Perspectives about Environmental Tobacco Smoke Exposure from Mothers of Premature Infants.

OBJECTIVE: The study aimed to better understand the perceptions of mothers of preterm infants regarding smoking behaviors and environmental tobacco smoke (ETS) exposure using qualitative methodology. STUDY DESIGN: Using a Grounded Theory approach, we conducted in-depth, semi-structured interviews with mothers of preterm infants, both smokers and nonsmokers. Using the Theory of Planned Behavior (TPB) as a conceptual framework for our questions, we conducted and analyzed interviews until theoretical saturation was reached. Analysis included an iterative coding process resulting in theme development. RESULTS: Our key themes aligned with the TPB domains of attitudes, perceived control, and social norms. Regarding attitudes, mothers expressed that smoking was bad for their infants and that preterm infants were more vulnerable than term infants. Regarding perceived control, mothers commented on their perceived ability to avoid ETS exposure with subthemes including strategies utilized to mitigate ETS exposure risk. Some mothers expressed difficulty avoiding ETS exposure, for example, when residing in high-density housing. Regarding perceived social norms, mothers whose family and friends were nonsmokers expressed ease avoiding ETS, while mothers whose family and friends were smokers expressed more difficulty avoiding ETS. CONCLUSION: Mothers used a variety of behaviors within the domains of the TPB to reduce ETS exposures in their preterm infants which can inform future neonatal intensive care unit-based interventional strategies. KEY POINTS: · Mothers felt ETS is harmful for preterm infants.. · Mothers reported strategies for ETS avoidance.. · Mothers reported barriers to ETS avoidance.. · TPB can frame mothers' ETS-related behaviors..

Maternal Informal Learning Experiences that Shape Parenting Practices.

Objective: Current understanding of the linkage between maternal education and parenting practices has largely been informed using a narrow definition of educational attainment-the highest level of education an individual has completed. However, the proximal processes that shape parenting, including informal learning experiences, are also important to understand. Less is known about the informal learning experiences that shape parenting decisions and practices. To this end, we conducted a qualitative inquiry about the informal learning experiences of mothers of children ages 3 to 4 years with the specific goal of understanding how maternal informal learning experiences shape parenting decisions and practices. Design: We conducted interviews with 53 mothers from across the United States who had previously participated in a randomized controlled trial (RCT) of an intervention targeting infant care practices. We recruited a purposive sample of mothers chosen to maximize diversity across educational attainment and adherence to infant care practices targeted in the RCT. Using a grounded theory approach, data were analyzed using an iterative process for organizing codes and themes that mothers identified as informal learning experiences. Results: We identified seven themes representing distinct types of maternal informal learning experiences that impact parenting practices, including: (1) experiential learning during childhood; (2) experiential learning during adulthood; (3) interpersonal interactions including via social media; (4) experiences with non-interactive media sources; (5) informal trainings; (6) beliefs; and (7) current circumstances. Conclusions: Multiple informal learning experiences inform the parenting decisions and practices of mothers with varying levels of formal educational attainment.

Maternal Attitudes and Other Factors Associated with Infant Vaccination Status in the United States, 2011-2014.

OBJECTIVE: To assess the role of maternal attitudes and other factors associated with infant vaccination status. STUDY DESIGN: Data on reported vaccination status were analyzed from a nationally representative prospective survey of mothers of 2- to 6-month-old infants. Weighted univariate and multiple logistic regression analyses were conducted. Latent profile analysis of mothers reporting nonimmunized infants identified distinct groups, RESULTS: Of 3268 mothers, 2820 (weighted 86.2%), 311 (9.1%), and 137 (4.7%), respectively, reported their infant had received all, some, or no recommended vaccinations for age. Younger infants and infants with younger mothers were more likely to have received no vaccinations. Mothers with neutral and negative attitudes toward vaccination were >3 (aOR 3.66, 95% CI 1.80-7.46) and 43 times (aOR 43.23, 95% CI 20.28-92.16), respectively, more likely than mothers with positive attitudes to report their infants had received no vaccinations. Two subgroups of mothers reporting that their infants had received no vaccinations were identified: group A (52.5%) had less than positive attitudes and less than positive subjective norms about vaccination (ie, perceived social pressure from others); group B (47.5%) had positive attitudes and positive subjective norms. Group A mothers were more likely to be white (76.1% vs 48.3%, P?=?.002), more educated (43.5% vs 35.4% college or higher, P?=?.02), and to exclusively breastfeed (74.9% vs. 27.3%, P?

