A smartphone app to communicate child passenger safety: an application of theory to practice.

Child passenger safety remains an important public health problem because motor vehicle crashes are the leading cause of death for children, and the majority of children ride improperly restrained. Using a mobile app to communicate with parents about injury prevention offers promise but little information is available on how to create such a tool. The purpose of this article is to illustrate a theory-based approach to developing a tailored, smartphone app for communicating child passenger safety information to parents. The theoretical basis for the tailoring is the elaboration likelihood model, and we utilized the precaution adoption process model (PAPM) to reflect the stage-based nature of behavior change. We created assessment items (written at ≤6th grade reading level) to determine the child's proper type of car seat, the parent's PAPM stage and beliefs on selected constructs designed to facilitate stage movement according to the theory. A message library and template were created to provide a uniform structure for the tailored feedback. We demonstrate how messages derived in this way can be delivered through new m-health technology and conclude with recommendations for the utility of the methods used here for other m-health, patient education interventions.

Fire and scald burn risks in urban communities: who is at risk and what do they believe about home safety?

While largely preventable, fire and hot water-related injuries are common in the United States. Measures recommended to reduce these injuries are smoke alarms (SAs) and lowered hot water temperatures. This study aims to: (i) describe the prevalence of working SAs and safe water temperatures among low-income, urban communities and (ii) explore the relationship between these behaviors and individuals' knowledge and beliefs about them. In this cross-sectional study, the Health Belief Model was used as a guide for understanding the safety behaviors. A total of 603 households had their SAs and hot tap water temperatures tested and were surveyed about their knowledge and beliefs related to these safety behaviors. We found that 40% of households had working SAs on every level and 57% had safe hot water temperatures. Perceived severity and self-efficacy were significantly associated with SA coverage, whereas perceived susceptibility and beliefs about benefits were significantly associated with safe hot water temperatures. This study demonstrates the need to increase the number of homes with working SAs and safe hot water temperatures. Messages focused on a safe home environment could communicate the ease and harm reduction features of SAs and benefits and risk reduction features of safe hot water temperatures.

Urban Students' Perceptions of the School Environment's Influence on School Violence.

This article provides information about the aspects of the school environment students perceive influence the occurrence of school violence. Concept mapping, a mixed methods methodology, was used with two groups of urban, primarily African American high school students (n=27) to create conceptual frameworks of their understanding of the school social and physical environment's influence on school violence. Each group of students identified over 50 different ways they perceived their school environment contributed to school violence. These ideas were categorized into six main topics: Student Behaviors, Norms of Behavior, Relationships with School Staff, Learning Environment, School Safety, and Neighborhood Environment. Students' perceptions supported the current conceptualization of the role of the school environment in school violence. However, this study supplements the current literature by identifying school level aspects of the social and physical environment that contribute to students perceptions of the safety of their school. At this level, differences were seen between the two school environments, indicating a need for intervention tailoring.

If you build it, will they come? Using a mobile safety centre to disseminate safety information and products to low-income urban families.

OBJECTIVE: To examine the utilisation-related outcomes associated with visiting the Johns Hopkins CareS (Children are Safe) Mobile Safety Center (MSC), a 40-foot vehicle designed to deliver effective injury prevention interventions and education to low-income urban families. DESIGN AND SETTING: Utilisation-related data were collected when the MSC was accessible at a community health centre and at community events from August 2004 to July 2006 in Baltimore City. SUBJECTS: Adults bringing their child for well child care at a community health centre and MSC visitors at community events. INTERVENTIONS: Low-cost safety products and free personalized educational services are provided on the MSC, which replicates a home environment and contains interactive exhibits. MAIN OUTCOME MEASURES: Perceived benefits of visiting the MSC; products and services received. RESULTS: MSC visitors (n = 83) and non-visitors (n = 127) did not differ in sociodemographic and injury-related characteristics; 96% of visitors reported learning something new as a result of their visit and 98% would recommend the MSC. During the first 2 years of operation, the MSC made 273 appearances, serving 6086 people. Home child safety products accounted for 71% of the 559 products distributed; educational materials made up 87% of the 7982 services received. Car safety seats accounted for 23% of the products distributed; installations made up 4% of the services received. CONCLUSIONS: This approach to disseminating injury prevention interventions holds promise for enhancing the appeal of safety information and increasing the protection of children.

