Ultrasound feedback and motivational interviewing targeting smoking cessation in the second and third trimesters of pregnancy.

INTRODUCTION: Cigarette smoking during pregnancy is associated with poor maternal and child health outcomes. Effective interventions to increase smoking cessation rates are needed particularly for pregnant women unable to quit in their first trimester. Real-time ultrasound feedback focused on potential effects of smoking on the fetus may be an effective treatment adjunct, improving smoking outcomes. METHODS: A prospective randomized trial was conducted to evaluate the efficacy of a smoking cessation intervention consisting of personalized feedback during ultrasound plus motivational interviewing-based counseling sessions. Pregnant smokers (N = 360) between 16 and 26 weeks of gestation were randomly assigned to one of three groups: Best Practice (BP) only, Best Practice plus ultrasound feedback (BP+US), or Motivational Interviewing-based counseling plus ultrasound feedback (MI+US). Assessments were conducted at baseline and end of pregnancy (EOP). RESULTS: Analyses of cotinine-verified self-reported smoking status at EOP indicated that 10.8% of the BP group was not smoking at EOP; 14.2% in the BP+US condition and 18.3% who received MI+US were abstinent, but differences were not statistically significant. Intervention effects were found conditional upon level of baseline smoking, however. Nearly 34% of light smokers (< or =10 cigarettes/day) in the MI+US condition were abstinent at EOP, followed by 25.8% and 15.6% in the BP+US and BP conditions, respectively. Heavy smokers (>10 cigarettes/day) were notably unaffected by the intervention. DISCUSSION: Future research should confirm benefit of motivational interviewing plus ultrasound feedback for pregnant light smokers and explore mechanisms of action. Innovative interventions for pregnant women smoking at high levels are sorely needed.

Relationship between English language use and preferences for involvement in medical care among Hispanic women.

OBJECTIVE: To assess how English language use by Hispanic women affects their preferences for participating in decision making and information seeking regarding medical care. METHODS: The study included 235 Hispanic women aged 35-61 years participating in a larger multicenter study, the Ethnicity, Needs, and Decisions of Women (ENDOW) Project. Participants were recruited from community settings and primary care public health clinics. Bilingual (English and Spanish speaking) interviewers asked participants questions about demographic characteristics, health status, reproductive history, menopausal status, access to healthcare, experience with hormone replacement therapy (HRT) and hysterectomy, outcome expectations about HRT and hysterectomy, medical decision making, and social support. Using univariate and multivariate analyses, we assessed the relationships between the participants' preferences for participating in decision making and information seeking, their language use, and other covariates of interest. RESULTS: Overall, the participants expressed a strong desire for information about and participating in medical decisions. However, they expressed a lower preference for participating in decisions related to use of HRT compared with the desire for engaging in decision involving invasive medical procedures (hysterectomy and cholecystectomy) and high blood pressure management. Increased use of English language was significantly associated with preferences for participating in medical care decision making, in general (p < 0.001), and with information seeking (p = 0.044). Decreased use of English language was associated with a lower desire for participating in medical care decision making. CONCLUSIONS: Increased use of English language may influence Hispanic women's preferences for participating in medical decisions and their information-seeking behavior.

Secondary prevention of intimate partner violence: a randomized controlled trial.

BACKGROUND: Despite the recognition of intimate partner violence (IPV) against women as a global health issue associated with significant morbidity and mortality, evidence-based treatment strategies for primary care settings are lacking. OBJECTIVE: To assess the comparative safety behaviors, use of community resources, and extent of violence following two levels of intervention. METHODS: A randomized, two-arm, clinical trial was completed in urban public primary care clinics with 360 abused women who assessed positive for physical or sexual abuse within the preceding 12 months. Two interventions were tested: a wallet-sized referral card and a 20-minute nurse case management protocol. Outcome measures were differences in the number of threats of abuse, assaults, danger risks for homicide, events of work harassment, safety behaviors adopted, and use of community resources between intervention groups over a 24-month period. RESULTS: Two years following treatment, both treatment groups of women reported significantly (p <.001) fewer threats of abuse (M = 14.5; 95% CI 12.6, 16.4), assaults (M = 15.5, 95% CI 13.5, 17.4), danger risks for homicide (M = 2.6; 95% CI 2.1, 3.0), and events of work harassment (M = 2.7; 95% CI 2.3, 3.1), but there were no significant differences between groups. Compared to baseline, both groups of women adopted significantly (p <.001) more safety behaviors by 24 months (M = 2.0; 95% CI 1.6, 2.3); however, community resource use declined significantly (p <.001) for both groups (M = -0.2; 95% CI -0.4,-0.2). There were no significant differences between groups. DISCUSSION: Disclosure of abuse, such as what happens with abuse assessment, was associated with the same reduction in violence and increase in safety behaviors as a nurse case management intervention. Simple assessment for abuse and offering of referrals has the potential to interrupt and prevent recurrence of IPV and associated trauma.

