8652 Ridgeway, N. A., Harvill, D. R., Harvill, L. M., Falin, T. M., Forester, G. M. & Gose, O. D. (1999) Improved control of type 2 diabetes mellitus: A practical education/behavior modification program in a primary care clinic, Southern Medical Journal, 92(7), pp. 667-672, accessed online: http://www.journals.lww.com/smajournalonline/pages/default.aspx Robert Wood Johnson Foundation, A National Program of the Robert Wood Johnson Foundation (2006) Diabetes initiative: Assessment of primary care resources and supports for chronic disease self management (PCRS), accessed online: http://www.diabetes initiative.org Robert Wood Johnson Foundation, A National Program of the Robert Wood Johnson Foundation Advancing Diabetes Management Project (2005) Diabetes initiative: Readiness for change, accessed online: http://www.diabetesinitiative.org Robert Wood Johnson Foundation, A National Program of the Robert Wood Johnson Foundation, Advancing Diabetes Management Project (2005) Diabetes initiative: Self- efficacy, accessed online: http://www.diabetesinitiative.org Robert Wood Johnson Foundation, A National Program of the Robert Wood Johnson Foundation, Wilder Research Center (2004) Diabetes initiative: Lifestyle Survey, accessed online: http://www.diabetesinitiative.org

A. King and M. Biggs IJSHIM - Volume 5, Issue 11 (2012), pp. 45-52

Sarkadi, A., Veg, A. & Rosenqvist, U. (2005) The influence of participant’s self-perceived role on metabolic outcomes in a diabetes group education program, Patient Education and Counseling, 58, pp. 137-145, doi: 10.1016/j.pec.2004.08.002 Sarkadi, A. & Rosenqvist, U. (2004) Experience-based group education in type 2 diabetes, Patient Education and Counseling, 53, pp. 291-298, doi: 10.1016/j.pec.2003.10.009 Smith, M. K. (1997, 2002) Paulo Freire and informal education, the encyclopaedia of informal education, accessed online: http://www.infed.org/thinkers/et-freir.htm U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (2008) Diabetes overview (NIH Publication No. 09-3873, accessed online: http://www.diabetes.niddk.nih.gov/dm/pubs /overview/ Wagner, E. H., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J. & Bonomi, A. (2001) Improving chronic illness care: Translating evidence into action, Health Affairs, 20, pp. 64- 78, doi: 10.1377/hlthaff.20.6.64 World Health Organization (2011) Diabetes (Fact sheet No. 312), accessed online: http://www.who.int/topics/en/

Diabetes: An Educational Opportunity

APPENDIX A Percentage of Patient and Staff Responses as Improved or Not Improved / No Response on Patient and Staff Questionnaires 100% ------

80% ------

60% ------

40% ------

20% ------

0% ------Not Improved/No Response Improved

APPENDIX B

Post-Intervention Changes in HbA1C Values

No Change Or ------Not Improved

Improved_ ------

------Patient A Patient B Patient C Patient D

APPENDIX C Comparison of Costs for Intervention and Organizational Savings through a Decrease in Reimbursement Losses

$1,500 ------

$1,000 ------

$500 ------

$250 ------

$125 ------

$0 ------Cost/Savings Cost/Savings Cost/Savings Cost/Savings Cost/Savings Cost/Savings February March April May June Total

A. Halawa IJSHIM - Volume 5, Issue 11 (2012), pp. 53-62

Full Article Available Online at: Intellectbase and EBSCOhost │ IJSHIM is indexed with Cabell’s, JournalSeek, etc.

International Journal of Social Health Information Management

EFFECTS OF A TEN-WEEK COLLEGE-BASED PHYSICAL ACTIVITY PROGRAM ON FOUR HEALTH-RELATED FITNESS COMPONENTS

Abdelhadi Halawa Millersville University, USA

ABSTRACT urpose: The 2008 U.S. Department of Health and Human Services (HHS) Physical Activity Guidelines for Americans stated that regular physical activity is one of the P most important steps that Americans of all ages can take to improve their health condition and overall wellbeing. In addition, the Healthy People 2020 Phase I Report indicated that there is strong body of the scientifically-based empirical evidence supporting the health benefits of regular physical activity among youth and adults. Regular physical activity includes participation should include moderate to vigorous physical activities particularly cardiovascular endurance and muscle-strengthening activities. In 1996, HHS reported that during the university years (typically 18-22 years of age) the frequency of performing vigorous exercise three or more days a week declines by 6.2 percentage points for men and 7.3 percentage points for women. In a sports participation habits questionnaire, López, et al. (2010) further reported that 18% of a college student representative sample indicated not having participated in any sport activity during their spare time. The findings point out that was attributed to internal and external barriers such as lack of time, not seeing its usefulness, and being lazy. These data indicate that there is a strong need for more physical activity interventions and increasing the frequency of physical activity that target early adults, including college-aged students. The main goal of this research paper is to study the effects of the frequency of regular physical activity on four health-related fitness components in college-aged students. Methods: Ninety- four female and male participants took part in this investigation. Sixty participants took part in a ten-week university-based physical activity program with a frequency of exercise of one-day a week (Group 1), another group of thirty-four participants exercised two-day per week (Group 2). The health-related components of physical fitness tested are as follows: cardiovascular fitness, body composition, muscular endurance, and flexibility. Results: Measurable gains were made by the individuals in both groups on all four assessments; however, significant gains were found in the muscular endurance and body composition components. Conclusion: The major finding in this study is that both once and twice per week physical activity participation improved participants’ results on all physical activity assessments with the only exception of cardiovascular fitness. Furthermore, it is noteworthy in the findings that the participants in both groups experienced statistically significant improvements in three out of the

Effects of a Ten-Week College-Based Physical Activity Program on Four Health-Related Fitness Components four health-related fitness assessments indicating the effects of the frequency of training on those improvements.

Keywords: College-Aged Students, Regular Physical Activity, Health-Related Fitness Components, Cardiovascular Fitness, Body Composition, Muscular Endurance, Flexibility, and Wellness Promotion.

INTRODUCTION There is a clear and imperative need for interventions that promote physical activity and health- related benefits for university-aged students. Half of them are not meeting the required public health recommendations for moderate-to-vigorous physical activity. Many young people do not engage in the recommended levels of regular physical activity. Furthermore, physical activity declines precipitously with age among adolescents. Comprehensive school-based health programs have the potential to slow this age-related decline in physical activity and help students establish lifelong healthy physical activity patterns (CDC-MMWR 1997). In its 2009 Annual Healthy Campus: Making It Happen, The American College Health Association (ACHA) listed physical activity at the top of its ten leading health indicators for college students followed by overweight and obesity. In 2004, Silliman, Rodas-Fortier, & Neyman examined exercise habits and perceived barriers following a healthy lifestyle program of 471 college students. The researchers reported that male students exercised more frequently and at a greater intensity than the female students. The most common barrier to exercise was “lack of time”. The results of this study have implications for the design of general and specific physical activity interventions among college students and young adults alike. In related studies, Lowry et al. (2000), Bray et al. (2004), & Gómez-López et al. (2010) concluded similar findings for high school and college students respectively. Additionally, 60% of North American college students acquire less than the recommended amounts of physical activity (U.S. Department of Health and Human Services, 1996 and 2008). It is estimated that over 14 million students attended colleges and universities in the United States in 1995, while 60% of high school graduates attend postsecondary institutions (Chronicle of Higher Education Almanac, 1996). During the university years (typically 18-22 years of age) the frequency of doing moderate-to-vigorous exercise three or more times a week declines 6.2 percentage points for men and 7.3 percentage points for women (U.S. Department of Health and Human Services, 1996). In a survey of recent graduates, 47% reported a decrease in their physical activity levels, compared to the time they were still students (Calfas, Sallis, Lovato, & Campbell, 1994.). Telama & Yang (2000) posited that interventions are necessary to support young adults in continuing healthful levels of physical activity in order to reduce health risks in young Finnish adults. These data indicate a need for promoting physical activity interventions targeting the early adult age groups. The Healthy People 2000 Surgeon General’s Report (USDHHS, 1991) specifically identifies postsecondary institutions as settings where large numbers of young adults can be reached with health promotion programs. Healthy People 2010 (USDHHS, 2000) Leading Health Indicator 22-2 suggests that we “Increase the proportion of adults who engage regularly, preferably daily, in moderate physical activity for at least 30 minutes per day (USDHHS, 2000, p. 13).