Differences in Infant Care Practices and Smoking among Hispanic Mothers Living in the United States.

OBJECTIVE: To assess the association between maternal birth country and adherence to the American Academy of Pediatrics safe sleep recommendations in a national sample of Hispanic mothers, given that data assessing the heterogeneity of infant care practices among Hispanics are lacking. STUDY DESIGN: We used a stratified, 2-stage, clustered design to obtain a nationally representative sample of mothers from 32 US intrapartum hospitals. A total of 907 completed follow-up surveys (administered 2-6 months postpartum) were received from mothers who self-identified as Hispanic/Latina, forming our sample, which we divided into 4 subpopulations by birth country (US, Mexico, Central/South America, and Caribbean). Prevalence estimates and aORs were determined for infant sleep position, location, breastfeeding, and maternal smoking. RESULTS: When compared with US-born mothers, we found that mothers born in the Caribbean (aOR 4.56) and Central/South America (aOR 2.68) were significantly more likely to room share without bed sharing. Caribbean-born mothers were significantly less likely to place infants to sleep supine (aOR 0.41). Mothers born in Mexico (aOR 1.67) and Central/South America (aOR 2.57) were significantly more likely to exclusively breastfeed; Caribbean-born mothers (aOR 0.13) were significantly less likely to do so. Foreign-born mothers were significantly less likely to smoke before and during pregnancy. CONCLUSIONS: Among US Hispanics, adherence to American Academy of Pediatrics safe sleep recommendations varies widely by maternal birth country. These data illustrate the importance of examining behavioral heterogeneity among ethnic groups and have potential relevance for developing targeted interventions for safe infant sleep.

The Effect of Nursing Quality Improvement and Mobile Health Interventions on Infant Sleep Practices: A Randomized Clinical Trial.

Importance: Inadequate adherence to recommendations known to reduce the risk of sudden unexpected infant death has contributed to a slowing in the decline of these deaths. Objective: To assess the effectiveness of 2 interventions separately and combined to promote infant safe sleep practices compared with control interventions. Design, Setting, and Participants: Four-group cluster randomized clinical trial of mothers of healthy term newborns who were recruited between March 2015 and May 2016 at 16 US hospitals with more than 100 births annually. Data collection ended in October 2016. Interventions: All participants were beneficiaries of a nursing quality improvement campaign in infant safe sleep practices (intervention) or breastfeeding (control), and then received a 60-day mobile health program, in which mothers received frequent emails or text messages containing short videos with educational content about infant safe sleep practices (intervention) or breastfeeding (control) and queries about infant care practices. Main Outcomes and Measures: The primary outcome was maternal self-reported adherence to 4 infant safe sleep practices of sleep position (supine), sleep location (room sharing without bed sharing), soft bedding use (none), and pacifier use (any); data were collected by maternal survey when the infant was aged 60 to 240 days. Results: Of the 1600 mothers who were randomized to 1 of 4 groups (400 per group), 1263 completed the survey (78.9%). The mean (SD) maternal age was 28.1 years (5.8 years) and 32.8% of respondents were non-Hispanic white, 32.3% Hispanic, 27.2% non-Hispanic black, and 7.7% other race/ethnicity. The mean (SD) infant age was 11.2 weeks (4.4 weeks) and 51.2% were female. In the adjusted analyses, mothers receiving the safe sleep mobile health intervention had higher prevalence of placing their infants supine compared with mothers receiving the control mobile health intervention (89.1% vs 80.2%, respectively; adjusted risk difference, 8.9% [95% CI, 5.3%-11.7%]), room sharing without bed sharing (82.8% vs 70.4%; adjusted risk difference, 12.4% [95% CI, 9.3%-15.1%]), no soft bedding use (79.4% vs 67.6%; adjusted risk difference, 11.8% [95% CI, 8.1%-15.2%]), and any pacifier use (68.5% vs 59.8%; adjusted risk difference, 8.7% [95% CI, 3.9%-13.1%]). The independent effect of the nursing quality improvement intervention was not significant for all outcomes. Interactions between the 2 interventions were only significant for the supine sleep position. Conclusions and Relevance: Among mothers of healthy term newborns, a mobile health intervention, but not a nursing quality improvement intervention, improved adherence to infant safe sleep practices compared with control interventions. Whether widespread implementation is feasible or if it reduces sudden and unexpected infant death rates remains to be studied. Trial Registration: clinicaltrials.gov Identifier: NCT01713868.

