Transcript Recruitment and retention of Colorado's primary care

Data Chartpack
Recruitment and retention of
Colorado’s primary care workforce:
Rural/urban differences
October 22, 2009
2nd Colorado Health
Professions Workforce
Summit
Colorado Health Institute
1576 Sherman Street, Suite 300
Denver, Colorado 80203-1728
www.coloradohealthinstitute.org
Overview of CHI study
Five areas of inquiry -




Workforce diversity
Educational pipelines
Aging of the workforce
Career ladders
Scopes of practice and collaborative models of care
Three primary care health professionals reviewed - Physicians
 Nurses
 Oral health providers (dentists and dental hygienists)
2
Study methods
• Synthesis of peer-reviewed literature and available
Colorado data
• Literature review included abstract reviews and
analyses of evidence-based studies
• Analysis of CHI health professions’ workforce
surveys by age, geography, race/ethnicity and other
relevant variables (2005-09 surveys)
3
PHYSICIANS
4
Physician diversity: What the literature
says…
EFFECTS ON ACCESS TO CARE
• Minority physicians are providing a disproportionate share of
care to the underserved1
– Minority status is a stronger predictor of service to the
underserved than National Health Service Corp
participation, socioeconomic background or growing up in
underserved area2
• Lack of cultural sensitivity by health professionals is associated
with reduced care-seeking by parents for their children3
• Diversity among medical school students is associated with
higher levels of cultural sensitivity of all students and greater
willingness to serve diverse populations4
5
Physician diversity: What the literature
says…
EFFECT ON HEALTH OUTCOMES
• Language barriers between physicians and patients
increase costs and potential for medical errors5
• Cultural competency/racial concordance are
associated with higher patient satisfaction and levels of
patient participation in their care6
• Lack of cultural understanding and awareness can lead
to withholding information, noncompliance, delays in
care and incorrect diagnoses7
6
Physician diversity: What the literature
says…
EFFECTS ON PATIENT SATISFACTION
Racial/ethnic identification with physician is associated
with:
– Improved satisfaction among minority patients8
– Higher perceived quality of care9, 10
– Higher levels of patient participation in their care11
7
Physician diversity: A Colorado perspective
Race/ethnic background of licensed, active Colorado physicians
Colorado Population
Non-rural Physicians
Rural Physicians
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
White non-hispanic
Hispanic/Latino (of any race)
Black/African-American
Asian or Asian/Pacific Islander
Native Hawaiian/Pacific Islander
American Indian/Alaskan Native
100%
Other/Multiple
SOURCE: United States Census: 2008 Population Estimates, Colorado Health Institute 2005
Physician Workforce Survey (Q2), 2009 Rural Physician Survey (Q10)
8
Physician diversity: A Colorado perspective
Payer mix by physician race/ethnicity, rural practice, 2009
Rural practicing physicians, White
Rural practicing physicians, non-White
2%
8%
15%
3%
32%
6%
37%
5%
4%
3%
1%
3%
13%
19%
24%
25%
SOURCE: Colorado Health Institute 2009 Rural Physician Survey (Q10, Q27)
9
Physician diversity: A Colorado
perspective
Percent Responding “Interested” (4 or 5)
Practice plans at medical school admission by physician
race/ethnicity for currently practicing physicians in rural areas,
2009
59.8%
54.8%
White
44.9%
Non-white
44.5%
42.3%
48.4%
40.7%
36.2%
29.9%
28.1%
Choosing primary care Rural medical practice Medical practice in an Medical practice for
specialty
underserved area
underserved
population
Living in rural
community
SOURCE : Colorado Health Institute 2009 Rural Physician Survey (Q10, Q29)
10
Physician pipeline: What the literature says…
KEY FINDINGS
• The success of particular pipeline interventions such as
pairing middle and high school students with mentors to
increase students’ interest in the health professions varies
depending on age of student12
• Pipeline programs and interventions can have an effect on
physician supply13
• Selective admissions, institutional commitment, debt
forgiveness and other efforts are effective in promoting
rural practice and primary care specialties14
11
Physician pipeline: What the literature says…
