A randomized controlled trial of directive and nondirective smoking cessation coaching through an employee quitline.

BACKGROUND: Telephone quitlines can help employees quit smoking. Quitlines typically use directive coaching, but nondirective, flexible coaching is an alternative. Call-2-Quit used a worksite-sponsored quitline to compare directive and nondirective coaching modes, and evaluated employee race and income as potential moderators. METHODS: An unblinded randomized controlled trial compared directive and nondirective telephone coaching by trained laypersons. Participants were smoking employees and spouses recruited through workplace smoking cessation campaigns in a hospital system and affiliated medical school. Coaches were four non-medical women trained to use both coaching modes. Participants were randomized by family to coaching mode. Participants received up to 7 calls from coaches who used computer assisted telephone interview software to track topics and time. Outcomes were reported smoking abstinence for 7 days at last contact, 6 or 12 months after coaching began. Both worksites implemented new tobacco control policies during the study. RESULTS: Most participants responded to an insurance incentive introduced at the hospital. Call-2-Quit coached 518 participants: 22 % were African-American; 45 % had incomes below $30,000. Income, race, and intervention did not affect coaching completion rates. Cessation rates were comparable with directive and nondirective coaching (26 % versus 30 % quit, NS). A full factorial logistic regression model identified above median income (odds ratio = 1.8, p = 0.02), especially among African Americans (p = 0.04), and recent quit attempts (OR = 1.6, p = 0.03) as predictors of cessation. Nondirective coaching was associated with high cessation rates among subgroups of smokers reporting income above the median, recent quit attempts, or use of alternative therapies. Waiting up to 4 weeks to start coaching did not affect cessation. Of 41 highly addicted or depressed smokers who had never quit more than 30 days, none quit. CONCLUSION: Nondirective coaching improved cessation rates for selected smoking employees, but less expensive directive coaching helped most smokers equally well, regardless of enrollment incentives and delays in receiving coaching. Some subgroups had very low cessation rates with either mode of quitline support. TRIAL REGISTRATION: ClinicalTrials.gov NCT02730260 , Registered March 31, 2016.

A cluster-randomized trial shows telephone peer coaching for parents reduces children's asthma morbidity.

BACKGROUND: Childhood asthma morbidity remains significant, especially in low-income children. Most often, asthma management is provided by the child's primary care provider. OBJECTIVE: We sought to evaluate whether enhancing primary care management for persistent asthma with telephone-based peer coaching for parents reduced asthma impairment and risk in children 3 to 12 years old. METHODS: Over 12 months, peer trainers provided parents with asthma management training by telephone (median, 18 calls) and encouraged physician partnership. The intervention was evaluated in a cluster-randomized trial of 11 intervention and 11 usual care pediatric practices (462 and 486 families, respectively). Patient outcomes were assessed by means of telephone interviews at 12 and 24 months conducted by observers blinded to intervention assignment and compared by using mixed-effects models, controlling for baseline values and clustering within practices. In a planned subgroup analysis we examined the heterogeneity of the intervention effect by insurance type (Medicaid vs other). RESULTS: After 12 months, intervention participation resulted in 20.9 (95% CI, 9.1-32.7) more symptom-free days per child than in the control group, and there was no difference in emergency department (ED) visits. After 24 months, ED visits were reduced (difference in mean visits/child, -0.28; 95% CI, -0.5 to -0.02), indicating a delayed intervention effect. In the Medicaid subgroup, after 12 months, intervention participation resulted in 42% fewer ED visits (difference in mean visits/child, -0.50; 95% CI, -0.81 to -0.18) and 62% fewer hospitalizations (difference in mean hospitalizations/child, -0.16; 95% CI, -0.30 to -0.014). Reductions in health care use endured through 24 months. CONCLUSIONS: This pragmatic telephone-based peer-training intervention reduced asthma impairment. Asthma risk was reduced in children with Medicaid insurance.

Partner randomized controlled trial: study protocol and coaching intervention.

