Janet Y. Groff

Secondary Prevention of Intimate Partner Violence: A Randomized Controlled Trial

Background: Despite the recognition of intimate partner violence (IPV) against women as a global health issue associated with significant morbidity and mortality, evidence-based treatment strategies for primary care settings are lacking. Objective: To assess the comparative safety behaviors, use of community resources, and extent of violence following two levels of intervention. Methods: A randomized, two-arm, clinical trial was completed in urban public primary care clinics with 360 abused women who assessed positive for physical or sexual abuse within the preceding 12 months. Two interventions were tested: a wallet-sized referral card and a 20-minute nurse case management protocol. Outcome measures were differences in the number of threats of abuse, assaults, danger risks for homicide, events of work harassment, safety behaviors adopted, and use of community resources between intervention groups over a 24-month period. Results: Two years following treatment, both treatment groups of women reported significantly (p <.001) fewer threats of abuse (M = 14.5; 95% CI 12.6, 16.4), assaults (M = 15.5, 95% CI 13.5, 17.4), danger risks for homicide (M = 2.6; 95% CI 2.1, 3.0), and events of work harassment (M = 2.7; 95% CI 2.3, 3.1), but there were no significant differences between groups. Compared to baseline, both groups of women adopted significantly (p <.001) more safety behaviors by 24 months (M = 2.0; 95% CI 1.6, 2.3); however, community resource use declined significantly (p <.001) for both groups (M = −0.2; 95% CI −0.4,−0.2). There were no significant differences between groups. Discussion: Disclosure of abuse, such as what happens with abuse assessment, was associated with the same reduction in violence and increase in safety behaviors as a nurse case management intervention. Simple assessment for abuse and offering of referrals has the potential to interrupt and prevent recurrence of IPV and associated trauma.

Activation of Emergency Medical Services for Acute Stroke in a Nonurban Population The T.L.L. Temple Foundation Stroke Project

BACKGROUND AND PURPOSE Activating emergency medical services (EMS) is the most important factor in reducing delay times to hospital arrival for stroke patients. Determining who calls 911 for stroke would allow more efficient targeting of public health initiatives. METHODS The T.L.L. Temple Foundation Stroke Project is an acute stroke surveillance and intervention project in nonurban East Texas. Prospective case ascertainment allowed chart abstraction and structured interviews for all hospitalized stroke patients to determine if EMS was activated, and if so, by whom. RESULTS Of 429 validated strokes, 38.0% activated EMS by calling 911. Logistic regression analysis comparing those who called 911 with those who did not activate EMS found that individuals who were employed were 81% less likely to have EMS activated (OR 0.19, 95% CI 0.04 to 0.63). Of the 163 cases in which 911 was called, the person activating EMS was: self (patient), 4.3%; family member of significant other, 60. 1%; paid caregiver, 18.4%; and coworker or other, 12.9%. Significant associations between the variables age group (P=0.02), insurance status (P=0.007), and living alone (P=0.05) with who called 911 was found on chi(2) analysis. CONCLUSIONS Educational efforts directed at patients themselves at risk for stroke may be of low yield. To increase the use of time dependent acute stroke therapy, interventions may wish to concentrate on family, caregivers, and coworkers of high-risk patients. Large employers may be good targets to increase utilization of EMS services for acute stroke.

Decision making, beliefs, and attitudes toward hysterectomy: a focus group study with medically underserved women in Texas.

Variations in hysterectomy rates have been associated with assorted physician and patient characteristics, and the disproportionate rate of hysterectomies in African American women has been attributed to a higher prevalence of leiomyomas. The role of womens beliefs and attitudes toward hysterectomy and participation in decision making for medical treatment has not been explored as a source of variance. The purposes of this qualitative study were to explore these constructs in a triethnic sample of women to understand beliefs, attitudes, and decision-making preferences among underserved women; to facilitate development of a quantitative survey; and to inform development of interventions to assist women with such medical decisions. Twenty-three focus groups were conducted with 148 women from community sites and public health clinics. Thirteen self-identified lesbians participated in three groups. Analysis of audiotaped transcripts yielded four main themes: perceived outcomes of hysterectomy, perceived views of men/partners, opinions about healthcare providers, decision-making process. Across groups, the women expressed similar expectations from hysterectomy, differing only in the degree to which dimensions were emphasized. The women thought men perceived women with hysterectomy as less desirable for reasons unrelated to childbearing. Attitudes toward physicians were negative except among Hispanic women. All women expressed a strong desire to be involved in elective treatment decisions and would discuss their choice with important others. Implications for intervention development include enhancing womens skills and confidence to evaluate treatment options and to interact with physicians around treatment choices and creation of portable educational components for important others.

