Relationships among organ damage, social support, and depression in African American women with systemic lupus erythematosus.

OBJECTIVES: Systemic lupus erythematosus (SLE) disproportionately strikes African American women. Social support can potentially reduce disease impact. The purpose of this study is to understand the relationship between organ damage and depression in African American women and how social support influences this relationship. METHODS: We used a mixed methods design, analyzing self-reported data on lupus-related organ damage, depression, and social support in 437 African American women with SLE recruited in the Georgians Organized Against Lupus (GOAL) cohort. Moreover, we conducted interviews among 15 GOAL participants to gather patients' perspectives about the role of social support in people who live with lupus. RESULTS: We found a significant association between organ damage and depression ( r = 0.163, p = 0.001), as well as between depression and social support ( F = 17.574, p < 0.001). The quantitative analysis did not render social support as a significant moderator in the organ damage-depression relationship. Interviews, however, revealed that African American women with the most severe organ damage have the greatest need for support. CONCLUSIONS: Social support is a key resource for lupus patients with high disease burden. Overall, these findings highlight the importance of monitoring depressive symptoms in this population and developing interventions aimed to increase social support available to lupus patients.

Using behavioral science to improve fire escape behaviors in response to a smoke alarm.

Although the likelihood of fire-related death in homes with smoke alarms is about one-half that in homes without alarms, alarm effectiveness is limited by behavior. Only 16% of residents of homes with alarms have developed and practiced plans for escape when the alarm sounds. We reviewed literature to identify behavioral constructs that influence smoke alarm use. We then convened experts in the behavioral aspects of smoke alarms who reviewed the constructs and determined that the appropriate areas for behavioral focus were formulating, practicing, and implementing escape plans should an alarm sound. They subsequently identified important behaviors to be addressed by burn-prevention programs and incorporated the constructs into a behavioral model for use in such programs. Finally, we organized the available literature to support this model and make programmatic recommendations. Many gaps remain in behavioral research to improve fire escape planning and practice. Future research must select the target behavior, apply behavioral theories, and distinguish between initiation and maintenance of behaviors associated with planning, practicing, and implementing home fire escape plans.

Investigation of healthcare providers' patterns of referring breast cancer patients to Reach to Recovery.

Providers who referred patients to Reach to Recovery (Reach), an American Cancer Society breast cancer support group, were compared with those who did not to evaluate whether providers who identified problems with the program were less likely to make referrals. Also considered were contact with a Reach volunteer, having a Reach program in the area, years since residency or medical training, perceived value of the Reach program, belief that one's peers refer patients to Reach, urban or rural location of practice, and size of practice. When other variables were considered, physicians who identified problems with Reach were no less likely to refer patients to the program than those who did not. The factors most associated with referral (P < .001) were "having a Reach program in the area" and "having had contact with a Reach volunteer." Implications of these findings and the experience of conducting the evaluation through the Collaborative Evaluations Fellows Project are discussed.

A randomized controlled trial of a clinic-based support staff intervention to increase the rate of fecal occult blood test ordering.

BACKGROUND: Colorectal cancer is the second most common fatal malignancy in the United States. Early detection using fecal occult blood tests has been shown to reduce mortality, but these tests are underutilized among those eligible for this screening. Attempts to increase use of fecal occult blood tests in eligible populations have focused on the provider, patient, or system. But none have examined whether a support-staff intervention is effective in achieving this aim. We therefore conducted a randomized controlled trial to test the impact of authorizing support staff to order fecal occult blood tests in a general internal medicine clinic organized into four teams. METHODS: A total of 1,109 patients were included in the study, 545 of whom were in the two teams randomized to treatment. Univariate and multivariate regression analyses were used to evaluate the impact of the intervention. RESULTS: The intervention resulted in significantly more fecal occult blood test ordering in the treatment group than in the control group for all patients (52% vs 15%, P < 0.001). Treatment fecal occult blood test cards were returned as frequently as the control cards for all patients (44% vs 48%, P = 0.571). CONCLUSION: Delegation of selected screening tasks to support staff can enhance patient access to preventive care.

Predicting breast-feeding intention among low-income pregnant women: a comparison of two theoretical models.

