Standardizing contact investigation protocols

SETTING

The State of Alabama Department of Public Health Division of Tuberculosis Control.

OBJECTIVE

To standardize contact investigation protocols and implement an intervention to increase TB field worker adherence to the protocols with the goal of promoting efficiency and effectiveness in contact investigations.

DESIGN

A process evaluation of existing data collection and management systems and protocols was performed. Standardized protocols and an intervention to increase TB field worker adherence to the protocols were created and pilot tested. These were then implemented and formative evaluation data were collected.

RESULTS

The process evaluation revealed considerable variance among field workers with regard to protocols and definitions of variables related to contact investigations. Protocols were standardized and an intervention targeted at TB field workers was developed. The intervention consisted of a training workshop and the development of a computer-based contact investigation module. This was successfully implemented throughout the state.

CONCLUSIONS

To perform effective contact investigations and conduct studies to improve the effectiveness of these investigations, TB control programs must pay careful attention to precisely defining variables and concepts related to the contact investigation. Furthermore, protocols must be standardized and resources devoted to training of TB field workers to ensure adherence to protocols.

The process of pregnancy smoking cessation: implications for interventions

OBJECTIVE

There is a growing body of knowledge about the pregnant smoker and what happens as she goes through the pregnancy and postpartum periods. This article reviews the process of smoking cessation in the context of pregnancy.

DATA SOURCES

Epidemiological data, extant reviews of the literature, and current original research reports are used to examine characteristics of the women and of the change process for those women smokers who quit, stop, or modify their smoking during pregnancy and the postpartum period.

DATA SYNTHESIS

An analysis of the interaction of the process of smoking cessation with pregnancy was conducted to gain insight into the unique problems faced by the pregnant smoker and discover directions for intervention.

CONCLUSIONS

Pregnancy and the postpartum period provide a window of opportunity to promote smoking cessation and smoke free families. Understanding obstacles and pathways for pregnancy and postpartum smoking cessation can guide implementation of effective existing programs and development of new ones. Recommendations include promoting cessation before and at the beginning of pregnancy, increasing delivery of treatment early in pregnancy, helping spontaneous and intervention assisted quitters to remain tobacco free postpartum, aiding late pregnancy smokers, and involving the partner of the woman smoker.

Recommended cessation counselling for pregnant women who smoke: a review of the evidence

OBJECTIVE

To review the evidence base underlying recommended cessation counselling for pregnant women who smoke, as it applies to the steps identified in the Agency for Healthcare Research and Quality's publication, Treating tobacco use and dependence: a clinical practice guideline.

DATA SOURCES

Secondary analysis of literature reviews and meta-analyses.

DATA SYNTHESIS

A brief cessation counselling session of 5-15 minutes, when delivered by a trained provider with the provision of pregnancy specific, self help materials, significantly increases rates of cessation among pregnant smokers. This low intensity intervention achieves a modest but clinically significant effect on cessation rates, with an average risk ratio of 1.7 (95% confidence interval 1.3 to 2.2). There are five components of the recommended method-"ask, advise, assess, assist, and arrange".

CONCLUSIONS

We recommend these evidence based procedures be adopted by all prenatal care providers. The use of this evidence based intervention is feasible in most office or clinic settings offering prenatal care and can be implemented without inhibiting other important aspects of prenatal care or disrupting patient flow. If implemented widely, this approach has the potential to achieve an important reduction in a number of adverse maternal, infant, and pregnancy outcomes and to reduce associated, excess health care costs.

A process evaluation model for patient education programs for pregnant smokers

OBJECTIVE

To describe and apply a process evaluation model (PEM) for patient education programs for pregnant smokers.

METHODS

The preparation of a process evaluation plan required each program to define its essential "new" patient assessment and intervention procedures for each episode (visit) of patient-staff contact. Following specification of these core implementation procedures (p) by each patient education program, the PEM, developed by the Smoke-Free Families (SFF) National Program Office, was applied. The PEM consists of five steps: (1) definition of the eligible patient sample (a); (2) documentation of patient exposure to each procedure (b); (3) computation of procedure exposure rate (b/a = c); (4) specification of a practice performance standard for each procedure (d); (5) computation of an implementation index (c/d = e) for each procedure. The aggregate of all indexes (e) divided by the number of procedures (P(n)) produced a program implementation index (PII = Sigmae/P(n)).

PARTICIPANTS AND SETTINGS

Data from four SFF studies that represent different settings were used to illustrate the application of the PEM.

RESULTS

All four projects encountered moderate to significant difficulty in program implementation. As the number and complexity of procedures increased, the implementation index decreased. From initial procedures that included patient recruitment, delivery of the intervention components, and conducting patient follow ups, a variety of problems were encountered and lessons learned.