Behaviors of children following a randomized controlled treatment program for their abused mothers.

OBJECTIVE: To determine if a treatment program offered to abused mothers positively affects the behaviors of their children. METHODS: A randomized, two-arm, clinical trial was used to measure child behavior at 6, 12, 18, and 24 months following the application of two levels of abuse treatment services to abused mothers: (1) abuse assessment and receipt of a wallet-size referral card, or (2) abuse assessment, receipt of a wallet-size referral card, and nurse case management sessions. The setting was public primary care clinics. The participants were 233 women who reported physical or sexual abuse within the preceding 12 months, and who had at least one child, ages 18 months to 18 years, living with them. Outcome measures were scores on the Child Behavior Checklist (CBCL) at baseline, 6, 12, 18, and 24 months. CBCL scores for a clinically-referred sample of children served as a comparison group. RESULTS: All children improved significantly (p < .001) on CBCL scores from intake to 24 months, regardless of which treatment protocol their mother received. By 24 months, the majority of children and adolescents had scores significantly less than the referred norms. Children ages 18 months to 5 years showed the most improvement and teenagers showed the least improvement. CONCLUSIONS: Disclosure of abuse, such as that which happens during abuse assessment, was associated with the same improvement in child behavior scores as a nurse case management intervention. Routine abuse assessment and referral have the potential to positively improve the behavioral functioning of children exposed to domestic violence.

Behaviors of children exposed to intimate partner violence before and 1 year after a treatment program for their mother.

Children exposed to intimate partner violence against their mothers are at increased risk for emotional, behavior, physiological, cognitive, and social problems. To compare the behavioral functioning of children exposed to intimate partner violence before and 1 year after their mother received treatment, 206 Black, White, and Hispanic children, age 18 months to 18 years, were administered the Child Behavior Checklist. Behavior problems of all children significantly improved 1 year following treatment of their mother. When compared with a clinically referred sample of youngsters, scores of children of abused mothers were not significantly different before their mothers received treatment but most scores were significantly different after their mothers were treated. Screening and a treatment for abused women can have a positive effect on the behavior of their children.

Prevalence of partner violence against 7,443 African American, White, and Hispanic women receiving care at urban public primary care clinics.

Given inconclusive findings regarding racial/ethnic differences in risk for intimate partner violence (IPV), this study will estimate annual prevalence and severity of IPV and associated risk factors of homicide among a multiethnic population of English- and Spanish-speaking African American, White, and Hispanic women receiving public primary health care. A personal interview survey was conducted using three measurement instruments including a brief two-question screen. The sample consisted of 7,443 women, aged 18-44 years, receiving care at urban, primary health care clinics in southern Texas. White women disclosed abuse at a rate of 8.9%, followed by African American women at 6.0% and Hispanic women at 5.3%. More abuse was reported by White and African American women compared to Hispanic women. Use of a brief two-question screen provides racial/ethnic specific surveillance data for patient care programming and can track progress toward decreasing violence against women.

Implementation of a smoking cessation counseling module in a preceptorship program.

BACKGROUND: Family medicine preceptorships are underused opportunities for learning smoking cessation counseling skills. To prepare students for their future roles in preventing health problems in patients who use tobacco, we implemented a patient-centered instructional module within the elective Texas Statewide Family Practice Preceptorship Program. METHODS: Seventy-eight preclinical medical students learned to screen for tobacco use and perform smoking cessation counseling using brief motivational methods. Students practiced these skills under the supervision of community preceptors. Program evaluation included measurement of the percentage of students who documented that they could screen for tobacco use, their increase in knowledge and sense of self efficacy in conducting smoking cessation counseling, and performance of appropriate and time-efficient interventions. RESULTS: Fifty-four of 78 students screened 1,891 patients and documented 593 current tobacco users. The students provided appropriate smoking cessation intervention for 539 (91%) of these patients. Each intervention session took approximately 5 to 10 minutes. There was a more than 50% increase in the proportion of students who "agreed" or "strongly agreed" to having increased their knowledge and confidence in conducting smoking cessation counseling between the orientation and the end of their summer preceptorship. CONCLUSIONS: With focused training, preclinical medical students can successfully learn and practice patient-centered screening and smoking cessation counseling skills in a community preceptorship setting that fits the needs of busy preceptors and prepares students for their future roles in tobacco control.