Trust in Sources of Advice about Infant Care Practices: The SAFE Study.

Objectives (1) Determine the prevalence of maternal trust in advice sources on infant care practices; (2) Investigate the association of maternal and infant characteristics with trust in advice sources on infant care practices. Methods Using probability sampling methods, we recruited mothers from 32 U.S. maternity hospitals with oversampling of Black and Hispanic women resulting in a nationally representative sample of mothers of infants aged 2-6 months. Survey questions assessed maternal trust in advice sources (physicians, nurses, family, friends, and media) regarding infant care practices including infant sleep practices (sleep position, bed sharing, and pacifier use), feeding, and vaccination. Weighted frequencies of maternal trust in advice sources were calculated to obtain prevalence estimates. Multivariable logistic regression was used to assess the association of maternal and infant characteristics with maternal trust in advice sources. Results Mothers had the greatest trust in doctors for advice on all infant care practices (56-89 %), while trust was lowest for friends (13-22 %) and the media (10-14 %). In the adjusted analyses, there were significant associations of maternal race/ethnicity, education, and age with trust in advice sources. Conclusions for Practice Maternal trust in advice about infant care practices varied significantly by source. A better understanding of which advice sources are most trusted by mothers, as well as the factors associated with maternal trust, may guide the development of more effective strategies to improve adherence to health promoting infant care practices.

A longitudinal study of health professional students' attitudes towards interprofessional education at an American university.

Efforts to improve interprofessional education (IPE) are informed by attitudes of health professional students, yet there are limited US data on student characteristics and experiences associated with positive attitudes towards IPE. A cohort of US medical, nursing, and physician associate students was surveyed in their first and third years, using the Readiness for Interprofessional Learning Scale and Interdisciplinary Education Perception Scale. Information was also collected on demographics and experiences during training. Health professional students differed in their attitudes towards IPE; characteristics associated with having more positive attitudes at both time points included being a nursing student, female, older, and having more previous healthcare experience. Students who participated in interprofessional extracurricular activities (particularly patient-based activities) during training reported more positive attitudes in the third year than those who did not participate in such activities. Based on these findings, schools may consider how student characteristics and participation in interprofessional extracurricular activities can affect attitudes regarding IPE. Building on the positive elements of this interprofessional extracurricular experience, schools may also want to consider service-learning models of IPE where students work together on shared goals.

Experiences of patients identifying with chronic Lyme disease in the healthcare system: a qualitative study.

BACKGROUND: Chronic Lyme disease is a term that describes a constellation of persistent symptoms in patients with or without evidence of previous Borrelia burgdorferi infection. Patients labeled as having chronic Lyme disease have a substantial clinical burden. Little is known about chronic Lyme disease patient experiences in the healthcare system and their relationships with healthcare providers. The purpose of this study was to gather insights about the experiences of patients who carry a diagnosis of chronic Lyme disease in the United States healthcare system. METHODS: Qualitative, phenomenological study in 12 adult participants who identified themselves as having chronic Lyme disease. Semi-structured face-to-face in-depth interviews were conducted, 60-90 minutes in length, focusing on perceptions of disease burden and of their healthcare providers, using the dimensions of the Health Belief Model. Transcribed interviews were analyzed for emergent topics and themes in the categories of beliefs/understanding, personal history/narrative, consequences/limitations, management, and influences on care. RESULTS: Enrollment continued until theoretical saturation was obtained. Four major themes emerged from participants' descriptions of their experiences and perceptions: 1) changes in health status and the social impact of chronic Lyme disease, 2) doubts about recovery and the future, 3) contrasting doctor-patient relationships, 4) and the use of unconventional therapies to treat chronic Lyme disease. CONCLUSIONS: Participants reported a significant decline in health status associated with chronic Lyme disease and were often unsatisfied with care in conventional settings. Negative experiences were associated with reports of dismissive, patronizing, and condescending attitudes. Positive experiences were associated with providers who were reported to be attentive, optimistic, and supportive. Consultations with CAM practitioners and use of CAM therapies were common. Actively engaged and sympathetic clinical encounters may foster greater satisfaction in healthcare settings.