FACTORS ASSOCIATED WITH CHOOSING A RURAL
PRACTICE
•
•
•
•
•
Growing up rural15
Selective admissions by medical school16
Medical school focus on primary care and rural medicine17
Financial incentives, such as NHSC funding18
Medical school experiences, such as rural clinical
rotations19
12
Physician pipeline: What the literature says…
FACTORS ASSOCIATED WITH CHOICE OF
PRIMARY CARE PRACTICE
•
•
•
•
•
•
Interest at time of admission to medical school20
Selective admissions policies of medical school21
Growing up rural22
Having less medical school debt23
School’s commitment to primary care practice24
Being female25
13
Physician pipeline: A Colorado perspective
Where physicians practicing in rural Colorado grew up and state
conferring medical degree, 2009
Colorado, 18.9%
Texas, 5.9%
California, 5.0%
Other, 75.0%
Illinois, 4.9%
Place where
grew up
Percent of rural
physicians
Urban
18.0%
Suburban
42.4%
Rural
39.6%
Foreign Country,
4.8%
Missouri, 4.2%
SOURCE : Colorado Health Institute 2009 Rural Physician Survey (Q32, Q9)
14
Physician pipeline: A Colorado perspective
• Two medical schools in Colorado (DO and MD)
• 132 MD graduates in 2008—UC Denver only; no
graduates from Rocky Vista (DO) until 2012
• Colorado family medicine residency graduates:
– Of 172 family medicine residents in 2007-09, 114 remained
in Colorado to practice
– Approximately 87% of Colorado’s family medicine
residents are from out of state
SOURCE : American Association of Medical Colleges Graduation Data, 2009,
Correspondence – TonyPrado-Gutierrez, University of Colorado at Denver
15
Aging of the physician workforce: What the
literature says…
KEY FINDING
Many retired physicians are interested in
volunteering after retirement, but barriers include
malpractice concerns, paperwork and
bureaucracy26
16
Aging of the physician workforce:
A Colorado perspective
Proportion of physician workforce and overall Colorado workforce, age 55 and older, 2009
Percent age 55 and older
Colorado’s workforce
17.3%
Non-rural physicians
28.7%
Rural physicians
33.6%
Proportion of rural Colorado primary care physicians by age group, 2009
Primary care*
Age 44 and
younger
45-54 yrs
55-64 yrs
65+ yrs
57.0%
42.1%
45.8%
31.1%
* Primary care includes family medicine, general pediatrics and internal medicine
SOURCE : U.S. Census Bureau 2008 Workforce Estimates, Colorado Health Institute
2009 Rural Physician Survey (Q8, Q4), Peregrine Database April 2009
17
Aging of the physician workforce:
A Colorado perspective
Volunteerism and part-time practice among Colorado’s rural
practicing physicians by age, 2009
Ages 44 and
younger
45-54 yrs
55-64 yrs
65+ yrs
Proportion working part
time
12.8%
15.0%
24.5%
51.4%
Proportion volunteering,
not billing
0.4%
0.0%
1.4%
7.5%
Physician practice
SOURCE: Colorado Health Institute 2009 Rural Physician Survey (Q2, Q8)
18
Collaborative care models:
A Colorado perspective
Percent of rural physicians reporting mid-level providers (MLPs)
in their practice, 2009
% reporting staffing model that
includes MLPs
All rural practicing physicians
35.6%
Primary care rural practicing physicians
45.8%
Specialist rural practicing physicians
26.0%
SOURCE: Colorado Health Institute 2009 Rural Physician Survey (Q17)
19
REGISTERED NURSES (RNs)
and LICENSED PRACTICAL
NURSES (LPNs)
20
Diversity in the nursing workforce: What
the literature says…
• Literature does not include evidence-based studies
on nursing diversity/cultural competence relative to
patient outcomes and satisfaction
• Further research warranted to assess these
relationships in the practice of nursing
21
Diversity in the nursing workforce:
A Colorado perspective
Fluency in language other than English used to communicate with
patients, RNs (2008) and LPNs (2007)
Nurse by practice area
% fluent in another language
Non-rural practicing RNs
12.3%
Rural practicing RNs
11.9%
Non-rural practicing LPNs
8.8%
Rural practicing LPNs
4.4%
SOURCE: Colorado Health Institute 2008 Registered Nurse Survey (Q38), 2007 Licensed
Practical Nurse Survey (Q34, Q34b)
22
Nursing pipeline: What the literature says…
• Non-competitive faculty salaries contribute to faculty
shortages27
• A variety of approaches around the country have
successfully improved nursing student enrollment:
– Changing to year-round academic schedule and year-long
