Perspectives in Implementing a Pragmatic Pediatric Primary Care-Based Intervention Trial

The 2013 U.S. Preventive Services Task Force (USPSTF) concluded that behavioral interventions are effective in reducing initiation of smoking in youth, recommending primary care clinicians provide education or brief counseling to prevent initiation, and that there are promising trends toward behavioral interventions improving cessation in this population. Our primary care-based intervention RCT conducted between 2000 and 2004, Air It Out, informed these USPSTF recommendations. Our trial was designed to determine whether a pediatric primary care practice-based smoking prevention and cessation intervention would be effective in increasing abstinence rates among adolescents under usual clinic conditions, to inform clinical practice. Therefore, the trial was designed to be largely a pragmatic trial. In this paper, we describe where each of the Air It Out study components falls along the pragmatic-explanatory continuum regarding participant eligibility criteria, intervention and comparison condition design, follow-up and outcomes, compliance and adherence assessments, and analysis. Such an assessment assists researchers by providing a framework to guide decisions regarding study design and implementation. We then share a few principles and lessons learned in developing and implementing the primary care-based intervention trial, focusing on study setting selection, engaging providers who will be delivering the intervention and the target population who will be receiving it in designing the trial and interventions to be tested, and the need to carefully plan recruitment and retention procedures. The hope is to increase the number of well-designed studies that can be included in the evidence reviews to guide future USPSTF recommendation statements.

Field-scale monitoring of pharmaceutical compounds applied to active golf courses by recycled water

The scarcity of potable water in arid and semiarid environments has led to the wider use of recycled water for irrigating agricultural fields, parks, golf courses, and other areas. One concern using recycled water as a source of irrigation has been the presence, fate, and transport of pharmaceutical compounds in water that percolates below the root zone of plants; however, very few multiyear field studies have been reported in the peer-reviewed literature. Here, we assessed compound mass flux of 13 pharmaceuticals in the fairways of four golf courses in the southwestern United States during a 2-yr field study. The sites varied by climate and soil type but were similar regarding turfgrass management. The results showed the presence of at least one pharmaceutical compound in nearly all samples collected, although concentrations were substantially lower after transport through the soil. Percent reduction in compound mass fluxes in drainage water was effectively 100% in 22 of 52 cases, 98 to 100% in 27 of 52 cases, and 73 to 94% in 3 of 52 cases (a case is defined as a specific compound measured at a specific site). Mass fluxes migrating below the root zone were calculated as <250 × 10 g ha for all compounds and >100 × 10 g ha in only two cases. For cases where the majority of the analyses were reportable, all fluxes were <8.80 × 10 g ha. Carbamazepine, meprobamate, and sulfamethoxazole were most commonly found in drainage water, representing nearly 80% of all reportable detections. This research demonstrates the potential of turfgrass/soil systems to reduce contaminant loading below the root zone and potentially toward groundwater.

Effect of a pediatric practice-based smoking prevention and cessation intervention for adolescents: a randomized, controlled trial

OBJECTIVE

The purpose of this work was to determine whether a pediatric practice-based smoking prevention and cessation intervention increases abstinence rates among adolescents.

METHODS

Eight pediatric primary care clinics were randomly assigned to either intervention or usual care control condition. The provider- and peer-delivered intervention tested was based on the 5A model recommended by the US Public Health Service clinical practice guidelines and the American Academy of Pediatrics and consisted of brief counseling by the pediatric provider followed by 1 visit and 4 telephone calls by older peer counselors aged 21 to 25 years. A consecutive sample of patients aged 13 to 17 years scheduled for an office visit was eligible regardless of smoking status. Of 2711 patients who agreed to participate, 2709 completed baseline assessments, and 2700 (99.6%) and 2690 (99.2%) completed 6- and 12-month assessments, respectively.

RESULTS

Compared with the usual care condition, nonsmokers who received the provider- and peer-delivered intervention were significantly more likely to self-report having remained abstinent at 6-month and 12-month follow-up; smokers who received the provider- and peer-delivered intervention were more likely to report having quit at the 6-month but not the 12-month follow-up. A number of adolescent characteristics (eg, age, peer smoking, tobacco dependence, and susceptibility) were found to be predictive of abstinence at follow-up.

CONCLUSIONS

A pediatric practice-based intervention delivered by pediatric providers and older peer counselors proved feasible and effective in discouraging the initiation of smoking among nonsmoking adolescents for 1 year and in increasing abstinence rates among smokers for 6 months.

Smoking prevention and cessation intervention delivery by pediatric providers, as assessed with patient exit interviews

OBJECTIVE

The goal was to evaluate the degree to which a smoking prevention and cessation intervention was delivered by providers to adolescents in the pediatric office setting.

METHODS

Eight pediatric clinics in central Massachusetts were assigned randomly to either a special intervention (brief pediatric provider-delivered intervention plus peer counseling) or the usual care condition. Subjects (n = 2710) were adolescents 13 to 17 years of age, both smokers (smoked in the past 30 days) and nonsmokers/former smokers. The degree to which smoking prevention and treatment interventions were delivered by providers was assessed through patient exit interviews with adolescents after their clinic visits; interviews assessed the occurrence of 10 possible intervention steps.