CONCLUSION

This process evaluation provided specific insight about the difficulty of routine delivery of any new methods into diverse maternity care setting. The importance of pilot testing all procedures is emphasised. The application of the PEM to monitor program progress is recommended and revisions to improve program delivery are suggested.

Effectiveness of Agency for Health Care Policy and Research clinical practice guideline and patient education methods for pregnant smokers in medicaid maternity care

OBJECTIVE

The purposes of this study were (1) to determine the extent to which tobacco exposure assessment and new patient education methods, derived from a meta-analysis and the Agency for Health Care Policy and Research guideline recommendations, could be provided routinely by trained Medicaid maternity care staff members and (2) to document the behavioral impact of these interventions among pregnant smokers.

STUDY DESIGN

After 265 pregnant smokers were assigned at their first visit to an experimental group (n = 139) or a control group (n = 126), they received standardized risk information and were advised to quit smoking. The experimental group also received evidence-based patient education methods, including the videocassette Commit to Quit During and After Pregnancy, the publication A Pregnant Woman's Guide to Quit Smoking, and a brief counseling session. Self-report and saliva cotinine assessments of tobacco exposure were performed at baseline and at the end of pregnancy.

RESULTS

A significantly higher percentage of patients quit smoking in the experimental group (17.3%) than in the control group (8.8%).

CONCLUSIONS

The application of principles of organizational development and quality improvement at the management and clinical practice levels and the delivery of evidence-based health education methods by trained prenatal care providers significantly increased smoking cessation rates among pregnant Medicaid recipients.

Asthma self-management: do patient education programs always have an impact?

BACKGROUND

During the past 15 years, programs to improve self-management practices in adults with asthma have reported improvement in functional status and reduction of inappropriate use of health care services. However, these programs usually represent an ideal approach, applying multiple patient education methods. Consequently, when these programs are found to be efficacious, it is important to replicate the programs as well as to evaluate less complex methods that may be more appropriate for nonacademic health care settings.

METHODS

We compared the following 3 standardized self-management treatments in a randomized, controlled trial: (1) a replication of the self-management program developed at a university medical center that was previously shown to be efficacious; (2) a modified version of this program including only the core elements; and (3) a usual-care program. Outcome measures included medication and inhaler regimen adherence, asthma symptoms, respiratory illness, functional status, and use of health care resources.

RESULTS

All 3 groups improved on measures of respiratory illnesses, use of health care services, and functional status. Patients in both education groups did no better than the usual-care group.

CONCLUSIONS

The results are inconsistent with the results of the first asthma self-management study at this institution and with those of efficacy studies of similar programs. Two factors, selection of the patient population and historical changes in asthma treatment, most likely contributed to the lack of impact of the self-management programs. As a result of the improved standards for usual care due to both factors, the opportunity to effect patient outcomes was substantially reduced.

Factors associated with occupational exposure and compliance with universal precautions in an urban school district

Factors associated with occupational exposure and universal precautions (UP) compliance were assessed among employees in one urban school district. Half of the employees surveyed reported responding to bleeding injuries and cleaning blood or other body fluids (e.g., vomit, urine) during the previous school year. Also, 1 in 4 custodians and 1 in 10 teachers/teacher's aides had direct contact with blood or body fluids without protection. In multivariate logistic regression analyses, direct contact was most likely among secondary school employees in unpredictable situations who did not have protective equipment or comply with UP. UP compliance was greater among those who had protective equipment available and felt self-confident. Self-confidence was associated with having received training or protective equipment. Routine communications between administrators and employees, staff training, provision of protective equipment, and exposure incident monitoring are essential to effective implementation of UP policies in schools and work settings where occupational exposure could occur.

The use of significant reduction rates to evaluate health education methods for pregnant smokers: a new harm reduction behavioral indicator?

This article evaluates the evidence to support the use of biochemical measurement of significant reduction (SR) rates among pregnant smokers as a new behavioral indicator of "harm reduction" (HR). The results of four studies--three randomized patient education clinical trials of pregnant smokers (Trials I, II, and III) and an epidemiological study (Study IV)--are presented. Among Trial I, II, and III cohorts of pregnant smokers, control group SR rates of 7% (I), 9% (II), and 20% (III) were increased among experimental groups to 17% (I), 18% (II), and 32% (III) by the same patient education methods. Analyses of infant birthweight data in Study IV found that a patient SR rate representing a 50% or more decrease between a baseline and follow-up test was associated with an increase in adjusted birthweight of 92 grams.

Predictors of smoking cessation during pregnancy

AIMS

The purpose of this study was to determine predictors of smoking cessation from a sample of pregnant Medicaid recipients. Of special interest was whether patient stage of change, based on the transtheoretical model, was predictive of smoking behavior change during pregnancy.