A. Halawa IJSHIM - Volume 5, Issue 11 (2012), pp. 53-62

The benefits of physical activity in preventing disease and promoting overall well-being are well established and documented since 1970s. In 2004, Brankston et al. examined the effects of circuit-type resistance training on the need for insulin in women with gestational diabetes mellitus. Based on their findings, the researchers concluded that resistance exercise training may help to avoid insulin treatment for overweight women with gestational diabetes mellitus, +which might lead to reducing the need for taking insulin medication. Similar results were also reported by Snapp (2008) in investigated the effects of physical exercise on health outcomes in gestational diabetes mellitus (GDM). The results of this study suggested that moderate maternal leisure time physical exercise during GDM pregnancy may reduce the risk of delivery of an infant who is larger than expected for the age and gender (LGA). Furthermore, Brown & Blanton (2002) reported that college students who participated in physical activity and sports exhibited less suicidal behaviors and attempts. The question “How much exercise is enough to induce health benefits” has been frequently asked. Duey, O’Brien, and Crutchfield (1998) demonstrated that a six week, three days per week, endurance exercise training program made significant increases in aerobic fitness in African-American females (mean age = 23.1 years). A twelve week, three days per week, program of low impact aerobic dance was found to be as effective as other endurance training regimens in improving cardiovascular fitness and decreasing percent body fat in college-aged women (McCord, Nichols, & Patterson, 1989). MacDonald (1983) found that a six-week, two days per week, series of sequence training sessions were sufficient to cause a significant increase in the majority of physical fitness measurements (body fat, cardiovascular endurance, muscular endurance, flexibility and muscular strength).

The present research paper reports the initial effects of a ten-week wellness program on multiple health-related physical fitness components. The Wellness program was designed to promote wellness through regular physical activity in university students by teaching physical exercise and behavioral changes that could be applied during the program, as well as encouraged to continue after graduation. The primary purpose of the present study is to evaluate the effectiveness of exercising one time per week compared with two times per week in a university setting. The present study adopted current public health recommendations for moderate and vigorous physical activity (USDHHS 1996, American College of Sports Medicine 1998, Blair & Connelly, 1996 & Pate et al. 1995). The health-related components of physical fitness that were studied are as follows: cardiovascular endurance (CVE), body composition (BC), muscular endurance (ME), and flexibility (FLEX). In this study fitness is defined as the ability to perform moderate-to-vigorous levels of physical activity without undue fatigue and the capability of maintaining such ability throughout lifetime (Wilmore, 1988); also defined as a set of physical attributes that allows the body to respond or adept to the demands and stress of daily physical effort (Fahey et al. 2011).

METHODS Subjects and Procedures: The representative sample was composed of ninety-four college- aged undergraduate students of whom female (N=42) and male (N=52) recruited from two universities in Central Northern and Southern the State of Pennsylvania, USA with an average

Effects of a Ten-Week College-Based Physical Activity Program on Four Health-Related Fitness Components age of 18-22 years of age. All participants were provided with informed consent forms and voluntarily took part in this study. None of the participants had prior experience with the experimental aspects of this study. The researcher followed the American College of Sports Medicine Guidelines for Exercise Testing and Prescription instruction manuals and established university human subject protocol. Sixty of these subjects took part in a ten-week university- based physical activity program with a frequency of exercise of one-day a week (Group 1), while the other thirty-four participants exercised with a two-day a week (Group 2) frequency of exercise. All of the ninety-four participants completed the entire protocol of a four-component physical fitness pre-test, a ten-week physical activity program, and a post-test. The physical activity program consisted of the following activities: Cardiovascular fitness, muscular endurance, flexibility, and body composition assessments. All participants were apparently healthy and did not suffer from any ailments or excluding physical conditions. Participants were supervised during all exercise sessions and maintained records of their exercise routines. The Rockport One-Mile Fitness Walking Field Test was employed on a level surface-banked indoor track to assess the cardiovascular fitness of participants (Adams & Beam, 2010). Participants were instructed to walk at the fastest pace and speed as possible. Immediately upon completion of the walking test, participants’ post-exercise heart rate (HRMax) was measured using a 10-second pulse count. An age and sex specific 60-Second Sit-Up Field Test was utilized to evaluate muscular endurance of participants. The maximal number of sit-ups performed consecutively without rest within the sixty seconds was counted as the recorded score. Trunk Flexion-Hamstring (Sit-and-Reach) Field Test was utilized to measure participants’ flexibility using a sit-and-reach box with a measurement scale of up to 28-inch mark. Prior to testing, participants were instructed to perform a short warm-up of three to five minutes, remove their shoes, and refrain from jerky, fast, or high impact movements to avoid injury. Participants placed both feet flat against the back edge of the sit-and-reach box with fully extended legs with their feet forward approximately shoulder width apart. Participants were instructed to slowly reach extending their arms while sliding both hands parallel as far as possible along the scale. When a maximum stretch was reached, the score of the most distant point of these trials was recorded. To assist subjects with the best performance, they were instructed to breathe normally during the test and to not hold their breath at any time. Body Composition Field Test assessments employing the three-site skin-fold analysis method using calibrated SKYNDEX calipers was administered. Skin-fold sites included the chest, abdominal, and thigh for male participants; and triceps, suprailiac, and thigh for female participants. Percent body fat (%BF) was determined by employing the Body Density Equations of body fat percentage developed by Jackson & Pollock (1980). Body composition determined from skinfold measurement correlated well (r>0.80) with body composition determined by the hydrostatic weighting method (ACSM 1995, 2000, & 2009 & JAP 1962 & 1967).

Limitations The applicability of the findings of this study was limited by the following: (1) No attempts were made to control the physical activity habits of participants outside of this study; (2) The daily activity and fitness levels of the subjects were not selected for participants’ control in this study; (3) No attempts were made to control the diet and eating habits of participants; (4) During this

A. Halawa IJSHIM - Volume 5, Issue 11 (2012), pp. 53-62 study, participants were not required to engage in any weight management program; (5) No attempts were made by the researcher to reduce or control percent body fat as a result of the cardiorespiratory fitness tests; (6) The age, race, and socioeconomic status of the participants were not assessed in this study.

Statistical Analyses All reported data are expressed as means + SD, P-values of <.05 and were considered statistically significant. Paired-mean differences for multiple comparisons were performed to determine the significance of changes of pre-test and post-test differences between the two groups and four fitness components. Paired t-test analyses were utilized to determine whether significant differences existed between the one-day a week, two-day a week frequency of exercise groups, and each individual fitness component in both pre-test and post-test values. The level of significance for t-tests was established at p < .05, and all statistical test results are expressed as means (+SE). Statistical analysis of data was conducted utilizing the SAS System for Information Delivery (version 6.09 statistical package) carried out on the university’s mainframe computer.

RESULTS Significant gains were made by Group 1 and Group 2 only in muscular endurance and body composition components. Therefore, there was a significant difference for two of the four physical fitness components. Based on the paired means differences (post-pre by group) there were significant improvements in muscular endurance, flexibility and body composition components, but not in cardiovascular endurance (Table 1, Figure 1, Figure 2, Figure 3 & Figure 4).

