Increasing asthma knowledge and changing home environments for Latino families with asthmatic children.

We tested an asthma education program in 204 underserved Latino families with an asthmatic child. The education program consisted of one or two sessions delivered in each family's home in the targeted participant's preferred language by a bilingual, bicultural educator. We encouraged, but did not require, attendance by the child. The curriculum was culturally-tailored, and all participants received education on understanding asthma, preventing asthma attacks, and managing asthma. Outcomes included change in asthma knowledge and change in home environment asthma management procedures. Asthma knowledge increased significantly (39 to 50% correct from pre- to post-test, P < 0.001) and participants made significant changes to the child's bedroom environment (mean number of triggers decreased from 2.4 to 1.8, P < 0.001; mean number of controllers increased from 0.7 to 0.9, P < 0.001). The results support the value of asthma education and its importance in the national agenda to reduce health disparities among minorities.

Reported measures of environmental tobacco smoke exposure: trials and tribulations.

OBJECTIVE: This report extends previous summaries of reported environmental tobacco smoke (ETS) exposure measures, reviews the empirical evidence of their validity for children's exposure, and discusses future research. DATA SOURCES: Studies were identified by computer search and from the authors' research. STUDY SELECTION: Studies were selected for inclusion of nicotine and/or cotinine and quantitative reported measures of ETS exposure. DATA SYNTHESIS: Five studies found significant associations between reported quantitative exposure of children to ETS and either environmental nicotine or urine cotinine assays. Correlation coefficients between parent reports and nicotine ranged from 0.22 to 0.75. Coefficients for cotinine ranged from 0.28 to 0.71. Correlations increased over time and were stronger for parents' reports of their own smoking as a source of children's exposure than for reports of exposure from others. CONCLUSIONS: Empirical studies show general concordance of reported and either environmental or biological measures of ETS exposure. Relationships were moderate, and suggest sufficient validity to be employed in research and service programs. Future studies need to identify the differences in types of reported or objective measures, population characteristics, etc, contributing to observed variability in order to understand better the conditions under which more valid reported ETS exposure and other measures can be obtained. Reported and either environmental or biological measures should be used in combination, and existing measures should be directed to interventions that may reduce ETS exposure among children.

Reducing children's exposure to environmental tobacco smoke: the empirical evidence and directions for future research.

OBJECTIVE: To summarise the issues and empirical evidence for reduction of children's residential environmental tobacco smoke (ETS) exposure. DATA SOURCES: Literature was obtained by computer search, with emphasis on studies that included quantitative measures of ETS exposure in children's residences and interventions based on social learning theory. STUDY SELECTION: Review and empirical articles concerning ETS exposure were included and inferences were drawn based on a synthesis of these studies as contrasted with a quantitative meta-analysis. DATA SYNTHESIS: Interventions designed for residential/child ETS exposure control have included policy/legal regulations, minimal clinical services, and counselling services. Divorce court and adoption services have limited custody to protect children from ETS exposure. Controlled trials of clinicians' one time counselling services have shown null results. One controlled trial found that repeated physician ETS counselling increased parent cessation. Three trials found that repeated counselling/shaping procedures reduced quantitative estimates of ETS exposure in asthmatic children. CONCLUSIONS: Insufficient controlled studies of repeated session counselling procedures have been completed to determine efficacy for ETS exposure reduction, but evidence is promising. One time minimal interventions appear ineffective, but large scale studies may be warranted. No studies have been conducted to assess court or adoption agency regulations; no community ordinances for regulating residential ETS exposure have been invoked. Ethical and enforcement issues are discussed.

Involuntary smoking and asthma.

