Reducing tobacco smoke exposure in children aged below 4 years - a randomized controlled trial.

OBJECTIVE: To explore the reach of a German population-based household sample using proactive recruitment and to test the efficacy of a behavioral change counseling intervention including feedback about children's urine cotinine level (CUCL). METHODS: A randomized controlled trial (2008-2010) was conducted in households with at least one child aged below 4years and at least one current smoker. The study area comprised of 3570 households. A screening assessment was provided in 2641 households; 1282 included one current smoker and 852 completed the study protocol. The intervention group (IG; n=428) received feedback about CUCL and up to two counseling sessions. The control group (CG; n=424) received a leaflet. Assessments were provided at baseline and 12-month follow-up. Heckman's selection model analysis was used to consider the detection limit of cotinine in urine (10ng/ml). RESULTS: CUCL below the detection limit in the IG was found in 43.2% at baseline and 44.6% at follow-up and in 44.8% of the CG at baseline and 47.2% at follow-up. The CUCL difference between follow-up and baseline was smaller in the CG than in the IG. The effect was not significant. CONCLUSIONS: Data revealed a high reach of the target population but failed to identify an intervention effect. Clinical Trial Registration www.clinicaltrials.gov (NCT00647413).

[The outpatient provision of care for psychiatric patients in a rural area]. / Zur ambulanten Versorgung psychischer Störungen in einer ländlichen Region.

An analysis of reimbursement claims in Mecklenburg West-Pomerania from the year 2007 showed that of all reimbursement claims made for outpatient treatment of patients with mental disorders, the majority has been claimed by general practitioners. Using the reimbursement claims from the last 3 months from 2010, again, most treatment claims were made by general practitioners. The patients were treated by general practitioners in 50.5%. neurologists/psychiatrists 16%, internal practitioners 10.6%, gynaecologists 5.3% and by psychotherapists in 2.3%. The actual analyses of reimbursement claims show again that the majority of patients with psychiatric disorders is not treated by the respective professional group.

Interobserver agreement of the German translation of the Motivational Interviewing Sequential Code for Observing Process Exchanges (MI-SCOPE;D).

The aim of this study is to assess the interobserver agreement of the German translation of the MI-SCOPE. We applied it to transcribed counseling sessions on smoking cessation and relapse prevention with women postpartum. The MI-SCOPE is an instrument to assess and quantify MI-specific processes. Twenty percent random samples for parsing and coding each were drawn from 162 transcripts of MI sessions from the treatment arm of an RCT to assess interobserver agreement. Whole transcripts were coded. Each transcript was randomly assigned to two of three raters who parsed and coded the transcripts separately. Cohen's κ was computed to assess interobserver agreement. Concordance about parses ranged between κ = .702 and κ = .955 (25th percentile-median-75th percentile: .896-.918-.936). The kappas did not differ significantly between the three combinations of raters (H = 2.648; df = 2, p = .266). Concordance about codes for all 46 categories ranged between κ = .590 and κ = .822 (25th percentile-median-75th percentile: .680-.718-.748). The kappas did not differ significantly between the three combinations of raters (H = 4.095; df = 2, p = .129). The German translation of the MI-SCOPE yielded good to excellent κ for parsing as well as for coding. This indicates that MI as an intervention can be taught, learned, and adherence to MI as an intervention may be objectively observed and assessed.

The outpatient provision of care for mental disorders in a rural area: an analysis of reimbursement claims in mecklenburg-west pomerania*.

Mental disorders cause a substantial amount of the burden of disease. Although they are less frequent in rural areas, their provision of care is disproportionately lower. Reimbursement claims in the federal state of Mecklenburg-West Pomerania of the years 2006/2007 serve as the basis for the descriptive distribution of subgroups on the total number of mental disorders and their outpatient care. Of all claims, 35.3% were allotted to neurotic, stress-related and somatoform disorders, 24.2% to affective disorders and 12.5% to substance use disorders. Claims for reimbursement were made for 44.7% by general practitioners, 15.1% by neurologists and psychiatrists, 12.6% by gynaecologists, and 8.1% by internists. Psychotherapists claimed 3.1%. These results cause considerations regarding the establishment of psychotherapeutic and neurological / psychiatric practices as well as the significance of mental disorders in the training of general practitioners.

