Does Screening or Providing Information on Resources for Intimate Partner Violence Increase Women's Knowledge? Findings from a Randomized Controlled Trial.

BACKGROUND: Screening for IPV in health care settings might increase women's knowledge or awareness around its frequency and its impact on health. When IPV is disclosed, assuring women it is not their fault should improve their knowledge that IPV is the perpetrator's responsibility. Providing information about IPV resources may also increase women's knowledge about the availability of solutions. METHODS: Women (n=2708) were randomly assigned to one of three groups: (1) partner violence screen plus video referral and list of local partner violence resources if screening was positive (n=909); (2) partner violence resource list only without screen (n=893); and (3) a no-screen, no-partner violence resource list control group (n=898). One year later, 2364 women (87%) were re-contacted and asked questions assessing their knowledge of the frequency of partner violence, its impact on physical and mental health, the availability of resources to help women experiencing partner violence, and that it is the perpetrator's fault. RESULTS: There were no differences between women screened and provided with a partner violence resource list compared to a control group as to women's knowledge of the frequency of IPV, its impact on physical or mental health, or the availability of IPV services in their community. However, among women who experienced IPV in the year before or year after enrolling in the trial, those who were provided a list of IPV resources without screening were significantly less likely to know that IPV is not the victim's fault than those in the control or list plus screening conditions. CONCLUSIONS: The results of this study suggest that providing information on partner violence resources, with or without asking questions about partner violence, did not result in improved knowledge.

Health perceptions and symptom burden in primary care: measuring health using audio computer-assisted self-interviews.

PURPOSE: To assess the relationships among somatic symptoms and health perception measures in data collected from the implementation of audio computer-assisted self-interview (ACASI) technology in a primary care clinic of a safety-net healthcare system. METHODS: We approached 2,848 English- or Spanish-speaking patients to complete an ACASI-administered survey before their clinic appointment between April 2011 and July 2012. We administered the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health-10 assessing General Self-Rated Health (GSRH), Global Physical and Mental Health; Memorial Symptom Assessment Scale (MSAS) assessing symptom burden; and the Patient Health Questionnaire-2 (PHQ-2). We calculated population attributable fractions (PAF) of symptoms on poorly perceived health. RESULTS: Participation rate was 90 %, but 51 % of observations were analyzable. Mean age was 57 years; 53 % were non-Hispanic black; and 20 % completed the survey in Spanish. All but 2 % reported at least one symptom most commonly lack of energy (87 %) and pain (83 %). The MSAS was well correlated with PHQ-2 (r = 0.65) and Global Physical Health (r = -0.65), but less with GSRH (r = -0.49). All negative health perception measures were largely attributable to lack of energy and pain, while depression-range PHQ-2 was attributable also to less prevalent symptoms including decreased appetite and sexual disinterest. CONCLUSIONS: Symptom burden was less correlated with GSRH than with other measures of poor health perception. Fatigue and pain contributed the highest PAF to all measures of perceived poor health. Success with collecting PROMs in a resource-limited clinical setting demonstrates that the implementation of ACASI technology is feasible.

Effect of screening for partner violence on women's quality of life: a randomized controlled trial.