Overview of women's decision making regarding elective hysterectomy, oophorectomy, and hormone replacement therapy.

Over 600,000 hysterectomies are performed each year in the United States, the majority of which are to improve quality of life for perimenopausal women. Hysterectomy rates for common conditions differ between African American and white women, and African American women undergo surgery at a younger age for most diagnoses. Many hysterectomies are accompanied by elective oophorectomy, and hormone replacement therapy (HRT) is commonly used, especially among women experiencing surgical menopause, despite questions about its long-term benefits and risks. Despite the high rates of hysterectomy in the United States, little is known about how women make decisions regarding this surgery and, in particular, how ethnic and cultural factors may influence these decisions. This article provides a review of what is currently known about the epidemiology of hysterectomy, oophorectomy, and HRT use and identifies gaps in knowledge about womens decision making, with a special focus on ethnic variations and cultural influences, issues addressed by the Ethnicity, Needs, and Decisions of Women (ENDOW) project.

Weight gain associated with prenatal smoking cessation in white, non- Hispanic women

OBJECTIVE Our purpose was to assess the effect of prenatal smoking cessation on maternal weight gain and infant birth weight in women who smoked at least five cigarettes per week. STUDY DESIGN This prospective study followed up a sample of white, non-Hispanic pregnant smokers enrolled in three multispecialty clinics. By use of t tests, women quitting smoking before 28 weeks and continuing smokers were compared on total weight gain, Institute of Medicine weight gain categories, and infant birth weight. RESULTS Quitters gained 36.6 pounds (SD 14.5) and smokers 28.9 pounds (SD 11.7) (p < 0.001). The relative risk of quitters gaining less than the Institute of Medicine minimum was 0.47 (95% confidence interval 0.27 to 0.81). Quitters also gained more than Institute of Medicine standards (relative risk 1.74, 95% confidence interval 1.21 to 2.51), and they were 3.1 times as likely to be delivered of infants weighing > 4000 gm (95% confidence interval 1.18 to 7.97). The four low-birth-weight babies were born to smokers with low weight pain. CONCLUSION In this population smoking cessation is associated with a lower risk of gaining too little by Institute of Medicine standards and also with higher risk of gaining more than the Institute of Medicine standard and having infants weighing > 4000 gm. The clinical significance of these effects needs to be determined in further studies.

Ultrasound feedback and motivational interviewing targeting smoking cessation in the second and third trimesters of pregnancy

INTRODUCTION Cigarette smoking during pregnancy is associated with poor maternal and child health outcomes. Effective interventions to increase smoking cessation rates are needed particularly for pregnant women unable to quit in their first trimester. Real-time ultrasound feedback focused on potential effects of smoking on the fetus may be an effective treatment adjunct, improving smoking outcomes. METHODS A prospective randomized trial was conducted to evaluate the efficacy of a smoking cessation intervention consisting of personalized feedback during ultrasound plus motivational interviewing-based counseling sessions. Pregnant smokers (N = 360) between 16 and 26 weeks of gestation were randomly assigned to one of three groups: Best Practice (BP) only, Best Practice plus ultrasound feedback (BP+US), or Motivational Interviewing-based counseling plus ultrasound feedback (MI+US). Assessments were conducted at baseline and end of pregnancy (EOP). RESULTS Analyses of cotinine-verified self-reported smoking status at EOP indicated that 10.8% of the BP group was not smoking at EOP; 14.2% in the BP+US condition and 18.3% who received MI+US were abstinent, but differences were not statistically significant. Intervention effects were found conditional upon level of baseline smoking, however. Nearly 34% of light smokers (< or =10 cigarettes/day) in the MI+US condition were abstinent at EOP, followed by 25.8% and 15.6% in the BP+US and BP conditions, respectively. Heavy smokers (>10 cigarettes/day) were notably unaffected by the intervention. DISCUSSION Future research should confirm benefit of motivational interviewing plus ultrasound feedback for pregnant light smokers and explore mechanisms of action. Innovative interventions for pregnant women smoking at high levels are sorely needed.