faculty appointments at University of Nevada Las Vegas28
– In Colorado, partnership between Poudre Valley Hospital
and University of Northern Colorado29
23
Nurse pipeline: A Colorado perspective
• 24 accredited 2-year associate degree in nursing
(ADN) degree programs
• 11 accredited 4-year bachelor of science in nursing
(BSN) degree programs
• 10 accredited licensed practical nurse (LPN)
programs
• 15 accredited 2-year and one 4-year nursing
programs with LPN exit option
SOURCE: Colorado State Board of Nursing
24
Nurse pipeline: A Colorado perspective
Colorado nursing program graduates, 2007
Program
Approximate total graduates
Graduates licensed
LPN
615
544
ADN
879
717
BSN
941
847
Area where nurse grew up and was educated, active RNs (2008) and LPNs (2007)
Percent trained in Colorado
Percent from rural area
RNs – Non-rural
46.1%
31.9%
RNs – Rural
47.0%
60.7%
LPNs – Non-rural
58.0%
43.5%
LPNs – Rural
78.7%
69.8%
SOURCE: Colorado State Board of Nursing, Colorado Health Institute 2008 RN Survey (Q4, Q34), 2007 LPN
Survey (Q1a, Q30)
25
Nursing pipeline: A Colorado perspective
PIPELINE CAPACITY ISSUES
• Wait lists—3,579 qualified applicants not admitted due to lack of
slots (2008-09)
• Faculty vacancies (2008)
– 15% of associate degree in nursing (ADN) faculty positions
– 8% of bachelor of science in nursing (BSN) faculty positions
– 15% of licensed practical nurse (LPN) faculty positions
– 11% of master of science in nursing (MSN) faculty positions
– 17% of doctor of nursing practice (DNP) faculty positions
– 76 FTE vacancies for clinical nurse instructors
• Reported barriers to program expansion include faculty shortages,
securing clinical placements, lack of funds, noncompetitive salaries
for faculty
SOURCE: Colorado Health Institute 2008/2009 Nursing Faculty Studies
26
Aging of the nurse workforce: What the
literature says…
• Incentives such as improved benefits, flexible
schedules, ergonomic improvements in the work
environment and institutional support/recognition
can influence older nurses to delay retirement30
• Turnover highly expensive both monetarily and in
terms of loss of expertise31
• No single retention strategy works across all settings,
multiple factors involved32
27
Aging of the nursing workforce:
A Colorado perspective
Proportion of RN (2008) and LPN (2007) workforce age 55 and older
% 55 and older
RNs in a non-rural practice
27.4%
RNs in a rural practice
31.9%
LPNs in a non-rural practice
20.4%
LPNs in a rural practice
32.1%
SOURCE: Colorado Health Institute 2008 RN Survey (Q36, Q17), 2007 LPN
Survey (Q19, Q31)
28
Aging of the nursing workforce:
A Colorado perspective
OF NURSES PLANNING TO LEAVE THE
WORKFORCE:
• 14% of non-rural and 10% of rural RNs ages 55 and older
reported planning to leave their primary nursing position
in next 12 months (2008)
– Highest reported reasons included insufficient wages, too
much stress, insufficient benefits, lack of respect and
retirement
• 15% of non-rural and 25% of rural LPNs ages 55 and older
planned to leave their primary nursing position in next 12
months (2007)
– Highest reported reasons included too much stress,
insufficient wages, retirement, workplace safety issues, and
not feeling respected
SOURCE: Colorado Health Institute 2008 RN Survey (Q29, Q30, Q36), 2007 LPN
Survey (Q25, Q36, Q31)
29
Nurse scope of practice/models of care:
What the literature says…
• Nurse practitioners (NPs) deliver comparable
quality of care to physicians within the scope of
their practice
• Patients report greater satisfaction with NPs and
certified nurse midwives (CNMs) than with
physicians in specific care settings
• NPs and CNMs are more likely to work in an
underserved area and/or with an underserved
population
SOURCE: Colorado Health Institute, Collaborative Scopes of Care Study, 2009
30
Nurse scope of practice/collaborative
models of care: A Colorado perspective
• More than 80% of RNs agreed that their relationship
with physicians was good (2008)
• Most nurses (74% non-rural and 77% rural) agreed
that they participated in decisions related to their
patients’ care
• Approximately 2,322 practicing nurse practitioners in
Colorado*
* The American Academy of Nurse Practitioners estimates that 90% of
registered NPs are practicing in the field; Colorado had 2,580 actively
licensed nurse practitioners as of January 5, 2009.