CONTEXT: Although partner violence screening has been endorsed by many health organizations, there is insufficient evidence that it has beneficial health outcomes. OBJECTIVE: To determine the effect of computerized screening for partner violence plus provision of a partner violence resource list vs provision of a partner violence list only on women's health in primary care settings, compared with a control group. DESIGN, SETTING, AND PARTICIPANTS: A 3-group blinded randomized controlled trial at 10 primary health care centers in Cook County, Illinois. Participants were enrolled from May 2009-April 2010 and reinterviewed 1 year (range, 48-56 weeks) later. Participants were English- or Spanish-speaking women meeting specific inclusion criteria and seeking clinical services at study sites. Of 3537 women approached, 2727 were eligible, 2708 were randomized (99%), and 2364 (87%) were recontacted 1 year later. Mean age of participants was 39 years. Participants were predominantly non-Latina African American (55%) or Latina (37%), had a high school education or less (57%), and were uninsured (57%). INTERVENTION: Randomization into 3 intervention groups: (1) partner violence screen (using the Partner Violence Screen instrument) plus a list of local partner violence resources if screening was positive (n = 909); (2) partner violence resource list only without screen (n = 893); and (3) no-screen, no-partner violence list control group (n=898). MAIN OUTCOME MEASURES: Quality of life (QOL, physical and mental health components) was the primary outcome, measured on the 12-item Short Form (scale range 0-100, mean of 50 for US population). RESULTS: At 1-year follow-up, there were no significant differences in the QOL physical health component between the screen plus partner violence resource list group (n = 801; mean score, 46.8; 95% CI, 46.1-47.4), the partner violence resource list only group (n = 772; mean score, 46.4; 95% CI, 45.8-47.1), and the control group (n = 791; mean score, 47.2; 95% CI, 46.5-47.8), or in the mental health component (screen plus partner violence resource list group [mean score, 48.3; 95% CI, 47.5-49.1], the partner violence resource list only group [mean score, 48.0; 95% CI, 47.2-48.9], and the control group [mean score, 47.8; 95% CI, 47.0-48.6]). There were also no differences between groups in days unable to work or complete housework; number of hospitalizations, emergency department, or ambulatory care visits; proportion who contacted a partner violence agency; or recurrence of partner violence. CONCLUSIONS: Among women receiving care in primary care clinics, providing a partner violence resource list with or without screening did not result in improved health. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00526994.

Comparative cost analysis of housing and case management program for chronically ill homeless adults compared to usual care.

OBJECTIVE: To assess the costs of a housing and case management program in a novel sample-homeless adults with chronic medical illnesses. DATA SOURCE: The study used data from multiple sources: (1) electronic medical records for hospital, emergency room, and ambulatory medical and mental health visits; (2) institutional and regional databases for days in respite centers, jails, or prisons; and (3) interviews for days in nursing homes, shelters, substance abuse treatment centers, and case manager visits. Total costs were estimated using unit costs for each service. STUDY DESIGN: Randomized controlled trial of 407 homeless adults with chronic medical illnesses enrolled at two hospitals in Chicago, Illinois, and followed for 18 months. PRINCIPAL FINDINGS: Compared to usual care, the intervention group generated an average annual cost savings of (-)$6,307 per person (95 percent CI: -16,616, 4,002; p = .23). Subgroup analyses of chronically homeless and those with HIV showed higher per person, annual cost savings of (-)$9,809 and (-)$6,622, respectively. Results were robust to sensitivity analysis using unit costs. CONCLUSION: The findings of this comprehensive, comparative cost analyses demonstrated an important average annual savings, though in this underpowered study these savings did not achieve statistical significance.

Comparison of screening and referral strategies for exposure to partner violence.

BACKGROUND: Although under debate, routine screening for intimate partner violence (IPV) is recommended in health care settings. This study explored the utility of different screening and referral strategies for women exposed to IPV in primary health care. METHODS: Using a randomized controlled trial design we compared two screening strategies (health care providers [HCP] versus audio computer-assisted self-interviews [A-CASI]) and three referral strategies (HCP alone, A-CASI referral with HCP endorsement, and A-CASI alone). English-speaking women who were 18 years and older and were attending women's health clinics at a public hospital were eligible to participate. Participants were randomly assigned to one of three study groups (HCP screen and referral, A-CASI screen and referral with HCP referral endorsement, and A-CASI screen and referral). Women were reinterviewed by telephone 1 week later. The primary outcome was rate of IPV disclosure; secondary outcomes were screening mode preference, reactions to IPV screening, and use of referral resources. RESULTS: Of the 129 eligible women, 126 women were enrolled (98%); 102 women (81% of those enrolled) completed the follow-up telephone interview. Disclosure rates were higher for women screened with A-CASI compared with HCP-screened women (21% vs. 9%; p = .07). Screening mode preference, impact of screening (positive and negative reactions), and rates of use of referral resources were similar between study groups. CONCLUSION: A-CASI tended to yield higher rates of IPV disclosure and similar rates of use of referral resources. A-CASI technology may be a practical way to screen for IPV.

