Changes in physician practice for the prevention of cardiovascular disease.

To determine recent changes in physicians' practices for cardiovascular disease risk reduction, a randomly selected sample of practicing primary care physicians in the upper Midwest was interviewed by telephone in 1987 and again in 1989 (response rates, greater than 90%; N = 241). The reported mean cutoff levels for labeling a total serum cholesterol level as abnormal dropped from 5.84 to 5.43 mmol/L (226 to 210 mg/dL) and for initiating medication, from 7.34 to 6.54 mmol/L (284 to 253 mg/dL). The proportion of physicians using diuretics as preferred step 1 antihypertensive agents dropped from 60% to 32%. Preferences became evenly divided among diuretics, angiotensin-converting enzyme inhibitors, and beta-blockers. Advice about physical exercise changed little, but consensus among practicing physicians was high. Substantial improvements were found in smoking cessation activities. Practicing physicians are proving to be responsive to new scientific evidence and education in the prevention of cardiovascular disease.

Effect of screening and referral on follow-up and treatment of high blood cholesterol levels.

Public screening for elevated blood cholesterol has become a common practice, supported by national recommendations. However, little is known about the response to referral for medical follow-up of those found to have high cholesterol levels. During a one-year period, 424 adults from a population-based screening and education program were referred to medical care after twice having elevated blood cholesterol levels. When they were remeasured approximately six months later, they were contacted for a telephone interview and 98% agreed to participate. While 82% remembered the referral, only 57% had actually visited a physician. An additional 8% had had telephone contact with a physician. Of the 237 who visited a physician, 76% had a cholesterol determination done during the first visit and 76% were advised to alter their diet by changing their fat consumption or losing weight. Referral to a nutritionist was suggested for 16%. Of the 424 participants, 280 (66%) reported substantial dietary change, either self-initiated or as a result of seeing a physician. Nineteen subjects (5%) were on lipid-lowering medication at the time of the interview. These observations suggest that a substantial portion of those screened will obtain follow-up care after two elevated blood cholesterol measurements in a screening setting. However, many never receive attention for this condition. Continued public and physician education is necessary to treat hypercholesterolemic individuals appropriately.

Survey of smoking patterns, attitudes, and interest in quitting.

We conducted a survey of 875 smokers in a Minnesota Heart Health Program community who were nonparticipants in screening and intervention. We found particular levels of interest in quitting and in formal cessation topics and programs among these smokers. Also, we collected information on smoking history, social environment, and anticipated barriers to quitting. Most noteworthy was the finding that more than half of the respondents indicated a desire to be contacted by telephone to receive information on materials on, classes on and ways of quitting smoking. Topics of particular interest to smokers included physical addiction, stress reduction, and (for women) methods of avoiding weight gain after quitting. Only 7% of respondents reported that they definitely did not want to quit, and approximately one-third of those interested in quitting indicated that they would seek outside help in doing so. The findings support the viability of "reverse" helpline procedures in which smokers are contacted directly and offered assistance in quitting.

Reported treatment of hypercholesterolemia by family physicians in Sweden and Minnesota.

Swedish guidelines on treatment of hyperlipidemia recommend higher cut-off levels for initiating treatment than do American guidelines, but are virtually identical for instituting and performing therapy. The aim of this study was to compare family physicians' reported practices in Sweden and Minnesota. We selected random samples of family physicians in southern Sweden and Minnesota for telephone interviews. Participation rates were 236/264 (89%) and 183/209 (88%), respectively. Swedish and Minnesota physicians adhered to their guidelines on cut-off levels in a case describing a 48-year-old man but, contrary to guidelines, reported higher cut-off levels for a 65-year-old man and a 65-year-old woman. In all cases described, Swedish physicians reported significantly higher cut-off levels. Swedish physicians were less prone to institute medication in older patients and less familiar with drugs. Minnesota physicians were more inclined to advise nicotinic acid derivatives (P < .0001 for all patient categories). Swedish physicians more frequently preferred resins (P = .00029) or fibrates (P = .0028) for the 48-year-old man and resins for the 65-year-old man (P = .0026). Despite common medical knowledge, the two medical communities are directed by different guidelines. Although adherence to cut-off levels was equally high in both groups, the use of lipid-lowering drugs has not become a familiar part of the therapeutic armamentarium for Swedish family physicians.

