Kimber P. Richter

Using empowerment theory in collaborative partnerships for community health and development

Models of community empowerment help us understand the process of gaining influence over conditions that matter to people who share neighborhoods, workplaces, experiences, or concerns. Such frameworks can help improve collaborative partnerships for community health and development. First, we outline an interactive model of community empowerment that describes reciprocal influences between personal or group factors and environmental factors in an empowerment process. Second, we describe an iterative framework for the process of empowerment in community partnerships that includes collaborative planning, community action, community change, capacity building, and outcomes, and adaptation, renewal, and institutionalization. Third, we outline activities that are used by community leadership and support organizations to facilitate the process of community empowerment. Fourth, we present case stories of collaborative partnerships for prevention of substance abuse among adolescents to illustrate selected enabling activities. We conclude with a discussion of the challenges and opportunities of facilitating empowerment with collaborative partnerships for community health and development.

Evaluating Community Coalitions for Prevention of Substance Abuse: The Case of Project Freedom

In the United States alone, there are more than 2,000 community coalitions to address local concerns about abuse of alcohol, tobacco, and other drugs. This article describes an evaluation system used to examine the process, outcome, and impact of coalitions for the prevention of substance abuse. The evaluation addresses five key questions: (a) Was the community mobilized to address substance abuse (Process)? (b) What changes in the community resulted from the coalition (Outcome)? (c) Is there a change in reported use of alcohol and other substances by youths (Outcome)? (d) Does the coalition have a community-level impact on substance abuse (Impact)? and (e) Is community-level impact related to changes facilitated by the coalition (Impact)? To address these and other questions, using eight core measurement instruments, the evaluation system collects 15 distinct measures. This evaluation system is illustrated with a multiyear study of Project Freedom, a substance abuse coalition in a large midwestem city.

Differences among African American light, moderate, and heavy smokers

This study examined differences in demography, behavior, attitude, and physician intervention among African American light, moderate, and heavy smokers. Data were derived from an intervention study designed to assess whether a smoking status stamp would increase screening for smoking status and cessation counseling by physicians. Current analysis included 879 African American smokers categorized into three groups: light (<10 cigarettes/day), moderate (10-19 cigarettes/day), or heavy (> or =20 cigarettes/day) smokers based on number of cigarettes per day smoked. Light smokers constituted 40% of study sample, 33% were moderate smokers, and 27% were heavy smokers. Light smokers were more likely to be female (p<0.001) and have a shorter smoking history (p<0.001). Light smokers were not different in age (p=0.334), or the number of previous quit attempts (p=0.551). Although light smokers were more likely than moderate and heavy smokers to be preparing to quit (p<0.001), they were less likely to be asked their smoking status (p=0.031) or told to arrange follow-up for smoking cessation (p=0.034) by their physicians. Many African American smokers are light smokers. Light smokers are more likely to be female and have a shorter smoking history. Despite their readiness to quit, compared to heavier smokers, African American light smokers are asked about smoking less often by their physicians. Programs are needed to enhance physician intervention in this understudied population of smokers.

Smoking Cessation in Homeless Populations: A Pilot Clinical Trial

This study, which tested two motivational interviewing treatment approaches, assessed the feasibility of conducting a community-based smoking cessation intervention among homeless smokers. Participants (N = 46) were recruited from multiple facilities in the Kansas City area and were randomized to two counseling conditions in which they received five individual motivational interviewing sessions, six group meetings, and their choice of 8 weeks of 21-mg nicotine patch or 4-mg nicotine lozenge. The two counseling conditions consisted of motivational interviewing targeted either to smoking behaviors exclusively (smoking only) or to smoking and other addictions or life events that could affect ability to quit (smoking plus). Group meetings were designed to provide educational information and social support. Measures of feasibility assessed included the proportion of participants who returned for randomization among those eligible, adherence to prescribed nicotine replacement therapies, retention rates at the week 26 final study visit, and biochemically verified 7-day abstinence at week 26. Most participants (69.6%) chose nicotine patches, and 32% of those participants reported using at least four patches per week. Carbon monoxide verified 7-day abstinence rates in the smoking-only and smoking-plus groups were 13.04% and 17.39% (ns), respectively, at week 8 and 8.70% and 17.39% (ns), respectively, at week 26. Participants who used at least four patches per week were more likely to have quit at 8 weeks than were those who used fewer patches (33.3% vs. 10.5%, p = .30). Results support the feasibility of conducting a smoking cessation intervention among homeless smokers. Findings also show promising effects for nicotine replacement therapy and counseling in this population. Developing programs to improve smoking cessation outcomes in underserved populations is an essential step toward achieving national health objectives and for ultimately reducing tobacco-related health disparities.

Infection control practices in U.S. burn units.

The purpose of this study was to determine infection control procedures most commonly used in burn units in the United States. We used two data collection formats: a brief quantitative survey and a brief qualitative interview. Our response rate was 75% (104/139). We found wide variability in general infection control practices as well as in wound care practices in intensive care units. The majority of units reported having written infection control guidelines specific to the burn unit. Respondents noted challenges that burn injury presents to infection control. A broad range of techniques for preventing device- and procedure-related infection also were provided by respondents. Compliance with hand washing on the part of physicians and ancillary staff remains a major challenge. To improve the quality of infection control and reduce variation in practice, we must continue to monitor the types of practices that are delivered, provide feedback to providers on how they care for their patients, where evidence exists disseminate best practices, and build the evidence base through efficacy trials.