Involuntary smoking is the third leading preventable cause of death, and among children it causes lower respiratory infections, middle ear disease, sudden infant death syndrome, and asthma. Half the world's children may be exposed to environmental tobacco smoke (ETS), exacerbating symptoms in 20% of children with asthma. Recent studies have reinforced previous conclusions that ETS exposure causes onset of childhood asthma and exacerbation of symptoms throughout life. The exact mechanisms by which this is accomplished are still unclear, as are the relative contributions of prenatal versus postnatal exposure. However, favorable health outcomes can be attained with reduced exposure. Among the few studies of ETS exposure reduction interventions, low-intensity advice methods appeared ineffective, and counseling parent smokers appeared successful. Direct counseling of school-aged children to avoid ETS has yet to be tested. Community norms may need to shift further in favor of protecting children and others from ETS before minimal interventions can be successful. This will require combined and ongoing efforts of the medical and public health establishments, in concert with legislation mandating tobacco-free public places and with ETS-related media campaigns.

Measuring environmental tobacco smoke exposure in infants and young children through urine cotinine and memory-based parental reports: empirical findings and discussion.

OBJECTIVE: This study examined the reliability and potential biases of two urine collection methods from which cotinine measures were obtained and the validity of memory-based parental reports of their children's exposure to environmental tobacco smoke (ETS). DESIGN: Structured interviews were conducted with mothers of infants and young children to obtain memory-based estimates of recent ETS exposure. Urine samples were collected through standard and cotton roll collection methods for cotinine analysis. SETTING: All interviews took place at an off-campus research facility. Urine samples were collected at the study office or the subjects' homes. PARTICIPANTS: Mothers were recruited from San Diego county sites of the Women, Infants, and Children (WIC) Supplemental Food and Nutrition Program. Sample 1 (infants) consisted of eight boys and eight girls aged 1-44 months (mean = 12.6 months). Sample 2 (children) included 10 boys and 10 girls aged 3-8 years (mean = 61.2 months). MAIN OUTCOME MEASURES: Urine cotinine and memory-based parent reports of ETS exposure from structured interviews. RESULTS: There was overall high reliability for urine cotinine measures and no effect of collection method on urine cotinine levels. Memory-based reports obtained from smoking mothers showed moderately strong and consistent linear relationships with urine cotinine measures of their infants and children (r = 0.50 to r = 0.63), but not for reports obtained from non-smoking mothers. CONCLUSIONS: Memory-based parental reports of short-term ETS exposure can play an important role in quantifying ETS exposure in infants and children.

Effects of noradrenergic and serotonergic antidepressants on chronic low back pain intensity.

To understand the relative efficacy of noradrenergic and serotonergic antidepressants as analgesics in chronic back pain without depression, we conducted a randomized, double-blind, placebo-control head-to-head comparison of maprotiline (a norepinephrine reuptake blocker) and paroxetine (a serotonin reuptake blocker) in 103 patients with chronic low back pain. Of these 74 completed the trial; of the 29 who did not complete, 19 were withdrawn because of adverse effects. The intervention consisted of an 8-week course of maprotiline (up to 150 mg daily) or paroxetine (up to 30 mg daily) or an active placebo, diphenhydramine hydrochloride (up to 37.5 mg daily). Patients were excluded for current major depression. Reduction in pain intensity (Descriptor Differential Scale scores) was significantly greater for study completers randomized to maprotiline compared to placebo (P=0.023), and to paroxetine (P=0.013), with a reduction of pain by 45% compared to 27% on placebo and 26% on paroxetine. These results suggest that at standard dosages noradrenergic agents may provide more effective analgesia in back pain than do selective serotonergic reuptake inhibitors.

Health behavior in persons with spinal cord injury: development and initial validation of an outcome measure.

OBJECTIVE: To describe the development and initial psychometric properties of a new outcome measure for health behaviors that delay or prevent secondary impairments associated with spinal cord injury (SCI). DESIGN: Persons with SCI were surveyed during routine annual physical evaluations. SETTING: Veterans Affairs Medical Center Spinal Cord Injury Unit, which specializes in primary care for persons with SCI. PARTICIPANTS: Forty-nine persons with SCI, aged 19-73 years, 1-50 years post-SCI. MAIN OUTCOME MEASURE: The newly developed Spinal Cord Injury Lifestyle Scale (SCILS). RESULTS: Internal consistency is high (alpha = 0.81). Correlations between clinicians' ratings of participants' health behavior and the new SCILS provide preliminary support for construct validity. CONCLUSIONS: The SCILS is a brief, self-report measure of health-related behavior in persons with SCI. It is a promising new outcome measure to evaluate the effectiveness of clinical and educational efforts for health maintenance and prevention of secondary impairments associated with SCI.