Tobacco, alcohol, and caffeine use and cessation in early pregnancy.

OBJECTIVES: Little is known about what happens when individuals attempt to make multiple behavior changes simultaneously. Pregnant women in particular are often in the position of needing to change several behaviors at once, including giving up more than one pleasurable substance. We investigated the success of pregnant women in spontaneously quitting tobacco, alcohol, or caffeine, alone or in combination. METHODS: Pregnant women (n = 7489) were identified in the practices of large health maintenance organizations in Seattle and Minneapolis and were interviewed by telephone. Analyses examined the patterns of using and quitting more than one substance, and the extent to which using more than one substance predicts ability to quit other substances. RESULTS: Use of the three substances tended to cluster within individuals. Users of multiple substances were less likely to quit each substance than users of single substances. However, in the subgroup of multiple substance users who had quit one substance, having quit a second substance was more, rather than less, common. In multivariate analyses predicting quitting, demographic variables, and not having been pregnant previously were significant predictors of quitting each substance; being a nonsmoker predicted quitting alcohol, and being a nonsmoker and nondrinker predicted quitting caffeine. CONCLUSIONS: The reasons for difficulty in quitting more than one substance are unknown but may include the difficulty of formulating appropriate behavioral strategies or less concern about healthy behavior in pregnancy. Many women in the study successfully quit using two substances, however, and counseling should focus on achieving that outcome.

Evaluation of a community-based program to improve infant immunization rates in rural Minnesota.

OBJECTIVE: The purpose of this study was to evaluate the effects of enrollment in a community-based public health nursing program, Communities Caring for Children (CCC), on infant immunization rates in rural Minnesota. The program involved health education, a registry, and a reminder system. DESIGN: The evaluation was a collaborative effort of university, public health agency, and private managed-care personnel. Two data sources were used to assess the association of program enrollment and immunization compliance; public birth certificates and a telephone survey of 421 CCC enrollees and non-enrollees. RESULTS: Birth certificate and survey data showed that CCC enrollees were significantly younger, less educated, more likely to be white, and of lower parity than non-enrollees. The average age of subjects' infants was eight months. The survey data showed that, overall, CCC enrollees perceived less danger in infant immunizations than did non-enrollees and were more likely than non-enrollees to have access to infant immunization reminder cards. CCC enrollees reported significantly higher immunization compliance for their infants than did non-enrollees. CONCLUSIONS: The area served by this program is relatively low-income and rural. Infant immunization status was among the lowest in Minnesota prior to the implementation of CCC. The evaluation suggested that enrollment in CCC was one of the most powerful predictors of infant immunization compliance.

Characteristics of participants and nonparticipants in a community cardiovascular disease risk factor screening: the Minnesota Heart Health Program.

This research attempts to characterize participants and nonparticipants in a cardiovascular risk screening and education program in terms of their beliefs about personal susceptibility to heart disease, integration into the community, and general pattern of health-promoting behaviors. Telephone surveys were conducted with 76 participants and 76 nonparticipants in the risk factor screening. Participation was strongly related to several health-promoting behaviors (dental checkups and seat belt use) and several measures of integration into the community. Health beliefs (in personal threat, susceptibility to disease, and the efficacy of preventive action) were not related to participation. Future research in the area of program participation may need to move beyond the model of disease-specific health beliefs to the realms of social pressures to participate and general health values.

Community attitudes toward public policies to control alcohol, tobacco, and high-fat food consumption.

We report the results of a survey conducted in upper-midwestern communities to assess public attitudes toward policy level interventions to moderate the use of alcohol, tobacco, and high-fat food. Four hundred thirty-eight women and 383 men were asked to indicate how much they favored or did not favor 29 policy proposals. Results showed that regulatory controls in all three areas were favored by the general public. Support was strongest for alcohol and tobacco controls, less so for high-fat food. Interventions designed to protect children and youths were most strongly endorsed, followed by restrictions on advertising and direct control over conditions of sale. Women favored all interventions more than men. There was a strong positive association between age and support for measures to moderate alcohol use. Individuals reporting least personal use of alcohol, tobacco, and high-fat foods were most in favor of control policies. The results of this survey indicate specific measures that might be most readily enacted and what segments of the population are likely to be most and least receptive.