Maternal employment during the early postpartum period: effects on initiation and continuation of breast-feeding.

This study sought to determine whether and to what extent maternal employment in the early post-partum period is associated with the initiation and continuation of breast-feeding in a heterogeneous, urban population. A panel of women were interviewed twice during the first 3 months postpartum. In analyses adjusted for maternal demographic characteristics, there was no association between planning to be employed within the first 6 months postpartum and initiation of breast-feeding. However, actually being employed was significantly associated with cessation of breast-feeding as early as 2 or 3 months postpartum, even after adjustment for maternal demographic variables. Less than one half of mothers who were employed were still breast-feeding at the second postpartum interview, whereas two thirds of those who were not employed were still breast-feeding. Among employed mothers, working no more than 20 hours per week appeared to be protective for continued breast-feeding.

Injury prevention counseling in an urban pediatric clinic. Analysis of audiotaped visits.

OBJECTIVE: To determine the content of injury prevention counseling (an expected component of pediatric anticipatory guidance) and the communication methods used with data from an urban pediatric clinic that serves low-income families. DESIGN: Audiotapes of well-child visits with 52 pediatric residents were analyzed for 178 children aged 0 to 4 years. A specific coding methodology was developed to analyze counseling by injury topics, prevention strategies, and communication methods. RESULTS: Less than half (ie, 47%) of the visits included injury prevention counseling. During the 83 visits that included counseling, an average of 1.96 injury topics were discussed. The average time spent on injury topics was 1.08 minutes per visit and 33 seconds per injury topic. An average of 2.68 prevention strategies were mentioned, although a statement specifically recommending their use was made for only 35% of the prevention strategies. The most frequently discussed injury topics were ingestion, falls, and pedestrian safety, house fires and firearms were never discussed. The most frequently mentioned prevention strategies were storing dangerous substances and items out of reach, using cabinet locks, calling the poison-control center, having outlet covers, using stair gates, and using car seats. Information-giving by the resident was the most frequently used communication method. Physician elicitation of information from parents was associated with more parental participation in the discussion. CONCLUSIONS: Pediatric residents in this sample spent little time discussing injury prevention, and problems thought to be important to the specific population being served were never mentioned. Communication methods to enhance compliance other than eliciting and giving information (ie, soliciting feedback, obtaining a commitment, and giving reinforcements) were rarely or never used. Priorities need to be defined so that the most important injury prevention topics and strategies are discussed effectively in the limited time available. Further research about pediatric injury prevention counseling is needed to examine the feasibility and effect of resident training in communication methods that enhance compliance.

Randomized trial of enhanced anticipatory guidance for injury prevention.

OBJECTIVE: To develop and evaluate an injury prevention anticipatory guidance training program for pediatric residents. DESIGN: Thirty-one residents were randomly assigned to an intervention or control group. Both groups attended a 1-hour seminar about injury prevention and the American Academy of Pediatrics TIPP (The Injury Prevention Program) materials. The intervention group also received 5 hours of experiential instruction on injury prevention content and counseling skills (SAFE Counseling Framework). Families with infants from birth to age 6 months were enrolled in the study (N = 196); they were followed up until the child was aged 12 to 18 months. Data were collected by means of baseline and follow-up interviews, audiotapes of medical visits, parent exit surveys, and home observations. SETTING: A hospital-based continuity clinic that serves families living in low-income, inner-city neighborhoods. OUTCOMES: Physician counseling and parent satisfaction, knowledge, beliefs, and behaviors. RESULTS: Parents seen by physicians in the intervention group received significantly more injury prevention counseling for 5 of the 6 safety practices, and they were significantly more satisfied with the help their physicians provided on safety topics. They were no less satisfied with their physicians' counseling on other anticipatory guidance topics. Parents' knowledge, beliefs, and home safety behaviors did not differ between the 2 groups. CONCLUSIONS: The frequency and impact of pediatric counseling can be enhanced by experiential training that targets specific injury hazards. Because low-income families face many barriers to carrying out the recommended safety practices, supplemental strategies are needed to ensure safer homes.

The impact of pregnancy on women's prenatal and postpartum smoking behavior.