PARTICIPANTS/SETTING

The sample was drawn from a cohort of pregnant smokers who were participants in a prospective, randomized clinical trial conducted in four public health maternity clinics in Birmingham, Alabama, USA.

DESIGN/MEASUREMENTS

The 435 participants entered prenatal care on or before their 24th week of gestation and had saliva collected for cotinine assays at baseline and follow-up. In this secondary analysis, descriptive statistics defined the sample, cross-tabulation procedures identified a preliminary set of predictor variables, and discriminant function analyses predicted group membership--quitter or smoker.

FINDINGS/CONCLUSIONS

Discriminant function analyses revealed that patient baseline cotinine value, duration of smoking habit, self-efficacy, exposure to environmental tobacco smoke, and exposure to patient education methods were predictive of non-smoking status assessed during the third trimester of pregnancy.

A meta-evaluation of smoking cessation intervention research among pregnant women: improving the science and art

In 1986 Windsor and Orleans described guidelines and standards to evaluate the quality of smoking cessation intervention research among pregnant women. This paper presents a meta-evaluation (ME) of the evaluation research in this area from 1986 to 1998. ME is defined as a systematic review of experimental and quasi-experimental evaluation research using a standardized set of methodological criteria to rate the internal validity--efficacy or effectiveness--of intervention results. Five criteria were used to rate 23 smoking cessation intervention studies among pregnant smokers in prenatal care: (1) evaluation research design, (2) sample representativeness, sample size and power estimation, (3) population characteristics, (4) measurement quality, and (5) replicability of interventions. Eleven studies had sufficient methodological quality to produce results of high internal validity. Poor measurement of smoking status, patient selection biases and incorrect calculation of quit rates were the major methodological weakness. Recommendations for future evaluation research are made.

Quality of measurement of smoking status by self-report and saliva cotinine among pregnant women

OBJECTIVE

The objectives of this paper were to determine the rate of misclassification of smoking and nonsmoking status by self-reports and saliva continine of pregnant women participating in a smoking cessation trial, determine the relationship of the number of cigarettes smoked per day and saliva continine, and examine whether misclassification was due to an inappropriate saliva continine cutoff point.

METHODS

End of pregnancy self-reports of smoking status and saliva continine were used to calculate misclassification rates.

RESULTS

The findings revealed that 61 of 441 self-reported smokers had biochemical values inconsistent with smoking status for a smoking misclassification rate of 13.8%. The results also revealed that 28 of 107 self-reported quitters had continine values consistent with smoking status for a nonsmoking misclassification rate of 26.2%. Receiver Operating Characteristic (ROC) curves were then plotted to determine whether misclassification resulted from an inappropriate cutoff point. The continine cutoff point that maximized sensitivity and specificity for all women was 24 ng/ml. Racial ROC comparisons indicated a higher cutoff point for blacks than whites. Use of any of the ROC indicated cutoff points would not change the misclassification rates.

CONCLUSIONS

These findings suggest that underreporting of smoking status during pregnancy is high and that social desirability of nonsmoking status may have contributed to the lack of precision in saliva continine to distinguish smoking status in this study.

Assessing adherence to asthma medication and inhaler regimens: a psychometric analysis of adult self-report scales

Poor adherence to recommended regimens is a substantial problem in the clinical management of adults with asthma and other chronic diseases. Research on adherence assessment is complicated by methodological difficulties including limitations associated with the use of self-report measures. In this study, psychometric techniques were used to analyze two self-report scales for assessing adherence to recommended medication and inhaler use regimens in adults with asthma. Results indicated that the two scales had standard deviations large enough to detect variation adherence, had adequate reliability, and reflected the impact of an intervention designed to improve adherence. The results supported the usefulness of these scales for research on adherence. Additional analyses indicated that the two scales could be combined if the research goal required an overall measure of adherence.

Cost differences between low birthweight attributable to smoking and low birthweight for all causes

BACKGROUND

Low birthweight (< 2,500 g) is one of the major predictors of infant mortality. The clinical salience of low birthweight depends on its severity. The impact of smoking on low birthweight is greater in the 1,500-2,499-gm category than below 1,500 gm. This has an important implication for economic analyses of smoking cessation programs for pregnant women. Because health care cost is closely associated with birthweight, the cost of low birthweight attributable to smoking may be different than the average cost of low birthweight for all causes. Little is known about such cost differences.

METHODS

The population-attributable risk was used to estimate the number and percentage of low-birthweight infants due to maternal smoking. Costs by birthweight groups were used to determine cost differences between low birthweight due to smoking and for all causes.

RESULTS

The net incremental costs per low birthweight due to smoking range from $4,256 to $8,640 compared to the costs of $5,213 to $10,306 per low birthweight by all causes. The cost differences may be up to 18%.