Direct mail as a prompt for follow-up care among persons at risk for hypertension.

We undertook a direct mail campaign to urge persons identified as being at risk for hypertension to seek medical advice. Those who received a single mailing displayed a 28% increase in the proportion who subsequently discussed their blood pressure with a physician and a 12% increase in the proportion who had their blood pressure rechecked, while those persons who received six mailings reported an equivalent increase in physician discussions but a smaller increase in rechecking their blood pressure. These results support the use of inexpensive social marketing strategies as follow-up methods for blood pressure screening programs.

Partner smoking status and pregnant smoker's perceptions of support for and likelihood of smoking cessation.

Perceptions of support for cessation of smoking during pregnancy, likelihood of quitting, and partner smoking status were explored in a sample of 688 pregnant smokers (372 baseline smokers and 316 baseline quitters). Women with nonsmoking partners were significantly more likely to be baseline quitters than women with partners who smoked. Baseline quitters reported significantly more positive support from their partners than did continuing smokers (p = .02). Neither partner smoking status nor partner support at baseline was associated with cessation or relapse later in pregnancy. Women reported greater support, both positive and negative, from nonsmoking partners than from partners who smoked (p = .001). Among partner smokers, those who were trying to quit were perceived to be particularly supportive. Cessation interventions for expectant fathers may increase pregnant women's success at quitting.

Stress, depressive symptoms, and smoking cessation among pregnant women.

Perceived stress and depressive symptoms were examined as correlates and predictors of smoking cessation during pregnancy in a sample of 819 pregnant smokers (454 baseline smokers and 365 baseline quitters). Women who quit early in pregnancy had lower levels of stress and depressive symptoms than baseline smokers. Adjusting for level of addiction and other demographic factors related to stress and depressive symptoms eliminated the significant association between depressive symptoms and smoking cessation. Lower levels of stress and depressive symptoms were not predictive of cessation in later pregnancy. Prenatal healthcare providers should continue to assess level of addiction and provide targeted intensive cessation interventions. Interventions that reduce stress and depression may also be of benefit to women who are continuing smokers in early pregnancy.

Impact of a community health promotion program on existing organizations: the Minnesota Heart Health Program.

A community organization strategy was used in the delivery of health education programs by the Minnesota Heart Health Program (MHHP). The effectiveness of the approach was evaluated to determine whether an enhanced health promotion delivery system had developed in MHHP communities by the end of the intervention period or whether the intervention had suppressed community efforts. 'Social connectedness' among providers, as measured by health promotion network size, also was expected to be higher in intervention communities. Six Midwestern communities were studied: the MHHP communities of Mankato, MN and Fargo, ND--Moorhead, MN with two matched comparison communities for each (Winona, MN, St Cloud, MN and Eau Claire, WI, Sioux Falls, SD). Nine areas of health promotion were assessed, including the five heart disease risk factor areas where education campaigns had been implemented (smoking cessation, weight loss, eating patterns, exercise, and heart disease education and screening) and four other areas where community programs are common (chemical dependency; home, personal and drivers' safety; stress management; and cancer education and screening). Indicators of the health promotion delivery system were developed (program options and program participation), and data were collected in separate surveys of 438 community organization providers and 320 larger worksites in the six communities. Results showed no suppression of health promotion delivery systems in MHHP communities. Instead, the survey of larger worksites showed that there was greater participation in heart disease health promotion and greater 'social connectedness' among worksites in both intervention communities. Also, there were more heart disease health promotion programs in the larger intervention community of Fargo-Moorhead. In the community organization survey, results favored the larger intervention community over its comparison communities in heart disease health promotion program options and in 'social connectedness' but not in program participation. However, survey results favored one of the comparison communities (Winona) over the smaller intervention community (Mankato) on all indicators in this survey. The greater impact of the MHHP intervention at worksites suggests that institutionalization may be more likely in stable organizations whose current needs and interests fit the goals of the intervention activity.