Table 1: Study variables significantly associated (P>0.05) with mean and standard deviation (SD) Pre- and Post-training health-related fitness components for frequency of exercise one time per week (Group 1) and two times per week (Group 2 ) MEAN SD P Value Flexibility: Group 1 (N=56) .76 1.14 Group 2 (N=31) .96 1.29 .47 NS

Cardiovascular Endurance: Group 1 (N=56) 1.21 23.66 Group 2 (N=31) 2.75 13.33 .70 NS

Muscular Endurance Group 1 (N=56) 4.43 7.25 Group 2 (N=31) 8.51 8.31 .02

Body Composition Group 1 (N=56) .54 1.88 Group 2 (N=31) -2.18 3.82 .03

Effects of a Ten-Week College-Based Physical Activity Program on Four Health-Related Fitness Components

Pre and Post Test Scores for the Four Health-Related Components Comparing Group 1 and Group 2

Figure 1: FLEXIBILITY

Figure 2: C. V. E. (WALKING)

Figure 3: MUSCULAR ENDURANCE

Figure 4: BODY COMPOSITION (%BODY FAT)

A. Halawa IJSHIM - Volume 5, Issue 11 (2012), pp. 53-62

DISCUSSION The major finding in this study is that both once and twice a week physical activity participation was more effective in improving participants’ results on all physical activity assessments with the exception of cardiovascular fitness. Also notable are the findings that participants in both groups experienced statistically significant improvements in three of the four fitness assessments. These results, coupled with knowledge that pre-college school experiences in physical education do not effectively prepare students for the transition to self-directed regular physical activity (Sallis & McKenzie, 1991), provides support for the offering of college-level physical fitness or wellness courses and programs that focus on self-directed regular physical activity. These data provide strong support for participation in at least once weekly physical activity while noting the observed effect that the students participating in twice weekly physical activity made statistically greater improvements. The importance of these findings are supported by the joint Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine (ACSM) recommendations on physical activity and public health (i.e., each person should accumulate 30 minutes of moderate intensity physical activity on most, preferably all, days of the week), as well as the U.S. Surgeon General’s Report on Physical Activity and Health and National Institute of Health consensus statement on physical activity an cardiovascular health.

Interesting to note, while cardiovascular endurance results comparing Group 1 and Group 2 where not statistically significant, there were improvements and they were likely comparable. These data indicate that if college-aged subjects exercise a minimal of one time per week appreciably measurable physical fitness benefits can be realized. In light of the 2009 ACHA’s Companion Document to Healthy People 2010 and Sallis, et al. (1999) study, which indicated that the early adult-aged groups, specifically the college-aged population, are considered to be a high-risk group for developing sedentary negative lifestyle habits, including hypokinetic diseases for this particular cohort; therefore, the abovementioned beneficial results of regular physical activity are promising for greater health and fitness gains.

The limitations of this study include the restriction to two universities and the required enrollment and participation by the appreciable in the physical activity as part of a structured program of college study. Participants’ motivation for success in the course and to receive a higher grade may have influenced the results of the pre and post course assessments. Furthermore, the amount and type of physical activity that participants were involved in outside of the class and the current investigation were not controlled for the purpose of this study.

Suggestions for further study include the inclusion of dietary habits, as well as behavioral and cognitive pre and post program assessments. The researcher notes that physical activity improvements will be short lived unless coupled with the understanding and incorporating of appropriate behavioral changes. Likewise, assessing participants’ knowledge and appreciation for individual lifestyle decision-making and the impact of those decisions upon fitness and health should also be considered when investigating the benefits of participation in physical fitness and wellness activities.

Effects of a Ten-Week College-Based Physical Activity Program on Four Health-Related Fitness Components

REFERENCES Adams, G. & Beam, W. C. (5th ed.) (2010) Exercise Physiology Laboratory Manual, New York, NY: McGraw-Hill Publishers. Almanac Issue (1996 ) Campuses with Largest Students Enrollments, The Chronicle of Higher Education, Volume XLIII, No. 1, pp. 20-24. American College of Sports Medicine (2009) Guidelines for Exercise Testing and Prescription (8th ed. ) Philadelphia, PA: Wolters Kluwer-Lippincott Williams & Wilkins, pp. 18-27. American College of Sports Medicine (1995) Guidelines for Exercise Testing and Prescription (5th ed. ) Baltimore, PA: Williams and Wilkins, pp 5-6. American College of Sports Medicine and the American Heart Association (2007) Physical Activity and Public Health: Updated Recommendation for Adults, Circulation: Journal of the American Heart Association, 116: pp. 1081-1093. American College of Sports Medicine (2000) ACSM’s Guidelines for Exercise Testing and Prescription (6th ed.) American College of Sports Medicine Positions Stand (1998) The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Adults, Medicine and Science in Sports and Exercise, 30: pp. 975-991. American College Health Association (2009) Healthy College 2010: Healthy Campus 2010 Making It Happen, Companion Document to Healthy People 2010, Baltimore, MD. Bankstone, G. N., Mitchell, B. F., Ryan, E. A. & Okum, N. B. (2004) Resistance Exercise Decreases the Need for Insulin in Overweight Women with Gestational Diabetes Mellitus, American Journal of Obstetrics & Gynecology, 190 (1):188-93. Blair, S. N. & Connelly, J. C. (1996) How Much Physical Activity Should We Do? The Case for Moderate Amounts and Intensities of Physical activity, Research Quarterly for Exercise and Sport, 67: pp. 193-205. Bray, S. R. & Born, H. A. (2004) Transition to University and Vigorous Physical Activity: Implications for Health and Psychological Well-Being, Journal of American College Health, Volume 52 (4), pp. 181-188. Brown, D. R. & Blanton, C. J. (2002) Physical Activity, Sports Participation, and Suicidal Behavior Among College Students, Medicine & Science in Sports and Exercise, Volume 34-Issue 7- pp. 1087-1096. Butler, S. M., Black, D. R., Blue, C. L. & Gretebeck, R. J. (2004) Change in Diet, Physical Activity, and Body Weight in Female College Freshman, American Journal of Health Behavior, Volume 28- Issue 1, pp. 24-32. Calfas, K. J., Sallis, J. F., Lovato, C. Y. & Campbell, J. (1994) Physical activity and its determinants before and after college graduation, Medicine, Exercise, Nutrition and Health, 3: pp 323-334. Centers for Disease Controls-Morbidity and Mortality Weekly Report (1997) Youth Risk Behavior Surveillance in the United States, 1995, CDC-MMWR, Volume 45 (SS-4). Duey, W. J., O’Brien, W. L., Crutchfield, A. B., Brown, L. A., Williford, H. N. & Sharff-Olsen, M. (1998) Effects of Exercise Training on Aerobic Fitness in African-American Females, Ethnicity and Disease, 8, pp. 306-311.

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Fahey, T. D., Insel, P. M. & Roth, W. T. (9th ed.) (2011) Fit & Well: Concepts and Labs in Physical Fitness and Wellness, New York, NY: McGraw-Hill Publishers. Ferrara, C. (2009) The College Experience: Physical Activity, Nutrition, and Implications for Intervention and Future Research, Journal of Exercise Physiology (JEP online), 12: 1, pp. 23-31. Gómez-López, M., Gallegos, A. & Extremera, A. (2010) Perceived Barriers by University Students in the Practice of Physical Activities, Journal of Sports Science and Medicine, Volume 9, pp. 374-381. Healthy People 2010 (2000) HHS Secretary’s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2010, Washington, DC: Department of Health and Human Services. Jackson, A. S., Pollock, M. L. & Ward, A. (1980) Generalized Equation for Predicting Body Density in Women, Medicine and Science in Sports and Exercise, 12, pp. 175-182. Journal of Applied Physiology (1967) Estimation of Body Fat in Young Men, JAP, 23, pp. 311– 315. Journal of Applied Physiology (1962) Estimating Body Fat in Young Women, JAP, 17, pp. 967– 970. Kahn, E. B., Ramsey, L. T., Brownson, R. C, Heath, G. W., Howze, E. H., Powell, K. E., Stone, E. J., Rajab, M. W. & Corso, P. (2002) The Effectiveness of Interventions to Increase Physical Activity: A Systematic Review, American Journal of Preventive Medicine, 22 (4S), pp 73–107. Keating, X. D., Guan J., Piñero, J. C. & Bridges D. M. (2005) A Meta-Analysis of College Students’ Physical Activity Behaviors, Journal of American College Health, 54 (2), pp 116- 125. Lee, M., Howard, D., Oguma, Y. & Paffenbarger, R. S. (2003) Relative Intensity of Physical Activity and Risk of Coronary Heart Disease, Circulation: American Heart Association, 107, pp. 1110. Lowry, R., Galuska, D. A., Fulton, J. E., Wechsler, H., Kann, L. & Collins, J. L. (2000) Physical Activity, Food Choice, and Weight Management Goals and Practices Among U.S. College Students. American Journal of Preventive Medicine, Volume 18, Issue 1, pp. 18-27. MacDonald, R. P. (1983) Physiological changes seen after six weeks sequence training, British Journal of Sports Medicine, 17, pp. 76-83. McCord, P., Nichols, J. & Patterson, P. (1989) The Effect of Low Impact Dance Training on Aerobic Capacity, Submaximal Heart Rates and Body Composition of College-Aged Females, Journal of Sports Medicine & Physical Fitness, 29, pp. 184-188. Meyer, T. & Broocks, A. (2000) Therapeutic Impact of Exercise on Psychiatric Diseases: Guidelines for Exercise Testing and Prescription, Sports Medicine, Volume 30, Number 4, pp. 269-279. Pate, R. R., Pratt, M., Blair, S. N., Haskell, W. L., Macera, C. A., Bouchard, C., Buchner, D., Ettinger, W., Heath, G. W., King, A. C., Kriska, A., Leon, A. S., Marcus, B. H., Morris, J., Paffenbarger Jr., R. S., Patrick, K., Pollock, M. L., Rippe, J. M., Sallis, J. & Wilmore, J. H. (1995) Physical Activity and Public Health: a Recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine, Journal of the American Medical Association, 273, pp. 402-407.