Concordance in the measurement of quality of life and health indicators between two methods of computer-assisted interviews: self-administered and by telephone.

PURPOSE: The aim of this study was to establish the concordance for quality of life (QOL), disability, and use of health service indicators between two modes of computer-assisted interviews: audio-computer-assisted self-interview (A-CASI) and computer-assisted telephone interview (CATI). High concordance between these modes of data collection would allow comparisons and interchangeable use in cross-sectional or longitudinal assessments. METHODS: Adult English-speaking women (n = 126) were enrolled from women's health clinics at a public hospital. QOL using the short form 12 version 2, disability (days missed from work, inability to do household activities), and utilization of health services (number of emergency room visits and hospitalizations) were assessed first with A-CASI at the time of enrollment and again (n = 102) with CATI 1 week later. Participants assessed with both modes were 38 years old on average, predominantly African-American, 41% had a high school education or less, and 61% were uninsured. Lin's concordance correlation coefficient or Cohen's kappa was calculated to establish concordance between paired A-CASI and CATI assessments. RESULTS: Concordance between the two interview methods ranged from fair to substantial for the QOL components, (concordance correlation coefficient [CCC] of .76 and .87, respectively), the QOL subscales, and disability indices (CCC range; .53-.91). For health services utilization, there was moderate concordance for emergency room visits (CCC = .70) but only slight concordance for the number of hospitalizations in the past year (CCC = .37). CONCLUSIONS: Administering surveys through a telephone or self-administered computer-assisted interview resulted in moderate to substantial agreement for the short form QOL components and fair to substantial for the QOL subscales and disability measures. These findings suggest A-CASI and CATI can be used interchangeably for some QOL scales.

Using computer decision support to increase maternal postpartum tetanus, diphtheria, and acellular pertussis vaccination.

OBJECTIVE: To evaluate whether use of a computer-based clinical decision-support algorithm that used data stored in the electronic medical record increased administration of tetanus, diphtheria, and acellular pertussis (Tdap) vaccine to postpartum women. METHODS: We performed a before and after cohort study of postpartum women at an urban public teaching hospital. We compared the frequency of Tdap vaccination during the preintervention (October 1, 2008-January 14, 2009) and postintervention (January 15-April 30, 2009) time periods. We intervened by automating electronic presentation of preselected orders to physicians who provided postpartum care. The order was displayed when physicians ordered iron supplementation or patient discharge to a woman who met certain criteria. We evaluated whether patient characteristics were associated with receipt of vaccine. RESULTS: Tetanus, diphtheria, and acellular pertussis vaccination was more likely for postpartum women postintervention compared with preintervention (147 of 248 [59%] compared with zero of 183 [0%]; difference=59%; 95% confidence interval [CI] 53-65%). Among 248 women who delivered during the postintervention period, those who met pharmacologic criteria for decision support rule activation were vaccinated more often than those who did not meet criteria (146 of 232 [63%] compared with one of 16 [6%]; difference=57%; 95% CI 43-70%). Race and ethnicity and cesarean delivery were not associated with vaccine receipt; however, there was a lower likelihood of vaccination among older women (P=.05 by a trend test across age quartiles). CONCLUSION: We implemented a computer-based clinical decision-support algorithm that dramatically increased Tdap vaccination of postpartum women. Deployment of our algorithm in hospitals that have clinical decision support systems should increase rates of this important postpartum preventive intervention. LEVEL OF EVIDENCE: II.

Ethnic disparities in asthma morbidity in Chicago.

