Understanding Intimate Partner Violence Perpetration Involving the Deaf Population.

There has been an increase in intimate partner violence (IPV) research regarding the deaf population; however, no studies to date obtained data directly from members of the deaf population who disclose IPV perpetration. This community-based participatory research study explored the social context of IPV perpetration involving the deaf population through interviews with deaf or hard-of-hearing individuals who self-identified as perpetrating either physical or sexual abuse in an intimate relationship where at least one partner was deaf. Through semi-structured interviews using video relay, an interdisciplinary research team, which included deaf investigators, explored questions which included IPV triggers, types of IPV, weapon use, childhood victimization, and interactions with first responders and response systems (e.g., criminal justice, medical). The types of IPV abuse, resulting injuries, and systems used are discussed. The team collectively identified key elements of abuse and their relationships to each other through concept mapping of each interview. Through a method of constant comparison, we identified several themes: intergenerational transmission of violence, fund of information concerns, communication barriers with family and friends and resulting frustration, and help-seeking challenges. Many of these themes are specific to the deaf population, illustrating the need for continued research to understand IPV in diverse communities. Findings are compared with IPV trends in the general (hearing) population, and prompt concerns that universal IPV interventions may not effectively address the needs of the deaf population. Recommendations for diversifying screening efforts, modifying screening tools, and tailoring interventions to better address IPV involving deaf and hard-of-hearing populations are discussed.

Social capital, gender, and health: an ethnographic analysis of women in a Mumbai slum.

OBJECTIVE: Quantitative studies have demonstrated that social capital can positively impact community health, but qualitative explorations of the factors mediating this relationship are lacking. Furthermore, while the world's poor are becoming increasingly concentrated in the cities of lower-middle income countries, most of the existing literature on social capital and health explores these variables in Western or rural contexts. Even fewer studies consider the impact of social constructs like race, gender, or class on the creation of social capital and its operationalization in health promotion.Our study aimed to address these gaps in the literature through an ethnographic exploration of social capital among women living in Kaula Bandar (KB) - a marginalized slum on the eastern waterfront of Mumbai, India. We then sought to identify how these women leveraged their social capital to promote health within their households. METHODS: This was a mixed-method, qualitative study involving participant observation and 20 in-depth, semi-structured, individual interviews over a nine-month period. Field notes and interview transcripts were manually analyzed for recurring content and themes. RESULTS: We found that women in KB relied heavily on bonding social capital for both daily survival and survival during a health crisis, but that the local contexts of gender and poverty actively impeded the ability of women in this community to build forms of social capital - namely bridging or linking social capital - that could be leveraged for health promotion beyond immediate survival. CONCLUSIONS: These findings illustrate the context-specific challenges that women living in urban poverty face in their efforts to build social capital and promote health within their households and communities. Community-based qualitative studies are needed to identify the macro- and micro-level forces, like gender and class oppression, in which these challenges are rooted. Directly addressing these structural inequalities significantly increases the potential for health promotion through social capital formation.

A Qualitative Analysis of Family Dynamics and Motivation in Sessions With 15 Women in Drug Treatment Court.

Women with substance use disorders (SUDs) often experience inadequate health care, mental and physical health problems, trauma, lack of social support, and undermining of support for psychological needs of autonomy, competence, and relatedness needed for motivation and well-being. For women with SUD trying to reclaim sobriety and a healthy life, family can present both barriers and support. The aim of this study is to gain a deeper understanding of the intersection of family relationships with motivation of women in Drug Treatment Court (DTC) to attain their health goals. Data consist of transcribed intervention sessions between trained peer interventionists and 15 DTC participants from The Women's Initiative Supporting Health DTC Intervention Study. This analysis uses a qualitative framework approach to analyze the data. The Self-determination Theory of human motivation and Family Systems Theory provide the conceptual framework to understand how participants' expressions of motivation-related basic needs of autonomy, competence, and relatedness and change-related behaviors interfaced with family support. Analysis revealed more mentions of family in motivation-supportive contexts than in motivation-thwarting contexts, but highlighted complex roles families can play in health of women in recovery from SUD. Providers may be able to incorporate this knowledge to address the needs of this challenging population.

Physical activity, restrictions in activity, and body mass index among urban children with persistent asthma.