Effects of a Ten-Week College-Based Physical Activity Program on Four Health-Related Fitness Components

Sallis, J. F. & McKenzie, T. L. (1991) Physical Education’s Role in Public Health, Research Quarterly for Exercise and Sport, 62, pp. 124-137. Sallis, J. F., Calfas, K. J., Nichols, J. F., Sarkin, J. A., Johnson, M. F., Caparosa, S., Thompson, S. & Alcaraz, J. F. (1999) Evaluation of a University Course to Promote Physical Activity: Project GRAD, Research Quarterly for Exercise and Sport, 70, pp. 1-10. Sarkin, J. A., Nichols, J. F., Sallis, J. F. & Calfas, K. J. (2000) Self-Report Measures and Scoring Protocols Affect Prevalence Estimates of Meeting Physical Activity Guidelines, Medicine & Science in Sports & Exercise, Volume 32 - Issue 1, p. 149. Silliman, K., Rodas-Fortier, K. & Neyman, N. (2004) A Survey of Dietary and Exercise Habits and Perceived Barriers to Following a Healthy Lifestyle in a College Population, Californian Journal of Health Promotion, Volume 2, Issue 2, pp. 10-19. Snapp, C. A. (2008) Gestational Diabetes Mellitus: Physical Exercise and Health Outcomes, Biological Research For Nursing, Vol. 10, No. 2, pp. 145-155. Suminski, R. R, Petosa, R, Utter, A. C. & Zhang, J. J. (2002) Physical Activity Among Ethnically Diverse College Students, Journal of American College Health, 51(2), pp. 75-80. Telema, R. & Yang, X. (2000) Decline of Physical Activity from Youth to Young Adulthood in Finland, Medicine & Science in Sports & Exercise, 32, pp. 1617-1622. U.S. Department of Health and Human Services (2008) Phase I Report: Recommendations for the Framework and Format of Healthy People 2020, The secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, Washington, DC. U.S. Department of Health and Human Services (2008) Physical Activity Guidelines for Americans: Be Active, Healthy, and Happy, Washington, DC: ODPHP Publication No. U0036. U.S. Department of Health and Human Services (2000) Healthy People 2010: Understanding and Improving Health, (Conference Edition, in Two Volumes) Washington, DC. U.S. Department of Health and Human Services (1991) Healthy People 2000: National Health Promotion and Disease Prevention Objectives (full report, with commentary), Washington, DC: Department of Health and Human Services, Publication 91, 50212. U.S. Department of Health and Human Services (1996) Physical Activity and Health: A Report of the Surgeon General, Atlanta, GA: Centers for Disease Control and Prevention. Wilmore, J. H. (1988) Design Issues and Alternatives in Assessing Physical Fitness Among Apparently Healthy Adults in a Health Examination Survey of the General Population, in T. F. Drury (Ed.) Assessing Physical Fitness and Activity in General Population Studies (pp. 107-140) Washington, DC: U.S. Public Health Service, National Center for Health Statistics.

K. T. Crowe and M. Holloway IJSHIM - Volume 5, Issue 11 (2012), pp. 63-75

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International Journal of Social Health Information Management

ELECTRONIC COMMUNICATIONS AND UNINTENTIONAL SEXUAL HARASSMENT

Keith T. Crowe and Madison Holloway Metropolitan State College of Denver, USA

ABSTRACT he social and legal aspects of the American culture are shifting. Technology is becoming more ever present in daily life, causing a mixing of work and personal T lives on a scale never before seen. The outcomes of new social media and communication technologies have led to increases in productivity and decreased response times, but they come at a cost. Electronic social networking has helped to drive these changes and uses both home and work life to do so. However, activities which are legal and acceptable in the private domain are now crossing into the work place leading to actual and possible instances of sexual harassment. Sexual harassment law is also changing, bringing broader interpretations of behaviors that contribute to a hostile work environment which warrant severe consequences. These changes are drifting into what is termed as unintentional sexual harassment. This paper explores these changes, proposes a definition of unintentional sexual harassment, examines generational norm changes and creates a set of guidelines to help prevent unintentional harassment incidents. The guideline changes are as follows:

1. Understand what unintentional sexual harassment is. 2. Be wary of mixing the use of electronic devices between work and home. 3. Before engaging in any potentially harassing activity, stop and think. 4. Remember that your digital footprint never goes away. 5. Realize the differences in acceptable behavior in different settings. 6. Be aware that many activities gaining acceptance can be harassing. 7. Understand that perceptions of behavior can vary from person to person. 8. Be sensitive to coworkers “hot buttons.” 9. Remember that the consequences affect both individuals. 10. If you aren’t sure if it could be unintentional sexual harassment, don’t do it.

In an individual’s private domain, there are many acceptable behaviors, hobbies, and practices. They are completely legal in the individual’s private domain. The difficulty for the individual is to ensure that these activities do not exit the private domain. They feel that what

Electronic Communications and Unintentional Sexual Harassment they do in their own domain, on their own time, is their own business. This paper will delve into this attitude and the dangers it can present.

Keywords: Unintentional Sexual Harassment, Intentional Sexual Harassment, Hot Buttons, Pornography, Art, Technology, Guidelines, Social Media, Habituation, Desensitization, Generational Norms.

TRENDS IN SEXUAL HARASSMENT Our society is now entrenched in the digital age and electronic devices as more prevalent than ever before. The most common offenses of unintentional sexual harassment include emails, text messages, or what might be considered pornographic images that are seen by unintended individuals. An individual may intend to send a specific communication, but be entirely unaware of the possible perceptions of the material sent and why the material would be viewed as constituting a sexual harassment incident. These incidents are caused by two societal changes:

 Increasing use of technology that combines work and home life  Changes in what is perceived as social acceptable.

The Equal Employment Opportunity Commission defines sexual harassment as: “Unwelcome sexual advances, requests for sexual favors, or other verbal or physical conduct of a sexual nature when:

1. Submission to such conduct was made either explicitly or implicitly a term or condition of an individual's employment, 2. Submission to or rejection of such conduct by an individual was used as the basis for employment decisions affecting such individual, or 3. Such conduct has the purpose or effect of unreasonably interfering with an individual's work performance or creating an intimidating, hostile, or offensive working environment” (The U. S. Equal Employment Opportunity Commission, 1990).

This above definition predominately concerns itself with the concept of intentional sexual harassment. To summarize: intentional sexual harassment is either quid pro quo (this for that) or a hostile work environment. Intentional sexual harassment, as its name implies, is intentional, while unintentional sexual harassment is comprised of actions by an individual that result in sexual harassment where there was no intent to harass anyone. Since the introduction of Title VII and Title IX, the laws upon which the definition of sexual harassment is based, sexual harassment has been directly confronted by most institutions. This has resulted in creating a decline in sexual harassment throughout the United States (The U.S. Equal Employment Opportunity Commission, 2011). To achieve these results human resource departments and training managers have tailored pro-active campaigns towards intentional sexual harassment. Unintentional sexual harassment has not received the same attention from

K. T. Crowe and M. Holloway IJSHIM - Volume 5, Issue 11 (2012), pp. 63-75 these training managers and as society continues to embrace electronic communications and social media it will become a more pressing issue.