Transition to chronic pain in men with low back pain: predictive relationships among pain intensity, disability, and depressive symptoms.

Pain intensity, disability, and depressive symptoms are hallmarks of chronic pain conditions, but little is known about the relationships among these symptoms in the transition from acute to chronic pain. In this study, an inception cohort of men with low back pain (N = 78) was assessed at 2, 6, and 12 months after pain onset. At 6 months, pain intensity, disability, and depressive symptoms were predicted only by their respective levels at 2 months after pain onset. At 12 months, pain intensity and depressive symptoms were predicted by heightened disability at 6 months after pain onset; 12-month depressive symptoms also were predicted by 2-month disability. Pain intensity was not predictive of changes in disability or depressive symptoms. These findings suggest that functional disability plays a more prominent role than pain intensity in the transition from acute to chronic pain. A "failure to adapt" conceptual model is presented to account for these results.

The contribution of job satisfaction to the transition from acute to chronic low back pain.

OBJECTIVE: To determine the extent to which job satisfaction predicts pain, psychological distress, and disability 6 months after an initial episode of low back pain (LBP). DESIGN: A longitudinal design was used to follow an inception cohort experiencing first-episode low back pain with assessment at 2 and 6 months after pain onset. SETTING: Urban medical center outpatient orthopedic clinic. PATIENTS: The consecutive sample was comprised of 82 men with initial-onset acute LBP (T6 or below, daily pain for 6 to 10 weeks). INTERVENTION: Usual orthopedic care. MAIN OUTCOME MEASURES: The primary study outcomes were pain (Descriptor Differential Scale, Visual Analog Scales); disability (Sickness Impact Profile, Quality of Well-Being); and psychological distress (Beck Depression Inventory, Hamilton Rating Scale for Depression, Automatic Thoughts Questionnaire); predictor variables were orthopedic impairment (Waddell Physical Impairment Index) and job satisfaction (Job Descriptive Index, Work APGAR). RESULTS: Measures of job satisfaction, pain, disability, and psychological distress at baseline and 6 months after pain onset were separately reduced into factors using principle components factor analysis. In hierarchical multiple regression analyses, baseline job satisfaction significantly predicted variance in outcome scores at 6 months after pain onset, beyond the variance explained by control factors (demographics; baseline pain, mood, and disability; orthopedic impairment). Zero-order correlations between job satisfaction and orthopedic impairment were small and nonsignificant, suggesting that these two variables act independently in predicting outcome. Although type of work performed (desk work or work requiring light, moderate, or heavy lifting) and social position were correlated with job satisfaction at baseline, neither contributed to the prediction of outcome at 6 months. CONCLUSIONS: Satisfaction with one's job may protect against development of chronic pain and disability after acute onset back pain and, alternatively, dissatisfaction may heighten risk of chronicity. Vocational factors should be considered in the rehabilitation of acute back injury.

Tracking and follow-up of 16,915 adolescents: minimizing attrition bias.

This paper reports a multi-dimensional approach to minimize drop-outs from a two-year follow-up of a clinical trial designed to reduce initiation of tobacco use in 16,915 adolescent orthodontic patients. A hierarchical approach to data collection and tracking was employed. Seventy percent of participants were reached and interviewed at home by telephone. Strategies used to survey remaining participants included calling parents' work numbers and directory assistance, reviewing orthodontists' charts, sending surveys by mail, offering incentives, and using reverse telephone directories. More than 92% of the participants completed follow-up surveys. Multivariate analyses showed that baseline tobacco and alcohol use predicted loss to follow-up. Similarly, the number of procedures used to track each participant predicted presence of risk behaviors at post-test, demonstrating that an organized tracking hierarchy curtailed even greater compromises to internal and external validity. Evaluation and costs of individual strategies are discussed.