[The outpatient provision of care for mental disorders in a rural area. An analysis of reimbursement claims in Mecklenburg-West Pomerania]. / "Zur ambulanten Versorgung psychischer Störungen in einer ländlichen Region. Eine Analyse von Abrechnungsdaten der Kassenärztlichen Vereinigung Mecklenburg-Vorpommern.

Mental disorders cause a substantial amount of the burden of disease. Although they are less frequent in rural areas, their provision of care is disproportionately lower. Reimbursement claims in the federal state of Mecklenburg-West Pomerania of the years 2006/2007 serve as the basis for the descriptive distribution of subgroups on the total number of mental disorders and their outpatient care. Of all claims, 35,3% were allotted to neurotic, stress-related and somatoform disorders, 24,2% to affective disorders and 12,5% to substance use disorders. Claims for reimbursement were made for 44,7% by general practitioners, 15,1% by neurologists and psychiatrists, 12,6% by gynaecologists, and 8,1% by internists. Psychotherapists claimed 3,1%. These results cause considerations regarding the establishment of psychotherapeutic and neurological/psychiatric practices as well as the significance of mental disorders in the training of general practitioners.

Perceived barriers to prostate cancer screenings among middle-aged men in north-eastern Germany.

OBJECTIVES: Prostate cancer ranks high in mortality. Only 18% of men entitled for screenings take advantage of this. Social-cognitive models of health psychology describe and predict health behavior. This study investigates what barriers men perceive that impede the utilization of cancer screenings. DESIGN AND SAMPLE: Semistructured interviews were conducted in 2 general practices and 3 hospital wards. One hundred and seventy-eight men over 45 years were addressed; 64 utilized cancer screenings regularly, 3 had a diagnosis of prostate cancer, and 18 declined participation. MEASURES: Content analyses were conducted with 83 interviews. The interview tapped into the following domains: barriers, risk perception, outcome expectancies, self-efficacy, and intentions. RESULTS: 57 men regarded their health as very important, while 47 had never utilized cancer screenings. Barriers were divided into emotional/cognitive versus organizational/structural. Sixty-four men did not utilize cancer screenings because of lack of symptoms, 22 feared a positive result, 20 had more pertinent health issues, and 18 assumed that their physicians would screen for cancer "automatically." CONCLUSIONS: Mainly emotional/cognitive barriers were seen as important for nonutilization, especially the absence of symptoms. Following the reasoning of social-cognitive models, a first step to enhance utilization rates would be to enhance risk perception.

Population-based smoking cessation in women post partum: adherence to motivational interviewing in relation to client characteristics and behavioural outcomes.

AIMS: quantitative description of adherence to motivational interviewing (MI) in smoking cessation sessions; and examination of the relationships between client characteristics and adherence to MI, and between adherence to MI and future smoking status. METHODS: 84 sessions were conducted during a randomised controlled trial to test the effectiveness of a population-based smoking intervention in women during the postpartum period. Demographic and behaviour-related variables were included in a logistic regression to predict adherence to MI. MEASUREMENTS: adherence was measured using the MI Treatment Integrity Scale. FINDINGS: 38.1% of sessions showed good adherence to MI. Receiving a good MI session was not related to any demographic or behavioural variables. The relationship between adherence and intervention outcome after six months was not statistically significant (chi(2)=0.355, p=0.551). CONCLUSIONS: the smoking cessation sessions examined in this study failed to adhere to MI. There was no relationship between adherence to MI and behavioural outcome six months after the intervention, indicating that women who smoke post partum may be a high-risk group for whom specific smoking cessation interventions need to be developed.

Smoking cessation counselling for pregnant and postpartum women among midwives, gynaecologists and paediatricians in Germany.

The incorporation of guidelines for the treatment of tobacco smoking into routine care requires positive attitudes, counselling skills and knowledge about additional help available for smokers. The study assesses performance of smoking cessation intervention, attitudes, training status and knowledge about additional help for smokers in the care for pregnant and parenting women by midwives, gynaecologists and paediatricians. A survey of all midwives, gynaecologists and paediatricians registered for primary medical care in the federal state Saarland, Germany, was conducted. Participation in the postal questionnaires was 85 %. Depending on profession, 90 % to 100 % see smoking cessation counselling as their assignment, 17 % to 80 % screen for, 48 % to 90 % document smoking status, and 55 % to 76 % offer brief or extensive counselling. 61 % to 87 % consider training to enhance their knowledge and/or counselling skills necessary. The compliance of providers with the necessity to give support in smoking cessation is very high. However, the current status of cessation counselling does not sufficiently correspond to the evidence based requirements. Reports in medical press and advanced training courses should support health care providers and establish smoking as an inherent topic of the anamnesis and treatment of current and former pregnant or parenting smokers.