CONCLUSION

Considerably lower costs at birth were found in low birthweight due to smoking than for all causes. The cost difference was attributable to the difference in the severity of low birthweight.

A meta-evaluation of nutrition education intervention research among pregnant women

Inadequate nutrition during pregnancy retards human fetal growth and increases the risk of delivering a low birthweight (LBW) infant. Some studies place particular emphasis on reducing LBW through improved nutrition. Consensus documents have strongly recommended intense nutrition education programs for patients at risk. Despite this well-defined need few methodologically rigorous studies have been conducted to evaluate the behavioral impact of nutrition education for pregnant patients. Criteria are recommended in the following areas: (1) research design, (2) sample size and power, (3) specification of population characteristics, (4) measurement quality, and (5) replication. The methodological quality of completed evaluations are reviewed using these criteria. The authors advocate guidelines for future investigators for conducting rigorous trials in this critical public health area.

The impact on infant birth weight and gestational age of cotinine-validated smoking reduction during pregnancy

OBJECTIVE

To evaluate the impact of cotinine-confirmed smoking reduction during pregnancy on infant birth weight and gestational age at birth.

DESIGN

Group analyses from a prospective, randomized smoking-cessation intervention trial using cotinine levels to assess smoking cessation and reduction.

SETTING

Four maternity clinics of Jefferson County Health Department in Birmingham, Ala.

PATIENTS

A total of 803 pregnant smokers and 474 never smokers with a fetal gestational age of 32 weeks or less at the first prenatal visit to a clinic.

MAIN OUTCOME MEASURES

Infant birth weight and gestational age at birth.

RESULTS

Infants who were born to women who quit smoking (quitters) had the highest mean birth weight (3371 +/- 581 g), followed by infants who were born to women who did not change smoking behavior (no changers) (3043 +/- 587 g). The mean infant birth weight of infants born to the quitters, adjusted by mother's age, race, height, weight at baseline, and gestational age at delivery was 241 g heavier than that among the no changers (P = .0008) and 167 g heavier than the reducers (P = .04). The adjusted mean infant birth weight of infants born to the reducers was 92 g heavier than that among the no changers (P = .08). White reducers with baseline cotinine levels greater than 100 ng/mL had infants who were 241 g heavier than did white no changers. A 220-g difference was also seen in black reducers with a baseline cotinine level of 100 ng/mL or less. Although smoking cessation increased infant gestational age at delivery by 1 week, smoking reduction had little effect.

CONCLUSION

Cotinine-validated smoking reduction rates were positively associated with an increase in infant birth weight. While smoking cessation must continue to be the primary objective for pregnant smokers, specific intervention methods should also be directed toward smoking reduction for women who cannot quit.

Health education for pregnant smokers: its behavioral impact and cost benefit

OBJECTIVES

A randomized trial (the Birmingham Trial II) was conducted to evaluate the behavioral impact of health education methods among 814 female smokers at four public health maternity clinics.

METHODS

Four hundred patients were randomly assigned to an Experimental (E) Group, and 414 were assigned to a Control (C) Group. Self-reports and saliva cotinine tests confirmed smoking status at the first visit, at midpregnancy, and at end of pregnancy.

RESULTS

The E Group exhibited a 14.3% quit rate and the C Group an 8.5% quit rate. A Historical Comparison (C) Group exhibited a 3.0% quit rate. Black E and C Group patients had higher quit rates than White E and C Group patients. A cost-benefit analysis found cost-to-benefit ratios of $1:$6.72 (low estimate) and $1:$17.18 (high estimate) and an estimated savings of $247,296 (low estimate) and $699,240 (high estimate).

CONCLUSION

Health education methods are efficacious and cost beneficial for pregnant smokers in public health maternity clinics.

The dissemination of smoking cessation methods for pregnant women: achieving the year 2000 objectives

The smoking prevalence rate among adult women and pregnant women has decreased only 0.3 to 0.5% per year since 1969. Without a nationwide dissemination of efficacious smoking cessation methods based on these trends, by the year 2000 the smoking prevalence among pregnant women will be approximately 18%. This estimate is well above the US Department of Health and Human Services Year 2000 Objective of 10%. The US dissemination of tested smoking cessation methods could help an additional 12,900 to 155,000 pregnant smokers annually and 600,000 to 1,481,000 cumulatively to quit smoking during the 1990s. Dissemination could help achieve 31 to 78% of the Year 2000 Objectives for pregnancy smoking prevalence. (With dissemination, at best a 15% smoking prevalence during pregnancy, rather than the 10% objective, is likely to be observed.) Our results confirm a well-documented need for a national campaign to disseminate smoking cessation methods.