Maternal Education and Child Self-Regulation: Do Maternal Self-Regulation and Responsiveness Mediate the Association?

OBJECTIVE: To examine the mediating role of observed maternal responsiveness and maternal self-regulation on the association between maternal education and children's self-regulation. METHODS: English-speaking mother-child dyads (n = 189) were recruited from a previous study and were eligible if the child was kindergarten eligible at the start of the 2020 to 2021 or 2021 to 2022 school year. Key measures included: Difficulties in Emotion Regulation Scale-Short Form for maternal emotional self-regulation, Culturally Affirming and Responsive Experiences for maternal responsiveness, and the Head-Toes-Knees-Shoulders for child self-regulation. The association between years of maternal education and child self-regulation was examined with linear regression, and the mediation analyses utilized 4 subsequent steps examining their relations. These steps were checked through a series of linear regressions, and beta weights were used to describe associations. Each potential mediator was examined separately. RESULTS: Children of mothers with higher education had significantly higher self-regulation, slope of 1.3 (95% confidence interval 0.3, 2.4, P = 0.015, beta = 0.18). Further, mothers with higher education had significantly higher observed responsiveness. The beta-weight of 0.34 (P < 0.001) supported maternal responsiveness as a mediator. Finally, in the test for direct and indirect effects, observed maternal responsiveness explained 29% (95% confidence interval 3.3%, 115%) of the association between maternal education and child self-regulation. CONCLUSIONS: This study highlights a key mechanism related to children's self-regulation skills and the significant role of observed maternal responsiveness in explaining the association between maternal education and child self-regulation.

The importance of community resources for breastfeeding.

BACKGROUND: Breastfeeding has long-lasting effects on children's cognition, behavioral, mental and physical health. Previous research shows parental characteristics (e.g., education, race/ethnicity, income level) are associated with breastfeeding initiation and duration. Further, research shows significant variation in access to community resources by race/ethnicity. It is unclear how community resources may impact breastfeeding practices and how this might intersect with maternal race/ethnicity. METHODS: This study combined nationally-representative data from the Study of Attitudes and Factors Effecting Infant Care (SAFE), which surveyed US mothers immediately after the infant's birth and at two to six months of infant age, with the Child Opportunity Index (COI) 2.0, a census tract measure of community resources associated with child development, to explore the association between community resources and breastfeeding initiation and whether this varies based on maternal race/ethnicity and country of birth. The SAFE Study used a stratified, two-stage, clustered design to obtain a nationally representative sample of mothers of infants, while oversampling Hispanic and non-Hispanic (NH) Black mothers. The SAFE study enrolled mothers who spoke English or Spanish across 32 US birth hospitals between January 2011 and March 2014. RESULTS: After accounting for individual characteristics, mothers residing in the highest-resourced communities (compared to the lowest) had significantly greater likelihood of breastfeeding. Representation in higher-resourced communities differed by race/ethnicity. Race/ethnicity did not significantly moderate the association between community resources and breastfeeding. In examining within race/ethnic groups, however, community resources were not associated with non-US born Black and Hispanic mothers' rates of breastfeeding, while they were with US born Black and Hispanic mothers. CONCLUSIONS: Findings suggest that even health behaviors like breastfeeding, which we often associate with individual choice, are connected to the community resources within which they are made. Study implications point to the importance of considering the impact of the contextual factors that shape health and as a potential contributor to understanding the observed race/ethnicity gap.