SOURCE: Colorado Health Institute 2008 RN Survey (Q23), Colorado
Department of Regulatory Agencies
31
Career ladders in nursing: What the
literature says…
• Robust career ladder opportunities are associated
with increased productivity and satisfaction among
nurses33
• Two general types of career ladders34
– Clinical ladder achieved through on-the-job
performance and clinical evaluation
– Educational ladder based on obtaining higher
degrees
32
Career ladders in nursing: A Colorado
perspective
Highest degree earned by practice location, active RNs, 2008
Highest degree
Non-rural RNs
Rural RNs
Associate degree in nursing
24.5%
37.1%
Bachelor of science in nursing
46.9%
35.4%
Master of nursing degree
13.8%
11.0%
Non-nursing doctorate
0.3%
1.4%
Nursing-related doctorate
1.5%
0.7%
SOURCE: Colorado Health Institute 2008 RN Survey (Q1, Q2, Q7)
33
Career ladders in nursing: A Colorado
perspective
• Pursuit of additional education:
– More non-rural than rural nurses reported having
returned to school for an additional degree
– Greater proportion of nurses with bachelor’s degrees
in nursing (BSNs) returned to school for additional
nursing degrees
• RNs whose first degree was an associate degree in
nursing (ADN) began and ended their education
later than BSN graduates
SOURCE: Colorado Health Institute 2008 RN Survey (Q2, Q7)
34
Career ladders in nursing: A Colorado
perspective
• Type of facility where first employed
– More older, non-rural LPNs began work in hospitals
– More younger, non-rural LPNs began work in nursing
homes, clinics or physician offices
• Pursuit of additional education
– 15% of non-rural and 18% of rural LPNs reported
currently being enrolled in an RN program
– 36% of non-rural and 43% of rural LPNs reported plans to
pursue an RN education
SOURCE: Colorado Health Institute 2007 LPN Survey (Q7, Q7a, Q10, Q11, Q31)
35
DENTISTS AND DENTAL
HYGIENISTS
36
Diversity among oral health professionals:
What the literature says…
• Racial/ethnic minority dentists more likely to care for
underserved patients35
• Lack of cultural understanding by dentists associated
with barriers to care-seeking for Medicaid-enrolled
children36
• Available literature did not address diversity in the
dental hygiene workforce
37
Oral health professionals and diversity:
A Colorado perspective
Colorado Population
Dentists - Rural
Dental Hygienists
0%
10%
20%
30%
White non-hispanic
Black/African-American
Native Hawaiian/Pacific Islander
Other/Multiple
40%
50%
60%
70%
80%
90%
100%
Hispanic/Latino (of any race)
Asian or Asian/Pacific Islander
American Indian/Alaskan Native
SOURCE: U.S. Census Bureau 2008 population estimates, Colorado Health Institute 2008 Rural Dentist
Survey, 2006 Dental Hygienist Survey
38
Diversity among oral health
professionals: A Colorado perspective
Language proficiency among dental hygienists (2006)
and rural dentists (2008)
Language other than English
Rural dentists
27.5%
Dental hygienists (urban/suburban)
6.4%
Dental hygienists (rural)
5.9%
SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q23), 2006 Dental Hygienist
Survey (QC3)
39
Diversity among oral health
professionals: A Colorado perspective
• 27.5% of rural dentists indicate they speak a
language other than English to communicate
with some or all patients
• 6.4% of urban/suburban and 5.9% of rural
dental hygienists report being fluent in a
language other than English
SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q23), 2006 Dental Hygienist Survey
(QC3)
40
Diversity among rural oral health
professionals: A Colorado perspective
• Minority rural dentists report spending greater proportion of
time in direct patient care with children and older adults
• Payment sources
– More minority rural dentists offer a sliding-fee schedule than White
rural dentists
– More minority rural dentists report accepting Medicaid payment, new
Medicaid patients, Child Health Plan Plus (CHP+) payment and new
CHP+ patients
• Non-White dental hygienists report twice as many volunteer
hours as White dental hygienists
• More non-White dental hygienists report that their primary
worksite provides care to Medicaid patients, accepts new
Medicaid patients and provides care on a sliding-fee schedule
SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q3, Q20, Q22), 2006 Dental Hygienist Survey