Intention to change smoking in pregnant and postpartum women according to number of pregnancies.

BACKGROUND: The status of a pregnant woman might add to the motivation to stop smoking. However, little is known about whether women who are pregnant for the first time (primigravidae) show a motivation to quit smoking that is different from women who are pregnant at least the second time (multigravidae). The goal of the current study was to compare smoking status, urge to smoke and intention to change smoking behaviour of primigravidae and multigravidae. We hypothesized that amongst primigravidae there are less current smokers, that the smokers consume less cigarettes per day, have less urge to smoke and that more stop smoking after delivery when compared with multigravidae. METHODS: Among 642 women postpartum who had smoked before pregnancy smoking status, the Fagerström Test for Nicotine Dependence and intention to change smoking behaviour were assessed. The data were analysed with the Chi-square test, Mann-Whitney's U-test and the Sign-test. RESULTS: Primigravidae smoked less cigarettes (P < 0.01) and showed less urge to smoke (P < 0.05) than multigravidae. They did not differ according to the intention to change smoking behaviour (P > 0.05). CONCLUSION: Experience of first pregnancy does not seem to automatically induce more smoking cessation compared to multigravidae. Prevention measures are needed for primigravida women and multigravida women to the same extent.

Smoking cessation and relapse prevention for postpartum women: results from a randomized controlled trial at 6, 12, 18 and 24 months.

AIM: To test the efficacy of an aid to cessation/relapse prevention intervention for women postpartum. METHOD: Two-armed randomized controlled trial. Follow-ups at 6, 12, 18, and 24 months, screenings on maternity wards. Intervention group received face-to-face counseling 40 days postpartum plus telephone counseling calls 4 and 12 weeks later. Control group received usual care plus self-help material for each parent. RESULTS: With regard to smoking cessation, 4 week point prevalence abstinent rates were higher in the treatment group at 6, 12, and 18 months (7% vs. 1%, 7% vs. 2%, and 9% vs. 1%, respectively). Sustained abstinence was higher in the treatment group at 6 months follow-up (3% vs. 0%). No difference was observed with regard to relapse prevention. DISCUSSION: Regarding aid to cessation we observed small effects, regarding relapse prevention no effect. In order to capitalize on the opportunity childbirth poses with regard to smoking, theories on relapse prevention in smoking cessation that guide in designing interventions are needed.

[Frequency of remission in schizophrenia patients at one year follow-up]. / Remissionshäufigkeit bei schizophren erkrankten Patienten innerhalb eines Jahres nach der Klinikentlassung.

OBJECTIVE: This paper describes the frequency of remission in former inpatients with schizophrenia as well as its relations with sociodemographic and other relevant variables. METHODS: The characteristics of 88 schizophrenia patients (ICD-10 F20.x) were examined in an extensive quality-monitoring-project at the Ev. Krankenhaus Bethanien Greifswald, Germany, encompassing a one-year follow-up. RESULTS: 10.2 % of the patients reached remission during the 12-months follow-up. The rate of readmissions was 42.1 %. CONCLUSIONS: The frequency of remission in our sample is considerably less than the approximated 38 % from previous studies. This might be attributed to selection-bias and lack of representation in previous follow-up studies with schizophrenia inpatients.

Smoking during pregnancy and postpartum: smoking rates and intention to quit smoking or resume after pregnancy.