Businesses must pay close attention to this growing segment of sexual harassment as the fines for violations have continued to increase year to year (The U.S. Equal Employment Opportunity Commission, 2011). Even with a downtrend in total sexual harassment charges, the total fines (not including monetary awards through litigation) have remained constant with a slight upward trend. While there have been less incidents of sexual harassment the fines that have been have been much higher, increasing by multiple thousands of dollars. This of course, does not reflect the social and emotional costs of sexual harassment, as those will be discussed later.

COMMON TECHNOLOGY USAGE AT HOME & THE WORKPLACE The days of leaving work and being ‘done for the day’ are long past. Thanks to increased technology in email, smart phones, social networking, etc. the line between work and home life is now blurred or even non-existent. Work emails, personal emails, work calls, personals calls, all come from the same device that is permanently attached to the average American’s hip. It is estimated that American’s will buy 93 million additional smart phones in 2012 (Brownlow, 2011). The smart phone has become a standard part of American culture and individuals are becoming casual about its usage.

The smart phone has revolutionized communications and work efficiencies, but because they accomplish so much, few people feel the need to use one for work and one for home. This begins to pose a threat, especially if the individual engages in activities in their personal domain that would not be work environment acceptable. These could be activities as innocuous as dating, going to a bar, or flirting with their significant other, but if these activities cross into the work environment, through a mistake on the smart phone, they can have serious repercussions. Seen, by unintended eyes, they could expose an individual to sexual harassment. The receiver could perceive the material to be an unwanted sexual advance or it could lead to a feeling of a hostile work environment. This is a simple error, but one which can have real, long lasting implications.

There are many electronic social media activities which are perfectly acceptable, legal and widely engaged in at home. These same activities can cause huge problems in the work environment. Many employees engage in these behaviors and enjoy them, but when they are accidently brought to work through electronic means they most definitely can constitute unintentional sexual harassment. This crossing over from private to home life is where technology presents a risk leading to unintentional sexual harassment incidents.

DIGITAL FOOTPRINTS: THEY NEVER GO AWAY Sent emails, a quick text message, a wrong click, a status update on Facebook, all seem small, quick, even innocuous, but we should all be aware that they’re here to stay. Once

Electronic Communications and Unintentional Sexual Harassment something is posted, clicked or searched for, it is there in perpetuity on the internet just waiting to be found. Rarely, if ever, is anything truly deleted from the internet, and what is left is referred to as a person’s digital footprint. It is a way to track people through the net, and see what they have been doing. Over half of Americans have used a search engine to follow others footprints (Madden, 2007). It is here that unintentional sexual harassment occurs here. If inappropriate data is still there, it will pose a risk of being exposed. For example, the predictive text feature on cell phones or search engines, where the device uses only one or two letter to guess what the rest of the word or sentence will be, could show a co-worker what was typed previously. This could be offensive to them and possibly be viewed as sexual harassment.

Even if there is no intent, there can still be sexual harassment. The blurring of personal and work lives comes with risks because social media is expediting this convergence and mixing of information. Social networking sites, such as Facebook, encourage posting the most intimate and inane details of a person’s life. These details are then disseminated across the World Wide Web for all see and can be brought into the workplace through smart phones and linked with office computers. This information can be innocuous or can press a co-worker’s hot button and lead to serious repercussions.

According to a supplier of monitoring software, 77.7% of US companies monitor their employees’ internet usage (Snapshot Spy, 2011). This would be like a likely place for unintentional harassment to be found and it does pose a potential risk. The following are two examples where this might occur. One, when individuals who update computers through IT, or monitor the networks for problems have been exposed to unwanted material and are thereby become victims of unintentional sexual harassment. Two, all users must be cognizant of using correct passwords and never sharing them with others. The risk is that an unauthorized user or even someone with permission to use another’s account will use the opportunity to view adult material. This material may be left up and seen by others, leaving the original user responsible. This shows that internet security is an important consideration to be followed in an office environment.

The times are most definitely changing, and with that change new and profound advances in technology and communication have come. If not used properly these new technologies and outlooks can cause a great deal of harm to individuals that become intertwined with unintentional sexual harassment.

CHANGING GENERATIONAL NORMS Bob Dylan once said, “The times, they are a changing.” It could have been said today and it would be no less accurate. Behaviors, of a personal nature, once thought personal, if not taboo, are becoming more mainstreamed and socially accepted. Pornography was once a hidden vice, but through the use of the internet and other new technologies it has become more main stream. Now, a 2008 study published in the Journal of Adolescent Research shows that 67% of men 18 to 26 and 49% of women 18 to 26 “agree that viewing pornography is acceptable” (Carroll, Padilla-Walker, Nelson, Olson, McNamara Barry, & Madsen, 2008).

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These 18 to 26 year men and women are emerging the adults and the professionals of tomorrow. This shift in norms is contributing to unintentional sexual harassment. As the proliferation of pornography finds its way into smart phones it has also found its way into the workforce. With such a high engagement and acceptance level of pornography, the normal average emerging adult may not even understand that some of their behaviors and norms could be construed as sexual harassment by others. This lack of awareness can easily result in unintentional sexual harassment.

Art appreciation has been deemed a valuable activity for many individuals. This pastime is educational, enjoyable and socially acceptable on most any level. However, art can contain the image of a nude male or female. Until recent times the works of renaissance masters were not allowed to be shown or taught in American schools until the college level. Now they are taught in high school art classes as masterpieces, nudity and all. Many classical nude works are generally accepted as art, but generally accepted is not the same as accepted by all. Where is the line between art and pornography? This is moving target. Take the example of a classic artistic masterpiece, The Rape of the Sabine Women, by Peter Paul Rubens (Rubens, n. d.). This artwork depicts Roman men abducting Sabine women. The overt point of the abduction is for the purposes of rape. Could this be offensive to someone? Obviously yes, but it is still generally accepted as a masterpiece of renaissance art. There is no one clear cut way of presenting or perceiving a piece like this.

United States Supreme Court Justice Potter Stewart once said, “I can’t define pornography, but I know it when I see it.” Since he uttered those words in 1964 during the Jacobellis v. Ohio ruling the definition has improved. Merriam-Webster now defines pornography in three parts:

“ 1: the depiction of erotic behavior (as in pictures or writing) intended to cause sexual excitement 2: material (as books or a photograph) that depicts erotic behavior and is intended to cause sexual excitement 3: the depiction of acts in a sensational manner so as to arouse a quick intense emotional reaction ” (Merriam-Webster, Incorporated, 2008).

This definition does not adequately separate art from obscenity or from the definition of pornography, but serves as a good rule for the purposes of sexual harassment. This is not cut and dry but what is offensive can vary greatly, not just between cultures but also between generations. Just because it fits this current definition of pornography does not necessitate that the material is offensive to everyone or anyone. With all of this ambiguity a conservative approach to the matter has been advised.

Electronic Communications and Unintentional Sexual Harassment

As usage of and approval of pornographic material increase, a psychological response known as habituation has begun to occur. Habituation is a “decreasing responsiveness with repeated stimulation” (Myers, 2007). This habituation decrease the individual’s response to a given stimuli, in this case: pornography. As the individual is desensitized, there will become an increased likelihood that pornographic use and involvement will find its way into many parts of the individual’s life. Because the material is prevalent and the individual is desensitized to it, it might be seen as innocuous and not harmful and therefore may be passes on. This represents a failing of the individual to see the potential harm that certain materials can cause and how their actions or inactions might lead to unintentional sexual harassment.

Desensitization enters in our lives from other areas as well. Many people now believe that the censors used by network TV are becoming desensitized to much of the material of a sexual nature presented to them. This could account for the nearly doubling of sex acts depicted on TV from 1998 to 2005 (Kunkel & Eyal, 2005). This rise in sexual content on TV has been having an impact on society at large.