This study examined the applicability of the transtheoretical model and a model derived from the theory of reasoned action for predicting breast-feeding intention among low-income pregnant women. Participants completed a 70-item self-report questionnaire assessing their breast-feeding attitudes, intentions, and support. A positive correlation existed between Stages of Change for breast-feeding and the number of Processes of Change used by respondents. A negative correlation existed between Stages of Change for breast-feeding and the number of negative breast-feeding beliefs held by respondents. Furthermore, women's normative beliefs and outcome beliefs were significantly correlated with breast-feeding intention in manners consistent with the model developed from the theory of reasoned action. After accounting for significant sociodemographic and lifestyle factors, the Processes of Change and outcome beliefs remained independently correlated with breast-feeding intention. These models are capable of predicting the intention to breast-feed and might offer an innovative approach for further breast-feeding research and intervention development.

Partner abuse and posttraumatic stress disorder as risk factors for suicide attempts in a sample of low-income, inner-city women.

This study examined partner abuse and posttraumatic stress disorder (PTSD) as risk factors for suicidal behavior among women, and whether or not PTSD mediated the partner abuse-suicidal behavior association. Attempters (n = 119) were approximately three times more likely to be above clinical cut-points for physical partner abuse, nonphysical abuse, and PTSD than nonattempters (n = 85). Physical partner abuse, but not nonphysical partner abuse, was associated with an increased risk for PTSD. Further, PTSD mediated the link between physical partner abuse and suicidality, such that when PTSD was statistically controlled, the association between physical partner abuse and suicide attempt status was reduced to nonsignificance. Implications of findings for interventions for female victims of partner abuse, and women who make nonfatal suicide attempts are discussed.

Intention to breastfeed in low-income pregnant women: the role of social support and previous experience.

BACKGROUND: The purpose of this study was to describe the relationship between breastfeeding intention among socioeconomically disadvantaged pregnant women and maternal demographics, previous breastfeeding experience, and social support. METHODS: A cross-sectional, convenience sampling strategy was employed for data collection. Low-income women (n = 1001) in a public hospital completed a six-page questionnaire about their infant feeding plans, demographics, and social support. Simple regression analyses were conducted to compare maternal breastfeeding intention with the hypothesized correlates. RESULTS: Breastfeeding intention was positively correlated with older maternal age, higher education, more breastfeeding experience, Hispanic ethnicity, and hearing about breastfeeding benefits from family members, the baby's father, and lactation consultants, but not from other health professionals. Health professionals' attitudes were less influential on women's infant feeding decisions than the attitudes and beliefs of members of women's social support networks. When controlling for breastfeeding experience (none vs any), some findings, varied, indicating a need for breastfeeding interventions tailored to women's level of experience. CONCLUSION: Use of peer counselors and lactation consultants, inclusion of a woman's family members in breastfeeding educational contacts, and creation of breastfeeding classes tailored to influential members of women's social support networks may improve breastfeeding rates among low-income women, especially those with no breastfeeding experience, more effectively than breastfeeding education to pregnant women that is solely conducted by health professionals.

Health risk behaviors of adolescent participants in organized sports.

PURPOSE: To assess differences in health-related behaviors between athletes and nonathletes. METHODS: In Grades 9-12 in seven high schools during the 1991-1992 academic year, 7179 (82%) students were asked to complete a survey with six categories of health-related behaviors associated with adolescent morbidity and mortality. Of the 6849 students who completed the survey, 4036 (56%) were classified as athletes. Analyses of differences were controlled for age, race, and gender. RESULTS: Athletes and nonathletes differed in specific health-risk behaviors. Nonathletes were more likely than athletes ever to have smoked cigarettes (15% vs. 10%) or used marijuana (24% vs. 23%), and fewer ate breakfast daily (34% vs. 45%), never added salt to food (18% vs. 22%), consumed calcium (56% vs. 64%), or consumed fruit or vegetables (40% vs. 47%) daily. More nonathletes reported frequent feelings of hopelessness (15% vs. 10%) and rarely or never using seatbelts (24% vs. 20%), but more athletes reported exceeding the speed limit by 10 mph (39% vs. 35%) and riding bicycles (40% vs. 28%) and/or motorcycles (13% vs. 8%) without helmets. These differences were statistically significant. CONCLUSIONS: Because of their behaviors, adolescent athletes put themselves at significant risk for accidental injuries. However, athletes appear less likely to smoke cigarettes or marijuana, more likely to engage in healthy dietary behaviors, and less likely to feel bored or hopeless.