(QB3b, QC5, QB16, QB16a)
41
Dentist pipeline: What the literature
says…
• Perceived barriers to dental students’ practicing in
underserved areas/populations include lack of
information about practice opportunities, student
debt and lack of access to patient populations in
dental school37
• Untested effectiveness of dental pipeline
interventions to promote service to underserved
populations38
• Secondary school interventions and select
characteristics of dental school admissions and
curriculum known to promote dental graduates
practice with underserved populations39
42
Dentist pipeline: A Colorado
perspective
Dental school location of Colorado’s rural dentists, 2008
Colorado
20%
Other
50%
Nebraska
12%
Illinois
9%
Missouri
9%
SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q24, Q32)
43
Dentist pipeline: A Colorado
perspective
Factors important in the decision to practice in a rural community, 2008
Factor
% indicating “Yes”
Quality of life
95.1%
Good place to raise children
90.0%
Recreational/leisure activities
87.2%
Slower pace of life
86.2%
Personal/family reasons
57.9%
Opportunity to be involved in community
57.5%
Good schools
51.9%
Smaller practice
48.8%
Grew up in a rural area
43.1%
Took over established practice
42.5%
Other reason
32.5%
SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q12)
44
Dental hygienist pipeline: A Colorado
perspective
Dental hygienist background by work location, 2006
Trained in CO
Grew up in CO Grew up in rural area
Non-rural dental hygienists
44.9%
38.2%
30.3%
Rural dental hygienists
47.6%
36.8%
48.4%
Type of dental hygiene degree of dental hygienists by work location, 2006
Associate degree in dental
hygiene
Bachelor’s degree in dental
hygiene
Non-rural dental hygienists
61.3%
34.7%
Rural dental hygienists
73.8%
20.7%
SOURCE: Colorado Health Institute 2007 Dental Hygienist Survey (QA1, QC1, QC2, QB5, QA2)
45
Aging of the oral health workforce: A
Colorado perspective
• 41% of rural dentists are age 55 and older
• Greater proportion of older rural dentists support
the independent dental hygienist practice
• 13% of rural dental hygienists are age 55 and older
SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q1, Q34), 2007 Dental Hygienist
Survey (QC7, QC1)
46
Oral health scopes of practice: What
the literature says…
• Peer-reviewed studies indicate that dental
hygienists provide equal or better quality of care
within scope of practice
• Vast majority of dental hygienist patients are
satisfied with care
SOURCE: Colorado Health Institute, Collaborative Scopes of Care Report, 2009
47
Oral health scopes of practice/collaborative
models of care: A Colorado perspective
• 51% of rural dentists indicate they collaborate with
physicians/nurses in the community
• 72.8% work with at least one dental hygienist
• 25% indicate support for expanding the role of
dental hygienists as independent practitioners
• 3% of dental hygienists statewide report working in
independent practice
SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q17, Q33, Q34), 2007 Dental Hygienist
Survey (QB6)
48
Dental hygienist career ladders: What
the literature says…
A 2008 study found that a greater proportion of
dental hygienists who begin their dental hygiene
career with a bachelor’s degree
– Have or are seeking a master’s degree
– Are in faculty positions or other teaching
positions
– Are involved in research40
49
Dental hygienist career ladders: A
Colorado perspective
Highest degree (dental hygiene or other) obtained by working
dental hygienists, 2006
Degree
Highest Percent Non-rural
degree
highest degree
Percent Rural
highest degree
Associate
53.8%
52.5%
62.0%
Bachelor’s
39.4%
40.8%
30.9%
Master’s
3.8%
4.0%
2.8%
Doctorate
0.2%
0.2%
0.5%
Dental hygienists intending to pursue another degree/certification, 2006
Percent indicating “Yes”
Non-rural dental hygienists
18.7%
Rural dental hygienists
28.5%
SOURCE: Colorado Health Institute 2008 Dental Hygienist Survey (QB5, QA2, QA4)
50
References
Slide 5
1.
Komaromy, et al. (1996); Institute of Medicine; Rabinowitz, Diamond, Veloski and Gayle (2000); Edmunds (2006); Brotherton,
Stoddard and Tang (2000); Davidson and Montoya (1987); Saha and Shipman (2008); Cohen, Gabriel and Terrell. (2002); Smith,
Ester and Inglehart (2006).