Evaluation of the impact of dissemination of smoking cessation methods on the low birthweight rate and on health care costs: achieving year 2000 objectives for the nation

Nationwide dissemination of efficacious and cost-effective smoking cessation methods during the 1990s represents an important part of the solution to reducing the low birthweight (LBW) rate and associated health care costs. A minimum of 250,000 LBW births must be prevented during the 1990s to achieve the year 2000 LBW rate objective of 5% of total births. Annually 1,500 to 6,000 LBW births might be prevented between 1991 and 2000, and cumulatively 29,000 to 44,000, by dissemination of tested smoking cessation methods. Twelve to eighteen percent of the objective might be accomplished by dissemination. LBW births attributable to smoking might be reduced from the current 20% to 26% rate to a rate of 9% to 12% if the overall maternal smoking prevalence rate is reduced to 10% as projected in the Year 2000 Objectives. Smoking-attributable health care cost savings from dissemination would range from $22 million to $59 million.

Evaluation of the efficacy and cost effectiveness of health education methods to increase medication adherence among adults with asthma

We randomized 135 adult asthma patients to a control group, and 132 patients to an experimental group which received a special health education intervention. Four adherence measures were documented at baseline and 12-month follow-up: correct inhaler use, inhaler adherence, medication adherence, and total adherence rating. Costs to routinely deliver the intervention were $32.03/patient. Experimental group patients exhibited a significantly higher level of improvement in adherence (44 percent) than control group patients (2 percent).

Characteristics and correlates of asthma in a university clinic population

To contribute more comprehensive information about the characteristics of asthma, this article analyzed patients served by the University of Alabama at Birmingham Comprehensive Asthma Program. Their physicians rated one fifth of these patients as having "severe" asthma with the remainder about equally divided between "moderate" and "mild". One in two first received a diagnosis of asthma ten or more years previously. Common comorbidities were hypertension, obesity, rhinitis, bronchitis, sinusitis, and arthritis. One half had visited an emergency room or been hospitalized for asthma in the past year. Inhaled bronchodilators and continuous theophylline were the most commonly prescribed medications. Side effects, especially tachycardia and insomnia, were common and almost exclusively associated with theophylline or corticosteroid therapy. Spirometric assessment showed chronic airflow obstruction in those with more severe asthma. Prevalence of respiratory symptoms, intensity of medication regimen, incidence of side effects, and health care utilization increased as asthma severity increased.

A randomized trial to improve self-management practices of adults with asthma

The prevalence and impact of adult asthma are substantial, and poor self-management practices, especially failures to adhere to treatment regimens, appear to be a significant problem. Desirable characteristics of an intervention program to improve self-management were identified through needs assessment and review of existing patient education resources. A comprehensive program was developed that integrated a workbook with one-to-one counseling and adherence-enhancing strategies. A longitudinal 1-year study compared patients receiving this self-management program with "usual care" patients receiving standard asthma pamphlets. Patients were randomly assigned to conditions. Baseline score and asthma severity were statistically controlled. Self-management patients had substantially better adherence than usual care patients, as well as improved functional status, at follow-up. Hospital and emergency department visits decreased in both groups but did not differ between groups.

Quality assurance methods for managing employee health-promotion programs: a case study in smoking cessation

Many worksite health-promotion projects only evaluate a program by documenting employee program utilization or by determining what behaviors have or have not been changed. The failure of a program may be due to its implementation rather than to the science of the intervention. Often, program implementation problems are overlooked. Many managers do not set up an implementation monitoring program to assess problems prior to breakdowns. This article describes how to monitor program implementation through the establishment of a Quality Assurance System in a worksite health-promotion program. A case study approach for a quit-smoking program administered to a large corporation will be used to demonstrate this method.

Subjective symptomatology of asthma in an outpatient population

Characteristics of subjective symptomatology of asthma were examined within a group of 132 adult asthma patients receiving medical care in a university-based, ambulatory clinic setting. Patients responded to 36 symptom descriptions or adjectives associated with asthma which were included in a modified version of the Asthma Symptoms Checklist (ASC). A principal components exploratory factor analysis was conducted and five factors were identified. The five factors measured 1) panic-fear, 2) airways obstruction, 3) hyperventilation, 4) fatigue, and 5) irritability. Psychometric properties of the factor scores were satisfactory. The reliabilities were high, standard deviations were large, and differences in factor mean scores conformed to clinical experience. Correlational analyses support the construct validity of the ASC, especially the panic-fear factor. An important outcome of this study was to verify the ASC factor structure in an outpatient setting. The ASC was confirmed as a valuable instrument for use in self-management programs for adults with asthma. The five ASC factors represent highly stable components of subjective symptomatology of asthma among diverse adult patient populations and geographical settings.