BACKGROUND: Many children with asthma live with frequent symptoms and activity limitations, and visits for urgent care are common. Many pediatricians do not regularly meet with families to monitor asthma control, identify concerns or problems with management, or provide self-management education. Effective interventions to improve asthma care such as small group training and care redesign have been difficult to disseminate into office practice. METHODS AND DESIGN: This paper describes the protocol for a randomized controlled trial (RCT) to evaluate a 12-month telephone-coaching program designed to support primary care management of children with persistent asthma and subsequently to improve asthma control and disease-related quality of life and reduce urgent care events for asthma care. Randomization occurred at the practice level with eligible families within a practice having access to the coaching program or to usual care. The coaching intervention was based on the transtheoretical model of behavior change. Targeted behaviors included 1) effective use of controller medications, 2) effective use of rescue medications and 3) monitoring to ensure optimal control. Trained lay coaches provided parents with education and support for asthma care, tailoring the information provided and frequency of contact to the parent's readiness to change their child's day-to-day asthma management. Coaching calls varied in frequency from weekly to monthly. For each participating family, follow-up measurements were obtained at 12- and 24-months after enrollment in the study during a telephone interview. The primary outcomes were the mean change in 1) the child's asthma control score, 2) the parent's quality of life score, and 3) the number of urgent care events assessed at 12 and 24 months. Secondary outcomes reflected adherence to guideline recommendations by the primary care pediatricians and included the proportion of children prescribed controller medications, having maintenance care visits at least twice a year, and an asthma action plan. Cost-effectiveness of the intervention was also measured. DISCUSSION: Twenty-two practices (66 physicians) were randomized (11 per treatment group), and 950 families with a child 3-12 years old with persistent asthma were enrolled. A description of the coaching intervention is presented.

Worksite Opportunities for Wellness (WOW): effects on cardiovascular disease risk factors after 1 year.

OBJECTIVE: To evaluate the effectiveness of a worksite health promotion program on improving cardiovascular disease risk factors. METHODS: In St Louis, Missouri from 2005 to 2006, 151 employees (134 F, 17 M, 81% overweight/obese) participated in a cohort-randomized trial comparing assessments + intervention (worksite A) with assessments only (worksite B) for 1 year. All participants received personal health reports containing their assessment results. The intervention was designed to promote physical activity and favorable dietary patterns using pedometers, healthy snack cart, WeightWatchers(R) meetings, group exercise classes, seminars, team competitions, and participation rewards. Outcomes included BMI, body composition, blood pressure, fitness, lipids, and Framingham 10-year coronary heart disease risk. RESULTS: 123 participants, aged 45+/-9 yr, with BMI 32.9+/-8.8 kg/m(2) completed 1 year. Improvements (P< or =0.05) were observed at both worksites for fitness, blood pressure, and total-, HDL-, and LDL-cholesterol. Additional improvements occurred at worksite A in BMI, fat mass, Framingham risk score, and prevalence of the metabolic syndrome; only the changes in BMI and fat mass were different between worksites. CONCLUSION: A multi-faceted worksite intervention promoted favorable changes in cardiovascular disease risk factors, but many of the improvements were achieved with worksite health assessments and personalized health reports in the absence of an intervention.

Reducing medication prescribing errors in a teaching hospital.

BACKGROUND: Medication errors occur frequently, result in significant morbidity and mortality, and are often preventable. A multifaceted intervention was conducted to reduce prescribing errors in handwritten medication orders written by house staff. METHODS: A before-and-after design was used to evaluate the intervention--which included grand rounds, an interactive presentation for house staff, and reminders (a checklist, chart inserts, and requests for clarification)--and targeted 20 safe prescribing behaviors. RESULTS: At baseline, prescribing errors were more common among surgical house staff than medical house staff (1.08 errors/order versus 0.76 errors/order, p < .001). Only 1% of orders contained an overt error, but 49% were incomplete, 27% contained dangerous dose and frequency abbreviations, and 17% were illegible. Postintervention, the mean number of prescribing errors per order decreased for surgical house staff from 1.08 (standard deviation [SD], 0.23) to 0.85 (SD, 0.11; p < .001), with a more marked effect for house staff who attended the didactic portion of the intervention. In addition, the mean number of the more significant errors per order decreased from 0.65 (SD, 0.19) to 0.45 (SD, 0.13; p < .001), and significant decreases occurred in the proportion of orders that were incomplete, were illegible, and contained an overt error. However, prescribing errors per order increased in orders written by medical house staff from 0.76 (SD, 0.14) to 0.98 (SD, 0.11; p < .001). DISCUSSION: The intervention was associated with a modest improvement in the quality of medication orders written by surgical house staff. To reduce prescribing errors, multilevel interventions are needed, including training in safe prescribing for all physicians. Such training may need to be started in medical school and augmented and reinforced throughout residency.