Methodologies for informing beneficiaries of their rights: evaluating the Important Message from Medicare.

The Important Message from Medicare, a letter given to US Medicare patients upon hospital admission, was originally designed to allay the concerns of the Health Care Financing Administration (HCFA), Peer Review Organizations (PROs), and the beneficiary community that patients did not know their rights under Medicare and the PRO program. The effectiveness of the current Message may be adversely affected by the complexity of its language, the multifaceted admissions process, priorities of sick patients, and the demand for hospital resources. This study evaluated the effectiveness of the Message and various alternatives for informing beneficiaries of their rights. With HCFA financing, PROs in 10 states surveyed random samples of Medicare beneficiaries to measure knowledge of their rights under the current system and after the implementation of alternatives. This study found that there are alternative ways of informing Medicare beneficiaries of their rights which are more effective than the current Important Message from Medicare.

Do not resuscitate orders in the perioperative period: patient perspectives.

The purpose of this study was to determine the perspectives and opinions of terminally ill patients regarding the management of their do not resuscitate (DNR) orders in the perioperative period. Eighteen patients who had DNR orders and were willing to discuss those orders and their intentions were identified by hospital nurses or hospice workers. An in-depth interview was conducted with each patient. Patients' intentions for DNR orders focused on themes of "being ready to die" and concern regarding financial and emotional cost to themselves and their families. Fifteen of 18 patients would agree to some type of surgery, some to palliative procedures, others to procedures unrelated to their primary disease. After a brief explanation of the different types of anesthesia and their risks, patients were asked how they would like their DNR orders to be respected during the perioperative period. Some would allow procedures in the operating room that ordinarily would be prohibited by a DNR order and felt that DNR orders should be suspended. Many felt that their DNR orders should be discussed with them preoperatively. Some wanted to be involved with decisions regarding specific procedures. Others were satisfied with discussing the intent of their orders. For various reasons and for various procedures, many patients with DNR orders are willing to undergo anesthesia and surgery. Anesthesiologists' awareness of the variety of opinions and perspectives held by patients regarding their DNR orders will enhance their preoperative discussion.

The relationship of sexual abuse and HIV risk behaviors among heterosexual adult female STD patients.

Some effects of sexual abuse, for example, heightened sexual activity, are also risk factors for infection with the human immunodeficiency virus (HIV). Moreover, Social Cognitive theory suggests that the reduced self-esteem and increased sexual arousal that can result from abuse might alter self-efficacy for performing a behavior and expected outcomes of the behavior, making adoption of preventive behavior more difficult. Studies in the general population, adolescents, and male clients of sexually transmitted disease (STD) clinics, have found associations between childhood sexual abuse and HIV risk behaviors. This study was designed to measure: (a) whatever the association persists among female STD clinic clients; and (b) whether sexual abuse is associated with self-efficacy for condom use or condom use outcome expectations. Among the 83 female STD clinic clients studied, those sexually abused before age 18 had more sexual partners (p < .05), more positive hedonic outcome expectations for condom use (p < .01), and fewer positive partner-related outcome expectations for condom use (p < .05) than those never forced to have sex against their will. In summary, HIV risk behavior among female STD clients varies with childhood sexual abuse and Social Cognitive Theory suggests future directions for prevention.

Early detection of Alzheimer disease: methods, markers, and misgivings.

There is at present no reliable predictive test for most forms of Alzheimer disease (AD). Although some information about future risk for disease is available in theory through ApoE genotyping, it is of limited accuracy and utility. Once neuroprotective treatments are available for AD, reliable early detection will become a key component of the treatment strategy. We recently conducted a pilot survey eliciting attitudes and beliefs toward an unspecified and hypothetical predictive test for AD. The survey was completed by a convenience sample of 176 individuals, aged 22-77, which was 75% female, 30% African-American, and of which 33% had a family member with AD. The survey revealed that 69% of this sample would elect to obtain predictive testing for AD if the test were 100% accurate. Individuals were more likely to desire predictive testing if they had an a priori belief that they would develop AD (p = 0.0001), had a lower educational level (p = 0.003), were worried that they would develop AD (p = 0.02), had a self-defined history of depression (p = 0.04), and had a family member with AD (p = 0.04). However, the desire for predictive testing was not significantly associated with age, gender, ethnicity, or income. The desire to obtain predictive testing for AD decreased as the assumed accuracy of the hypothetical test decreased. A better short-term strategy for early detection of AD may be computer-based neuropsychological screening of at-risk (older aged) individuals to identify very early cognitive impairment. Individuals identified in this manner could be referred for diagnostic evaluation and early cases of AD could be identified and treated. A new self-administered, touch-screen, computer-based, neuropsychological screening instrument called Neurobehavioral Evaluation System-3 is described, which may facilitate this type of screening.

