Promoting smoking abstinence in pregnant and postpartum patients: a comparison of 2 approaches.

OBJECTIVE: To compare the implementation, delivery, and implications for dissemination of 2 different maternal smoking-cessation/relapse-prevention interventions in managed care environments. STUDY DESIGN: Healthy Options for Pregnancy and Parenting (HOPP) was a randomized, controlled efficacy trial of an intervention that bypassed the clinical setting. Stop Tobacco for OuR Kids (STORK) was a quasi-experimental effectiveness study of a point-of-service intervention. Both incorporated prenatal and postnatal components. PATIENTS AND METHODS: Subjects in both studies were pregnant women who either smoked currently or had quit recently. The major intervention in HOPP was telephone counseling delivered by trained counselors, whereas the STORK intervention was delivered by providers and staff during prepartum, inpatient postpartum, and well-baby visits. RESULTS: In HOPP, 97% of telephone intervention participants reported receiving 1 or more counselor calls. The intervention delayed but did not prevent postpartum relapse to smoking. Problems with intervention delivery related primarily to identification of the target population and acceptance of repeated calls. STORK delivered 1 or more cessation contacts to 91% of prenatal smokers in year 1, but the rate of intervention delivery declined in years 2 and 3. Modest differences were obtained in sustained abstinence between 6 and 12 months postpartum, but not in point prevalence abstinence at 12 months. CONCLUSIONS: The projects were compared using 4 of the 5 dimensions of the RE-AIM model including reach, adoption, implementation, and maintenance. It was difficult to apply the fifth dimension, efficacy, because of the differences in study design and purpose of the interventions. The strengths and limitations of each project were identified, and it was concluded that a combined intervention that incorporates elements of both HOPP and STORK would be optimal if it could be implemented at reasonable cost.

Barriers to mammography and Pap smear screening among women who recently had neither, one or both types of screening.

There is legitimate concern about whether cancer screening programs and other types of prevention and early detection programs are designed to reach those most in need of services. Previous research on barriers to screening has generally addressed screening for specific cancers. The purpose of this study was to evaluate and compare the types and strengths of barriers to both mammography and Pap smear screening experienced by three groups of women. Five hundred and twenty-two women, aged 52-69, who were members of a large health maintenance organization (HMO), completed a survey about cancer screening and associated barriers. Women with no mammogram in the preceding 2 years and with no Pap smear in 3 years were classified into a "safety net" program. We classified women as falling into both (Pap smear and mammography), one (Pap smear or mammography), or neither safety nets. Results consistently revealed that women needing both tests had more numerous and more intense barriers than other women to both types of screening. Factor analyses and descriptive analyses both showed that the types of barriers experienced were very similar for mammography and Pap smear screening. The discussion addresses intervention implications and the additional research needed on women who need both mammogram and Pap smear screening and who have much higher cancer risk than other women.

Sexual orientation and health: comparisons in the women's health initiative sample.

CONTEXT: Little is known about older lesbian and bisexual women. Existing research rarely compares characteristics of these women with comparable heterosexual women. OBJECTIVE: To compare heterosexual and nonheterosexual women 50 to 79 years on specific demographic characteristics, psychosocial risk factors, screening practices, and other health-related behaviors associated with increased risk for developing particular diseases or disease outcomes. DESIGN: Analysis of data from 93,311 participants in the Women's Health Initiative (WHI) study of health in postmenopausal women, comparing characteristics of 5 groups: heterosexuals, bisexuals, lifetime lesbians, adult lesbians, and those who never had sex as an adult. SETTING: Subjects were recruited at 40 WHI study centers nationwide representing a range of geographic and ethnic diversity. PARTICIPANTS: Postmenopausal women aged 50 to 79 years who met WHI eligibility criteria, signed an informed consent to participate in the WHI clinical trial(s) or observational study, and responded to the baseline questions on sexual orientation. MAIN OUTCOME MEASURES: Demographic characteristics, psychosocial risk factors, recency of screening tests, and other health-related behaviors as assessed on the WHI baseline questionnaire. RESULTS: Although of higher socioeconomic status than the heterosexuals, the lesbian and bisexual women more often used alcohol and cigarettes, exhibited other risk factors for reproductive cancers and cardiovascular disease, and scored lower on measures of mental health and social support. Notable is the 35% of lesbians and 81% of bisexual women who have been pregnant. Women reporting that they never had sex as an adult had lower rates of Papanicolaou screening and hormone replacement therapy use than other groups. CONCLUSIONS: This sample of older lesbian and bisexual women from WHI shows many of the same health behaviors, demographic, and psychosocial risk factors reported in the literature for their younger counterparts, despite their higher socioeconomic status and access to health care. The lower rates of recommended screening services and higher prevalence of obesity, smoking, alcohol use, and lower intake of fruit and vegetables among these women compared with heterosexual women indicate unmet needs that require effective interactions between care providers and nonheterosexual women.