BACKGROUND: A substantial number of women smoke while pregnant. The majority of those who quit return to smoking within 12 months. The aim of this study is to estimate smoking rates and to measure the urge to smoke and the motivation to change smoking behavior among women who recently delivered. METHODS: Data presented stem from two studies. Study 1 is an epidemiological survey investigating the health of neonates. Study 2 presents screening data of an efficacy trial for a smoking cessation and relapse prevention intervention. Participants were recruited on maternity wards within 7 days after delivery. RESULTS: Five hundred fifty-three (29.1%) women were never smokers, 145 (7.6%) were former smokers, 492 (25.9%) abstained during pregnancy, and 712 (37.4%) smoked throughout pregnancy. Of the smokers, 69% did not intend to quit smoking within the next 6 months. Of the women who quit during pregnancy, 80% did not want to resume smoking within the next 6 months or after weaning. CONCLUSIONS: Smoking and relapse rates indicate a need for increased efforts to reduce smoking during pregnancy and postpartum. Reported intention to quit or resume does not reflect the high number of relapses. Indicators for relapse need to be found.

Multiple health risk behaviors in German first year university students.

Multiple health risk behaviors have been identified as a problem in young adults which includes university students. The goals of this study included assessing the prevalence of major health risk behaviors in a cohort of German first year university students, analyzing the clustering of these behaviors and assessing readiness to change across multiple behaviors. A total of 1262 students from the schools of law, teaching and medicine at a German university participated in a voluntary and anonymous survey in 2005. The study assessed indicators and readiness for change regarding fruit and vegetable consumption, exercise, smoking and binge drinking as well as sociodemographic variables. Confirming the hypotheses, prevalences for risk behaviors were high; over 95% ate less than five servings of fruits and vegetables, 60% did not exercise sufficiently, 31% were current smokers and 62% reported binge drinking. Only 2% had none, 10.5% had one, 34.5% had two, 34.8% had three, and 18.2% showed all four risk behaviors. Readiness for behavior change was very low across multiple risk behavior combinations, especially for reducing binge drinking and increasing fruit and vegetable consumption. Medical students showed slightly more positive patterns than other students. The results indicate the need for addressing health behaviors in the student population of this university. If these findings can be replicated in other universities, programs that promote individual behavior change as well as changes in environmental conditions in the university environment are necessary to address this urgent problem.

Adherence to the principles of Motivational Interviewing, clients' characteristics and behavior outcome in a smoking cessation and relapse prevention trial in women postpartum.

OBJECTIVES: 1. Quantitative description of the adherence to the principles of Motivational Interviewing (MI) in smoking counseling sessions, 2. Examination of the relation between clients' characteristics and the adherence to the principles of MI, and between adherence to the principles of MI and future smoking status. METHODS: A sample of n=163 sessions conducted during a randomized controlled trial in testing the effectiveness of a population-based smoking intervention in women postpartum was investigated. Demographic and behavior-related variables were included in a logistic regression to predict adherence to MI. Adherence was measured using the Motivational Interviewing Treatment Integrity (MITI) scale. RESULTS: Of the sessions, 49.4% showed good adherence to MI. The OR of receiving a good MI session was 3.1 for non-smokers in comparison to daily smokers. No other demographic or behavioral variable gained statistical significance. The relation between adherence and intervention outcome after 6 months was statistically significant (chi(2)=6.459, p<0.05). CONCLUSIONS: This intervention study shows a satisfactory degree of adherence to and the effectiveness of MI. MI-adherence seems more likely in sessions concerned with smoking relapse prevention compared to smoking cessation sessions.

Midwives' attitudes to counselling women about their smoking behaviour during pregnancy and postpartum.

OBJECTIVE: to investigate the attitudes of midwives to counselling women about their smoking behaviour during pregnancy and postpartum. DESIGN: survey using postal questionnaires. SETTING: the entire federal state of Mecklenburg-West-Pomerania in Germany. PARTICIPANTS: 189 midwives constituting 77% of all midwives working in that State. FINDINGS: midwives reported that they assessed smoking behaviour regularly (77%), addressed the consequences of smoking (70%) and advised women to quit. Among the midwives, 81% saw low chances of success and parents' expectations as the biggest barriers to counselling. Midwives reported that about 28% of women quit following their advice. KEY CONCLUSIONS: smoking and exposure to environmental tobacco smoke are seen as prominent health threats that midwives reported they addressed routinely, including giving advice to stop smoking. IMPLICATIONS FOR PRACTICE: midwives should be supported in learning effective intervention strategies to further strengthen their work. They are a target population to deliver brief smoking interventions.

An intervention to support postpartum women to quit smoking or remain smoke-free.