Changes in weight and health behaviors from freshman through senior year of college.

OBJECTIVE: To assess weight changes, exercise and diet behaviors among college students from the beginning of freshman year until the end of senior year. DESIGN: Longitudinal observational study. SETTING: Private university in St. Louis, Missouri. PARTICIPANTS: College students (138 females, 66 males). MAIN OUTCOME MEASURES: Weight and height were measured, body mass index (BMI) was calculated, and exercise and dietary behaviors were assessed by questionnaire. ANALYSIS: Changes in weight, BMI, exercise, and dietary patterns from the beginning of freshman year to the end of senior year. RESULTS: Females gained 1.7 +/- 4.5 kg (3.75 +/- 9.92 lb) [mean +/- SD] from freshman to senior year, and males gained 4.2 +/- 6.4 kg (9.26 +/- 14.11 lb) (both P < .001). Weight changes were highly variable between students, however, ranging from -13.2 kg to +20.9 kg (-29.10 to +46.08 lb). CONCLUSIONS AND IMPLICATIONS: Weight gain was common but variable among college students. Importantly, exercise and dietary patterns did not meet the recommended guidelines for many college students, which may have long-term health implications.

Use of the transtheoretical model to enhance resources and supports for diabetes self management: lessons from the Robert Wood Johnson Foundation Diabetes Initiative.

PURPOSE: The purpose of this article is to describe how Resources and Supports for Self Management (RSSM) and strategies of the transtheoretical model (TTM) intersect to produce a comprehensive approach resulting in cutting-edge diabetes programs. METHODS: Specific components of RSSM, especially individualized assessment, collaborative goal setting, and enhancing skills, are reviewed in terms of contributions to the TTM. RESULTS: Specific examples from the Diabetes Initiative of using TTM constructs from 5 projects are shown to illustrate the first 3 RSSM constructs: individualized assessment, collaborative goal setting, and skill building. CONCLUSION: Diabetes Initiative grantees have demonstrated that the TTM enhances RSSM and facilitates the adoption of good diabetes self-management behaviors.

Safe medication prescribing: training and experience of medical students and housestaff at a large teaching hospital.

PURPOSE: To assess medical students' and housestaff's knowledge, attitudes, and behaviors regarding safe prescribing. METHOD: In 2003, 214 housestaff (interns and residents) and 77 medical students in medicine and surgery at Barnes-Jewish Hospital, St. Louis, Missouri, were asked to complete an anonymous, self-administered questionnaire about safe prescribing. Questions asked about training in and attitudes about safe-prescribing and current prescribing behaviors. Fisher exact test was used to compare attitudes and behaviors among subgroups. RESULTS: Of the 175 (60%) respondents, 73 (59%) of 123 housestaff and eight (15%) of 52 students agreed that their safe-prescribing training was adequate (p < .001), and 145 (83%) total respondents agreed that prescribing errors were unacceptable. Respondents reported always doing the following: 156 (89%) checked prescribing information before prescribing new drugs, 131 (75%) checked for drug allergies, 103 (59%) double-checked dosage calculations, 98 (56%) checked for renal impairment, and 53 (30%) checked for potential drug-drug interactions. CONCLUSION: Routine use of safe medication prescribing behaviors among housestaff and medical students was poor. Contributing factors may have included inadequate training and a culture that does not support safe prescribing. Effective strategies to increase safe medication prescribing need to be identified and implemented.

Weight changes, exercise, and dietary patterns during freshman and sophomore years of college.

Weight gain and behavioral patterns during college may contribute to overweight and obesity in adulthood. The aims of this study were to assess weight, exercise, and dietary patterns of 764 college students (53% women, 47% men) during freshman and sophomore years. Students had their weight and height measured and completed questionnaires about their recent exercise and dietary patterns. At the beginning of freshman year, 29% of students reported not exercising, 70% ate fewer than 5 fruits and vegetables daily, and more than 50% ate fried or high-fat fast foods at least 3 times during the previous week. By the end of their sophomore year, 70% of the 290 students who were reassessed had gained weight (4.1+/-3.6 kg, p < .001), but there was no apparent association with exercise or dietary patterns. Future research is needed to assess the contributions of fat, muscle, and bone mass to observed weight gain and to determine the health implications of these findings.

Application of the transtheoretical model to health education for older adults.