Predictors of tobacco use initiation in adolescents: a two-year prospective study and theoretical discussion.

OBJECTIVE: To test whether baseline data from a randomised clinical trial are predictive of initiation of tobacco use over a two-year follow-up interval, and to discuss results in the context of a theoretical model. DESIGN: Secondary, non-experimental analyses of data collected from a prospective cluster-randomised clinical trial comparing an intervention with a control condition for reduction of tobacco incidence rates. Orthodontic offices in southern California were recruited and randomised to an experimental or control group. Patient participants were sampled within each office, and completed a short survey, repeated two years later. SUBJECTS: 13,923 patients, 11-18 years of age, randomly sampled from each office. MAIN OUTCOME MEASURES: The ability of baseline data to predict initiation of tobacco use over the two-year follow-up interval was tested through a series of logistic regression models. Significant predictors and their interactions were identified in fixed-effects models, and verified in a mixed-effects logistic regression model to account for cluster randomisation. RESULTS: Clinician advice against tobacco use was associated with a lower rate of tobacco use initiation among young people whose peer group considered smoking socially desirable. Rates of initiation increased with age, but this association differed by gender and by whether the adolescent had been offered tobacco within 30 days prior to the baseline assessment. People from minority groups were less likely to initiate tobacco use than whites, and young people engaging in other risk practices were more likely to initiate tobacco use. CONCLUSIONS: Findings support predictions based on learning theory that social processes are critical in the development of health-risk behaviours. Future preventive efforts should target changing the density with which young people encounter pro- and anti-tobacco prompts and consequences in the community.

Toward a simplified measure of asthma severity for applied research.

There is no universally accepted and validated measure of asthma severity. For community research, clinical tests are too costly, and epidemiological assessments provide inadequate data on severity. Symptom measures may offer a practical alternative. This study assessed psychometric properties of symptom ratings of 91 asthmatic children. Reliability and validity of scales created from these items were examined. A sum scale of symptom ratings was internally consistent, reliable across time, and associated with concurrent health indices. This scale may be a practical measure of severity for use in community-based research.

Reduction of environmental tobacco smoke exposure in asthmatic children. A 2-year follow-up.

STUDY OBJECTIVE: To examine the long-term maintenance of a previously reported behavioral counseling intervention to reduce asthmatic children's exposure to environmental tobacco smoke (ETS). PARTICIPANTS: Families of asthmatic children (6 to 17 years), including at least one parent who smoked in the home, recruited from four pediatric allergy clinics. DESIGN: Participants were randomized to one of three groups: behavioral counseling to reduce ETS exposure, self-monitoring control, and usual medical care control. Counseling concluded at month 6, and the original trial ended at month 12. Two follow-up interviews occurred at months 20 and 30. MEASUREMENTS AND RESULTS: The originally reported analysis of baseline to 12 months was reanalyzed with a more robust restricted maximum likelihood procedure. The 2-year follow-up period was analyzed similarly. Significantly greater change occurred in the counseling group than the control groups and was sustained throughout the 2 years of follow-up. Further exploratory analyses suggested that printed counseling materials given to all participants at month 12 (conclusion of the original study) were associated with decreased exposure in the control groups. CONCLUSION: Such long-term maintenance of behavior change is highly unusual in the general behavioral science literature, let alone for addictive behaviors. We conclude that ETS exposure can be reduced and that a clinician-delivered treatment may provide substantial benefit.

The accuracy of environmental tobacco smoke exposure measures among asthmatic children.

This study determined the reliability and validity of parent-reported measures of environmental tobacco smoke (ETS) exposure among 91 asthmatic children. Test-retest reliability assessments were conducted for environmental, biological and parent-reported measures of ETS exposure. All measures except a urine cotinine assay resulted in satisfactory levels of reliability. The parent-reported measures of ETS exposure were compared to the environmental filter measure of nicotine as well as submitted to a construct validity test. Parent-reported home exposure to ETS proved moderately and significantly correlated to the filter measure. Approximately 80% of all hypothetical constructs agreed with the observed relationships for convergent, divergent and discriminant validity. It was concluded that middle class Caucasian parents' reports of their asthmatic child's residential ETS exposure are reliable and valid. These parent-reported measures should be valuable tools for epidemiological investigations and for clinical programs designed to reduce asthmatic children's residential exposure to ETS.