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.

Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.

PURPOSE: The purpose of this study was to gain insight into attitudes and perceptions about smoking during pregnancy, passive smoke exposure, barriers to quitting, and program preferences among women in a low-income, ethnically diverse setting. DESIGN: Nine focus group discussions were conducted with African-American, Native American, and white women. Discussions were moderated by local residents who shared the same ethnic background as group participants. SETTING: Discussions were held in neighborhood centers and clinics in an urban area. SUBJECTS: A total of 57 women participated. Moderators recruited participants from within their social networks and from neighborhood programs. The informal process of recruitment did not allow calculation of response rates. MEASURES: A series of open-ended questions with selected probes was used to guide the conversation. RESULTS: Participants were aware that smoking during pregnancy is harmful and were concerned to varying degrees about their smoking behavior. Most women who smoked took active steps to reduce the risks. Actions were frequently accompanied by beliefs that rationalized moderate levels of smoking. While concerned, women were uncertain about what constituted harmful, passive smoke exposure. Personal barriers to quitting included being around others who smoked, feelings of stress and boredom, addiction, and not believing smoking is dangerous enough. Participants tended to value pregnancy-related advice from female friends and relatives over advice from professionals. CONCLUSIONS: Results suggest that many women respond to warnings about smoking during pregnancy, but actions are not necessarily measured in quit rates. Misconceptions about the risks may help to rationalize continued smoking. Subjects lacked knowledge about how best to reduce the risks of passive smoke. Educational efforts may be effective when directed at networks of women who share information. The nature of qualitative data collection prevents extrapolation of these results to a larger population.

Support for restrictive tobacco policies among residents of selected Minnesota communities.

BACKGROUND: Tobacco related diseases remain the most important public health problem. Public policy approaches to tobacco control have been used historically, and remain a viable, though largely untested, tobacco control strategy. The purpose of this article is to report assessment of support for tobacco control policies among the general public. METHODS: A random sample of 821 residents from seven Minnesota communities was surveyed by telephone to assess their support for 12 measures designed to restrict smoking behavior and curb demand for tobacco. Some of these policies were similar to those already in place, while others had not yet been adopted. RESULTS: Over 50% of the respondents indicated that they strongly favored or somewhat favored each of the measures, suggesting that a constituency exists for further regulation of tobacco. Measures that restrict tobacco advertising, prohibit smoking in public places, increase the penalties for selling tobacco to minors, and reduce access of young people to tobacco are especially popular. Women, nonsmokers, and older people form the basis of support for these measures. CONCLUSIONS: These results suggest that Minnesota citizens are more supportive of restrictive tobacco control policies than policy makers might believe, and that more aggressive lobbying on behalf of such measures at the state and local level is warranted.

Results of a long-term community smoking cessation contest.

BACKGROUND: Successive quit smoking contests undertaken as part of the Minnesota Heart Health Program had generated diminishing impact. The 1988 contest attempted to rejuvenate community interest and participation through a substantially extended enrollment period. METHOD: Smokers were eligible for monthly prize drawings and a grand prize drawing by entering the contest at any point between June 1988 and January 1989 and remaining abstinent for at least one month. The contest was promoted through newspaper advertisements, contest flyers, schools, and a community-wide direct mail campaign. RESULTS: A total of 1,328 smokers returned initial interest cards and 918 (69.1%) of these smokers returned quit pledges. Self-reported abstinence for pledgers and nonpledgers was 16.7% and 9.2%, respectively. Survival analysis indicated significantly longer periods of abstinence for pledgers (p = .0001). DISCUSSION: The extended contest was successful in recruiting smokers (almost 7% of the entire Bloomington smoking population vs. 1% for a previous one-month contest), especially those with less than a high school education. The current contest required substantial expenditures. However, these costs could be dramatically reduced through innovative use of donated resources.

Infection control among professional tattooists in Minneapolis and St. Paul, MN.