BACKGROUND: Asthma and obesity are public health problems that disproportionately affect underserved children. Urban children with asthma may be limited in their participation in physical activity, further increasing their risk for overweight. OBJECTIVE: To determine the prevalence of overweight and obesity among high-risk children with persistent asthma, to assess physical activity and activity restrictions by level of asthma control, and to evaluate whether activity is associated with weight status. METHODS: We analyzed baseline data from 324 urban children with poorly controlled asthma (3-10 years old) enrolled in the School-Based Telemedicine Enhanced Asthma Management program in Rochester, New York. Caregivers reported their child's asthma symptoms, physical activity, and activity limitation, and height and weight were measured. RESULTS: Most children were black (59%), and 69% had Medicaid. Almost half (47%) of children had symptoms that indicated poorly controlled asthma, 15% were overweight, and 31% were obese. Few children (39%) participated in 1 or more hour of physical activity per day. In addition, most (85%) did not walk to and from school, 38% did not have any recess in school, and 35% reported no safe place to exercise. More children with very poorly controlled asthma symptoms, compared with children with more mild symptoms, reported limitation in gym class (58% vs 43%, P = .01) and even in mild activities (28% vs 14%, P = .004). Children with activity limitation were at significantly greater odds of being overweight or obese (odds ratio, 2.1; 95% confidence interval, 1.2-3.8). CONCLUSION: Many children with persistent asthma are overweight or obese, have limited opportunity for activity, and experience activity limitations. Efforts are needed to optimize asthma control and provide opportunity for increased physical activity in and outside school. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01650844.

Deaf Victims' Experiences With Intimate Partner Violence: The Need for Integration and Innovation.

While in recent years, intimate partner violence (IPV) has attracted considerable research attention, the experiences of IPV affecting the Deaf community have been understudied. As a linguistic and cultural minority, Deaf victims of IPV encounter significant barriers in accessing information and services designed to address the medical and legal consequences of victimization. The number of Deaf Americans who communicate via American Sign Language (ASL) may well exceed a half-million, yet little is known about Deaf IPV victims' experiences and the characteristics of persons who perpetrate IPV with ASL users. This study addressed both topics. The current study is based on interviews in ASL with 14 Deaf IPV victims (participants). We explored: the types of abuse participants experienced; characteristics of victims and perpetrators; participants' help-seeking behaviors; and the availability, use, and helpfulness of various resources. These findings were compared to what is known about IPV in the hearing community. Our findings include that lack of information regarding IPV and lack of access to specialized IPV services were pervasive problems affecting Deaf victims. For some victims, the close-knit nature of the Deaf community was a barrier for discussing IPV and accessing information and support. It was common for Deaf victims to receive services or information about IPV from providers who were not IPV specialists. Communication abuse was prevalent in our study. The nature of communication abuse is unique for Deaf victims compared to hearing victims.

A qualitative study of tobacco use in eight economically disadvantaged Dominican Republic communities.

Understanding social conditions prior to intervention design can enhance tobacco control interventions. This paper describes formative research conducted in 2010 about tobacco use in eight economically disadvantaged Dominican Republic communities, four of which participated in a previous intervention study (2003-2008). A combined US-Dominican team used a rapid assessment process to collect qualitative social and cultural data on tobacco use, knowledge and attitudes; plus observations about social and policy factors, such as exposure to secondhand smoke (SHS), tobacco regulations, pregnancy, health care provider (HCP) practices and sustainability of the 2003-2008 intervention. This assessment found that tobacco use varied by age. While all ages typically used cigarettes, older adults used relatively more unprocessed tobacco, which is seen as less harmful and less addictive. Middle-aged smokers typically used commercial cigarettes, which are viewed as dangerous, addictive, expensive and offensive. Young adults reported avoiding smoking, but using relatively more smokeless tobacco. Smoking during pregnancy has reportedly decreased. SHS was viewed as harmful, although smoke-free homes were uncommon. HCPs discussed tobacco issues mostly for patients with tobacco-related conditions. Sustainability of the 2003-2008 intervention appeared to be linked to active Community Technology Centers with strong leadership, and community social capital. This information could be used to design better targeted interventions in these communities.

Tobacco Cessation in Economically Disadvantaged Dominican Republic Communities: Who are the Ex-Users?