Parent smoking and asthmatic children's exposure patterns: a behavioral epidemiology study.

Exposure of nonsmokers to environmental tobacco smoke (ETS) has become an important public health issue; it is generally agreed that increased exposure is related to morbidity and mortality. Precise prevalence estimates of exposure are not yet available, and measurement methodology for ETS exposure rates is still in its formative stage. Recent interventions have attempted to reduce ETS exposure, particularly in children of smoking parents. Studies have relied primarily upon reduction of parents' smoking rates to indirectly reduce children's ETS exposure. In order to effectively design interventions to achieve reductions in ETS exposure, more attention must be given to smoking behaviors which lead to passive exposure. Ninety-one families with at least one smoking parent and an asthmatic child were recruited from four allergy clinics, and interviewed regarding their smoking history, current residential smoking patterns, and the children's exposure patterns. Descriptive data are presented. It is striking that the most smoking and most exposure did not occur in the same locations, times, or during the same activities. It is recommended that interventions focus closely on these patterns rather than on reduction of smoking rates alone, in order to effect reduction in ETS exposure.

Reduction of environmental tobacco smoke exposure among asthmatic children: a controlled trial.

STUDY OBJECTIVE: This randomized clinical trial tested a behavioral medicine program designed to reduce asthmatic children's exposure to environmental tobacco smoke (ETS) in the home. DESIGN: Families were randomly assigned to an experimental preventive medicine counseling group, a monitoring control group, or a usual treatment control group. Families were measured six times over 1 year. PARTICIPANTS: Ninety-one families were recruited from four allergy clinics. INTERVENTION: The experimental group received a 6-month series of counseling sessions designed to decrease ETS exposure. This group also monitored smoking, exposure, and children's asthma symptoms. The monitoring group did not receive counseling and the usual treatment control group received outcome measures only. MEASUREMENTS AND RESULTS: Parents reported the daily number of cigarettes children were exposed to during the week preceding interviews. A nicotine air monitor and construct validity analysis confirmed the validity of exposure reports. Exposure to the parent's cigarettes in the home decreased for all groups. The experimental group attained a 79 percent decrease in children's ETS exposure, compared with 42 percent for the monitoring control and 34 percent for the usual treatment control group. Repeated-measures analysis of variance resulted in a significant (F([10,350] = 1.92, p < 0.05) group by time effect. At the final 12-month visit, the experimental/counseling group sustained a 51% decrease in children's exposure to cigarettes in the home from all smokers, while the monitoring control group showed an 18% decrease and the usual treatment control group a 15% decrease from pre-intervention [corrected]. CONCLUSION: A behavioral medicine program was successful in reducing exposure to ETS in the home for these asthmatic children.

Promoting law enforcement for child protection: a community analysis.

The Colorado Occupant Protection Project (COPP) intervention provided police with brief instruction concerning the importance of citations for drivers' failure to use child safety seats and special coupons to accompany citations. Coupons were exchangeable by drivers for a safety seat and brief training in its use, plus a waiver of the $50 citation fine. Over 4.5 years of archival records were employed, using an ABA design and a comparison community to evaluate the program. Few tickets were issued for nonuse of safety seats during the 3-year baseline in either community. Citations for nonuse of safety seats increased to over 50 per month during the intervention period at the test site, whereas rates remained essentially zero at the comparison site. After the COPP intervention was removed at the intervention site, citation rates for nonuse of safety seats decreased to about 15 per month. Differences between intervention conditions and settings were statistically significant. During the intervention, officers were 44 times more likely to write citations than were controls. Results suggested that a behavioral program can increase police citation writing for child protection purposes.