We report patterns of prenatal smoking cessation and postpartum relapse for a large urban population of pregnant women. We examined associations between sociodemographic factors and prepregnancy, pregnancy, and early postpartum smoking behavior. Forty-one percent of women smoking before pregnancy quit smoking during pregnancy. Sociodemographic factors important in predicting smoking cessation during pregnancy, as determined through logistic regression analyses, differed significantly for white and black women. Among white women, education, age, and parity were important predictors of cessation, whereas among black women, only intention to breastfeed was a significant predictor of smoking cessation during pregnancy. Early postpartum smoking relapse rates differed by ethnicity. Twenty-eight percent of white women and 46% of black women who had quit during pregnancy relapsed within 6-12 weeks postpartum. Using logistic regression, we found formula feeding to be the most important predictor of early postpartum smoking relapse for both white and black women.

Effects of high school driver education on motor vehicle crashes, violations, and licensure.

OBJECTIVE: We sought evidence in the research literature to determine if (1) high school-aged persons who enroll in a driver education course have fewer motor vehicle-related crashes or violations, or are more likely to obtain a drivers license, than those who do not enroll in driver education courses, and (2) the availability of high school driver education courses is associated with lower community rates of motor vehicle crashes among young drivers. METHODS: To be included, a study must: (1) assess the effects of driver education courses or legislation for high school-aged persons; (2) present non-self-reported data for at least one of the following outcome measures: driver licensure rates, motor vehicle-related violations, or crashes; (3) include some form of no intervention comparison group; (4) adequately control for potentially confounding variables; (5) randomly assign participants to control or treatment groups, if a controlled trial. RESULTS: Nine studies met our inclusion criteria. Based on these studies, there is no convincing evidence that high school driver education reduces motor vehicle crash involvement rates for young drivers, either at the individual or community level. In fact, by providing an opportunity for early licensure, there is evidence that these courses are associated with higher crash involvement rates for young drivers. CONCLUSIONS: Although few driver education curricula have been carefully evaluated, in the absence of evidence that driver education reduces crash involvement rates for young persons, schools and communities should consider other ways to reduce motor vehicle-related deaths in this population, such as graduated licensing.

Women intending to breastfeed: predictors of early infant feeding experiences.

We conducted interviews prenatally and postpartum with 187 women, all of whom intended to breastfeed their newborns. However, 18% of these women either never initiated breastfeeding or stopped within one week. Among women who initiated breastfeeding, we identified four variables as significant predictors of failure to breastfeed for more than seven days: lower confidence in ability to breastfeed, less certainty in the decision to breastfeed, delayed first breastfeeding experience, and lack of rooming in with the baby. Results of this study suggest that women at high risk for not implementing their prenatal breastfeeding intention can be identified for additional support; interventions should focus on prenatal confidence building, early and continuing contact with the newborn, anticipatory guidance prior to discharge, and early pediatric follow-up.

Women's opinions about domestic violence screening and mandatory reporting.

BACKGROUND: The purpose of this paper is to describe women's opinions and policy preferences concerning domestic violence screening and mandatory reporting. METHODS: This case-control study included 202 abused women and 240 randomly selected non-abused women recruited from a large metropolitan health maintenance organization who were interviewed by telephone. Of these women, 46.6% had a college degree, 53.4% were white, and 60% had a household income of $50,000 or more. RESULTS: Forty-eight percent of the sample agreed that health care providers should routinely screen all women, with abused women 1.5 times more likely than non-abused women to support this policy. For mandatory reporting, 48% preferred that it be the woman's decision to report abuse to the police. Women thought it would be easier for abused women to get help with routine screening (86%) and mandatory reporting (73%), although concerns were raised about increased risk of abuse with both screening (43%) and reporting (52%) policies. Two thirds of the sample thought women would be less likely to tell their health care providers about abuse under a mandatory reporting policy. Interventions offered in managed care settings that would be well received, according to the women in this study, include counseling services, shelters, and confidential hotlines. CONCLUSIONS: Women expressed fears and concerns about negative consequences of routine screening and, even more so, for mandatory reporting. Domestic violence policies and protocols need to address the safety, autonomy, and confidentiality issues that concern women.

Smoking cessation interventions for pregnant women: review and future directions.