RESULTS

The percentage of providers engaging in the smoking interventions differed significantly between the special intervention and usual care conditions, according to adolescent reports in the patient exit interviews. For nonsmokers/former smokers, overall patient exit interview scores were 7.24 for the special intervention condition and 4.95 for the usual care condition. For current smokers, overall patient exit interview scores were 8.40 and 6.24 for the special intervention and usual care conditions, respectively. Intervention fidelity of special intervention providers was 72.2% and 84.0% for nonsmokers/former smokers and current smokers, respectively.

CONCLUSIONS

Pediatric providers who receive training and reminders to deliver a brief smoking prevention and cessation intervention to adolescents in the context of routine pediatric primary care practice can do so feasibly and with a high degree of fidelity to the intervention protocol.

A comparison of the psychometric properties of the hooked on nicotine checklist and the modified Fagerström tolerance questionnaire

We compared the psychometric properties of the Hooked on Nicotine Checklist (HONC) and the Modified Fagerström Tolerance Questionnaire (MFTQ). Adolescent current smokers (n = 215) completed both instruments three times, at baseline and 6- and 12-month follow-up. Internal consistency of the HONC was high (alpha = 0.92), as was its stability over the follow-up interval (intraclass correlation (ICC) = 0.93 over 6 months and 0.91 over 1 year). Internal consistency of the MFTQ was acceptable (alpha = 0.83), and its stability over the follow-up interval was similar to that reported previously (ICC = 0.79 at 6 months and 0.76 at 1 year). The HONC predicted smoking at both follow-up points, while the MFTQ did so only at 6 months. The HONC compared favorably with the MFTQ in all respects. The most important advantage of the HONC is that it is measuring a clearly defined concept, diminished autonomy over tobacco, which begins when the sequelae of tobacco use present a barrier to quitting.

Parent advisory groups in pediatric practices: parents' and professionals' perceptions

OBJECTIVE

To describe the benefits perceived by parents and professionals from their participation in parent advisory groups (PAGs).

DESIGN

Retrospective telephone survey.

SETTING

Parent advisory groups were established in 4 community-based pediatric practices. Each group included parents of children with chronic health conditions, health care providers, and a Department of Public Health staff member.

PARTICIPANTS

The mothers and fathers of children with chronic health conditions completed a telephone survey. These parents also were enrolled in a broader intervention aimed at providing primary care for children with chronic conditions.

INTERVENTION

Groups met regularly in the pediatric office setting. Logistical arrangements and activities varied among the 4 groups.

MAIN OUTCOME MEASURES

Parents and professionals rated their perceptions of the PAGs based on a structured list of potential benefits.

RESULTS

Mothers viewed the PAGs as most beneficial in diminishing their isolation, helping them to understand family concerns, increasing their influence on the pediatric care provided to their children, and improving their knowledge of community resources. Professionals believed that the PAGs enhanced their awareness of common family needs, increased their skills at collaborating with families, and helped them to feel more effective. All professionals and most parents were interested in continuing their involvement in a PAG.

CONCLUSIONS

Parent advisory groups may benefit families and professionals who care for them by (1) fostering collaborative relationships and communication, (2) increasing a sense of social support among families, (3) increasing families' knowledge of community-based resources, and (4) increasing the families' sense of efficacy and involvement in the care of their own and others' children.

Shared vision: concordance among fathers, mothers, and pediatricians about unmet needs of children with chronic health conditions

OBJECTIVE

These analyses were undertaken to investigate the number and types of services and assistance believed to be useful to children with a chronic health condition and their families. The perspective of mothers, fathers, and primary care physicians were sought separately and compared.

METHODS

Families that include at least 1 child with a chronic health condition were selected from pediatric practices in Central Massachusetts. All 3 respondents completed a questionnaire describing their own perspective of current needs and of the severity of the child's condition. The 3 perspectives are compared statistically and areas of agreement/disagreement are described.

RESULTS

Mothers, fathers, and physicians described children's and families' needs with a surprising degree of concordance. On the other hand, pediatricians identified fewer needs, despite rating the severity of children's illnesses as greater than did parents. Mothers and fathers agreed substantially about the level of severity of their child's condition and about their unmet needs.

CONCLUSIONS

It is important that pediatric practice systems include effective mechanisms to assess parents' opinions regarding the unmet needs of their child/family in the face of a child with a chronic health condition. Without input from families, pediatricians are aware of only some of the needs that parents identify.