Behaviors of Children Following a Randomized Controlled Treatment Program for Their Abused Mothers

Objective: To determine if a treatment program offered to abused mothers positively affects the behaviors of their children. Methods: A randomized, two-arm, clinical trial was used to measure child behavior at 6, 12, 18, and 24 months following the application of two levels of abuse treatment services to abused mothers: (1) abuse assessment and receipt of a wallet-size referral card, or (2) abuse assessment, receipt of a wallet-size referral card, and nurse case management sessions. The setting was public primary care clinics. The participants were 233 women who reported physical or sexual abuse within the preceding 12 months, and who had at least one child, ages 18 months to 18 years, living with them. Outcome measures were scores on the Child Behavior Checklist (CBCL) at baseline, 6, 12, 18, and 24 months. CBCL scores for a clinically-referred sample of children served as a comparison group. Results: All children improved significantly (p < .001) on CBCL scores from intake to 24 months, regardless of which treatment protocol their mother received. By 24 months, the majority of children and adolescents had scores significantly less than the referred norms. Children ages 18 months to 5 years showed the most improvement and teenagers showed the least improvement. Conclusions: Disclosure of abuse, such as that which happens during abuse assessment, was associated with the same improvement in child behavior scores as a nurse case management intervention. Routine abuse assessment and referral have the potential to positively improve the behavioral functioning of children exposed to domestic violence.

Enhanced prenatal case management for low income smokers

Smoking during pregnancy is highly prevalent in populations of white, low socioeconomic status women who are more addicted to nicotine than most other groups within their social class. Qualitative and quantitative assessments conducted by this research team suggested that eVective pregnancy smoking interventions should be oVered in the context of high risk counselling that also addressed sources of stress, depression, negative family support, and the various problems associated with poverty. 1‐3 Because many of these women are in early stages of change for smoking cessation, they need an approach focused on motivation and decision making rather than advice or quitting guides. Motivational interviewing is an approach that addresses the motivational enhancement needs of these women, meets them at their stage of change, and therefore seemed particularly appropriate for these women. 4 This project proposed using the existing prenatal high risk case management delivery system for motivational enhancement based smoking cessation counselling. The case manager’s role is to give support and marshal resources to address emotional and environmental stressors for high risk pregnancies, a role supported by Medicaid in most states. In addition, we believed that the interaction style and counselling skills of case managers in the cooperating clinic network were compatible with the demands of an individualised, comprehensive, motivational approach to pregnancy smoking cessation.

Perceptions of hormone replacement therapy among African American women.

Hormone replacement therapy (HRT) is commonly prescribed for women to relieve symptoms associated with menopause. The medical community does not uniformly recommend HRT, and ethnic and cultural differences may influence a womans decision to request and adhere to it. Thirty-eight African American women were enrolled in a qualitative study to investigate beliefs, attitudes, and knowledge about HRT. Data collected from six focus groups were part of Ethnicity, Needs, and Decisions of Women (ENDOW), a multisite project investigating decision making and hysterectomy. Participants, age 30 to 65 years, were recruited from community agencies and public health clinics. The women were aware of fa medical indications for HRT and its risks and benefits. Although a majority of participants were past or current users, they expressed reservations about the use of HRT and wanted a better dialogue with health care providers, including information about alternative treatments.

Original Research: Beliefs and Attitudes of Middle Aged Lesbians About Hysterectomy

Objective: The aim of this study was to identify the beliefs and attitudes of lesbians aged 30–65 years regarding hysterectomy. Design: This qualitative study comprised 12 lesbians in three focus groups, utilizing a semistructured guided discussion technique based on qualitative application of Multiattribute Utility Theory. Participants were chosen to represent various stages of decision making, and women who had undergone a hysterectomy were excluded from the study. Setting: All sessions were conducted in a Houston health clinic serving the lesbian community. Measurements: Transcripts were analyzed using Nonnumerical Unstructured Data Indexing Searching and Theorizing (NUD*IST). Results: Major categories, comprising multiple themes, were perceived outcomes of hysterectomy, help-seeking, and experiences with the physician or with the medical establishment. The lesbians in the study revealed both positive and negative outcomes of hysterectomy on sexuality. Loss associated with hysterectomy was perceived as physical, emotional, and ontological. Partner support emerged as a salient outcome. There were varying attitudes toward the use of hormone replacement following hysterectomy. For the lesbians, being in charge of decisions concerning their bodies was crucial, and they would seek information from a number of sources, including two or more physicians, before making a decision regarding hysterectomy. Although the women reported negative experiences with physicians, these experiences were not related to the physicians gender or sexual orientation. Conclusion: While being sensitive to the needs of lesbian patients, physicians also must keep in mind that hysterectomy is an individual decision.