A substantial proportion of disease and death in the US could be prevented if tobacco use was curtailed or eliminated. Low birth weight, pregnancy complications, and infant morbidity are but a few of the adverse outcomes experienced by pregnant and postpartum women and infants that result from cigarette smoking. Pregnancy may be an ideal time to intervene with smoking women. On learning of their pregnancy, many women reduce or quit smoking on their own. For those who do not quit, interventions during the childbearing year could provide additional incentive and support for complete cessation. Successful clinic-based interventions share similar characteristics and tailoring cessation messages to client populations may enhance the effectiveness of interventions. Assessing a smoker's degree of addiction and tailoring counseling for cessation according to the patient's readiness might enhance current clinical practices. Even with the most effective individual counseling, it is increasingly evident that additional strategies are needed to achieve population-wide reductions in smoking and its related health conditions. Examples of these efforts are increased taxation on cigarettes, community-based anti-tobacco programs, and increasing the number of smoke-free environments. Thus, in addition to clinic-based efforts, health professionals might take an active role in supporting the broad range of programmatic, legislative, and advocacy efforts.

The intersections of HIV and violence: directions for future research and interventions.

The purpose of this paper is to review the available literature on the intersections between HIV and violence and present an agenda for future research to guide policy and programs. This paper aims to answer four questions: (1) How does forced sex affect women's risk for HIV infection? (2) How do violence and threats of violence affect women's ability to negotiate condom use? (3) Is the risk of violence greater for women living with HIV infection than for noninfected women? (4) What are the implications of the existing evidence for the direction of future research and interventions? Together this collection of 29 studies from the US and from sub-Saharan Africa provides evidence for several different links between the epidemics of HIV and violence. However, there are a number of methodological limitations that can be overcome with future studies. First, additional prospective studies are needed to describe the ways which violence victimization may increase women's risk for HIV and how being HIV positive affects violence risk. Future studies need to describe men's perspective on both HIV risk and violence in order to develop effective interventions targeting men and women. The definitions and tools for measurement of concepts such as physical violence, forced sex, HIV risk, and serostatus disclosure need to be harmonized in the future. Finally, combining qualitative and quantitative research methods will help to describe the context and scope of the problem. The service implications of these studies are significant. HIV counseling and testing programs offer a unique opportunity to identify and assist women at risk for violence and to identify women who may be at high risk for HIV as a result of their history of assault. In addition, violence prevention programs, in settings where such programs exist, also offer opportunities to counsel women about their risks for sexually transmitted diseases and HIV.

Interpersonal conflict and physical violence during the childbearing year.

Reducing physical abuse directed at women by male partners is one of the nation's Year 2000 health objectives. An important target group for achieving this health objective is pregnant women. The present study examines the frequency, severity, perpetrators and psychosocial correlates of violence during the childbearing year. A panel of 275 women were interviewed 3 times during pregnancy and at 6 months postpartum. Moderate or severe violence was somewhat more common during the postpartum period than during the prenatal period--19% of women reported experiencing moderate or severe violence prenatally, compared to 25% in the postpartum period. For partner-perpetrated violence, being better educated was associated with increased risk of violence as was having had a sex partner who ever shot drugs; being older, having a confidant and having social support from friends were significant protective factors. For violence perpetrated by someone other than a male partner, having a confidant was a significant protective factor. Obstetric care providers who routinely come in contact with pregnant women, as well as emergency department staff, need to be systematically screening for violence against women. Efforts to enhance women's social support networks should be included in primary and secondary prevention programs.

Quality of life among women living with HIV: the importance violence, social support, and self care behaviors.

This paper describes the relationship between psychosocial factors and health related quality of life among 287 HIV-positive women using items from the Medical Outcomes Study HIV Health Survey to measure physical functioning, mental health and overall quality of life. Multivariate models tested the relative importance of sociodemographic characteristics, HIV-related factors and psychosocial variables in explaining these quality of life outcomes. A history of child sexual abuse and adult abuse, social support and health promoting self-care behaviors were the psychosocial factors studied. Women in the sample were on average 33 years old and had known they were HIV-positive for 41 months; 39% had been hospitalized at least once due to their HIV; 83% had children; 19% had a main sex partner who was also HIV-positive. More than one-half of the women (55%) had a history of injection drug use and 63% reported having been physically or sexually assaulted at least once as an adult. A history of childhood sexual abuse. reported by 41% of the sample, was significantly related to mental health after controlling for sociodemographic and HIV-related characteristics. Women with larger social support networks reported better mental health and overall quality of life. Women who practiced more self-care behaviors (healthy diet and vitamins, adequate sleep and exercise, and stress management) reported better physical and mental health and overall quality of life. The high prevalence of physical abuse and child sexual abuse reported by this sample underscores the importance of screening for domestic violence when providing services to HIV-positive women. That such potentially modifiable factors as social support and self care behaviors are strongly associated with health-related quality of life suggests a new opportunity to improve the lives of women living with HIV.