Behaviors of children who are exposed and not exposed to intimate partner violence: an analysis of 330 black, white, and Hispanic children.

OBJECTIVE: To compare the behaviors of black, white, and Hispanic children who were 18 months to 18 years of age and exposed to intimate partner violence with an age- and ethnically similar sample of children who were not exposed to violence and to compare both exposed and nonexposed children to normative samples. METHODS: As part of a study on treatments for abused women in primary care public health clinics and Women, Infants and Children clinics in a large urban area, 258 abused mothers completed the Child Behavior Checklist (CBCL) on 1 of their randomly selected children between the ages of 18 months and 18 years. An ethnically similar sample of 72 nonabused mothers also completed the CBCL. The CBCL is a standardized instrument that provides a parental report of the extent of a child's behavioral problems and social competencies. The CBCL consists of a form for children 18 months to 5 years and a version for ages 6 to 18 years. The CBCL is orally administered to a parent, who rates the presence and frequency of certain behaviors on a 3-point scale (0 = not true, 1 = somewhat or sometimes true, and 2 = very true or often true). The time period is the last 6 months for the child 6 to 18 years of age and 2 months for the child 18 months to 5 years of age. Examples of behaviors for the child age 6 to 18 years include "gets in many fights," "truancy, skips school." Examples of behaviors for the child 18 months to 5 years of age include "cruel to animals," "physically attacks people," and "doesn't want to sleep alone." Both forms of the CBCL consist of 2 broadband factors of behavioral problems: internalizing and externalizing with mean scale scores for national normative samples as well as clinically referred and nonreferred samples of children. Internalizing behaviors include anxiety/depression, withdrawal, and somatic complaints. Externalizing behaviors include attention problems, aggressive behavior, and rule-breaking actions. Behavior scales yield a score of total behavioral problems. Scores are summed and then converted to normalized T scores. T scores >or=60 are within the borderline/clinical referral range-higher scores represent more deviant behavior. Multivariate analyses of variance (MANOVAs) were used to determine whether children from abused mothers differed significantly in their internalizing behaviors, externalizing behaviors, and total behavior problems from children of nonabused mothers. One sample t tests were used to compare children from abused and nonabused mothers to the matched clinically referred and nonreferred normative sample. Four pair-wise comparisons were considered: 1) children from abused women to referred norm, 2) children from abused women to nonreferred norm, 3) children from nonabused women to referred norm, and 4) children from nonabused to nonreferred norm. The internal, external, and total behavior problem T scores were dichotomized into a referral status: nonreferred = T score < 60, referred = T score >or= 60. Frequencies and percentages were used to describe the distribution of referral status among the children from the abused and nonabused women, and chi(2) tests of independence were used to determine whether the groups were significantly different. RESULTS: No significant differences in demographic characteristics between children from the abused women and nonabused women were observed. The sample consisted of a large number of Hispanic children (68.9%) and slightly more girls (53.6%), and nearly half (45.2%) had annual household incomes <10,000 dollars. Means, standard deviations, and results from the MANOVAs performed on internal, external, and total behavior problem scores between children from abused and nonabused women revealed no significant differences (F[3,139] = 1.21) for children ages 18 months through 5 years. Results from the MANOVA performed for ages 6 through 18 years revealed a significant group difference (F[3,183] = 3.13). Univariate tests revealed significant group differences for internalizing behavior (F[1,185] = 6.81), externalizing behav = 6.81), externalizing behavior (F[1,185] = 7.84), and total behavior problems (F[1,185] = 9.45). Overall, children of abused mothers had significantly higher internalizing (58.5 +/- 12.1), externalizing (55.5 +/- 12.4), and total behavior problems (57.6 +/- 12.3) scores than the internalizing (52.9 +/- 13.7), externalizing (49.7 +/- 10.6), and total behavior problems (51.0 +/- 13.0) scores exhibited for children of nonabused mothers. Most comparisons of children from the abused women to the referred and nonreferred norms are significant. The mean internal, external, and total behavior problem scores from children of abused women were significantly higher than the nonreferred norms and significantly lower than the referred norms. In contrast, all comparisons for children from nonabused women were not significantly different from the nonreferred norms. CONCLUSIONS: Children, ages 6 to 18 years, of abused mothers exhibit significantly more internalizing, externalizing, and total behavior problems than children for the same age and sex of nonabused mothers. In addition, the mean internalizing behavior score for boys 6 to 11 years of age as well as girls and boys 12 to 18 years of age of abused mothers were not significantly different from the clinical referral norms. Internalizing behaviors of anxiety, withdrawal, and depression are consistent with suicidal risk. The association of a child's exposure to intimate partner violence and subsequent attempted and/or completed suicide demands research. Our data demonstrate that children of abused mothers have significantly more behavioral problems than the nonclinically referred norm children but also, for most children, display significantly fewer problems than the clinically referred children. These children of abused mothers are clearly suspended above normal and below deviant, with children ages 6 to 18 being at the greatest risk. If abused mothers can be identified and treated, then perhaps behavior problems of their children can be arrested and behavioral scores improved. The American Academy of Pediatrics Committee on Child Abuse and Neglect recommends routine screening of all women for abuse at the time of the well-child visit and implementation of a protocol that includes a safety plan for the entire family. Clinicians can use this research information to assess for intimate partner violence during child health visits and inform abused mothers of the potential effects on their children's behavior. Early detection and treatment for intimate partner violence against women has the potential to interrupt and prevent behavioral problems for their children.