RATIONALE: The role of ethnicity and socioeconomic status in explaining variations in asthma morbidity is unclear. OBJECTIVES: To describe the magnitude of ethnic disparities in asthma morbidity in Chicago and to determine whether differences in socioeconomic status explain these disparities. METHODS: We conducted a survey of 561 school-age children and 353 young adults with asthma and measured their self-reported ethnicity, socioeconomic status (using 11 variables), and asthma morbidity (symptom frequency, asthma-specific quality of life, and frequency of severe asthma exacerbations). MEASUREMENTS AND MAIN RESULTS: White children and adults had better asthma-specific quality of life and fewer severe asthma exacerbations compared to black and Hispanic children and adults. White children also had fewer days with asthma symptoms, but among adults there were no ethnic differences in the frequency of asthma symptoms. Socioeconomic status explained a large portion of the ethnic disparities in asthma quality of life but explained little of the disparities in other aspects of asthma morbidity. CONCLUSIONS: There are large disparities across ethnic groups in Chicago in asthma quality of life and in the frequency of severe exacerbations. Differences in socioeconomic status do not fully explain these disparities.

Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial.

CONTEXT: Homeless adults, especially those with chronic medical illnesses, are frequent users of costly medical services, especially emergency department and hospital services. OBJECTIVE: To assess the effectiveness of a case management and housing program in reducing use of urgent medical services among homeless adults with chronic medical illnesses. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial conducted at a public teaching hospital and a private, nonprofit hospital in Chicago, Illinois. Participants were 407 social worker-referred homeless adults with chronic medical illnesses (89% of referrals) from September 2003 until May 2006, with follow-up through December 2007. Analysis was by intention-to-treat. INTERVENTION: Housing offered as transitional housing after hospitalization discharge, followed by placement in long-term housing; case management offered on-site at primary study sites, transitional housing, and stable housing sites. Usual care participants received standard discharge planning from hospital social workers. MAIN OUTCOME MEASURES: Hospitalizations, hospital days, and emergency department visits measured using electronic surveillance, medical records, and interviews. Models were adjusted for baseline differences in demographics, insurance status, prior hospitalization or emergency department visit, human immunodeficiency virus infection, current use of alcohol or other drugs, mental health symptoms, and other factors. RESULTS: The analytic sample (n = 405 [n = 201 for the intervention group, n = 204 for the usual care group]) was 78% men and 78% African American, with a median duration of homelessness of 30 months. After 18 months, 73% of participants had at least 1 hospitalization or emergency department visit. Compared with the usual care group, the intervention group had unadjusted annualized mean reductions of 0.5 hospitalizations (95% confidence interval [CI], -1.2 to 0.2), 2.7 fewer hospital days (95% CI, -5.6 to 0.2), and 1.2 fewer emergency department visits (95% CI, -2.4 to 0.03). Adjusting for baseline covariates, compared with the usual care group, the intervention group had a relative reduction of 29% in hospitalizations (95% CI, 10% to 44%), 29% in hospital days (95% CI, 8% to 45%), and 24% in emergency department visits (95% CI, 3% to 40%). CONCLUSION: After adjustment, offering housing and case management to a population of homeless adults with chronic medical illnesses resulted in fewer hospital days and emergency department visits, compared with usual care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00490581.

The health impact of supportive housing for HIV-positive homeless patients: a randomized controlled trial.

OBJECTIVES: We assessed the health impact of a housing and case management program, the Chicago Housing for Health Partnership, for homeless people with HIV. METHODS: HIV-positive homeless inpatients at a public hospital (n = 105) were randomized to usual care or permanent housing with intensive case management. The primary outcome was survival with intact immunity, defined as CD4 count > or = 200 and viral load < 100,000. Secondary outcomes were viral loads, undetectable viral loads, and CD4 counts. RESULTS: Outcomes were available for 94 of 105 enrollees (90%). Of 54 intervention participants, 35 (65%) reached permanent housing in program housing agencies. After 1 year, 55% of the intervention and 34% of the usual care groups were alive and had intact immunity (P = .04). Seventeen intervention (36%) and 9 usual care (19%) participants had undetectable viral loads (P = .051). Median viral loads were 0.89 log lower in the intervention group (P = .03). There were no statistical differences in CD4 counts. CONCLUSIONS: Homelessness is a strong predictor of poor health outcomes and complicates the medical management of HIV. This housing intervention improved the health of HIV-positive homeless people.