Women's protective sexual behaviors: a test of the health belief model.

Heterosexual transmission of the human immunodeficiency virus (HIV) has become a significant health issue for women. The present study describes the extent to which a sample of women from an urban area report making efforts to protect themselves from becoming infected with HIV through several protective sexual behaviors. Secondly, we assess the extent to which adoption of these protective behaviors can be explained by health beliefs and previous HIV testing. Forty-nine percent of the sample reported having used a condom in the past year because of fear of AIDS and 48% reported having carried condoms. Women in this sample perceived themselves to be moderately susceptible to AIDS and they were well aware of the severity of the disease. Women tended to think that protecting themselves from AIDS would not be overly burdensome and that the recommended sexual protective behaviors were highly effective for preventing AIDS. Messages about the severity of AIDS and the effectiveness of protective sexual behaviors seem to be reaching women. Beliefs about personal susceptibility were consistently associated with the adoption of multiple protective behaviors, suggesting that messages emphasizing the ubiquity of risk, especially in demographically high-risk populations, may be particularly appropriate and effective.

PIP: The health belief structures that distinguish women who use condoms to protect themselves from themselves from the human immunodeficiency virus (HIV) and those who fail to take protective measures were investigated in a survey of 573 heterosexual women enrolled during their first prenatal visit to the Johns Hopkins Hospital Obstetrical Clinic. 90% of study subjects were African Americans, only 11% were currently married, and 65% were under 25 years of age. The proportions of respondents who had adopted any of the following 6 protective measures in the past year due to a fear of getting acquired immunodeficiency syndrome (AIDS) was the following: had fewer sexual partners (62%), had sex less often (48%), talked with a sex partner about AIDS (72%), decided to refuse sex because of concern a partner might be HIV-positive (47%), used condoms (49%), and carried condoms (48%). On the basis of the Health Belief Model of Janz and Becker, respondents were then questioned on their perceptions of susceptibility to AIDS, severity of the disease, barriers to condom use, and benefits of protected sex. Their mean scores on the preceding subscales, out of a maximum of 5.0, were 3.19, 4.08, 2.18, and 3.75, respectively. After adjusting for demographic factors and number of high-risk life-style practices, multiple regression analysis was used to determine the importance of these health beliefs to protective sexual behaviors. Beliefs about susceptibility and barriers emerged as the most significant correlates and were associated with having sex less often, deciding not to have sex, and carrying condoms. Condom use in the past year was correlated with beliefs about susceptibility, severity, and barriers. Overall, the findings suggest that women are motivated by feelings of personal susceptibility to try protective behaviors, but then conclude they are burdensome and discontinue.

Verbal abuse and physical violence among a cohort of low-income pregnant women.

We report on the occurrence of verbal abuse and physical violence during pregnancy for 358 low-income women. Overall, 65% of the women in our study experienced either verbal abuse or physical violence during their pregnancies. Twenty percent of the women in our sample experienced moderate or severe violence. Perpetrators, although primarily male partners, included family members and friends. These rates varied by age, with younger women experiencing significantly higher rates of verbal abuse and physical violence. There was no association between verbal abuse or physical violence and birth weight or gestational age. Prenatal care may be one of the only opportunities that women, and especially disadvantaged women, may have to get proper assistance with domestic violence. We conclude that enhanced screening, counseling, and referral by obstetricians and other health care providers are some of the immediate activities that could be implemented in prenatal care settings to address the compelling problems of violence during pregnancy.