Cable T. V. movies have traditionally been as permissive as films shown in regular theaters but even prime time TV shows viewers can lead to desensitization of sexual material. To increase ratings and increase advertising dollars, stations feel the pressure to stand out. An easy way to accomplish this is to be more salacious than the next (Strauss, 2011). This competition has encouraged more and more graphic depictions of sex acts and sexual situations on TV every year. Our most recent generations, having grown up with this network ratings race to add more sexual situations to their programming, is becoming more desensitized to it through habituation. This desensitization will make it more and more difficult to know where the line is drawn for sexual harassment, leading to more unintentional harassment as the conversation turns to something as simple as the previous night’s TV shows.

T. V. advertisers have also been engaging in the same race to add more sexual content to their commercials. Thus it is possible to be bombarded with sexual situations during a T.V. series or program but also during the advertising as well.

DAMAGE DONE: BOTH PARTIES AS VICTIMS The damage done by unintentional sexual harassment can be just as severe for the victim as intentional sexual harassment. The victim often wonders why this has happened to them. However, the individual who committed unintentional sexual harassment can also be harmed and suffer unexpected consequences that they never though could or should happen to them. The person who committed the unintentional sexual harassment, had no intent, but will suffer the some of the same psychological consequences as the victim and will also suffer the same consequences as the individual who commits intentional harassment. Without intending to do any harm to anyone, the reputation of the individual who commits unintentional sexual harassment can be destroyed. This loss of reputation can destroy the careers of both the individual and his or her family. However, in addition to the sanctions via law, career, and

K. T. Crowe and M. Holloway IJSHIM - Volume 5, Issue 11 (2012), pp. 63-75 community, the unintentional harasser also will suffer from psychological trauma as their actions did not reflect their intentions.

Intentional sexual harassment is harmful in many ways. The victim often feels powerless and the perpetrator can be exposed to harsh penalties. Here there is intent, knowledge, and willingness, even if the offenders perception of reality may be skewed to justify his/her actions. Unintentional sexual harassment does not have these same prerequisites, and, in many cases, the perpetrator of the unintentional sexual harassment feels the powerlessness of the victim. The effects of sexual harassment on the victim can be long lasting and severe. Northwestern University lists anxiety, depression, sleeplessness, headaches, fatigue, shame, absenteeism, stress, and career loss among many other effects (NorthWestern University Women's Center). These are long lasting and can haunt a victim for some time and even require therapy to correct. This can be caused by intentional or unintentional sexual harassment.

The individual committing unintentional sexual harassment will also struggle with many of the same symptoms felt by the victim and will struggle to deal with the repercussions of their unintended behavior. The perpetrator of unintentional sexual harassment is likely to experience cognitive dissonance. The cognitive dissonance theory states that, “we act to reduce the discomfort we feel when two of our thoughts are inconsistent” (Myers, 2007). Since the results of the individual’s actions and thoughts do not appear consistent they will struggle to find a way to return to balance. This struggle can lead to depression, discomfort, or a change in behavior or thoughts. The fear here: the individual may begin to believe, “since I have been found guilty of harassing women, I must think it is alright to harass them.” This is a mentally slippery path and can lead to much further psychological harm as the individual struggles to add or eliminate this new information to/from the individual’s schema.

Both individuals involved in a case of unintentional sexual harassment, the victim and the perpetrator can suffer from somewhat similar effects. The can both experience similar psychological trauma, the same social scrutiny, and mostly costly, both will be in danger of job and or career loss. These inflictions are real, serious, and damaging to all involved.

Politicians have been some of the most public, in recent times, to run afoul of unintentional sexual harassment. Private communications sent from one consenting adult to another consenting adult often become matters of public knowledge. There was no intent to expose their constituents to these messages or images, but nonetheless they are in the open. In the case of Anthony Weiner, images he sent to women were found by his constituents to be inappropriate. As more and more people viewed these images they also felt victimized by the harassment, he was forced to step down in June of 2011. He never intended to harass his constituents, yet it cost him his career as a congressman.

Beyond possible psychological harm the individual guilty of unintentional sexual harassment is exposed to a veritable buffet of other potential consequences. First and most monetarily damaging is career loss. This is more than just losing a job. Once and individual is labeled as a

Electronic Communications and Unintentional Sexual Harassment harasser within the industry, in which the individual works, finding another job may become difficult to impossible. Employers simply will not want to risk that these actions may be repeated at their company. Next, the individuals can find themselves ostracized from other segments of their communities as word spreads. People might assume the worst and assume the act was intentional and malicious. This will cause people within the community to avoid the individual and instruct others to do the same. As the individual suffers these consequences, problems within their families can mount; risk of divorce will increase (Western Cape Government, 2011). These consequences should be enough to encourage anyone to learn to avoid unintentional sexual harassment at all costs.

INTENTIONAL VS. UNINTENTIONAL SEXUAL HARASSMENT Intentional sexual harassment follows the original definition of sexual harassment and is generally known, studied and abhorred. While it is unlikely that it will be entirely eradicated from society, it has been greatly reduced and is continuing to decline (The U.S. Equal Employment Opportunity Commission, 2011). Historically, sexual harassment became a defined legal issue in 1964 through Title VII of the Civil Rights Act. This laid the ground work for eliminating harassment in general and included sexual harassment. This law was not felt to fully address all sexual harassment instances, and was found to be especially lacking in coverage for students and schools and so Title IX was passed in 1972 as an amendment to the Civil Rights Acts of 1964. These solidified the basis of sexual harassment law in the United States.

Throughout the 60’s, 70’s and 80’s intentional sexual harassment prosecutions were comprised predominately of quid pro quo sexual harassment cases. In these cases persons in a position of power exerted their authority to force a subordinate into a sexual act or sexual situation against their will. Beginning in the 1980’s, however, there became a shift in sexual harassment prosecution. It began to move out of flagrant quid pro quo and into the more difficult to define area of a hostile work environment. This sort of sexual harassment occurs when the work place is ‘filled’ with pin ups, pictures of nude women, foul jokes, etc. This causes a person to feel intimidated or harassed simply because of the surrounding work environment. These incidents had to be pervasive and severe to qualify under the law.

Hostile work environment harassment has no clear definition, but according to the US Supreme Court it must be pervasive or severe to qualify as sexual harassment. This was intended to prevent the court system from being overrun by frivolous cases. As society has become more sensitive to sexual harassment, the vagueness of the definition of severe has allowed the hostile work environment form of sexual harassment to be used in more and more situations. The classic example of a woman working in an auto garage surrounded by photos of nude women and crass jokes has been replaced by the single incident of email or memo, now defined as severe. As judges and lawyers focus more heavily upon the definition pervasive or severe, a new form of sexual harassment has been created: unintentional sexual harassment. This was born of the concept that a severe incident did not need intent to be harassment. Merely the act itself was enough.

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As sexual harassment law has matured in the United States, unintentional sexual harassment has become an identified and growing issue. The individual accused of this form of harassment, has no intent to harass and, possibly, no intent for the harassed individual to have ever been privy to the harassing material. Traditionally this could have been an off color comment, over heard by a co-worker, or an inappropriate gesture not meant to be seen. These actions may be innocuous at the time but they can be interpreted quit differently for a multitude of reasons. As the relatively high standard of severe is relaxed, more behaviors will be included in this type of harassment.

HOT BUTTONS AND UNINTENTIONAL SEXUAL HARASSMENT Unintentional sexual harassment can be committed in two distinct ways. First is the more obvious, whereby and individual treats an obviously offensive email, text, or other message in such a way that it is discovered by a victim through no fault of the victim’s own, such as pornographic pictures unintentionally left on an office copying machine. Second is when a message is discovered by, or even sent to an individual who will feel sexually harassed, due to that person’s particular hot buttons or a misunderstanding of the social acceptance of the message. This second type or condition is much more difficult for the perpetrator to prevent and can be unclear, as each individual has different hot buttons due to different life experiences. Hot buttons are areas of sensitivity that elicit a strong emotional response which an individual develops over time. These areas of enhanced sensitivity can be due to negative personal or shared experiences or they can be from a high level of exposure to the topic area. These hot buttons often cannot be seen or known by others until the emotional response is elicited, thereby causing great concern for all parties involved.

The media has provided many of us with an increased sensitivity to areas intentional sexual harassment on the nightly news involving individuals or institutions of high stature. These stories are seen nightly, discussed at work and enter into the social consciousness of the nation. Certain individuals may key on these incidences and magnify them out of proportion. Once this has happened many individuals may be more apt to have an increased sensitivity to any form of sexual harassment. This forms a hot button for the individual and can cause the person to respond disproportionately to an event of unintentional sexual harassment because of this sensitivity.