The application of theory to practice can be challenging. This article describes the experiences of one organization in applying the Transtheoretical Model (TTM) to a health promotion program for older adults, Health Stages. The concepts of the model, especially stage of change, were successfully used for program planning, curriculum development, and program evaluation. A Programming Grid was developed to guide curriculum development and evaluate if programs were reaching out to people at all stages of readiness to make healthy changes. Other TTM constructs, including self-efficacy, decisional balance, and processes of change were incorporated into the Health Stages curriculum. Evaluation showed that the pilot sites increased their offering of action- and maintenance-oriented programs, filling in the gaps in current programming. Older adults were receptive and interested in the model. The TTM enhanced the program by providing a framework for design and a method for reaching a wider audience of older adults with important health information.

Telephone coaching for parents of children with asthma: impact and lessons learned.

OBJECTIVE: To determine whether an asthma coaching program can improve parent and child asthma-related quality of life (QOL) and reduce urgent care events. DESIGN: Randomized controlled trial of usual care vs usual care with coaching. Comparisons were made between groups using mixed models. SETTING: A Midwest city. PARTICIPANTS: A community-based sample of 362 families with a child aged 5 to 12 years with persistent asthma. INTERVENTION: A 12-month structured telephone coaching program in which trained coaches provided education and support to parents for 4 key asthma management behaviors. MAIN OUTCOME MEASURES: Parental and child QOL measured with a validated, interview-administered, 7-point instrument and urgent care events in a year (unscheduled office visits, after-hours calls, emergency department visits, or hospitalizations) determined by record audit. RESULTS: Parental asthma-related QOL scores improved by an average of 0.67 units (95% confidence interval [CI], 0.49 to 0.84) in the intervention group and 0.28 units (95% CI, 0.10 to 0.46) in the control group. The difference between study groups was statistically significant (difference, 0.38; 95% CI, 0.14 to 0.63). No between-group difference was found in the change in the child's QOL (difference, -0.17; 95% CI, -0.47 to 0.12) or in the mean number of urgent care events per year (difference, 1.15; 95% CI, 0.82 to 1.61). The proportion of children with very poorly controlled asthma in the intervention group decreased compared with the control group (difference, 0.34; 95% CI, 0.21 to 0.48). CONCLUSIONS: A telephone coaching program can improve parental QOL and can be implemented without additional physician training or practice redesign.

A randomized controlled evaluation of the effect of community health workers on hospitalization for asthma: the asthma coach.

OBJECTIVE: To test whether community health workers are able to reach low-income parents of African American children hospitalized for asthma and to reduce rehospitalization among them. DESIGN: A randomized controlled evaluation of usual care vs 2-year asthma coach intervention. SETTING: An urban children's hospital and the surrounding community. PARTICIPANTS: A population-based sample of 306 children hospitalized for asthma met the inclusion criteria of being 2 to 8 years of age, of African American ethnicity, and having Medicaid coverage. Of these, 200 were contacted and 191 recruited with commitment to evaluation activities but, in order to assess reach, no commitment to participating in intervention. INTERVENTIONS: Coaches reinforced basic asthma education and encouraged key management behaviors through home visits and phone calls tailored to parent's readiness to adopt management practices and emphasizing a nondirective supportive style (cooperative and accepting of feelings and choices). OUTCOME MEASURES: The reach of intervention to parents, contacts with coaches, and rehospitalization over 2 years based on hospital records. RESULTS: Within 3 months of randomization to the asthma coach group, 89.6% of parents had at least 1 substantive contact with the coach, with an average of 21.1 contacts per parent over the 24-month intervention. The proportion of children rehospitalized was 35 of 96 (36.5%) in the asthma coach group and 55 of 93 (59.1%) in the usual care group (P < .01), controlling for parental education and child age, sex, and hospitalization in the year prior to the index hospitalization. In surveys, parents indicated the importance of the nondirective approach to support. CONCLUSIONS: An asthma coach can reach low-income parents of African American children hospitalized for asthma and reduce rehospitalization among the children.

Home use of albuterol for asthma exacerbations.