PIP: This study examines the frequency, perpetrators, and impact of verbal abuse and physical violence among low-income pregnant women. A cohort of 358 low-income pregnant women attending the Johns Hopkins Hospital Adult Obstetric Clinic between December 1989 and September 1990 were included in the study. Information gathered through interview and descriptive analysis revealed that 65% of the women experienced verbal abuse and physical violence during pregnancy; 20% had been through moderate to severe violence. Violence was primarily inflicted by male partners and also by other family members and friends. Moreover, the occurrence of verbal abuse and physical violence were significantly higher among younger aged women, but no association was noted between violence and birth weight and gestational age. Due to the fact that prenatal care may be the only opportunity for low-income women to obtain medical assistance and referral services, prenatal care should include enhanced screening, counseling, and good referral by obstetricians and other health providers in order to address this problem.

Reproductive preferences of pregnant women under shifting probabilities of vertical HIV transmission.

PIP: Between December 1989 and September 1990 in Baltimore, Maryland, researchers interviewed 363 pregnant women attending the Johns Hopkins Hospital obstetric clinic concerning their perspectives on HIV infection and childbearing. All women who agreed to be tested for HIV infection (91%) tested negative for HIV infection. The women lived in a community with a high prevalence of HIV infection. 90% were African-American. As the stated probability of vertical transmission increased so did the women's stated willingness to undergo an abortion. Specifically, if the stated transmission rate was 30%, 28% said they would have an abortion. If the rate was 50%, 47% would have an abortion. At a 70% transmission rate, 68% would have an abortion. At a 100% transmission rate, 74% would have an abortion. 23% of the women would never have an abortion, even if the vertical transmission rate were 100%. 36% of the women had had at least 1 abortion. They were more likely than the non-abortion group to have an abortion at all stated transmission rates. 74% of the women stated that prayer was important during personal problems. 28% of women had a planned pregnancy. These 2 aforementioned groups were less likely than their counterparts to have an abortion at the 30% transmission rate. 48% reported that HIV infection is the only reason for an abortion. An increase in the stated probability of vertical transmission did not strongly influence the women's willingness to avoid pregnancy. 78% would avoid pregnancy at the 30% transmission rate. At the 50% transmission rate, 97% would avoid pregnancy. 99% would avoid pregnancy at the 70% transmission rate. Only 3 women would not avoid pregnancy at the 100% transmission rate. These findings suggest that HIV-positive pregnant women need access to health care providers who are as comfortable respecting and supporting decisions to continue their pregnancies as they are referring them to abortion facilities.^ieng

Pediatricians and breastfeeding promotion: attitudes, beliefs, and practices.

Abstract This study investigated both the degree to which pediatricians promote breastfeeding in their practices, and the attitudes and beliefs about breastfeeding which are associated with their breastfeeding promotion activities. We interviewed a sample of 59 pediatricians from a large urban area who had a variety of practice types and differing patient populations. Almost one half of the pediatricians in this study reported they did not routinely recommend breastfeeding to the mothers of their patients. In addition, few specific interventions to assist in breastfeeding continuation were reported. However, the overwhelming majority of pediatricians sampled reported very favorable attitudes toward breastfeeding promotion by pediatricians. Infrequent prenatal pediatric visits and the lack of formal training in breastfeeding and its management are discussed as potential barriers to more active participation of pediatricians in current efforts to achieve increased rates of breastfeeding.

Long-term effectiveness of a peer-based intervention to promote condom and contraceptive use among HIV-positive and at-risk women.

OBJECTIVE: The authors used data from a larger study to evaluate the long-term effects of a peer advocate intervention on condom and contraceptive use among HIV-infected women and women at high risk for HIV infection. METHODS: HIV-infected women in one study and women at high risk for HIV infection in a second study were selected from the Women and Infants Demonstration Project and assigned to a standard or an enhanced HIV prevention treatment group. The enhanced intervention included support groups and one-on-one contacts with peer advocates tailored to clients' needs. The authors interviewed women at baseline and at 6-, 12- and 18-months, and measured changes in consistency of condom and contraceptive use and in self-efficacy and perceived advantages and disadvantages of condom and contraceptive use. RESULTS: Of HIV-infected women, the enhanced group had improved consistency in condom use, increased perceived advantages of condom use, and increased level of self-efficacy compared with the standard group. Of women at risk, the enhanced intervention group at six months maintained consistent condom use with a main partner and perceived more benefit of condom use compared with the standard group. These differences diminished at 12 months. CONCLUSIONS: The enhanced intervention was generally effective in the HIV+ study. In the at-risk study, however, intervention effects were minimal and short-lived. Factors related to the theory, intervention design, and sample characteristics help explain these differences.