Utilization and safety of oral acyclovir over an 8-year period.

The primary purpose of this project was to develop and implement surveillance systems to monitor the short- and long-term safety of acyclovir in oral dosage forms in a general population, the Kaiser Permanente Northwest (KPNW) region membership. KPNW is a group model HMO providing comprehensive care to over 390,000 members located primarily in the Portland, Oregon-Vancouver, Washington metropolitan area. Data were collected from the automated outpatient prescription, hospital discharge, tumor registry, KPNW membership information, and from medical record reviews, over an 8-year period. The findings showed oral acyclovir use increased substantially, and females were twice as likely to receive oral acyclovir as males. Most use was short-term. When the hospitalizations of oral acyclovir users with select serious morbidities conditions were examined following the receipt of acyclovir, no temporal association was observed between exposure to oral acyclovir and the hospitalizations. Similarly, where oral acyclovir was being used within a time frame possibly associated with serious life-threatening conditions, other morbidities rather than acyclovir were the likely cause of the condition, and no mention was made in the medical record that acyclovir might have been involved in the condition. In summary, oral acyclovir was a safe drug within the use patterns of the HMO population over an 8-year period.

Epidemiology of lung cancer: a worldwide epidemic.

OBJECTIVES: To examine patterns and trends in lung cancer and the risk factors associated with development of this disease. DATA SOURCES: Epidemiologic studies, research studies, review articles, and government reports pertaining to epidemiology of lung cancer. CONCLUSION: Epidemiological evidence documents that most lung cancer cases could be prevented. With 3 million persons worldwide dying annually from lung cancer attributable to smoking, cigarette smoking remains the number one target for public health action to reduce cancer risk in the general population. IMPLICATIONS FOR NURSING PRACTICE: A useful resource for nurses is the descriptive epidemiology of lung cancer, a knowledge base that identifies who is at risk. Linking this risk information with knowledge of strategies for reducing these risks provides a basis for planning and implementing interventions to prevent lung cancer.

Design of a questionnaire: occupational and environmental risks for Parkinson's disease.

1. Research linking disease with occupational and environmental exposures is often predicated on obtaining accurate exposure information from affected persons. 2. Exposure history questionnaires are used to obtain comprehensive information about work history, residential history, behavioral patterns, and lifetime exposures. 3. The process of questionnaire development includes: establishing the conceptual background of the research; assuring integrity of the research questions; specifying the content domain of the questionnaire; wording, level, and formatting decisions; establishing evidence for questionnaire validity; assessment of questionnaire reliability; and final edit and polishing. 4. The careful and systematic development of an exposure history questionnaire can be a key determinant in the success of occupational health research.

The PREP system of nursing interventions: a pilot test with families caring for older members. Preparedness (PR), enrichment (E) and predictability (P).