INTRODUCTION: Tobacco use and harm continue to increase in low- and middle income countries (LMICs) globally. Smoking cessation is the most effective means of reducing morbidity and mortality from tobacco use. Increasing the prevalence of ex-users is an indicator of population cessation. AIMS: This study provides the first examination of factors associated with ex-tobacco use status in the Dominican Republic (DR), a LMIC in the Latin America and Caribbean region. METHODS: Baseline surveillance was conducted for 1177 randomly selected households in 7 economically disadvantaged DR communities (total N=2680 adult household members). RESULTS: Ex-user prevalence was 10.6% (1.0%-18.5% across communities), 14.8% were current users (9.1-20.4), and quit ratios were 41.7% (9.7%-52.7%). Among ever-users, females (OR 2.02, 95% CI 1.41, 2.90), older adults (45-64: OR 1.75, 95% CI 1.12, 2.74; 65+: OR 2.09, 95% CI 1.29, 3.39), and those who could read/write (OR 1.64, 95% CI 1.08, 2.50), had health conditions (OR 1.63, 95% CI 1.11, 2.41), and lived with ex-users (OR 1.70, 95% CI 1.12, 2.58) were over 60% to two times as likely to be ex-users. Those from remote communities (OR 0.52, 95% CI 0.36, 0.74), using chewed tobacco (OR 0.14, 95% CI 0.04, 0.48) and living with tobacco users (OR 0.55, 95% CI 0.37, 0.81) were less likely to be ex-users. CONCLUSIONS: Ex-user prevalence and quit ratios were lower than for high income countries. Implementing broad tobacco control measures, combined with clinically targeting vulnerable groups, may increase tobacco cessation to most effectively reduce this public health crisis.

Lessons Learned from Twelve Years of Partnered Tobacco Cessation Research in the Dominican Republic.

Engaging partners for tobacco control within low and middle income countries (LMICs) at early stages of tobacco control presents both challenges and opportunities in the global effort to avert the one billion premature tobacco caused deaths projected for this century. The Dominican Republic (DR) is one such early stage country. The current paper reports on lessons learned from 12 years of partnered United States (US)-DR tobacco cessation research conducted through two NIH trials (Proyecto Doble T, PDT1 and 2). The projects began with a grassroots approach of working with interested communities to develop and test interventions for cessation and secondhand smoke reduction that could benefit the communities, while concurrently building local capacity and providing resources, data, and models of implementation that could be used to ripple upward to expand partnerships and tobacco intervention efforts nationally. Lessons learned are discussed in four key areas: partnering for research, logistical issues in setting up the research project, disseminating and national networking, and mentoring. Effectively addressing the global tobacco epidemic will require sustained focus on supporting LMIC infrastructures for tobacco control, drawing on lessons learned across partnered trials such as those reported here, to provide feasible and innovative approaches for addressing this modifiable public health crisis.

Should Health Numeracy Be Assessed Objectively or Subjectively?

INTRODUCTION: Because current evidence suggests that numeracy affects how people make decisions, it is an important factor to account for in studies assessing the effectiveness of medical decision support interventions. Subjective and objective numeracy assessment methods are available that vary in theoretical background, skills assessed, known relationship with decision making skills, and ease of implementation. The best way to use these tools to assess numeracy when conducting medical decision-making research is currently unknown. METHODS: We conducted Internet surveys comparing numeracy assessments obtained using the subjective numeracy scale (SNS) and 5 objective numeracy scales. Each study participant completed the SNS and 1 objective numeracy measure. Following each assessment, participants indicated willingness to repeat the assessment and rated its user acceptability. RESULTS: The overall response rate was 78%, resulting in a total sample size of 673. Spearman correlations between the SNS and the objective numeracy measures ranged from 0.19 to 0.44. Acceptability assessments for the short form of the Numeracy Understanding in Medicine Instrument and the SNS did not differ significantly. The other objective scales all had lower acceptability ratings than the SNS. CONCLUSIONS: These findings are consistent with prior research suggesting that objective and subjective numeracy scales measure related but distinct constructs. Due to current uncertainty regarding which construct is more likely to influence the effectiveness of decision support interventions, these findings warrant further investigation to determine the proper use of objective versus subjective numeracy assessments in medical decision-making research. Pending additional information, a reasonable approach is to measure both objective and subjective numeracy so that the full range of actual and perceived numeracy skills can be taken into account.

Decision Aids: The Effect of Labeling Options on Patient Choices and Decision Making.

BACKGROUND: Conscious and unconscious biases can influence how people interpret new information and make decisions. Current standards for creating decision aids, however, do not address this issue. METHOD: Using a 2×2 factorial design, we developed surveys that contained a decision scenario (involving a choice between aspirin or a statin drug to lower risk of heart attack) and a decision aid. Each aid presented identical information about reduction in heart attack risk and likelihood of a major side effect. They differed in whether the options were labeled and the amount of decisional guidance: information only (a balance sheet) versus information plus values clarification (a multicriteria decision analysis). We sent the surveys to members of 2 Internet survey panels. After using the decision aid, participants indicated their preferred medication. Those using a multicriteria decision aid also judged differences in the comparative outcome data provided for the 2 options and the relative importance of achieving benefits versus avoiding risks in making the decision. RESULTS: The study sample size was 536. Participants using decision aids with unlabeled options were more likely to choose a statin: 56% versus 25% (P < 0.001). The type of decision aid made no difference. This effect persisted after adjustment for differences in survey company, age, gender, education level, health literacy, and numeracy. Participants using unlabeled decision aids were also more likely to interpret the data presented as favoring a statin with regard to both treatment benefits and risk of side effects (P ≤ 0.01). There were no significant differences in decision priorities (P = 0.21). CONCLUSION: Identifying the options in patient decision aids can influence patient preferences and change how they interpret comparative outcome data.