Reasons why women accept or reject the trivalent inactivated influenza vaccine (TIV) during pregnancy.

The aim of the study was to gain an in-depth understanding of the reasons why pregnant women accept or reject the seasonal influenza vaccine. The qualitative descriptive design used a face-to-face semi-structured interview format. Sixty pregnant and postpartum women at two hospitals in the Northeastern United States participated. Content analysis was the inductive method used to code the data and identify emergent themes. Six themes emerged from the data: differing degrees of influence affect action to vaccinate; two-for-one benefit is a pivotal piece of knowledge that influences future vaccination; fear if I do (vaccinate), fear if I don't; women who verbalize 'no need' for the vaccine also fear the vaccine; a conveniently located venue for vaccination reduces barriers to uptake; H1N1-a benefit and barrier to the seasonal vaccine. Our study supports previous findings and reveals a deeper understanding and interpretation of the behavior and decision-making to accept or reject the influenza vaccine. Understanding the reasons behind the behavior of vaccine rejection gives us the chance to change it.

Racial and Ethnic Disparities in Breastfeeding Continuation Among U.S. Hispanic Mothers: Identification of Mechanisms.

Objective: We examined the extent to which social, maternal, and infant factors and Theory of Planned Behavior (TPB) domains-attitudes, perceived control, and subjective norms-mediate the relationship between maternal race and ethnicity and birth country, and breastfeeding continuation. Materials and Methods: A nationally representative cohort of 2,810 mothers with self-reported race, ethnicity, and birth country was used. Main outcomes included any and exclusive breastfeeding at 2-6 months of infant age. A conceptual framework with the aforementioned mediators of interest was developed. Logistic regression was used to examine main associations, and structural equation modeling was used to identify the extent to which proposed mediators explained the relationship between independent and dependent variables. Results: One thousand two hundred twenty-one mothers were U.S.-born non-Hispanic white (NHW), 432 U.S.-born Hispanic, 329 Mexico-born Hispanic, 107 Central- or South America-born Hispanic, 33 Caribbean-born Hispanic, and 688 U.S.-born non-Hispanic black (NHB). No differences in breastfeeding continuation among U.S.-born NHW and U.S.-born Hispanic mothers were found. In contrast, compared with U.S.-born NHW mothers, Mexico-born (odds ratio [OR] 1.99, 95% confidence interval [CI] 1.46-2.72) and Central- or South America-born (OR 3.42, 95% CI 1.89-6.17) Hispanic mothers had higher odds, and Caribbean-born Hispanic mothers had lower odds (OR 0.45, 95% CI 0.26-0.76) of any breastfeeding. These relationships were mediated by attitudes and subjective norms. Conclusions: Breastfeeding continuation among U.S. Hispanic mothers varied by birth country, highlighting the heterogeneity of breastfeeding populations of Hispanic mothers in the United States. Tailored interventions should strengthen policies supportive of positive attitudes toward and subjective norms around breastfeeding.

Student and Teacher Perspectives on Equity in Clinical Feedback: A Qualitative Study Using a Critical Race Theory Lens.

PURPOSE: The authors aimed to gain a better understanding of students' and teachers' perspectives about whether clinical clerkship feedback is provided equitably irrespective of a student's race/ethnicity. METHOD: A secondary analysis of existing interview data was conducted, focusing on racial/ethnic disparities in clinical grading. Data had been acquired from 29 students and 30 teachers at 3 U.S. medical schools. The authors performed secondary coding on all 59 transcripts, writing memos focused on statements related to aspects of feedback equity and developing a template for coding students' and teachers' observations and descriptions specific to clinical feedback. Using the template, memos were coded, and thematic categories emerged describing perspectives on clinical feedback. RESULTS: Forty-eight (22 teachers and 26 students) participants' transcripts provided narratives about feedback. Both student and teacher narratives described how students who are racially/ethnically underrepresented in medicine may receive less helpful formative clinical feedback needed for professional development. Thematic analysis of narratives yielded 3 themes related to feedback inequities: 1) teachers' racial/ethnic biases influence the feedback they provide students, 2) teachers have limited skill sets to provide equitable feedback, and 3) racial/ethnic inequities in the clinical learning environment shape clinical and feedback experiences. CONCLUSIONS: Narratives indicated that both students and teachers perceived racial/ethnic inequities in clinical feedback. Teacher- and learning environment-related factors influenced these racial/ethnic inequities. These results can inform medical education's efforts to mitigate biases in the learning environment and provide equitable feedback to ensure every student has what they need to develop into the competent physician they aspire to be.