The PREP system of nursing interventions, designed to increase preparedness (PR), enrichment (E), and predictability (P) in families providing care to older people, was pilot tested for acceptability and preliminary effectiveness. Eleven family units were assigned to the PREP group and 11 to a standard home health control group. The PREP group scored approximately one SD higher than the control group (p < .05) on the Care Effectiveness Scale, indicating greater preparedness, enrichment, and predictability. Further, on a rating of overall usefulness, the PREP group rated their assistance from PREP nurses (M = 9.75) as significantly higher (p < .01) than the control group rated assistance from the home health nurse or physical therapist (M = 6.57). Although not statistically significant, mean hospital costs for the PREP group ($2,775) were lower than for the control group ($6,929). Results provided support for a full intervention trial.

Urinary biological monitoring markers of anticancer drug exposure in oncology nurses.

People handling anticancer drugs or their wastes may absorb these potent genotoxic agents. The aim of this study was to determine the utility of some general urinary markers among 24 female oncology nurses handling these drugs in comparison with 25 "unexposed" nurses. The markers were the Salmonella typhimurium reverse and forward mutation assays, total thioethers, and D-glucaric acid. The reverse mutation assay was the most specific and sensitive marker for anti-cancer drug exposure. Use of the marker battery was no great advantage as a screening tool relative to use of the reverse mutation assay alone. Better recording of work practices in nurse work logs would have improved interpretation of results.

Implementing a cancer-control study in a National Cancer Institute clinical trials network.

In this article, a case study is presented to highlight issues involved in implementing a cancer-control project through one of the National Cancer Institute's collaborative clinical trials networks. Health and Occupational Exposure to Anti-Cancer Drugs was a two-phase epidemiologic investigation that focused on clarifying occupational health risks of anticancer drug handling. The National Cancer Institute approved the study as an official cancer-control protocol and awarded Community Clinical Oncology Program (CCOP) accrual credits to participating CCOP member institutions of the National Surgical Adjuvant Breast and Bowel Project (NSABP). Implementing the study through the NSABP network and the CCOP program had major advantages, including access to large numbers of study subjects, data on a wide range of drug exposure and health outcomes, and the NSABP's excellent resources for project operations. However, accruing study subjects and completing data collection in a timely manner were major challenges. The authors discuss organizational aspects of the study and review strategies they found to be effective in dealing with various implementation issues. Investigators planning cancer-control projects and clinicians helping to implement these projects may benefit from the authors' experience.

Acute symptoms associated with antineoplastic drug handling among nurses.

Antineoplastic drug handling in the absence of adequate protective measures has been associated with biological uptake of the drugs among pharmacists and nurses. This study investigated the association between occupational exposure to antineoplastics and the presence of acute symptoms in a nationwide sample of 2,048 nurses and nurses' aides. Reported skin contact with the drugs was associated with a small but statistically significant increase in reported symptoms. Although number of doses handled and extent of protection used were significantly associated with number of symptoms, their effect was not independent of skin contact.

Environmental antecedents of young-onset Parkinson's disease.

We conducted an exploratory study of young-onset Parkinson's disease (YOPD) to examine occupational and environmental factors associated with disease risk. This case-control study included 63 YOPD patients (diagnosis on or before age 50); controls (n = 68) were diagnosed with rheumatoid arthritis. Crude odds ratios (ORs) were computed to identify exposure variables for logistic regression analyses. After controlling for the variables of race, educational level, sex, age, age at diagnosis, and family history of Parkinson's disease (PD), PD was positively associated with insecticide exposure (OR = 5.75, p < 0.001), past residency in a fumigated house (OR = 5.25, p = 0.046), herbicide exposure (OR = 3.22, p = 0.033), rural residency at time of diagnosis (OR = 2.72, p = 0.027), and nuts and seed eating 10 years before diagnosis (OR = 1.49, p = 0.021). PD was inversely associated with cigarette smoking at 5 years (OR = 0.50, p = 0.027), 10 years (OR = 0.43, p = 0.012), and 15 years (OR = 0.37, p = 0.005) before diagnosis, farm residency (OR = 0.38, p = 0.018), and exposure to dimethyl sulfoxide (OR = 0.10, p < 0.001). These findings are consistent with hypotheses linking PD to exposure to pesticide agents.