Improving asthma self-efficacy: developing and testing a pilot community-based asthma intervention for African American adults.

BACKGROUND: Low-income African American adults in Chicago have disproportionately high asthma morbidity and mortality rates. Interventions that improve asthma self-efficacy for appropriate self-management behaviors might ultimately improve asthma control in this population. OBJECTIVE: We sought to pilot test an intervention to improve asthma self-efficacy for appropriate self-management behaviors. METHODS: Participants for this trial were recruited through 2 primary care clinics located in the largest African American community in Chicago. Participants were then randomized into one of 2 groups. The control group received mailed asthma education materials. The intervention group was offered 4 group sessions led by a community social worker and 6 home visits by community health workers. Telephone interviews were conducted at baseline (before intervention), 3 months (after intervention), and 6 months (maintenance). RESULTS: The 42 participants were predominantly African American and low income and had poorly controlled persistent asthma. The intervention group had significantly higher asthma self-efficacy at 3 months (P < .001) after the completion of the intervention. Asthma action plans were more common in the intervention group at 3 months (P = .06). At 6 months, the intervention group had improved asthma quality of life (P = .002) and improved coping (P = .01) compared with control subjects. Trends in behavioral and clinical outcomes favored the intervention group but were not statistically significant. CONCLUSIONS: This community-based asthma intervention improved asthma self-efficacy, self-perceived coping skills, and asthma quality of life for low-income African American adults. Larger trials are needed to test the efficacy of this intervention to reduce asthma morbidity in similar high-risk populations.

Predictors of first and second dose acceptance of hepatitis B vaccine among STD clinic patients.

Our goal was to identify attitudinal, behavioural and pragmatic factors predictive of receipt of the first and second doses of hepatitis B virus (HBV) vaccine. In this study, 431 adult sexually transmitted disease clinic patients with no reported history of prior HBV vaccination or infection completed a computer-assisted questionnaire, then were offered free HBV vaccine. Those who accepted were scheduled for follow-up doses. Twenty-nine percent received the first dose of vaccine. Of these individuals, 21% returned for the second dose. Seven participants received all three doses. Health beliefs and caring for three or more children predicted first dose acceptance. Less travel time to the clinic and caring for two or fewer children predicted return for the second dose. HBV vaccination rates were low in this study. Interventions designed to modify health beliefs may increase first dose uptake. Increases in receipt of subsequent vaccine doses might best be accomplished through approaches designed to decrease pragmatic barriers to vaccine access.

A 6-item brief measure for assessing perceived control of asthma in culturally diverse patients.

BACKGROUND: A concise yet accurate measurement tool is needed for use in research and practice in asthma self-management perceptions across culturally diverse patient populations. OBJECTIVES: To evaluate the psychometric properties of the 11-item Perceived Control of Asthma Questionnaire (PCAQ) and to derive a brief, psychometrically sound, and culturally sensitive measure using item response theory. METHODS: The PCAQ was administered as one of a battery of measures to 375 adults with asthma as part of an ongoing larger project studying asthma disparities. Analyses of differential item functioning (DIF) were conducted to detect the effects of sex, race/ethnicity, and health literacy on psychometric properties. RESULTS: Forty-eight percent of the sample was non-Hispanic white and 44% was African American. The mean +/- SD age was 43.7 +/- 13.7 years. The derived 6-item version, with 5 DIF items not scored, correlated highly with its full version (r = 0.903; P < .001). CONCLUSIONS: The 6-item PCAQ short form has the potential to maintain scale integrity while reducing administration time and lessening survey fatigue in studies using multiple questionnaires. DIF analyses also enabled us to understand the unique aspects of perceived asthma control in demographic groups most affected by asthma.

Assessing the Perceived Stress Scale for African American adults with asthma and low literacy.