Hot buttons are usually not something an individual usually intends to push. Things might be said by a sender who does not realize might have different interpretations in the mind or view of the receiver. In most cases the sender of a message cannot be expected to read the receiver’s mind. If the sender stumbles across a hot button, unintentionally, the sender must realize the sensitivity of the issue (once informed) and discontinue the use of the offending behavior. Hot buttons can vary wildly and expecting and individual to be aware of hidden hot buttons is impractical and unrealistic, but can still be a basis for a sexual harassment claim.

Electronic Communications and Unintentional Sexual Harassment

RECOMMENDATIONS ”Prevention is the best tool to eliminate sexual harassment in the workplace” (The U.S. Equal Employment Opportunity Commision, 2011). The EEOC has it right, prevention is the key and the key to prevention, especially for unintentional sexual harassment, is education. Most individuals do know about intentional sexual harassment, but haven’t yet considered the pitfalls and difficulties of electronics with regards to unintentional sexual harassment. Understanding the issue and using care with electronics and social media will be the greatest aid in preventing unintentional sexual harassment.

To help in the process of preventing unintentional sexual harassment the author proposes the following ten steps:

1. Understand what unintentional sexual harassment is. Ignorance of the law is no excuse. The modern business professional is expected to know and understand the legal environment of sexual harassment. This requires time and effort, but can prevent many future incidences of unintentional sexual harassment from occurring.

2. Be wary of mixing the use of electronic devices between work and home. Intermingling of work and home communications can allow material to cross from one to the other. This can/will allow items acceptable in the private domain to become public. This can lead easily to the exposure of material to another individual, creating an environment for harassment.

3. Before engaging in any activity that might, in any way, be thought of as harassment, stop and think. Just because the behavior to be engage in is legal and acceptable in the private domain, it can come with risks. The individual must weigh those risks and decide if the activity is worth pursuing or if it could be too easily construed as harassment.

4. Remember that your digital footprint never goes away. Even deleted information can last forever on the internet. A one-time slip up can haunt the individual forever. The individual must be wary of this and realize that one time dalliances can be exposed years later.

5. Realize the differences in acceptable behavior in different settings. In the private domain many activities are acceptable, allowed, legal, even enjoyable, but is thy cross into the public or work domain they can easily be construed as harassing. Special care must be taken to ensure the separation of these activities and work life.

6. Be aware that many activities gaining acceptance can be harassing. Societal acceptance is not static. It is constantly changing and evolving. Activities now considered acceptable were once taboo and once acceptable activities are now taboo. The law will always lag behind society changes.

K. T. Crowe and M. Holloway IJSHIM - Volume 5, Issue 11 (2012), pp. 63-75

7. Understand that perceptions of behavior can vary from person to person. A behavior deemed innocuous by one can be severe harassment in another’s eyes. The individual needs to aware that their actions may have differing reactions from different individuals.

8. Be as sensitive as possible to coworkers “hot buttons.” Different individuals have different sensitivity to different issues. Just because the language used or the action undertaken was not intended to harassment it can touch these “hot buttons” in another individual causing mental anguish. The sender cannot be expected to predict the receiver’s hot buttons, but is expected to respect them once revealed.

9. Remember that the consequences of unintentional sexual harassment affect both individuals. Not only is the harassed individual affected, but also is the individual who committed the unintentional harassment. The consequences to both are both strong and severe enough to warrant special attention to the prevention of unintentional sexual harassment.

10. If you aren’t sure if it could be unintentional sexual harassment, don’t do it. As a general safety rule: if the action is close or questionable, don’t do it. The long term damage to all involved is not worth the risk. With the vagueness of unintentional sexual harassment law, safety can come through caution.

These are a simplified version of reality, but can greatly aid in avoiding unintentional sexual harassment.

While the individuals involved are ultimately responsible for their actions and for the resulting consequences it is important to realize that companies and schools bear the burden of teaching the individuals what is and what is not acceptable. The consequences to the institution can be steep as well, just as with intentional sexual harassment and should be enough to encourage training in this area.

CONCLUSION Changing times are affecting the way the American law and society look at sexual harassment. It no longer takes intent or an overwhelming culture or quid pro quo action to constitute sexual harassment. Now a single incident of an unintentional nature can constitute a severe infraction of the hostile work environment. This is the new realm of unintentional sexual harassment. The courts are now more loosely defining the term severe as society has less tolerance for anything approaching sexual harassment. This will lead to more infractions, more people harmed, and more confusion regarding appropriate behaviors.

To aide in alleviating the forthcoming confusion, this author proposes a new definition for unintentional sexual harassment. Unintentional sexual harassment is the lack of due diligence

Electronic Communications and Unintentional Sexual Harassment in protecting sensitive material, generally accepted as obscene, threatening, or degrading, leading the release of the material to unwarranted parties, resulting in emotional damage or distress. This definition requires three situations to occur to warrant a claim of unintentional sexual harassment. First the sending party must have a lack of due diligence. This means that the sender is not guilty if the infraction occurs due to a virus, glitch or other computer error out of their control. They are only responsible if through their own actions they did not take precautions to separate the material from work life. Second, the material must be generally accepted as obscene, threatening or degrading. This requires a reasonable person to see the material as such. Hot buttons, or vague areas, un-revealed to the sender cannot hold the send to account, until the sender has been made aware. Lastly, the person receiving the material must suffer emotional damage or distress because of the incident. This requires the incidents have some lasting effects before action should be taken.

Due to the unintentional nature of unintentional sexual harassment, it should be viewed as a lesser charge than that of intentional sexual harassment. Traditional, or intentional, sexual harassment involves malice of forethought and thereby shows intent. Sexual harassment of this form should be eliminated and reviled and should have severe consequences. Unintentional sexual harassment does not have this malice and therefore should have less severe consequences. It should be actively avoided but it does not warrant severe repercussions.

It is in the best interest of companies and individuals to become educated on this changing evolution within the legal system. Beyond the dollar costs of lost time, lawsuits, and turn over, the emotional costs can be great. The guidelines and definitions found in this paper can serve as the beginning of an education program to help stem further infraction from occurring.

WORKS CITED Brownlow, M. (2011, November) Smartphone statistics and market share, Email Marketing Reports, accessed online December 01, 2011: http://www.email-marketing-reports.com/ wireless-mobile/smartphone-statistics.htm Carroll, J. S., Padilla-Walker, L. M., Nelson, L. J., Olson, C. D., McNamara Barry, C. & Madsen, S. D. (2008) Generation XXX: Pornography Acceptance and Use among Emerging Adults, Journal of Adolescent Research, pp. 6-30. Kunkel, D. & Eyal, K. (2005, November 9) Number of Sex Scenes on TV Nearly Double Since 1998, Kaiser Family Foundation, accessed online December 14, 2011: http://www.kff.org /entmedia/entmedia110905nr.cfm Madden, M. (2007, December 16) Digital Footprints: Online Identity Management and Search in the Age of Transparency, PewResearchCenter Publications, accessed online December 04, 2012: http://pewresearch.org/pubs/663/digital-footprints Merriam-Webster Incorporated (2008) Pornography Definition and More, Merriam-Webster Online, accessed online 12 9, 2011, from Dictionary and Thesaurus -: http://www.merriam- webster.com/dictionary/pornography Myers, D. G. (2007) Psychology (8th Ed.) Holland, Michigan: Worth Publishers.