Risk factors for violent behavior among incarcerated male psychiatric patients: a multimethod approach

A multimethod approach that included demographic, criminal offense, drug use, neuropsychological, Rorschach, psychiatric diagnosis, and psychopathy characteristics was used to evaluate 131 incarcerated male psychiatric inpatients. Each criminal offense was ranked from nonviolent to severely violent, and participants were classified as having lifetime histories of either high or low violent behavior. Univariate analyses revealed 12 characteristics which independently discriminated inmates with lifetime histories of high or low violent behavior (married, non-Caucasian race, Axis I psychotic diagnosis, drug other than alcohol or marijuana used most, positive for psychopathy on the Hare Psychopathy Checklist Revised, scores indicating impairment on the Halstead Impairment Index and Category Test, and five Rorschach measures). Logistic regression revealed that eight of those characteristics (married, non-Caucasian race, Axis I psychotic diagnosis, positive for psychopathy on the Hare Psychopathy Checklist Revised, scores indicating impairment on the Halstead Impairment Index, and Rorschach Coping Deficit Index, Personal Responses, and Raw Sum Special Scores) significantly contributed to identifying inmates with lifetime histories of highly violent behavior. Data are provided for sensitivity, specificity, positive and negative predictive power, and overall correct classification rate for neuropsychological and Rorschach measures. Because this sample represented only incarcerated male psychiatric inpatients, and not a general prison population, caution as to limits of generalization are discussed. Implications for use of this information in understanding violent behavior are also discussed.

Neuropsychological functioning of inmates referred for psychiatric treatment

This article describes the Neuropsychological (NP) functioning of 71 psychiatrically hospitalized male prisoners. Demographic description, patterns of drug use, patterns of violence, psychiatric diagnosis, and performance on the Halstead-Reitan Neuropsychological Battery (HRNB) are described. Using age and education adjusted norms (Heaton, Grant, & Matthews, 1991), 84% of this sample demonstrated impairment on the Halstead Impairment Index. Sensory Exam-Left, Tapping Dominant and Non-Dominant, Speech Perception, Tactual Performance Test Times/Memory/and Location, Trailmaking A and B, and Category Test were all impaired. Multivariate Analyses (MANOVAS) demonstrated significantly impaired performance on tasks of Motor, Psychomotor, and Reasoning, with FTT-Dominant, TPT-Total, and Category Test contributing the most meaningful contribution to the multivariate effect. Varimax Rotated Principle Components Analysis revealed a five-factor model (Motor, Learning, Attention, Abstraction, and Processing Speed), which accounted for 69.9% of the total variance. Need for further research, and implications for the use of this information in developing treatment programs for psychiatrically disturbed prisoners are discussed.

Functional encopresis: symptom reduction and behavioral improvement

This study assessed the relationship between functional encopresis and accompanying problems: emotional, behavioral, and social. Symptom resolution and changes in these concomitant problems were studied. Seventy-six children, 6 to 12 years of age, enrolled in this "self-selected," nonequivalent, control (contrast) group research design with 38 children in each group. Using the Child Behavior Checklist, children were tested before treatment and 6 months later. The results showed that children with encopresis had significantly more emotional/behavioral problems and poorer social competence before treatment than children in the contrast group; combined medical and psychotherapeutic intervention led to a significant reduction in soiling frequency, and children with encopresis experienced significantly fewer behavioral problems and significantly improved social competence after treatment. There was a small group of children for whom treatment was difficult. The data suggest that highly elevated behavior problem scores, especially in association with parental negativeness, may be related to poor treatment outcome.

Self-hypnosis, sensory cuing, and response prevention: decreasing anxiety and improving written output of a preadolescent with learning disabilities

In this case study we describe a hypnobehavioral procedure used in the successful treatment of a 10 1/2-year-old boy who suffered from an adjustment disorder with academic inhibition, manifested by an anxiety reaction secondary to learning disabilities that affected his written-language output. Treatment consisted of three self-management techniques: self-monitoring and charting of conditions that preceded anxiety-related behaviors; self-hypnosis and a progressive-muscle-relaxation induction technique; and response-prevention training. The hypnobehavioral procedure decreased anxiety and increased written-language output. We discuss the results in relation to the specific benefits obtained by the preadolescent studied, the advantages of the hypnobehavioral procedure over previous methods to resolve anxiety, the role of self-hypnosis in problem resolution, and future research directions.

The impact of JRA on children, adolescents, and their families. Current research and implications for future studies

This article focusses on the impact of Juvenile Rheumatoid Arthritis (JRA) on children, adolescents, and their families. Investigations reported in the literature that consider the etiologic role of psychopathology and JRA, psychologic adjustment/maladjustment of adolescents with JRA, family adaptation to chronic illness, and changes in the family that affect health outcomes and treatment compliance are critically reviewed. Methodologic and research design issues are discussed in relation to previous investigations, and implications for future research are presented.

The epidemiology of accidental poisoning in children

During a 1-year period (1 March 1982-28 February 1983) 272 children were admitted to the Red Cross War Memorial Children's Hospital, Cape Town, after accidental poisoning. More boys than girls were admitted, and children between the ages of 12 months and 3 years were the most vulnerable. More than half the patients were coloured; blacks and whites represented minorities. Most cases appear to occur during the summer months (November, December and January). Medicines were responsible for most cases of accidental poisoning in whites and coloureds, but household preparations were responsible for most cases in blacks. The above findings are compared with previous yearly statistics.

The operative treatment of sacro-iliac subluxation and disruption of the symphysis pubis

A method of internal fixation of the disrupted symphysis publis is discribed which uses readily available AO plates and tools. Patients can be mobilized at 3 days and discharged within 2 weeks. This method of treatment represents a considerable saving in nursing time and a great improvement for the patient, who is usually free from pain after 1 week.