Breastfeeding Decision-Making Among Mothers with Opioid Use Disorder: A Qualitative Study.

Background: Factors that contribute to low initiation and continuation of breastfeeding among mothers with opioid use disorder (OUD) are poorly understood. Objective: To understand barriers and facilitators to breastfeeding initiation and continuation beyond the birth hospitalization for mothers with OUD. Materials and Methods: We conducted 23 in-depth, semistructured interviews with mothers with OUD who cared for their infants at home 1-7 months after birth. Our interview guide was informed by the Theory of Planned Behavior (TPB) framework, which has been used to understand decision-making regarding breastfeeding. An iterative approach was used to develop codes and themes. Results: Among 23 participants, 16 initiated breastfeeding, 10 continued after hospital discharge, and 4 continued beyond 8 weeks. We identified factors influencing breastfeeding decisions in the four TPB domains. Regarding attitudes, feeding intentions were based on beliefs of the healthiness of breastfeeding particularly pertaining to infant withdrawal or exposure to mothers' medications. Regarding social norms, breastfeeding was widely recommended, but mothers had varying levels of trust in medical professional advice. Regarding perceived control, infant withdrawal and maternal pain caused breastfeeding to be difficult, with decisions to continue modulated by level of outside support. Regarding self-efficacy, mothers weighed their own recovery and well-being against the constant demands of breastfeeding, impacting decisions to continue. Conclusion: Mothers with OUD face unique barriers to breastfeeding related to their infants' withdrawal as well as their own health, recovery, and social context. Overcoming these barriers may serve as future intervention targets for breastfeeding promotion among this high-risk population.

Drivers of decision-making regarding infant sleep practices among mothers with opioid use disorder.

OBJECTIVE: To understand the perspectives and perceived facilitators of and barriers to following safe infant sleeping practices among mothers with opioid use disorder (OUD). STUDY DESIGN: Using the Theory of Planned Behavior (TPB) framework, we conducted qualitative interviews with mothers with OUD regarding infant sleep practices. We created codes and generated themes, concluding data collection upon achieving thematic saturation. RESULTS: Twenty-three mothers with infants 1-7 months of age were interviewed from 08/2020 to 10/2021. Mothers chose sleeping practices they perceived made their infants safer, more comfortable, and minimized infant withdrawal symptoms. Mothers in residential treatment facilities were influenced by facility infant sleep rules. Hospital sleep modeling and varied advice by providers, friends and family influenced maternal decisions. CONCLUSIONS: Mothers reported factors unique to their experience with OUD that influenced their decisions about infant sleep that should be considered when developing tailored interventions to promote safe infant sleep in this population.

Understanding cigarette smoking among mothers with opioid use disorder.

