How health care setting affects prenatal providers' risk reduction practices: a qualitative comparison of settings.

BACKGROUND: We sought to understand how systemic factors might facilitate or impede providers' ability to screen for and intervene on prenatal behavioral risks. METHODS: We convened eight focus groups of 60 prenatal care providers to explore methods for assessing and counseling pregnant women about tobacco, alcohol, and illicit drug use. Because practice setting was often mentioned as either an inducement or barrier to risk prevention, we conducted a re-analysis of focus group transcripts to examine systemic factors. RESULTS: Practice setting strongly influenced providers' behavior, and settings differed by continuity of care, availability of resources, and organized support for risk prevention. The most striking contrasts were found between private practice and a large HMO. CONCLUSION: Each setting had features that facilitated prevention counseling. Understanding such systemic factors could lead to improved risk prevention practices during pregnancy across all health care settings.

Comparing prenatal providers' approaches to four different risks: alcohol, tobacco, drugs, and domestic violence.

OBJECTIVE: We explored prenatal care providers' methods for addressing four behavioral risks in their pregnant patients: alcohol use, smoking, drug use, and domestic violence. DESIGN: We used qualitative, purposively sampled, focus group data. SETTING: Groups met in professional focus group settings. PARTICIPANTS: We conducted six focus groups (five with OB/Gyn physicians, one with nurse practitioners and certified nurse midwives), with a total of N = 49. MEASUREMENTS: The moderator used a focus group guide with open-ended questions, with probes where appropriate. FINDINGS: Providers' discussions reflected differences in how they approach each risk, including: (1) ambivalence about abstinence messages for alcohol; (2) relative comfort and confidence about assessing smoking and counseling to reduce smoking; (3) disparities across practice settings for toxicology screening for drugs; and (4) discomfort and pessimism with domestic violence. Investigators also analyzed providers' statements for each risk within the framework of the "Five A's" construct (Assess, Advise, Agree, Assist, and Arrange) for evaluating risk behavior interventions. CONCLUSIONS: A comparison of each risk across the Five A's illuminates the gaps between recommended and actual prevention methods and suggests directions for development of interventions and educational efforts.

Changing dentists' knowledge, attitudes and behavior regarding domestic violence through an interactive multimedia tutorial.

BACKGROUND: Dentists have a unique opportunity to address the problem of domestic violence (DV). The authors tested the effectiveness of a tutorial designed to educate dentists in identifying and responding to DV. METHODS: The authors developed a brief interactive multimedia tutorial for dentists and recruited practicing dentists (N = 174) for a randomized, controlled trial. A 24-question instrument assessed participants' knowledge, attitudes and practice behaviors regarding DV at two time points. The control group took the tutorial before completing a posttest. The authors also administered a 20-question empathy scale. RESULTS: The experimental group demonstrated significantly greater improvement in scores on most items, including knowledge, attitudes and behaviors, relative to control subjects (P < .01). Empathy scores did not show significant correlation with change scores on the DV assessment instrument. CONCLUSIONS: The tutorial is effective in helping dentists learn how to identify and help patients who are experiencing abuse. CLINICAL IMPLICATIONS: Broad dissemination of the tutorial about DV would introduce dentists to simple strategies for responding to patients who experience DV.

Reframing "prevention with positives": incorporating counseling techniques that improve the health of HIV-positive patients.

Federal HIV prevention strategy seeks to increase efforts by health care providers to identify and reduce their HIV-positive patients' transmission-related behaviors. Implementation of these recommendations will be hindered if providers perceive these efforts have the potential to harm their relationships with patients. Because transmission-related behaviors (unsafe sex and sharing needles) and the related issues of drug and alcohol use also jeopardize the health of HIV-positive patients, providers can use patient-centered counseling when addressing those behaviors. We suggest efforts to increase provider-delivered transmission-prevention counseling be reframed so that "prevention with positives" includes the goal of protecting HIV-positive patients' health. We review the specific consequences of these risky behaviors on HIV-positive patients' health and review brief counseling strategies appropriate for HIV care providers.

Seizing the 9-month moment: addressing behavioral risks in prenatal patients.

