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.

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.