BACKGROUND: To reduce symptoms and emergency department (ED) visits, the National Asthma Education and Prevention Program (NAEPP) guidelines recommend early treatment of acute asthma symptoms with albuterol and oral corticosteroids. Yet, ED visits for asthma are frequent and often occur several days after onset of increased symptoms, particularly for children from low-income, urban neighborhoods. OBJECTIVES: To describe home use of albuterol and identify factors associated with appropriate albuterol use. METHODS: A total of 114 caregivers in the intervention group of a randomized trial to reduce emergent care for low-income, urban children completed a structured telephone interview with an asthma nurse to evaluate home management of their child's acute asthma symptoms. Interviews lasted approximately 20 minutes and were conducted from November 5, 2003, through September 30, 2005. Albuterol use as reported by caregivers was categorized as appropriate or inappropriate based on NAEPP recommendations. RESULTS: Albuterol use for worsening asthma symptoms was categorized as appropriate for only 68% of caregivers and was more likely if the children had an ED visit or hospitalization for asthma in the prior year. The remaining 32% of caregivers used albuterol inappropriately (overtreatment or undertreatment). Appropriate albuterol use was not associated with caregiver report of having an asthma action plan (AAP) or a recent primary care physician visit to discuss asthma maintenance care. CONCLUSIONS: Caregivers reported that they would use albuterol to treat their child's worsening asthma symptoms, but many described inappropriate use. Detailed evaluation of proper albuterol use at home may provide insight into how health care professionals can better educate and support parents in their management of acute exacerbations and more effective use of AAPs.

Development of Stage of Readiness and decisional balance instruments: tools to enhance clinical decision-making for adherence to antiretroviral therapy.

This study presents the development of Stage of Readiness (SOR) and decisional balance instruments based on the Transtheoretical Model of Behavior Change (TTM) to improve adherence to antiretroviral therapy (ART). These instruments were tested on HIV positive women who enrolled in an adherence support study at a women's HIV clinic at a mid-western medical school. The decisional balance instrument was analyzed and 8 of 11 items were retained. These items were validated by follow-up administration of the instrument. Baseline stage of change and decisional balance scores prospectively predicted 1-year viral load level, thus identifying participants in need of adherence support interventions. Use of these instruments can give a provider added objective data on which to base a decision to either prescribe ART immediately or to first implement an intervention tailored to enhance this patient's readiness to adhere.

Safe prescribing: an educational intervention for medical students.

BACKGROUND AND PURPOSE: Errors in handwritten medication orders are common and can result in patient harm. We evaluated an intervention for increasing safe prescribing by medical students. METHODS: We conducted a pre-post evaluation to evaluate a brief educational intervention to increase safe prescribing by medical students. Two 1-hr, small-group, interactive educational sessions for 3rd-year medical students were held 2 weeks apart at Washington University in St. Louis. Prescribing errors were measured with a verbal transcription test. RESULTS: Twenty-eight students participated. Following the intervention, the average number of error-free orders in the 10-order test increased 5-fold from 0.82 per student to 4.54 per student, and the average number of errors and dangerous errors per student decreased from 13.96 to 7.36 (p < .0001) and from 4.75 to 2.68 (p < .0001), respectively. CONCLUSIONS: After a brief interactive educational intervention for medical students, the frequency of error-free handwritten orders increased, and prescribing errors decreased. Additional training may be required to further improve and maintain safe prescribing.

Asthma coaching in the pediatric emergency department.

OBJECTIVES: Coaching and monetary incentives have been used to modify medical behavior of individuals with several chronic diseases, including asthma. The authors performed a randomized, controlled trial of an intervention combining asthma coaching during an emergency department (ED) visit for asthma, and monetary incentive to improve follow-up with primary care providers (PCP). METHODS: Subjects were parents of children 2-12 years of age, with Medicaid or no medical insurance, receiving treatment for asthma in the ED. The primary outcome was a verified PCP visit for asthma within two weeks of the index ED visit. All parents received 15 dollars for their time in the ED. Parents in the intervention group were told that they would receive an additional 15 dollars monetary incentive if a PCP visit was completed. The coach engaged in a dialogue with the parent during the ED visit, and discussed the importance and advantages of seeking follow-up care with the child's PCP. All parents received the usual discharge instructions, including advice to see the PCP within three days. RESULTS: The authors enrolled 92 parents; outcome data were available for 86 (42 controls, 50 intervention). Demographic characteristics were similar in both groups. There was no significant difference in the proportion of patients who had follow-up PCP visits between the intervention (22.0%; 95% confidence interval [95% CI] = 11.5% to 36.0%) and control (23.8%; 95% CI = 12.0% to 39.4%) groups (p = 0.99). CONCLUSIONS: An intervention combining asthma coaching during acute ED visits and a monetary incentive to return for a PCP visit does not appear to increase follow-up with the PCP.