Psychological and Behavioral Factors Predicting Attendance at a Community-based HIV Prevention Intervention.

To date, virtualiy no research has addressed individuals' characteristics which influence their participation in prevention interventions targeting the human immunodeficiency virus (HIV). Identification of these characteristics is important, for no intervention is effective if not attended. This study explored stage of condom adoption and selected other psychological and behavioral factors, to determine which of these predicted attendance at a clinic-based HIV intervention. Stage of condom adoption (p = .03) and frequency of drunkenness (p = .05) were significant predictors of attendance for persons with more than one sex partner. For persons with only one sex partner, self-efficacy and outcome expectations were identified. The implications of these findings are discussed.

A survey of knowledge and attitudes about HIV and AIDS among medical students.

Researchers have found that a significant number of medical students harbor attitudes that have a negative impact on their willingness to care for persons who are HIV positive or have AIDS. To assess current HIV and AIDS knowledge and attitudes, the authors administered a 25-item survey tailored for medical professionals to 63 preclinical medical students. Respondents' mean score on the knowledge scale was 6.25 (SD 1.63) out of a possible score of 10. Factor analysis suggested three major groupings of medical students with regard to attitudes. The largest group had generally positive attitudes about patients with HIV and AIDS; two subgroups, however, would tend to refer such patients to another physician. One subgroup reported feeling more uncomfortable with homosexual behavior and with HIV-seropositive patients than they did with patients with other infectious diseases. This group also expressed discomfort with physically touching HIV-seropositive clients. The other group expressed discomfort with taking a patient's sexual history. Effective educational interventions must take these findings into account.

Predictors of coping with pain in mothers and their children with sickle cell syndrome.

OBJECTIVE: This study examined predictors of strategies used to cope with pain in children with sickle cell disease and their mothers. METHOD: Disease severity, socioeconomic status, child adjustment and adaptive behavior, maternal psychopathology, and family functioning were examined in 55 mother-child dyads to determine the predictive potential of these factors on engagement and disengagement coping. RESULTS: While controlling for socioeconomic status and psychopathology in the mothers, 15% of the variance in engagement coping was predicted by family adaptability. Disengagement coping was predicted by internalizing symptoms exhibited by the child, including a negative and pessimistic attributional style, which accounted for nearly one fifth of the variance. Finally, mothers who reported more active strategies for coping with their child's pain were more likely to endorse greater use of techniques to prevent and effectively manage pain in their children. CONCLUSIONS: Neither coping strategy was predicted by severity of disease presentation in the children, suggesting the importance of psychosocial factors in adapting to childhood chronic illness and that severity of disease may not necessarily be a marker for families at risk for adjustment difficulties. Findings were interpreted to support a systemic family model in promoting active and adaptive engagement coping in caretakers of children with sickle cell syndrome.

Unintended pregnancy and sex education in Chile: a behavioural model.

This study analysed factors associated with unintended pregnancy among adolescent and young adult women in Santiago, Chile. Three variations of a behavioural model were developed. Logistic regression showed that the effect of sex education on unintended pregnancy works through the use of contraception. Other significant effects were found for variables reflecting socioeconomic status and a woman's acceptance of her sexuality. The results also suggested that labelling affects measurement of 'unintended' pregnancy.