Images of a Healthy Worksite: A Group-Randomized Trial for Worksite Weight Gain Prevention With Employee Participation in Intervention Design.

OBJECTIVES: We assessed the effects of a worksite multiple-component intervention addressing diet and physical activity on employees' mean body mass index (BMI) and the percentage of employees who were overweight or obese. METHODS: This group-randomized trial (n = 3799) was conducted at 10 worksites in the northeastern United States. Worksites were paired and allocated into intervention and control conditions. Within- and between-groups changes in mean BMIs and in the percentage of overweight or obese employees were examined in a volunteer sample. RESULTS: Within-group mean BMIs decreased by 0.54 kilograms per meter squared (P = .02) and 0.12 kilograms per meter squared (P = .73) at the intervention and control worksites, respectively, resulting in a difference in differences (DID) decrease of 0.42 kilograms per meter squared (P = .33). The within-group percentage of overweight or obese employees decreased by 3.7% (P = .07) at the intervention worksites and increased by 4.9% (P = .1) at the control worksites, resulting in a DID decline of 8.6% (P = .02). CONCLUSIONS: Our findings support a worksite population strategy that might eventually reduce the prevalence of overweight and obesity by minimizing environmental exposures to calorically dense foods and increasing exposures to opportunities for energy expenditure within worksite settings.

A qualitative assessment of program characteristics for preventing secondary conditions in individuals with fetal alcohol spectrum disorders.

BACKGROUND: Fetal alcohol spectrum disorders (FASD) are a major public health problem that affects 2 to 5 percent of the population. Individuals with FASD are at high risk for secondary conditions, such as mental health problems, school disruptions, and trouble with the law. Evidence-based intervention programs are needed to prevent and treat secondary conditions in this population. OBJECTIVES: The purpose of this study was to identify intervention program characteristics for preventing secondary conditions in individuals with FASD from the perspectives of parents and service providers. METHODS: This qualitative study utilized a phenomenological approach to identify program characteristics for preventing secondary conditions. Twenty-five parents of children (ages 3 to 33) with FASD and 18 service providers participated in focus groups or individual interviews. Data was systematically analyzed using a framework approach. Themes did not differ by participant type. RESULTS: Participants emphasized five primary characteristics of intervention programs for individuals with FASD. Programs need to 1) be available to individuals across the lifespan, 2) have a prevention focus, 3) be individualized, 4) be comprehensive, and 5) be coordinated across systems and developmental stages. Participants discussed a variety of specific intervention strategies for each developmental stage and setting. CONCLUSIONS: Program characteristics identified in this study are consistent with a positive behavior support framework. This framework is discussed in the context of research on existing interventions for individuals with FASD, and recommendations for future intervention development and evaluation are highlighted.

Meeting health and psychological needs of women in drug treatment court.

We explored healthcare-related experiences of women drug court participants through combining context from the socio-ecological model with motivation needs for health behavior as indicated by self-determination theory. Five focus groups with 8 women drug court participants, 8 court staff, and 9 community service providers were examined using qualitative framework analysis. Themes emerged across the socio-ecological model and were cross-mapped with self-determination theory-defined motivation needs for autonomy, relatedness, and competence. Socio-ecological levels contained experiences either supporting or eroding women's motivation needs: (1) intrapersonal challenges participants termed an "evil cycle" of relapse, recidivism, trauma, and life challenges; (2) interpersonal context of parenting and stigma involving features of this "evil cycle"; (3) institutions with logistical barriers to legal and medical assistance; (4) community resources inadequate to support living and employment needs. Self-determination theory helps explain motivation required to address the women's healthcare needs and multiple demands at all levels of the socio-ecological model.

Prevention of secondary conditions in fetal alcohol spectrum disorders: identification of systems-level barriers.