Patient characteristics relevant to effective self-management: scales for assessing attitudes of adults toward asthma

The Asthma Opinion Survey, a 33-item Likert-type instrument, was designed to measure attitudes relevant to self-management in adult outpatients. Items fall into eleven clusters; General Vulnerability, Specific Vulnerability, Attitudes Toward Patient Knowledge, Recognition of Airway Obstruction, Accessibility of Health Care, Panic-Fear, Belief in Treatment Efficacy, Staff-Patient Relationships, Sense of Control, Personal Impact, and Social Impact. Factor analysis of the clusters yielded three factors Vulnerability, Perceived Quality of Care, and Recognition and Control. The items, clusters, and factors all had adequate to good score spreads and internal consistencies. Asthma opinions covaried significantly with demographic characteristics, asthma severity, and intensity of health care utilization, and correlated with the Asthma Symptoms Checklist, an instrument developed at the National Jewish Hospital-National Asthma Center, in ways supporting construct validity. These results suggest the Asthma Opinion Survey is achieving its intended purpose.

Assessing the use of metered dose inhalers by adults with asthma

The development and analysis of an instrument to evaluate the use of metered dose inhalers by patients in the University of Alabama at Birmingham (UAB) Asthma Program is presented. A total of 238 adult asthma patients demonstrated use of the metered dose inhaler for this analysis. Patient skill in using the inhaler was recorded using the instrument, Inhaler-Use Checklist, developed at UAB. The study found that most patients use metered dose inhalers incorrectly, despite training received from their physicians on proper use of inhalers.

The effectiveness of a worksite self-help smoking cessation program: a randomized trial

A 2 x 2 randomized, factorial pretest/posttest group design was used to evaluate the effectiveness of self-help smoking cessation methods at the worksite. The study investigated the effect of a multicomponent health education and skill intervention versus the effect of a monetary incentive to the employee for quitting. All employees received, in addition, a standardized self-help smoking cessation manual and maintenance manual. Following agreement to participate and a baseline smoking history, all participants were followed for 6 weeks, 6 months, and 12 months. Saliva was obtained for thiocyanate (SCN) analysis of smoking status. Of the estimated 2000 smokers at the site, 387 smokers were recruited. Employees were randomly assigned to one of four groups. Results of this random trial indicate that those employees receiving a multicomponent program were most successful in quitting and remaining abstinent. The monetary incentive appears to have no effect on quit rate.

Some simple scales for use in asthma research

Several reviewers have recently identified a need for systematic efforts to improve the quality of questionnaires and other measures used in asthma research. This article applies standard psychometric techniques to scales developed to help meet this need. These scales assess asthma symptoms, respiratory diseases, the extent to which asthma inconveniences patients, medication regimens, and medication side effects. Scale quality was assessed by using data from 262 adult asthma patients. The results in general support the usefulness of these scales. The reliabilities indicate an acceptable to good level of internal consistency; the spread of scores is good; and correlations with external variables support validity.

A cost-effectiveness analysis of self-help smoking cessation methods for pregnant women

Estimates of the cost effectiveness and cost benefit of health promotion-health education methods for pregnant smokers designed to increase birth weight are not available. This paper presents the results of a cost-effectiveness analysis from a recently completed randomized trial to evaluate the effectiveness of self-help smoking cessation methods for pregnant women in public health maternity clinics. The study population--309 pregnant smokers from 3 prenatal clinics--were randomly assigned, during their first clinic visit, to 1 of 3 groups: (a) group 1 received the standard clinic information and advice to quit smoking, (b) group 2 received the standard clinic information and advice to quit plus the manual "Freedom From Smoking in 20 Days" by the American Lung Association, and (c) group 3 received the standard clinic information and advice to quit plus the pregnancy-specific manual "A Pregnant Woman's Self-Help Guide to Quit Smoking." The quit rates by the end of pregnancy were 2 percent for group 1, 6 percent for group 2, and 14 percent for group 3. Analyses also indicated that the method used for group 3 was the most cost effective: group 3 achieved smoking cessation at less than half the cost experienced by the other two groups. Although additional studies are needed concerning the behavioral impact, cost effectiveness, and cost benefit of self-help health education methods for smoking cessation, the methods tested in this trial are promising as solutions to part of the problem of low birth weight among infants of smoking mothers in the United States.

Promoting self-management in adults with asthma: an overview of the UAB program

Most asthma self-management programs have focused on children, but the prevalence and impact, both personal and economic, of adult asthma is substantial. Moreover, failure to adhere to treatment regimens appears to be a significant problem in adult asthma. It appears important, therefore, to develop asthma self-management programs for adults. The UAB program is based on the Health Belief Model for health behavior and on the PRECEDE Model for patient education. A needs assessment and a review of existing educational materials were used to specify the content of a self-care workbook. This workbook seeks to increase cognitive skills, encourage daily self-assessment of asthma, demonstrate success in asthma self-management, and promote effective social support. The overall intervention integrates this workbook with systematic reinforcement of self-monitoring and self-management. A prospective controlled study is comparing patients receiving this "special intervention" with "usual care" patients who receive only routinely available pamphlets providing information about asthma. Patients are randomly assigned to treatments by the closed envelope technique. Sample sizes were determined on the basis of statistical power. Outcomes in five areas are assessed: (1) health care utilization, (2) functional status, (3) knowledge, (4) adherence, and (5) psychological reactions.

