Edward Bernstein

Introduction to Community Empowerment, Participatory Education, and Health

Nina Wallerstein is Assistant Professor, Department of Family and Community Medicine, University of New Mexico, Albuquerque, New Mexico. Edward Bernstein is Associate Professor, Boston University School of Public Health, Boston City Hospital, Boston, Massachusetts. Address reprint requests to Nina Wallerstein, Department of Family and Community Medicine, University of New Mexico, Albuquerque, NM 8713

Project ASSERT: An ED-Based Intervention to Increase Access to Primary Care, Preventive Services, and the Substance Abuse Treatment System

STUDY OBJECTIVE To test the feasibility and effectiveness of Project ASSERT, an innovative program developed by us to facilitate access to the substance abuse treatment system and to primary care and preventive services for emergency department patients with drug- and alcohol-related health problems. METHOD Multicultural health promotion advocates (HPAs) were trained by ED personnel to screen patients using a health needs history, to administer a brief negotiated interview based on readiness-to-change principles, and to use an active referral process to capture the marginal capacity of the substance abuse treatment system. Outcome measures included (1) number of referrals to the substance abuse treatment system, (2) patient self-report of satisfaction with services received from Project ASSERT and utilization of treatment resources, and (3) changes in self-reported frequency of drug and alcohol use and in Drug Abuse Screening Test scores between enrollment and follow-up at 60 to 90 days. RESULTS Between March 1, 1995, and February 29, 1996, 7,118 adult ED patients were screened. Substance abuse was detected among 2,931 patients (41%), and 1,096 (37% of detected patients) were enrolled. A total of 8,848 referrals were made: 3,189 to primary care, 2,018 to a variety of substance abuse treatment services, 2,253 for smoking cessation, 339 for mammography, and 689 to other support services (eg, psychiatric nurse, social worker, battered womens advocate or shelter). Comparison of enrollment and follow-up scores for the 245 enrollees who kept a follow-up appointment demonstrated significant reductions, including a 45% reduction in severity of drug problem, a 56% reduction in alcohol use, and a 64% reduction in the frequency of drinking six or more drinks at one sitting. At follow-up, patients expressed satisfaction with Project ASSERT: 91% were satisfied with their referrals; 93% thought the HPAs explained things well; and 99% thought the HPAs respected them as individuals. Among the follow-up group, 50% self-reported that they had kept an appointment for treatment. CONCLUSION Project ASSERT is an innovative approach to link ED patients with the substance abuse treatment system and with primary care and other preventive services. Its success is further demonstrated by its adoption by Boston Medical Center as a funded ED value-added service.

Trained Medical Interpreters in the Emergency Department: Effects on Services, Subsequent Charges, and Follow-up

The study was conducted to investigate the impact of an Interpreter Service on intensity of Emergency Department (ED) services, utilization, and charges. This study describes the effects of language barriers on health care service delivery for the index ED visit and a subsequent 90-day period. In all 26,573 ED records from July to November, 1999, resulted in a data set of 500 patients with similar demographic characteristics, chief complaint, acuity, and admission rate. Noninterpreted patients (NIPs) who did not speak English had the shortest ED stay (LOS) and the fewest tests, IVs and medications; English-speaking patients had the most ED services, LOS, and charges. Subsequent clinic utilization was lowest for NIPs. Among discharged patients, return ED visit and ED visit charges were lowest for interpreted patients (IPs). Use of trained interpreters was associated with increased intensity of ED services, reduced ED return rate, increased clinic utilization, and lower 30-day charges, without any simultaneous increase in LOS or cost of visit.

A Brief Motivational Interview in a Pediatric Emergency Department, Plus 10-Day Telephone Follow-Up, Increases Attempts to Quit Drinking Among Youth and Young Adults Who Screen Positive for Problematic Drinking