Association of antineoplastic drug handling with acute adverse effects in pharmacy personnel.

The relationship between occupational exposure to antineoplastic drugs and the presence of acute symptoms of exposure was investigated by questionnaire. Data were derived from a questionnaire distributed to 8566 pharmacists, pharmacy technicians, nurses, and nurse aids at 57 member institutions of the National Surgical Adjuvant Breast and Bowel Project nationwide. Of the 4659 respondents (54%), 1057 were pharmacists or pharmacy technicians; after exclusions, the sample size was 738. Data were collected on four handling activities: mixing of antineoplastic drugs, administering these drugs, cleaning up spills, and handling patient excreta. Information on mixing was divided into dose, duration, use of protection, and reported skin contact. Respondents indicated which of 27 acute symptoms they had experienced during the past three months. Handling of antineoplastics was associated with a small but significant increase in the number of symptoms compared with controls; reported skin contact was the most important predictor of symptoms. The number of doses handled and the extent of protection were significantly associated with the number of symptoms, but their effect was not independent of that of skin contact. Body mass was significantly associated with the number of symptoms in women but not men. Pharmacists and technicians who handle antineoplastic drugs reported more symptoms associated with exposure than did those who do not handle such agents. All available protective measures should be used.

Acyclovir use and its surveillance in a general population.

This study examined the extent and patterns of use of acyclovir in a health maintenance organization (HMO) population. The development and implementation of a system to survey acyclovir users for possible acute adverse effects is also described. Acyclovir users were members of Kaiser Permanente (KP), Northwest Region, who received one or more prescriptions for acyclovir from an automated outpatient prescription system over a two-year period (1986 and 1987). KP members with genital herpes were identified from the automated Outpatient Utilization System, which abstracts medical record data from a random sample of about two percent of KP members. Acyclovir users with hospital admissions were identified from the automated KP hospital discharge abstract system. During the two years, there were 2940 users who received a total of 6182 prescriptions for acyclovir; 47 percent used oral acyclovir and 56 percent of prescriptions were for the oral dosage form. Females received two-thirds of the prescriptions, and people 15 through 45 years of age received 80 percent of the prescriptions. The estimated incidence density of oral acyclovir usage was 2.3/1000 KP members. Most oral acyclovir prescriptions were for the treatment of genital herpes. More than 60 percent of the prescriptions appeared to be for first treatment, more than 30 percent for repeat treatment, and about 6 percent for continuing treatment. Hospitalizations of oral acyclovir users appeared to be unrelated to the use of the drug.

Home pregnancy testing kits: prevalence of use, false-negative rates, and compliance with instructions.

This study investigated the prevalence of home pregnancy kit use, incidence of false-negative results, and compliance with testing procedures. Among 144 pregnant women, identified through three health care settings, prevalence of test-kit use was 28.5 per cent. The false-negative rate was 24.3 per cent. Total compliance with instructions was reported by only 32 per cent of users. Women testing less than nine days after menstrual period was due had false-negative rates of 33 per cent contrasted with 21 per cent for those testing after the nine days.

Ratings of physical and mental health in the older bereaved.

Subjective and objective ratings of mental and physical health were compared, using data from a larger study of older bereaved persons. Variation by age, race, and sex of subjects also was investigated. Sixty widowed individuals, aged 58-83, whose spouses died within the previous three months were identified through death certificates. Subjects were interviewed in their homes using a modification of the older Americans' Resources and Services, Multidimensional Functional Assessment Questionnaire (OARS), which provides objective and subjective ratings of mental and physical health. The Zung Self-Rating Depression Scale was used to quantify intensity of depression. Subjective ratings of physical health are primarily positive and significantly better than the objective ratings, particularly for women. In general, subjective and objective ratings of mental health do not differ. Interviewer ratings of physical health show significant variation by age of subjects rated. Findings are discussed in terms of reference group comparisons and of implications for design and interpretation of morbidity studies of widowed.