Fetal alcohol spectrum disorders (FASD) impact 2-5% of the US population and are associated with life-long cognitive and behavioral impairments. Individuals with FASD have high rates of secondary conditions, including mental health problems, school disruptions, and trouble with the law. This study focuses on systems-level barriers that contribute to secondary conditions and interfere with prevention and treatment. Using a phenomenological methodology, semi-structured interviews and focus groups were conducted with parents of children with FASD and service providers. Data were analyzed using a framework approach. Participants emphasized the pervasive lack of knowledge of FASD throughout multiple systems. This lack of knowledge contributes to multi-system barriers including delayed diagnosis, unavailability of services, and difficulty qualifying for, implementing, and maintaining services. FASD is a major public health problem. Broad system changes using a public health approach are needed to increase awareness and understanding of FASD, improve access to diagnostic and therapeutic services, and create responsive institutional policies to prevent secondary conditions. These changes are essential to improve outcomes for individuals with FASD and their families and facilitate dissemination of empirically supported interventions.

Worksite Environmental Interventions for Obesity Prevention and Control: Evidence from Group Randomized Trials.

Worksites provide multiple advantages to prevent and treat obesity and to test environmental interventions to tackle its multiple causal factors. We present a literature review of group-randomized and non-randomized trials that tested worksite environmental, multiple component interventions for obesity prevention and control paying particular attention to the conduct of formative research prior to intervention development. The evidence on environmental interventions on measures of obesity appears to be strong since most of the studies have a low (4/8) and unclear (2/8) risk of bias. Among the studies reviewed whose potential risk of bias was low, the magnitude of the effect was modest and sometimes in the unexpected direction. None of the four studies describing an explicit formative research stage with clear integration of findings into the intervention was able to demonstrate an effect on the main outcome of interest. We present alternative explanation for the findings and recommendations for future research.

The impact of congenital and childhood myotonic dystrophy on quality of life: a qualitative study of associated symptoms.

This study systematically evaluated the symptoms associated with congenital and childhood myotonic dystrophy, and how these symptoms affect health related quality of life. We conducted interviews with patients affected by congenital or childhood myotonic dystrophy and their affected parent to identify which symptoms have the greatest effect on their lives. Each interview was recorded, coded, and analyzed using a qualitative framework technique. In 34 interviews with 13 parents and 21 patients, we identified 189 symptoms, representing 22 themes in physical, emotional, social, and disease-specific quality of life. Communication difficulties, cognitive impairment, and social role limitations were the most frequently identified themes. These interviews identified multiple themes and symptoms, some previously under-recognized, which play a key role in the disease burden associated with congenital and childhood myotonic dystrophy.

Deaf mothers and breastfeeding: do unique features of deaf culture and language support breastfeeding success?

BACKGROUND: Deaf mothers who use American Sign Language (ASL) consider themselves a linguistic minority group, with specific cultural practices. Rarely has this group been engaged in infant-feeding research. OBJECTIVES: To understand how Deaf mothers who use ASL learn about infant feeding and to identify their breastfeeding challenges. METHODS: Using a community-based participatory research approach, we conducted 4 focus groups with Deaf mothers who had at least 1 child 0-5 years old. A script was developed using a social ecological model (SEM) to capture multiple levels of influence. All groups were conducted in ASL, filmed, and transcribed into English. Deaf and hearing researchers analyzed data by coding themes within each SEM level. RESULTS: Fifteen mothers participated. All had initiated breastfeeding with their most recent child. Breastfeeding duration for 8 of the mothers was 3 weeks to 12 months. Seven of the mothers were still breastfeeding, the longest for 19 months. Those mothers who breastfed longer described a supportive social environment and the ability to surmount challenges. Participants described characteristics of Deaf culture such as direct communication, sharing information, use of technology, language access through interpreters and ASL-using providers, and strong self-advocacy skills. Finally, mothers used the sign for "struggle" to describe their breastfeeding experience. The sign implies a sustained effort over time that leads to success. CONCLUSION: In a setting with a large population of Deaf women and ASL-using providers, we identified several aspects of Deaf culture and language that support breastfeeding mothers across institutional, community, and interpersonal levels of the SEM.

"What Fresh Hell Is This?" Victims of Intimate Partner Violence Describe Their Experiences of Abuse, Pain, and Depression.

Traditionally, professionals working with intimate partner violence (IPV) survivors view a victim through a disciplinary lens, examining health and safety in isolation. Using focus groups with survivors, this study explored the need to address IPV consequences with an integrated model and begin to understand the interconnectedness between violence, health, and safety. Focus group findings revealed that the inscription of pain on the body serves as a reminder of abuse, in turn triggering emotional and psychological pain and disrupting social relationships. In many cases, the physical abuse had stopped but the abuser was relentless by reminding and retraumatizing the victim repeatedly through shared parenting, prolonged court cases, etc. This increased participants' exhaustion and frustration, making the act of daily living overwhelming.