BACKGROUND: Cigarette smoking is highly prevalent among mothers with opioid use disorder (OUD). Organizations such as the American College of Obstetrics and Gynecology recommend cessation of cigarettes during the pre- and postnatal periods. Factors that inform decisions to continue or stop smoking cigarettes among pregnant and postpartum mothers with OUD are unclear. AIMS: This study aimed to understand (1) the lived experience of mothers with OUD regarding cigarette smoking and (2) barriers and facilitators to reduction of cigarette smoking during the pre- and postnatal periods. METHODS: Guided by the Theory of Planned Behavior (TPB) framework, we completed semi-structured, in-depth interviews with mothers with OUD with infants 2-7 months of age. We used an iterative approach to analysis by conducting interviews and developing and revising codes and themes until we reached thematic saturation. RESULTS: Fifteen of 23 mothers reported smoking cigarettes prenatally and postnatally, 6 of 23 smoked cigarettes during the prenatal period only, and 2 mothers were non-smokers. We found that mothers: 1) believed that smoke exposure had negative health consequences and may exacerbate withdrawal symptoms for their infants; 2) implemented risk mitigation practices, which were dictated both by themselves and by outside rules, to reduce the harmful effects of smoke around infants; 3) were motivated to quit or cut-down on smoking because of the desire to optimize the health and well-being of their infants; 4) continued to smoke because they felt that the stress related to caregiving and their own recovery were a higher priority than quitting smoking; and 5) were influenced by exposure to smokers with whom they lived, as well as by the varied advice of medical providers, family, and friends. CONCLUSION: While mothers with OUD acknowledged the negative health impact of cigarette smoke exposure to their infants, many experienced stressors related to recovery and caregiving unique to those with OUD that impacted their cigarette smoking behaviors.

Understanding and Addressing Bias in Grading: Progress at Washington University School of Medicine.

In 2020, the authors published work examining disparities in clerkship grading and found students who identify as White were more likely to receive honors grades compared with students from races/ethnicities traditionally underrepresented in medicine. Through a quality improvement approach, the authors identified the following 6 areas where improvements could mitigate grading disparities and, therefore, put processes in place to: ensure equitable access to examination preparation resources, change student assessment, develop medical student curriculum interventions, improve the learning environment, change house staff and faculty recruitment and retention practices, and provide ongoing program evaluation and continuous quality improvement processes to monitor for success. While the authors cannot yet be sure that they have achieved their goal of promoting equity in grading, they believe this evidence-based, multipronged intervention is a clear step in the right direction and encourage other schools to consider a similar approach to tackling this critically important problem at their own institutions.

Relationship between sleep position and risk of extreme cardiorespiratory events.

OBJECTIVE: To determine whether infants at sleep in the prone side positions are at higher risk for an extreme cardiorespiratory event compared with infants at sleep in the supine position. STUDY DESIGN: We used a case-control study to compare sleep position, determined with an accelerometer, in 116 infants during an extreme cardiorespiratory event with that in 231 matched control subjects (2 per case) who did not experience any extreme events during monitoring. RESULTS: From calculation of adjusted ORs and 95% CIs, infants placed in the prone or side position were no more likely to experience an extreme cardiorespiratory event compared with infants at sleep in the supine position. We used conditional logistic regression to account for the matched design of the study and to adjust for potential confounders or effect-modifiers. CONCLUSION: These findings, coupled with our earlier observation that the peak incidence of severe cardiorespiratory events occurred before the peak incidence of sudden infant death syndrome, strongly suggest that the supine sleeping position decreases the risk of sudden infant death syndrome by mechanisms other than by decreasing extreme cardiorespiratory events detected by monitoring.

A qualitative study of postpartum mothers' intention to smoke.

BACKGROUND: Many women stop smoking during pregnancy. Factors associated with relapse are known, but no intervention prevents the return to smoking among pregnant women. The objective of this study was to determine why women return to smoking after prolonged abstinence during pregnancy by examining mothers' intention to smoke at the time of delivery and the perceptions that shape their intention. METHODS: We conducted in-depth, semi-structured interviews during their postpartum hospital stay with 24 women who stopped smoking while pregnant. We asked participants whether they intended to resume smoking after pregnancy and why. Transcripts were analyzed using grounded theory-based qualitative methods to identify themes. RESULTS: Participants ranged in age from 18 to 36 years, and 63 percent were white. Three themes emerged from the interviews with the mothers: 1) they did not intend to return to smoking but doubted whether they would be able to maintain abstinence; 2) they believed that it would be possible to protect their newborns from the harms of cigarette smoke; and 3) they felt that they had control over their smoking and did not need help to maintain abstinence after pregnancy. CONCLUSIONS: Although most participants did not intend to resume smoking, their intentions may be stymied by their perceptions about second-hand smoke and by their overestimation of their control over smoking. Further study should quantify these barriers and determine their evolution over the first year after pregnancy with the goal of informing more successful, targeted interventions.