OBJECTIVE: This study investigated infection control knowledge, beliefs, and practices of professional tattooists. METHODS: In a cross-sectional study of professional tattooists (N = 61), a self-administered questionnaire measured knowledge and beliefs related to blood-borne pathogen transmission and control and self-reported infection control procedures. The study also involved direct observation of the infection control practices of 25 tattoo artists. RESULTS: All respondents believed that bloodborne pathogens could be transmitted via tattooing, and most denied that trouble or expense were barriers to infection control. Knowledge about infection transmission and control was high and was positively associated with learning about infection control from a health official. Subjects were observed implementing an average of 44 of 62 recommended procedures. The percentage of recommended procedures used was negatively associated with years of tattooing experience. CONCLUSIONS: Tattooists have an understanding of the risks associated with exposure to blood, but this knowledge is not fully operationalized in the workplace. Interventions should focus on needle disposal, handwashing, cross-contamination, and cleaning prior to sterilization. Tattooists with > or = 10 years of experience are most in need of intervention. National guidelines for tattooing infection control and strategies for collaboration between public health officials and tattooists are needed.

Current status of health promotion activities in four midwest cities.

Community-wide surveys were conducted in Winona and St. Cloud, MN, Eau Claire, WI, and Sioux Falls, SD, in 1986 and 1987 to determine the current status of the supply and demand of health promotion activities in nine categories. Supply and demand indicators were conceptualized and defined as program options (different activities in a coded list) and participation (registrations). An annual inventory of all health promotion activities in each community was complied from interviews with providers of such activities. Interviews of probable community providers was followed by a nomination process to identify others. Providers at worksites were interviewed in a separate study with matching data endpoints. Results show that exercise programs have the highest levels of options and participation in all four cities. On the supply side of total programs offered, there was similarity in rates among three of the cities, with only Winona offering more health promotion opportunities. There was similarity also in the areas of health where most programs are offered, favoring exercise, followed by the heart disease risk factor areas of screening, smoking cessation, and nutrition education. On the demand side of participation, there was similarity in total participation rates among three of the four cities with Sioux Falls showing substantially higher demand. Exercise showed the highest participation in all cities, but there was little similarity among the cities in ranking participation in the other areas of health promotion. In the four cities combined, high levels of program options with low participation were characteristic of smoking cessation. In contrast, low levels of program options and high participation were shown in chemical dependency. Worksites are the main providers of health promotion programs for adults, with schools and colleges also major program providers. Educational organizations account for the largest percentage of total participation in health promotion.

Postpartum smoking relapse.

While it has been established that many women quit smoking during pregnancy, little is known about postpartum maintenance of smoking cessation and relapse. A sample of 567 women were surveyed at about 6 months postpartum in order to (a) describe the patterns of smoking relapse; (b) assess the perceived importance of smoking cessation in pregnancy and postpartum; and (c) identify potentially high risk situations for smoking relapse. Results indicate that about half (56%) of the women who quit smoking during pregnancy relapse to smoking by 30 days postpartum. Most of these relapses occur in the company of other smokers. Socializing and/or living with a smoker had a powerful negative impact on ability to maintain abstinence in postpartum. Smoking cessation programs for pregnant women should emphasize the importance of continued abstinence in postpartum.

A comparison of self-help approaches to smoking cessation.

The current study evaluated the effectiveness of widely used self-help materials for quitting smoking. Five hundred and seventy smokers volunteered during a baseline survey to participate in the evaluation. After random assignment, 200 were mailed National Cancer Institute (NCI) "Quit for Good" materials, 200 the Minnesota "Quit and Win" program, and the remaining 170 were assigned to a nonintervention control condition. Results at 7-month follow-up failed to indicate treatment effects either for abstinence or for reported quit attempts. A number of smokers quit prior to the mailing of self-help materials, suggesting that a telephone prompt in itself may have been an important stimulus to cessation. Overall abstinence at follow-up was 10%. Contrary to expectation, successful participants were less likely to use a number of specific preparation strategies for quitting. The results are instructive in providing a large-scale assessment of self-help materials in a population of smokers that was not specifically seeking treatment.