OBJECTIVES Adolescents in their late teens and early 20s have the highest alcohol consumption in the United States; binge drinking peaks at age 21-25 years. Underage drinking is associated with many negative consequences, including academic problems and risk of intentional and unintentional injuries. This study tested the effectiveness of pediatric emergency department (PED) screening and brief intervention to reduce alcohol consumption and associated risks. METHODS A three-group randomized assignment trial was structured to test differences between intervention (I) and standard assessed control (AC) groups in alcohol consumption and alcohol-related behaviors from baseline to 12 months and to compare the AC group with a minimally assessed control (MAC) group to adjust for the effect of assessment reactivity on control group behavior. Patients aged 14-21 years were eligible if they screened positive on the Alcohol Use Disorders Identification Test (AUDIT) or for binge drinking or high-risk behaviors. The MAC group received a resource handout, written advice about alcohol-related risks, and a 12-month follow-up appointment. Patients in the AC group were assessed using standardized instruments in addition to the MAC protocol. The I group received a peer-conducted motivational intervention, referral to community resources and treatment if indicated, and a 10-day booster in addition to assessment. Measurements included 30-day self-report of alcohol consumption and alcohol-related behaviors, screens for depression and posttraumatic stress disorder, and self-report of attempts to quit, cut back, or change conditions of use, all repeated at follow-up. Motor vehicle records and medical records were also analyzed for changes from baseline to 1-year follow-up. RESULTS Among 7,807 PED patients screened, 1,202 were eligible; 853 enrolled (I, n = 283; AC, n = 284; MAC, n = 286), with a 12-month follow-up rate of 72%. At 12 months, more than half of enrollees in Reaching Adolescents for Prevention (RAP) attempted to cut back on drinking, and over a third tried to quit. A significantly larger proportion of the I group made efforts to quit drinking and to be careful about situations when drinking compared to AC enrollees, and there was a numerically but not significantly greater likelihood (p = 0.065) among the I group for efforts to cut back on drinking. At 3 months, the likelihood of the I group making attempts to cut back was almost triple that of ACs. For efforts to quit, it was double, and for trying to be careful about situations when drinking, there was a 72% increase in the odds ratio (OR) for the I group. Three-month results for attempts were sustained at 12 months for quit attempts and efforts to be careful. Consumption declined in both groups from baseline to 3 months to 12 months, but there were no significant between-group differences in alcohol-related consequences at 12 months or in alcohol-related risk behaviors. We found a pattern suggestive of assessment reactivity in only one variable at 12 months: the attempt to cut back (73.3% for the I group vs. 64.9% among the AC group and 54.8% among the MAC group). CONCLUSIONS Brief motivational intervention resulted in significant efforts to change behavior (quit drinking and be careful about situations while drinking) but did not alter between-group consumption or consequences.

Empowerment Forum: A Dialogue between Guest Editorial Board Members

This forum involves several members of the guest editorial board for the Health Education Quarterly (HEQ) two-issue set on &dquo;Community Empowerment, Participatory Education, and Health.&dquo; The purpose of holding a forum was to expand on some of the issues that emerged through the review process related to power and power dynamics within health professional and community relationships. Although many of the articles touched on these issues, we wanted to take advantage of the collective wisdom within the guest editorial board to deepen our understanding of the potential implications for incorporating community empowerment into our practice. As a result of reviewing the articles, a common set of theoretical and practical questions were circulated to and agreed upon by the entire guest editorial board. The questions concerned definitions of community empowerment (CE) and power, the underlying values in these terms, the parameters of empowerment processes and outcomes, and the contradictions and paradoxes that confront us as we try to

The lack of efficacy of phenytoin in the prevention of recurrent alcohol-related seizures

STUDY OBJECTIVE To determine the effectiveness of IV phenytoin in the prevention of recurrent alcohol-related seizures during a six-hour observation period. DESIGN Prospective, randomized, double-blind trial comparing IV phenytoin with normal saline placebo, conducted from January 1990 through December 1991. SETTING Emergency department of an inner-city, university-affiliated, teaching hospital. PARTICIPANTS One hundred forty-seven consecutive adults more than 25 years of age who presented with a witnessed generalized seizure in the setting of chronic alcohol abuse. INTERVENTIONS Eligible subjects received 15 mg/kg of phenytoin or normal saline at an equivalent volume over 20 minutes by IV pump. Patients were observed for six hours in the ED after drug administration. Those experiencing a second seizure were admitted to the hospital. RESULTS One hundred patients completed the study. Recurrent alcohol-related seizures occurred in ten of 49 patients (20.4%) in the phenytoin group and in 12 of 51 patients (23.5%) in the placebo group. chi 2 analysis revealed no statistically significant difference between the two groups (chi 2 = 0.142; P = .706). The 95% confidence interval for the difference was -0.13 to + 0.19. The relative risk of recurrence between groups was 0.868 with a 95% confidence interval of 0.412 to 1.826. CONCLUSION No significant benefit of phenytoin administration in the prevention of recurrent alcohol-related seizures during a six-hour observation period was demonstrated.