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NorthWestern University Women's Center (n.d.) Effects of Sexual Harassment: Women's Center, Women's Center - NorthWestern University, accessed online December 11, 2011: http://www.northwestern.edu/womenscenter/issues-information/sexual-harassment/effects- sexual-harassment.html Rubens, P. P. (n.d.) The Rape of the Sabine Women, The National Gallery, UK, London, accessed online: http://www.nationalgallery.org.uk/paintings/peter-paul-rubens-the-rape-of- the-sabine-women.. Snapshot Spy (2011) Employee Computer & Internet Abuse Statistics, Snapshot Spy, accessed online December 04, 2011: http://www.snapshotspy.com/employee-computer- abuse-statistics.htm Strauss, G. (2011, January 20) Sex on TV: It's increasingly uncut — and unavoidable. USA Today. The U. S. Equal Employment Opportunity Commission (1990, March 19) Notice Number N- 915-050, Policy Guidance on Current Issues of Sexual Harassment, U.S. Government. The U.S. Equal Employment Opportunity Commision (2011) Facts About Sexual Harassment, U.S. Equal Employment Opportunity Commision, accessed online December 2, 2011: http://www.eeoc.gov/eeoc/publications/fs-sex.cfm The U.S. Equal Employment Opportunity Commission (2011) Sexual Harassment Charges: EEOC & FEPAs Combined: FY 1997 - FY 2010, U.S. Equal Employment Oppportunity Commission, accessed online Decemeber 01, 2011:: http://www.eeoc.gov/eeoc/statistics/ enforcement/sexual_harassment.cfm Western Cape Government. (2011) Consequences, Western Cape Government - Better Together, accessed online December 9, 2011: http://www.westerncape.gov.za/eng/pu bs/guides/S/63925/5

Call for Article Submissions International Journal of Social Health Information Management

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† By submitting a paper, authors implicitly assign Intellectbase the copyright license to publish and agree that at least one (if more authors on a paper) will register, attend and participate at the conference to present the paper.

All submitted papers are peer reviewed by the Reviewers Task Panel (RTP) and accepted papers are published in a refereed conference proceeding. Articles that are recommended to the Executive Editorial Board (EEB) by Reviewers have a higher probability of being published in one of the Intellectbase double-blind reviewed Journals. For Intellectbase Journals and publications, please visit: www.intellectbase.org/Journals.php

All submitted papers must include a cover page stating the following: location of the conference, date, each author(s) name, phone, e-mail, full affiliation, a 200 - 500 word Abstract and a minimum of 3 Keywords. Please send your submission in Microsoft Word format.

For more information concerning conferences and Journal publications, please visit the Intellectbase website at www.intellectbase.org. For any questions, please do not hesitate to contact the Conference Chair at [email protected]

CONFERENCE REGISTRATION GUIDELINES

Registration Type Fee Early Registration $395.00^ Normal Registration $450.00^ Student Registration¥ $195.00^ Additional Papers (No More than 3 Articles per Conference) $150.00^ ea. Second & Subsequent Author Attendance $95.00^ ea. ^ Prices may be subject to change ¥ Must provide evidence of Full Time student status with ID.

Cancellation Policy A 22% processing fee will be applied to all refunds. Cancellations received at least three weeks prior to conference date will be refunded 100% of registration fee (minus processing fee). Cancellations received 2-3 weeks to conference commencement are eligible for a 50% refund of the registration fee (minus processing fee). No refunds will be made within two weeks to the conference commencement. All cancellations must be in writing, include Author's Name and Paper Title and be mailed to: Intellectbase International Consortium, 1615 Seventh Avenue North, Nashville TN 37208. Attn: Dr. David King ([email protected]).

INTELLECTBASE DOUBLE-BLIND REVIEWED JOURNALS

Intellectbase International Consortium promotes broader intellectual resources and publishes reviewed papers from all disciplines. To achieve this, Intellectbase hosts approximately 4-6 academic conferences per year and publishes the following Double-Blind Reviewed Journals (http://www.intellectbase.org/journals.php).

JAGR Journal of Applied Global Research – ISSN: 1940-1833 IJAISL International Journal of Accounting Information Science and Leadership – ISSN: 1940-9524 RHESL Review of Higher Education and Self-Learning - ISSN: 1940-9494 IJSHIM International Journal of Social Health Information Management - ISSN: 1942-9664 RMIC Review of Management Innovation and Creativity - ISSN: 1934-6727 JGIP Journal of Global Intelligence and Policy - ISSN: 1942-8189 JISTP Journal of Information Systems Technology and Planning - ISSN: 1945-5240 JKHRM Journal of Knowledge and Human Resource Management - ISSN: 1945-5275 JIBMR Journal of International Business Management & Research - ISSN: 1940-185X

The US Library of Congress has assigned ISSN numbers for all formats of Intellectbase Journals - Print, Online and CD-ROM. Intellectbase Blind-Review Journals are listed in major recognized directories: e.g. Cabell’s, Ulrich’s, JournalSeek and Ebsco Library Services and other publishing directories. Intellectbase International Consortium publications are in the process to be listed in the following renowned Journal databases e.g. ABI/INFORM, ABDC, etc.

Note: Intellectbase International Consortium prioritizes papers that are selected from Intellectbase conference proceedings for Journal publication. Papers that have been published in the conference proceedings, do not incur a fee for Journal publication. However, papers that are submitted directly to be considered for Journal publication will incur a US$195 fee to help cover the cost of formatting, printing, processing, archiving, indexing & listing, postage & handling if accepted. Papers submitted direct to a Journal may be emailed to [email protected]* (e.g. [email protected]*, [email protected]*, etc.). * By submitting a paper, authors implicitly assign Intellectbase the copyright license to publish and agree that at least one (if more authors) will order a copy of the journal.

International Journal of Social Health Information Management Individual Subscription Request

Please enter my subscription for the International Journal of Social Health Information Management

Name ______Title ______Telephone ( ______) ______Mailing Address ______City ______State ______Zip Code ______Country ______Fax ( _____ ) ______E-mail ______Please check the appropriate categories: Within the United States Outside the United States

□ Annual Individual Subscription - US$145 □ Annual Individual Subscription - US$170

Begin the annual subscription with the: □ Current Issue □ Next Issue

□ Single Issue - US$95 □ Single Issue - US$105 If you are requesting a single issue, which issue (Volume, and Issue) are you requesting ? ______

Payment by check in U.S. Dollars must be included. Make check payable to: Intellectbase International Consortium

Send this Subscription Request and a check to:

IJSHIM Subscription Intellectbase International Consortium 1615 7th Ave N. Nashville, TN, 37208, USA

All e-mail enquiries should be sent to: [email protected]

International Journal of Social Health Information Management Library Recommendation (Please complete this form and forward it to your Librarian)

Dear ______(Librarian’s name) I recommend that ______(Library’s name) subscribe to the following publication.

□ International Journal of Social Health Information Management (IJSHIM) ISSN: 1942-9664 (US$225 /Year)

I have indicated the benefits of the above journal to our library: (1=highest benefit; 2=moderate benefit; 3=little benefit) 1 2 3 REFERENCE: For research articles in the field of Social Health Information and Management. 1 2 3 STUDENT READING: I plan to recommend articles from the above to my students. 1 2 3 PUBLICATION SOURCES: This journal is suitable to my current research agenda. 1 2 3 PEER EVALUATION: This journal is highly regarded by my peers around the world.

Name ______Title ______Telephone ( ______) ______Mailing Address ______City ______State ______Zip Code ______Library Subscriptions: Within the US - US$225 Outside the US (includes air mail postage) - US$255

Payment by check in U.S. Dollars must be included. Make check payable to: Intellectbase International Consortium

Send this Subscription Request and a check to: IJSHIM Subscription Intellectbase International Consortium 1615 7th Ave N. Nashville, TN, 37208, USA

Tel: +1 (615) 944-3931; Fax: +1 (615) 739-5124 www.intellectbase.org

All e-mail enquiries should be sent to: [email protected]

For information about the following Journals, please visit www.intellectbase.org

JIBMR-Journal of International JOIM-Journal of Organizational RMIC-Review of Management JGIP-Journal of Global Business Management & Information Management Innovation and Creativity Intelligence and Policy Research

IJEDAS-International Journal of JWBSTE-Journal of Web-Based RHESL-Review of Higher JKHRM-Journal of Knowledge Electronic Data Administration Socio-Technical Engineering Education and Self-Learning and Human Resource and Security Management

IJAISL-International Journal of JAGR-Journal of Applied Global IHPPL-Intellectbase Handbook JISTP-Journal of Information Accounting Information Research of Professional Practice and Systems Technology and Science and Leadership Learning Planning

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MULTI-DISCIPLINARY FOUNDATIONS

SOCIOLOGY & INTELLECTUAL TECHNOLOGY PERSPECTIVES

POLITICAL MUSIC ARTS