Effectiveness studies among pregnant and postpartum women indicate that pregnancy and the postpartum period provide a window of opportunity to promote smoking cessation and smoke-free families. Yet, there is a lack of information about interventions that are portable to routine care. The goal of this article is to describe the structure, basic strategies, and the application of a smoking cessation and relapse prevention intervention for postpartum women in the general population. By using the stages of change concept and motivational interviewing, a classification of current and former smokers is given, and basic strategies and techniques are described to counsel women postpartum with regard to smoking.

Postpartum return to smoking: identifying different groups to tailor interventions.

OBJECTIVE: (a) To describe a population-based sample of women postpartum who smoked before pregnancy on grounds of the perceived advantages and disadvantages of nonsmoking and the self-efficacy not to smoke. (b) To identify grouping characteristics that can differentiate among those women. This could lead to the development of intervention strategies that are of different efficacy depending on the cluster the woman is member of. SAMPLE: A population-based sample of 317 women who had smoked at the beginning of pregnancy and who were smoke-free at the time of giving birth. DATA: Data about the acquisition stages of change to restart smoking, the perceived advantages of nonsmoking and the self-efficacy to remain smoke free on grounds of the Transtheoretical Model of Behavior Change was assessed. Smoking status was assessed 12 months later. STATISTICAL ANALYSIS: A cluster analysis was used to identify different groups; a logistic regression was calculated to assure the external validity of the clusters identified. RESULTS: The acquisition stages of change do not fit the situation of nonsmoking women postpartum in Germany, but four different clusters of ex-smoking women postpartum were identified on grounds of the other TTM-constructs. These are: the protected, the high risk, the premature and the ambivalent group. The clusters are associated with relapse after 12 months, none of the other variables controlled for was statistically significant. CONCLUSIONS: The TTM contributes to a better understanding of nonsmoking women postpartum. Further studies have to replicate the clusters found and have to find whether interventions tailored to these clusters are more effective in preventing relapse than other interventions.

Stage of change transitions and processes of change, decisional balance, and self-efficacy in smokers: a transtheoretical model validation using longitudinal data.

Interactions were examined between stage of change transitions and intraindividual increases or decreases in the processes of change, pros and cons of smoking, and situational temptations longitudinally. A total of 786 ever smokers was assessed 2 times, 6 months apart, with respect to the transtheoretical model (TTM) constructs. Two significant discriminant functions within initial precontemplators and 1 significant function within initial contemplators were found. Ten out of 15 TTM variables contributed to at least 1 function. The functions mainly distinguished between preabstinence (precontemplation, contemplation, or preparation) and abstinence (action or maintenance) stages of change, that is, between current and former smokers. This is one of the few studies providing a longitudinal validation of the postulates of the TTM.

Predicting outcomes of inpatient psychotherapy using quality management data: comparing classification and regression trees with logistic regression and linear discriminant analysis.

Abstract Three classification models are compared with regard to their ability to identify unsuccessful treatment outcomes. Data from the Stuttgart-Heidelberg model on quality management of 1,401 inpatients were used. According to the evaluation algorithm used, 82% benefited from therapy. Outcomes were classified using logistic regression, linear discriminant analysis, and classification and regression trees. For the regression techniques, variables were selected stepwise backward; for the CART model, the method-inherent selection scheme was adopted. Because there were few signal cases in the data, these cases were double weighted. Model performance was obtained using classic cross-validation. Overall misclassification rates did not differ between methods for the construction sample but differed when applied to the validation sample. Overall classification rates for the given problem are modest.

Short report: Paediatricians' attitude towards counselling parents postpartum about their smoking behaviour.

BACKGROUND: To investigate the attitudes of paediatricians in private practice towards counselling smoking parents of infants on their smoking behaviour. METHODS: Questionnaires were mailed to 188 eligible paediatricians in Mecklenburg-West Pommerania. RESULTS: The response rate to this survey was 62%. With regard to risk factors, 54% of respondents counsel parents on the occasion of well-child visits. Around 89% grant Environmental Tobacco Smoke (ETS) a high priority with regard to counselling and 26% of respondents obtain smoking status from parents routinely. From the sample, 66% wish to be trained in a brief intervention for counselling in everyday practice. CONCLUSION: Smoking and ETS are seen as prominent health threats and paediatricians look for brief interventions to be used in clinical practice.