Perceptions of hormone replacement therapy among African American women.

Hormone replacement therapy (HRT) is commonly prescribed for women to relieve symptoms associated with menopause. The medical community does not uniformly recommend HRT, and ethnic and cultural differences may influence a woman's decision to request and adhere to it. Thirty-eight African American women were enrolled in a qualitative study to investigate beliefs, attitudes, and knowledge about HRT. Data collected from six focus groups were part of Ethnicity, Needs, and Decisions of Women (ENDOW), a multisite project investigating decision making and hysterectomy. Participants, age 30 to 65 years, were recruited from community agencies and public health clinics. The women were aware of the medical indications for HRT and its risks and benefits. Although a majority of participants were past or current users, they expressed reservations about the use of HRT and wanted a better dialogue with health care providers, including information about alternative treatments.

Family medicine month in a university-based program: establishing a family medicine identity.

"Family Medicine Month," a rotation forfirst-year residents, was developed to clarifyfirst-year residents'new roles as family physicians. The rotation explored the meaning and history of the specialty, as well as teaching core family medicine clinical and behavioral skills. Twenty residents who participated in the rotation in 1999 and 2000 indicated satisfaction with the rotation and endorsed its usefulness. They also reported greater self efficacy in performing family practice skills after the rotation, compared with before the rotation. Results suggest that a curriculum based on the context of family medicine as a specialty enhances resident satisfaction and self efficacy.

Improving delivery of acute stroke therapy: The TLL Temple Foundation Stroke Project.

BACKGROUND AND PURPOSE: Only a small minority of acute stroke patients receive approved acute stroke therapy. We performed a community and professional behavioral intervention project to increase the proportion of stroke patients treated with approved acute stroke therapy. METHODS: This study used a quasi-experimental design. Intervention and comparison communities were compared at baseline and during educational intervention. The communities were based in 5 nonurban East Texas counties. The multilevel intervention worked with hospitals and community physicians while changing the stroke identification skills, outcome expectations, and social norms of community residents. The primary goal was to increase the proportion of patients treated with intravenous recombinant tissue plasminogen activator (rTPA) from 1% to 6% of all cerebrovascular events in the intervention community. RESULTS: We prospectively evaluated 1733 patients and validated 1189 cerebrovascular events. Intravenous rTPA treatment increased from 1.38% to 5.75% among all cerebrovascular event patients in the intervention community (P=0.01) compared with a change from 0.49% to 0.55% in the comparison community (P=1.00). Among the ischemic stroke patients, an increase from 2.21% to 8.65% was noted in the intervention community (P=0.02). The comparison group did not appreciably change (0.71% to 0.86%, P=1.00). Of eligible intravenous rTPA candidates, treatment increased in the intervention community from 14% to 52% (P=0.003) and was unchanged in the comparison community (7% to 6%, P=1.00). CONCLUSIONS: An aggressive, multilevel stroke educational intervention program can increase delivery of acute stroke therapy. This may have important public health implications for reducing disability on a national level.