Effectiveness of impersonal versus interpersonal methods to recruit employees into a worksite quit smoking program

One of the first salient issues a worksite quit smoking program must face is how to motivate employees to enroll and participate. The purpose of this study was to determine the effectiveness of impersonal versus interpersonal recruitment strategies used by an ongoing worksite quit smoking program. One hundred and nineteen smokers who stated on a questionnaire that they would be either "strongly yes" or "yes" interested in participating in a quit smoking program were randomized into two groups. One group was sent letters by employee mail from the director of the quit smoking program. This letter briefly described the program and invited employees to participate. The other group received a personal phone call from the staff health educator inviting them to participate. Results indicate that of the 46 individuals randomly assigned to Group 1 who were sent letters, none responded to the invitation; while 37 of the 44 employees who received a personal phone call, 19 scheduled an appointment, 7 kept their appointments. These results indicate the possible increased effectiveness of an impersonal versus interpersonal communications in recruiting full-time smoking employees.

Guidelines and methodological standards for smoking cessation intervention research among pregnant women: improving the science and art

While the evidence confirming the risks of smoking during pregnancy is unequivocal, smoking rates for U.S. women remain high. From 1965 to 1975 the proportion of women smokers, aged 18 to 35, rose from 34% to 36%. Rates of heavy smoking increased from 51% to 61%. Significant increases were noted in the United States, especially for teenaged girls, with 1979 data showing higher smoking rates among girls aged 17 to 18 (26%), than among the same-aged boys (19%). Moreover, adolescents have one-fifth of all U.S. births. Exact rates of smoking during pregnancy are unknown but several reports suggest 20-40% of pregnant U.S. women smoke at the onset of pregnancy. A national survey showed 35% of young women smokers able to quit smoking during pregnancy, with another 32% cutting down. Although 62% believed that smoking could harm the fetus, the majority were unable to stop smoking during their pregnancy. Most women who succeed in quitting or cutting down revert to their usual smoking habits late in pregnancy or after delivery. Since almost all data are based on self-reports, some degree of inaccuracy and underreporting can be assumed.

Use of a bogus pipeline method to increase accuracy of self-reported alcohol consumption among pregnant women

Pregnant women (N = 220) attending urban maternity care clinics were randomly assigned to study groups to determine the effectiveness of a "bogus pipeline" method to increase the accuracy of behavioral self-reports of alcohol consumption. Results indicate a significant difference (p less than .025) between those who reported alcohol consumption and those who were told their behavioral self-report of alcohol consumption would be confirmed by a physiological test (bogus pipeline). Only 14% in the self-reported group said they currently used alcohol during pregnancy, whereas 27% in the bogus pipeline group reported consumption of alcohol during pregnancy. The results suggest that the use of the bogus pipeline may increase the accuracy of self-reported alcohol consumption data from a cohort of pregnant women.

The effectiveness of smoking cessation methods for smokers in public health maternity clinics: a randomized trial

Little insight is available in the literature on how best to assist the pregnant smoker in public health maternity clinics to quit during pregnancy. A randomized pretest/posttest experiment was used to evaluate the effectiveness of two different self-help cessation methods. Three hundred and nine pregnant women from three public health maternity clinics were assigned randomly to one of three groups with one-third assigned to each: a control group; a group receiving the American Lung Association's Freedom From Smoking Manual; and those receiving A Pregnant Woman's Self-Help Guide to Quit Smoking. Using a saliva thiocyanate (SCN) and behavioral report at mid-pregnancy and end of pregnancy to confirm cessation or reduction, 2 per cent in the control group quit and 7 per cent reduced their SCN levels substantially. Of the women assigned to the ALA method, 6 per cent quit and 14 per cent reduced their SCN levels substantially. Of the women who used the Guide, 14 per cent quit and 17 per cent reduced their SCN levels substantially. Results of this trial indicate that health education methods tailored to the pregnant smoker are more effective in changing smoking behavior than the standard clinic information and advice to quit and/or the use of smoking cessation methods not tailored to the needs of the pregnant smoker.

Health education and medicine: competition or cooperation?