Refinement of an instrument to evaluate parental attitudes about follow-up care after an acute emergency department visit for asthma.

INTRODUCTION: Prompt follow-up after emergency department (ED) care for asthma allows the primary care provider (PCP) and family to review factors that led to the ED visit, update current care plans, and plan for prevention of future exacerbations. METHODS: The Initial Questionnaire to assess parental impressions of Pros and Cons of follow-up was administered to parents who brought their children to the ED for treatment of an acute asthma exacerbation (N = 309). After a planned interim analysis, 19 new items were generated, and this Expanded Questionnaire was given to 198 parents. Principal Component Analysis (PCA) was used to identify well-defined items and discard ambiguous and confusing items. RESULTS: PCA of the Expanded Questionnaire revealed 18 of 43 items related to four dimensions of parents' Pros and Cons for obtaining follow-up care. Four distinct categories were identified: two Pros and two Cons. Pro items related to practical things parents get from a follow-up visit and to positive parental beliefs about follow-up care. Con items emphasized practical considerations that make it difficult to go to a follow-up visit and identified the misconception that follow-up is not necessary for asymptomatic children. In addition, two distinct clusters of parents were identified: those that value and those that do not value follow-up care. CONCLUSION: We developed an 18-item measure that assesses Pros and Cons of follow-up care for asthma following emergency care, which has four reliable factors: Pro Practical, Pro Attitude, Con Practical, and Con Attitude. This questionnaire may help guide interventions to change perceptions of the need for follow-up. Attention to increasing Pros among those who are reluctant to attend follow-up care may be especially effective.

Improving follow-up for children with asthma after an acute Emergency Department visit.

OBJECTIVE: To improve follow-up with primary care providers after acute Emergency Department (ED) asthma visits for children from low-income urban families. STUDY DESIGN: A prospective, randomized, controlled trial evaluated combined telephone asthma coaching and monetary incentive. The primary outcome was asthma-planning visits with primary care providers within 15 days of index ED visits. The subjects were urban parents whose children were treated for asthma in the ED and had Medicaid or no insurance. RESULTS: We enrolled 527 parents (264 control and 263 intervention). There was a significant difference ( P < .0001) between the intervention (35.7%) and control (18.9%) groups in the proportion of children who had asthma-planning visits and decreased mean nights/days with asthma symptoms by 4.36 intervention and 3.31 control at 2 weeks. The proportions of children with asthma-planning visits and acute asthma care visits during the 16-day to 6-month period were similar for both groups. CONCLUSIONS: Telephone coaching and a monetary incentive significantly increased the proportion of low-income urban parents who brought their children for asthma-planning visits, and decreased asthma symptoms shortly after asthma ED visits. The intervention did not increase subsequent asthma-planning visits or decrease ED visits or hospitalizations.

Parental impressions of the benefits (pros) and barriers (cons) of follow-up care after an acute emergency department visit for children with asthma.

OBJECTIVE: Asthma morbidity, with increasing emergency department (ED) visits, is prevalent among low-income, urban children. Follow-up care after ED visits is infrequent. We developed and evaluated an instrument that describes the parental benefits (pros) and barriers (cons) of obtaining follow-up care for interventions to promote follow-up. METHODS: We enrolled a convenience sample of low-income, urban parents who brought their children to the ED for treatment of asthma. These parents rated 41 items about the pros and cons of making a follow-up visit. Principal component analysis was used to identify the underlying structure of the instrument. RESULTS: One hundred forty-seven participants were interviewed in the ED. Principal component analysis retained 24 total items, which were identified by this sample as highly associated with deciding to take their child to a follow-up visit. Two types of pros were identified, informational and attitudinal, including "ask the doctor questions," and " children with asthma are healthier if they see their doctor regularly." Two types of cons were identified, practical and attitudinal, including "I have to find transportation," and "I don't need to see the doctor unless my child is sick." The mean total pro and con scores were 4.05 +/- 0.63 and 1.73 +/- 0.67, respectively. CONCLUSIONS: The pros and cons are not unidimensional. Even among those with infrequent follow-up, pros were endorsed more highly than cons. Programs that target these pros and cons may improve adherence to follow-up and regular care for low-income urban children.