PIP: Using data from the Santiago Young Adult Reproductive Health Survey on 306 females aged 15-24 years living in greater Santiago in 1988 and having experienced premarital intercourse, the authors model the relationship of sex education and unintended pregnancy using social learning theory which posits that any health behavior is part of a dynamic model in which an individual's behavior is determined by the interaction of personal factors and environmental influences. Three variations of a behavioral model are developed. They found that women who had sex education before first intercourse and used contraception at that intercourse were one-third as likely to have a later unintended pregnancy as those with sex education who did not use contraception at first intercourse. Women who did not have sex education and who did not use contraception at first intercourse, however, were less likely to have an unintended pregnancy than women with no sex education who did use contraception. Across all models, moral ambivalence about premarital sexual activity is related to having an unintended pregnancy, Catholic women are twice as likely to have an unintended pregnancy as non-Catholics, and women from poorer backgrounds are less likely to use contraception and more likely to have early pregnancies. How women define their pregnancies can also affect the measurement of unintended pregnancy. It is important to effectively teach the use of contraceptives to reduce unintended pregnancies among adolescents and young adults who have premarital sexual intercourse.

Predicting injury risk in adolescent football players: the importance of psychological variables.

Explored the relationship of anger/aggression, attention, and stressful life events to injury while addressing the methodological limitations of prior studies. An additional objective was to determine whether the relationship of stressful life events to injury is mediated either by anger (directed either inward or outward) or by impaired attention, either vigilant (broad, external) or focused (narrow, internal). At the beginning of summer practice, 120 first-string high school football players completed measures of anger (Framingham Anger Scale), vigilant attention (Symbol Digit Modalities test), focused attention (Pursuit subtest, MacQuarrie Test of Mechanical Ability), and stressful life events (abbreviated form of the Social Readjustment Rating Scale as modified for use with adolescents by Coddington, 1972). Players were then followed through one season to identify those injured. Logistic regression indicated that high anger directed outward (p < .05) and low focused attention (p < .01) increased injury risk, while stressful life events and vigilant attention interacted. Injury risk was elevated when recent stress was present (p < .05), and increased as vigilance decreased, suggesting that stressful life events elevate injury risk by reducing vigilance.

"Do not resuscitate" (DNR) orders in the perioperative period--a comparison of the perspectives of anesthesiologists, internists, and surgeons.

The purpose of this descriptive study is to compare and contrast the experience, perceptions, and opinions of practicing anesthesiologists, internists, and surgeons regarding "do not resuscitate" (DNR) orders in the perioperative period. A questionnaire was mailed to 600 internists and 600 surgeons. Responses from these two groups were analyzed and compared with the results of a previously reported survey of 420 anesthesiologists. One hundred ninety-two of 570 (34%) and 199/584 (34%) acknowledged responses were received from internists and surgeons, respectively. Anesthesiologists (114/190; 60%) were more likely than internists (61/182; 34%) or surgeons (71/194; 37%) to assume DNR suspension in the perioperative period and were less likely than their colleagues to discuss with the patient the implications of their DNR order during anesthesia and surgery. This assumption of DNR suspension by anesthesiologists was underestimated by both surgeons and internists. Anesthesiologists and surgeons were more similar than internists in their manner of utilization of resuscitative measures in the setting of a cardiopulmonary arrest. All groups were more likely to require DNR suspension for elective than for palliative cases. The majority of all groups concurred that physician responsibility for defining DNR status in the perioperative period should be shared by the anesthesiologist, surgeon, and primary care physician and not prescribed by hospital policy. The manner in which a DNR order is perceived in the perioperative period varies considerably among specialties and warrants further discussion among these groups.

"Do not resuscitate" (DNR) orders and the anesthesiologist: a survey.

Anesthesiologists were surveyed to determine their experience and opinions regarding "Do Not Resuscitate" (DNR) orders in the perioperative period. Four hundred fifteen questionnaires were mailed and 193 (47%) were returned. One hundred sixty-one (87%) of 186 respondents had been requested to provide (and more than two-thirds had provided) monitored anesthesia care, regional anesthesia, or general anesthesia to a patient with a DNR order. Almost two-thirds of the respondents assume DNR suspension in the perioperative period and only half discuss this assumption with the patient/guardian. Less than 50% of respondents would require DNR suspension for a palliative procedure contrasted with > 60% for an elective procedure. After agreeing to a patient's decision to retain their DNR status, > 67%, > 58%, < 49%, and < 33% would utilize positive pressure ventilation with a mask, vasoactive drugs, endotracheal intubation, or defibrillation, respectively, in the event of a cardiopulmonary arrest in the perioperative period. These findings suggest much ambiguity regarding DNR orders in the perioperative period. Further discussion among physicians and patients is warranted.