Effectiveness of Alcohol Screening and Brief Motivational Intervention in the Emergency Department Setting

In primary care, the data are in and the case is closed: screening and brief intervention reduces alcohol consumption. Screening and brief intervention received the US Preventive Services Task Force seal of approval in 2004, and the Committee on Trauma of the American College of Surgeons requires documentation of universal alcohol screening and brief intervention for Level I and II certification. The federal government has spent more than

Perceptions of emergency care by the elderly: Results of multicenter focus group interviews

180 million on state screening and brief intervention grants since 2001 and is considering funding emergency departments (EDs) for screening and brief intervention implementation. The Centers for Medicare & Medicaid Services recently approved billing codes for screening and brief intervention, and the American Medical Association has approved Current Procedural Terminology codes applicable to ED screening and brief intervention. But does screening and brief intervention work as well in the ED as it does in primary care? If it is efficacious, who can be expected to benefit? A recent Cochrane database systematic review of brief alcohol interventions delivered in person found significant reduction in consumption compared with controls (4 standard drinks per week), but only 5 of 28 trials were in trauma/ED settings, and the benefit was not clear for women. The Academic ED SBIRT (Screening, Brief Intervention, and Referral to Treatment) Collaborative recently reported short-term reductions of 3.25 drinks per week versus controls across 14 ED sites, with 28% of the intervention group no longer exceeding drinking guidelines versus 18% of controls. A National Institutes of Health press release for this study says, “These new findings underscore the importance of using the American Medical Association health care codes for substance abuse screening and brief intervention.” Among young adults, 2 randomized, controlled, ED-based studies have demonstrated reductions in alcohol consumption and reductions in alcohol-related consequences. In this journal issue, however, D’Onofrio et al report no difference between intervention and control groups at follow-up

Opioid education and nasal naloxone rescue kits in the emergency department.

STUDY OBJECTIVE To determine the elderlys perception of emergency care and to identify specific problems and solutions. DESIGN Focus group interviews. SETTING AND TYPE OF PARTICIPANTS Community senior citizen centers in Boston; Los Angeles; Pittsburgh; Youngstown, Ohio; and Norwalk, Connecticut. Senior citizens who had had emergency care in the past year participated. MEASUREMENT AND RESULTS Participants were satisfied with their overall medical care. Long waits were a hardship for patients and their families. The elderly are not familiar with the process of emergency care. They were frightened by their injury or illness. Their anxiety was not allayed until they were informed of the nature of their illness and what their treatment and disposition was to be. The emergency department environment frequently made them uncomfortable. There was considerable confusion caused by the billing process. CONCLUSIONS The elderly would benefit from prior or concurrent education regarding emergency care. Staff should be more sensitive to the anxiety felt by the elderly, should explain the reasons for delays in care, and what to expect. Patients should be informed of the nature and seriousness of their illness as soon as possible. Family and friends may be encouraged to stay with patients. The billing process needs to be clarified and simplified.

The Timing of Alcohol Use and Sexual Initiation Among a Sample of Black, Hispanic, and White Adolescents

Introduction Emergency departments (EDs) may be high-yield venues to address opioid deaths with education on both overdose prevention and appropriate actions in a witnessed overdose. In addition, the ED has the potential to equip patients with nasal naloxone kits as part of this effort. We evaluated the feasibility of an ED-based overdose prevention program and described the overdose risk knowledge, opioid use, overdoses, and overdose responses among participants who received overdose education and naloxone rescue kits (OEN) and participants who received overdose education only (OE). Methods Program participants were surveyed by telephone after their ED visit about their substance use, overdose risk knowledge, history of witnessed and personal overdoses, and actions in a witnessed overdose including use of naloxone. Results A total of 415 ED patients received OE or OEN between January 1, 2011 and February 28, 2012. Among those, 51 (12%) completed the survey; 37 (73%) of those received a naloxone kit, and 14 (27%) received OE only. Past 30-day opioid use was reported by 35% OEN and 36% OE, and an overdose was reported by 19% OEN and 29% OE. Among 53% (27/51) of participants who witnessed another individual experiencing an overdose, 95% OEN and 88% OE stayed with victim, 74% OEN and 38% OE called 911, 26% OEN and 25% OE performed rescue breathing, and 32% OEN (n=6) used a naloxone kit to reverse the overdose. We did not detect statistically significant differences between OEN and OE-only groups in opioid use, overdose or response to a witnessed overdose. Conclusion This is the first study to demonstrate the feasibility of ED-based opioid overdose prevention education and naloxone distribution to trained laypersons, patients and their social network. The program reached a high-risk population that commonly witnessed overdoses and that called for help and used naloxone, when available, to rescue people. While the study was retrospective with a low response rate, it provides preliminary data for larger, prospective studies of ED-based overdose prevention programs.