Shifts in the expectations of the public, in the practice of medicine, and in the state of the art of health education call for an examination of the nature of the relationship between the health education and medical professions. Their relationship can be characterized in terms of competition or cooperation. This paper examines a number of issues related to these shifts and discusses the potential and pitfalls of this relationship. It is concluded that power is a fundamental issue to be recognized and addressed by health education specialists.

Personal health practices of urban adults in Alabama: Davis Avenue Community Study

The need to establish baseline data on and monitor the personal health practices and beliefs of adults in a community served by health care facilities is well documented. The purpose of the survey was to determine health care practices, personal health behaviors, and health services use of the adults living in the Davis Avenue Community (DAC), a six-census tract area located in Mobile, AL. The DAC's population is approximately 95 percent black. Using methods developed by the National Center for Health Statistics, 402 adults between the ages of 20 and 69 years were interviewed by telephone by trained personnel to ascertain the health-related characteristics of residents in this health services area. Information collected in this survey provided the staff of the Franklin Memorial Primary Health Center, who provide primary health care in the area, with an empirical base on which to plan and market health promotion and education programs for the health services area.

Employee self-help smoking cessation programs: a review of the literature

The purpose of this article is to present a review of the literature on employee self-help smoking cessation programs. Included in this discussion are: (1) a rationale for self-help smoking cessation interventions; (2) a synopsis of their applicability to occupational settings; (3) a rational and description of the self-help smoking cessation interventions selected for a large group of employees; and (4) several methodological issues faced in conducting evaluations of smoking cessation programs.

An assessment of the Environmental Protection Agency's asbestos hazard evaluation algorithm

We performed an exploratory evaluation of the Environmental Protection Agency's algorithm for assessment of risk of exposure to asbestos in buildings. Observers scored five sites using the algorithm. One group (N = 23) conducted their assessments relying only on written instructions, while another (N = 20) was trained in the use of the algorithm. Five professional industrial hygienists, experienced in risk assessment, also used the algorithm on the same sites. A wide range of highly variable results, for both untrained and trained observers coupled with poor comparability with expert's scores raise concern as to the reliability of this assessment tool. The development of a valid and reliable "lay" index of risk is still needed.

Qualitative issues in developing educational diagnostic instruments and assessment procedures for diabetic patients

With one exception, psychometric analyses of the quality of instrumentation and educational assessment procedures for diabetic patients have not been reported in the literature. Following an extensive internal review process, a pilot test of 56 diabetic patients found that the newly developed instrument had a high degree of internal consistency for the major indexes, 0.89 and 0.85, respectively. An item analysis found individual questions to be of an acceptable quality. An analysis of interrater reliability of patient assessment procedures produced an r = 0.93. Some support for content and concurrent validity was noted. Using an external review by an expert panel, a revised instrument and protocol was used to conduct a formal field test of 100 diabetic patients. Levels of internal consistency similar to the pilot, 0.87 adn 0.86, were found. An item analysis produced similar positive results. While some support for concurrent validity of the data was found, little support for discriminant validity was evident. The instrument and assessment procedures need to undergo more extensive and rigorous examination of its psychometric characteristics, particularly stability and predictive validity.

Increasing utilization of a rural cervical cancer detection program

The Alabama Department of Public Health established, in 1973, a Cancer Screening Program (CSP). Although 66,000 women have been screened, many rural females had never used the program. After a community health organization education effort was introduced into a target rural county, an examination of CSP new user data for two intervention quarters revealed 345 and 150 per cent increases, respectively, in the pattern of use.

A continuing medical education program in chronic obstructive pulmonary diseases: design and outcome

A continuing medical education course was developed to improve the care of patients with chronic bronchitis and emphysema (COPD); 44 primary care physicians completed the course. The physicians were randomly assigned to experimental and control groups, with 3 of the 4 experimental groups assisting in the selection of topics for the programs and/or receiving feedback on tests given during the course. The course's impact was assessed using written tests to measure knowledge and simulated patient visits to observe physician performance. Experimental groups retained significantly greater amounts of information 9 months after completing the program and used more program material during patient visits than did the control group (p < 0.05). The test scores and patient visits of the 3 experimental groups involved in determining the audiovisual topics and/or receiving feedback were not significantly different from one another nor from the fourth experimental group.

Improving patient-education assessment skills of hospital staff: a case study in diabetes

While the importance of collecting patient education data of high quality is well established, few studies have examined the quality of patient educational assessment procedures. Utilizing a standardized instrument and assessment protocol, an observational trial of nine insulin-controlled adult diabetics was conducted using pairs of trained patient assessors. Although the overall mean percent agreement for the first trial was very good (90%), lack of agreement was noted for several important subcategories. A training program was conducted to improve accuracy, addressing the assessment problems found in the first trial. A second rater trial found an overall level of rater agreement of 99%. This study confirmed that routine assessment of patients should be periodically monitored using the quality control methods described to ensure program data of high quality.