The Perceived Stress Scale (PSS) is a widely used measure of stress that has not been validated in asthma patients. The psychometric properties of the PSS were explored using confirmatory factor analysis and item response theory. Study 1 involved 312 ambulatory care patients with asthma who completed the PSS during a routine visit. Study 2 involved 247 community-dwelling adults with asthma who completed the PSS as a part of a larger asthma study. Four items showed acceptable psychometric performance across ethnic groups and literacy. The short PSS is a rapid, valid measure of subjective stress in diverse asthma populations.

Detection of chlamydial and gonococcal urethral infection during jail intake: development of a screening algorithm.

OBJECTIVES: To determine risk factors for chlamydial or gonococcal urethral infection among adult male detainees at Cook County Jail. To develop a screening algorithm with high sensitivity and specificity for detection of urethral infection. STUDY DESIGN: We interviewed adult male detainees and tested them for chlamydial or gonococcal urethral infection during jail intake from June 24 through July 29, 2004. We supplemented the cross-sectional survey with a nested case-control study. RESULTS: We screened 5,634 (93%) of 6,028 detainees; 348 (6.2%) had chlamydial or gonococcal urethral infection. Interviews were completed and collected for 35%. By multivariable analysis, infected detainees were more likely to be <31 years of age, have more than 6 sex partners in the previous 12 months, or have symptoms. Age less than 31 years or symptoms would have identified 73% of infected detainees while screening only 50%. CONCLUSIONS: A simple algorithm that included age and symptoms best identified detainees at increased risk for chlamydial or gonococcal urethral infection.

Normalization of cerebrospinal fluid abnormalities after neurosyphilis therapy: does HIV status matter?

To identify factors that affect normalization of laboratory measures after treatment for neurosyphilis, 59 subjects with neurosyphilis underwent repeated lumbar punctures and venipunctures after completion of therapy. The median duration of follow-up was 6.9 months. Stepwise Cox regression models were used to determine the influence of clinical and laboratory features on normalization of cerebrospinal fluid (CSF), white blood cells (WBCs), CSF protein concentration, CSF Venereal Disease Research Laboratory (VDRL) reactivity, and serum rapid plasma reagin (RPR) titer. Human immunodeficiency virus (HIV)-infected subjects were 2.5 times less likely to normalize CSF-VDRL reactivity than were HIV-uninfected subjects. HIV-infected subjects with peripheral blood CD4+ T cell counts of < or =200 cells/ mu L were 3.7 times less likely to normalize CSF-VDRL reactivity than were those with CD4+ T cell counts of >200 cells/ mu L. CSF WBC count and serum RPR reactivity were more likely to normalize but CSF-VDRL reactivity was less likely to normalize with higher baseline values. Future studies should address whether more intensive therapy for neurosyphilis is warranted in HIV-infected individuals.

Cerebrospinal fluid abnormalities in patients with syphilis: association with clinical and laboratory features.

OBJECTIVE: To define clinical and laboratory features that identify patients with neurosyphilis. METHODS: Subjects (n=326) with syphilis but no previous neurosyphilis who met 1993 Centers for Disease Control and Prevention criteria for lumbar puncture underwent standardized history, neurological examination, venipuncture, and lumbar puncture. Neurosyphilis was defined as a cerebrospinal fluid (CSF) white blood cell count >20 cells/ microL or reactive CSF Venereal Disease Research Laboratory (VDRL) test result. RESULTS: Sixty-five subjects (20.1%) had neurosyphilis. Early syphilis increased the odds of neurosyphilis in univariate but not multivariate analyses. In multivariate analyses, serum rapid plasma reagin (RPR) titer > or =1 : 32 increased the odds of neurosyphilis 10.85-fold in human immunodeficiency virus (HIV)-uninfected subjects and 5.98-fold in HIV-infected subjects. A peripheral blood CD4+ T cell count < or =350 cells/ microL conferred 3.10-fold increased odds of neurosyphilis in HIV-infected subjects. Similar results were obtained when neurosyphilis was more stringently defined as a reactive CSF VDRL test result. CONCLUSION: Serum RPR titer helps predict the likelihood of neurosyphilis. HIV-induced immune impairment may increase the risk of neurosyphilis.