OBJECTIVE: Our qualitative study explored prenatal care providers' methods for identifying and counseling pregnant women to reduce or stop smoking, alcohol use, illicit drug use, and the risk of domestic violence. METHODS: We conducted six focus groups (five with OB/Gyn physicians, one with nurse practitioners and certified nurse midwives), total N=49, using open-ended questions. Investigators analyzed transcripts to identify and describe themes. RESULTS: Three major themes emerged: (1) specific risk-prevention tactics or strategies exist that are useful during pregnancy; (2) some providers address patients' isolation or depression; and (3) providers can adopt a policy of "just chipping away" at risks. Specific tactics included normalizing risk prevention, using specific assessment techniques and counseling strategies, employing a patient-centered style of smoking reduction, and involving the family. CONCLUSIONS: Providers generally agreed that addressing behavioral risks in pregnant patients is challenging. Patient-centered techniques and awareness of patients' social contexts help patients disclose and discuss risks. PRACTICE IMPLICATIONS: Brief but routine assessment and risk reduction messages require little time of the provider, but can make a big difference to the patient, who may make changes later.

Preparing dental students to recognize and respond to domestic violence: the impact of a brief tutorial.

BACKGROUND: The purpose of this study was to evaluate the impact of a brief, interactive multimedia tutorial designed to prepare dentists to recognize and respond to domestic violence. METHODS: The authors randomly assigned dentists and dental students to one of three groups: a control group or one of two experimental groups in a modified Solomon four-group design. RESULTS: One hundred sixty-one dental students and 13 dentists completed the multimedia tutorial. At the posttest, subjects in both experimental groups demonstrated significantly better scores than did subjects in the control group on most items. The two experimental groups (pretest and posttest, posttest only) did not differ significantly from each other. CONCLUSION: An engaging, interactive tutorial presenting a simplified model for ways in which dental professionals can recognize and respond to domestic violence significantly improved dental students' knowledge of, and attitudes toward, the topic. CLINICAL IMPLICATIONS: Clinicians may improve the care they provide to patients by accessing this brief tutorial and following the lessons contained in it.

Video study of physician selection: preferences in the face of diversity.

OBJECTIVES: To determine whether a diverse group of people would predominantly choose a white male physician regardless of group member's sex and ethnicity when given a choice among 6 actor-portrayed video doctors (males and females of Latino, European, and African descent) and whether further exposure would alter initial selections. STUDY DESIGN: Participants selected a video doctor after viewing a brief introduction and again after viewing the delivery of a prevention message. POPULATION: Three hundred ninety-five participants recruited at a shopping mall in the San Francisco Bay Area (61% female, 39% male; 30% Asian American, 29% European American, 26% Latino, 8% African American, and 7% other). OUTCOMES MEASURED: Initial and final video doctor selections; ratings of video doctors on interpersonal qualities. RESULTS: Most participants (85% of females and 63% of males) initially chose a female video doctor (P<.001) and even more did so at final selection. Approximately half initially chose a same-race video doctor (66% of European Americans, 51% of Latinos, and 50% of African Americans), but fewer did so at final selection (56% of European Americans, 44% of Latinos, and 52% of African Americans). In addition, at final selection 57% of Asian Americans and other-ethnicity participants chose a non-European American video doctor. CONCLUSIONS: Many healthcare consumers will accept physicians of both sexes and of different races. After observing the video doctors demonstrate a professional and warm affect, participants became even more receptive to choosing a video doctor of a different race. Video doctor technology holds promise for increasing our understanding of patients' preferences.

Domestic violence compared to other health risks: a survey of physicians' beliefs and behaviors.

BACKGROUND: Physicians routinely confront patient risk behaviors once considered private, including tobacco use, alcohol abuse, and HIV/STD-risk behavior. We compared physicians' behaviors and beliefs on screening and intervention for domestic violence with each other risk. METHODS: Survey of nationwide, random sample of 610 primary care physicians from the American Medical Association Physician Masterfile. RESULTS: Fewer primary care physicians screened for domestic violence than for other risks (p <0.001); once domestic violence was identified, however, physicians intervened with equal or greater frequency than for other risks. Fewer believed that they knew how to screen or intervene for domestic violence compared with other risks, and significantly fewer believed that domestic violence interventions were successful compared with interventions for tobacco and HIV/STD risks (Bonferroni adjusted p<0.001). CONCLUSIONS: Lower domestic violence screening rates may reflect physicians' beliefs that they do not know how to screen or intervene, and that interventions are less successful for domestic violence than for other risks. We may improve screening rates by educating physicians that a simplified role, as for other risks, can be effective for domestic violence.