2.
Saha and Shipman (2008); Rabinowitz, Diamond,Veloski and Gayle (2000).
3.
Lassetter and Baldwin (2004); Kelly, Binkley, Neace and Gale (2005).
4.
Institute of Medicine (2004); Saha, Guiton, Wimmers and Wilkerson (2008).
Slide 6
5.
Brotanek, Seeley and Flores (2008); Lassetter and Baldwin (2004).
6.
Lieu, et al. (2004); Cooper-Patrick, et al. (1999); Berger (2008); Institute of Medicine (2003).
7.
Institute of Medicine (2003); Berger (2008); Lassetter and Baldwin (2004).
Slide 7
8.
Cooper-Patrick, et al. (1999).
9.
Institute of Medicine (2003).
10. Berger (2008); Institute of Medicine (2003).
11. Halbert, Armstrong, Gandy and Shaker (2006); Cooper-Patrick, et al. (1999).
Slide 11
12. Cooney, Kosoko-Lasaki, Slattery and Wilson (2006).
13. Hsueh, Wilkinson and Bills. (2004); Ko, et al. (2005).
14. Hsueh, Wilkinson and Bills. (2004); Rosenblatt and Andrilla (2005); Colquitt, Zeh, Killian and Cultice (1996); Senf, CamposOutcalt, Watkins, Bastacky and Killian (1997).
51
References (cont.)
Slide 12
15. Ward, Kamien and Lopez (2004); Rhyne, Daniels, Skipper, Sanders and VanLett (2006); Hsueh, Wilkinson and Bills (2004);
Easterbrook, et al. (1999); Curran and Rourke (2004); Henry, Edwards and Crotty (2009).
16. Hsueh, Wilkinson and Bills (2004).
17. Hsueh, Wilkinson and Bills (2004); Curran and Rourke (2004).
18. Bärnighausen and Bloom (2009).
19. Rhyne, Daniels, Skipper, Sanders and VanLett (2006); Curran and Rourke (2004); Henry, Edwards and Crotty (2009).
Slide 13
20. Senf, Campos-Outcalt, Watkins, Bastacky and Killian (1997); Owen, Hayden and Connors (2002); Kassebaum, Szenas and
Schuchert (1996); Burack, Irby, Carline, Ambrozy, Ellsbury and Stritter (1997).
21. Burack, Irby, Carline, Ambrozy, Ellsbury and Stritter (1997).
22. Senf, Campos-Outcalt, Watkins, Bastacky and Killian (1997); Kassebaum, Szenas and Schuchert (1996).
23. Rosenblatt and Andrilla (2005); Colquitt, Zeh, Killian and Cultice (1996).
24. Senf, Campos-Outcalt, Watkins, Bastacky and Killian (1997).
25. Owen, Hayden and Connors (2002); Kassebaum, Szenas and Schuchert (1996); Ward, Kamien and Lopez (2004); Rosenblatt
and Andrilla (2005); Burack, Irby, Carline, Ambrozy, Ellsbury and Stritter (1997); Senf, Campos-Outcalt, Watkins, Bastacky and
Killian (1997).
Slide 16
26. Sloane, Cohen, Konrad, Williams, Schumacher and Zimmerman (2008).
Slide 23
27. Allan and Aldebron (2008); Yucha and Witt (2009).
28. Yucha and Witt (2009).
29. DeYoung, Bliss and Tracy (2002).
52
References (cont.)
Slide 27
30. Robert Wood Johnson Foundation (2006); Cyr (2005); Blakeley and Ribeiro (2008).
31. Robert Wood Johnson Foundation (2006).
32. Robert Wood Johnson Foundation (2006).
Slide 32
33. Nelson and Cook (2008); Goodrich and Ward (2004).
34. Nelson & Cook (2008).
Slide 37
35. Butters and Winter (2002); Mofidi, Konrad, Porterfield, Niska and Wells (2002); Okunseri, Bajorunaite, Abena, Self, Iacopino
and Flores (2008).
36. Kelly, Binkley, Neace and Gale (2005).
Slide 41
37. Davidson, Nakazono, Carreon, Bai and Afifi (2009).
38. Davidson, Nakazono, Carreon, Bai and Afifi (2009).
39. Davidson, Nakazono, Carreon, Bai and Afifi (2009).
Slide 48
40. Rowe, Massoumi, Hyde and Weintraub (2008).
53
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