Reducing Elementary School Children's Risks for Chronic Diseases through School Lunch Modifications, Nutrition Education, and Physical Activity Interventions

Abstract Many behaviors, such as physical inactivity or a poor diet, that put adults at risk for chronic diseases are established in childhood. This manuscript describes the outcomes of a comprehensive school health project, the Kansas LEAN School Intervention Project. The Kansas LEAN School Intervention Project in Salina and Dighton had four components, three of which were school based: (a) modified school lunches, (b) enhanced nutrition education, and (c) increased opportunities for physical activity. The fourth component, actions taken by a community partnership, is described elsewhere. Data from two case studies were used to address three primary evaluation questions: (a) did changes in the school lunch menu reduce the fat content yet maintain calories in meals served? ( b) did nutrition knowledge, skills, and attitudes of students improve? and (c) did students’ physical fitness improve? The findings suggest that the project was successful in reducing the fat content in school lunches in both communities from baseline levels of approximately 38% calories from fat to the target goal of 30% calories from fat during the 1993–94 school year. The schools also maintained adequate calories for students in this age group. Students’ knowledge, skills, and behaviors related to nutrition as well as their physical fitness improved in both Kansas communities. The strengths and limitations of this strategy of making healthy choices easy choices through school-based intervention are discussed.

A case for addressing cigarette use in methadone and other opioid treatment programs.

Abstract Most persons attending drug treatment smoke cigarettes. They will eventually experience predictable, but devastatingly high, tobacco-related mortality. Recent studies indicate that many clients are ready to quit smoking and that quitting does not threaten progress made in treatment. Methadone and other opioid treatment providers are in an excellent position to address tobacco use among their clients. The present paper describes the prevalence of smoking among methadone clients, reviews promising interventions, and describes how programs can implement a systematic approach to smoking cessation that includes creating a cue system for identifying smokers, providing brief on-site intervention, and arranging follow-up or more intensive treatment.

Smoking reduction practices among African American smokers

Despite smoking fewer cigarettes per day than Caucasians, African Americans bear a disproportionate share of health consequences of smoking. Because the risk of many tobacco-related diseases is dose-dependent, smoking reduction has been suggested as a method to reduce harm for smokers. Little information exists about behavioral smoking-reduction strategies and whether such strategies result in smoking fewer cigarettes. We conducted a survey of 484 African American smokers classified as occasional, light, moderate, and heavy smokers. The survey examined sociodemography, smoking characteristics, and eight smoking reduction strategies, including intentional limiting of smoking, smoking less than half of a cigarette, setting a daily limit for smoking, changing cigarette brand, reducing number of cigarettes, smoking only on some days, switching to a lighter tar cigarette, and not inhaling deeply. Compared to moderate and heavy smokers, occasional and light smokers were more likely to have engaged in most of these strategies. Smokers who used >or= 4 strategies on average smoked 11 cigarettes per day (cpd), compared to 14 cpd and 18 cpd for those who used 1 to 3 strategies and no strategies respectively (p <.0001). After analyses controlled for age, gender, and education, the number of smoking reduction strategies utilized was a significant predictor of smoking 10 or fewer cigarettes per day. This study provides evidence that African American smokers who engaged in multiple smoking reduction strategies smoked fewer cigarettes per day. Smokers not interested in quitting but willing to reduce their smoking should be encouraged to utilize a variety of smoking reduction strategies.

Patterns of smoking and methadone dose in drug treatment patients.

Cigarette smoking prevalence is very high, and cessation rates are very low, among people in methadone treatment. This may in part be due to interactions between methadone administration and cigarette smoking. The present study explores relationships between methadone dose timing and smoking rates. Twenty methadone patients, over a period of 19 days, used electronic cigarette packs to record their smoking patterns and called a voice mailbox daily to report their methadone dose and timing. The average proportion of daily cigarettes smoked was calculated for 2-hr blocks preceding and following methadone dose administration. For all participants, peak smoking rates occurred after methadone administration. Participants smoked a greater proportion of cigarettes in their first 2-hr block after methadone dosing (M = 0.368, SD = 0.135) than during their first 2-hr block of smoking of the day (M = 0.245, SD = 0.010; S = 85.5, p < .0001). The proportion of cigarettes smoked increased by 0.02 from more than 2 hr before methadone to the 2-hr time block before methadone, by 0.04 from the 2-hr time block before methadone to the 2-hr time block after methadone, and by 0.015 from the 2-hr time block after methadone to the next 2-hr time block. From this time block (2-4 hr after methadone), smoking decreased by 0.02 in the 4-plus hr postmethadone dose. All of these changes were statistically significant. Future research should use experimental designs to better examine whether a causal relationship exists and examine the impact of other types of opioid maintenance medications on smoking patterns.

Dual Pharmacotherapy and Motivational Interviewing for Tobacco Dependence Among Drug Treatment Patients

Abstract This pilot study is the first to examine the feasibility and outcomes of dual pharmacotherapy for smoking cessation among drug treatment patients. The intervention consisted of 7 weeks of bupropion (300 mg), 12 weeks of nicotine gum, and 6 sessions of motivational interviewing. The trial was conducted among 28 patients recruited from 5 methadone clinics and employed a pretest-posttest design. At 6 months post quit date, 14% of participants met criteria for biochemically-verified abstinence. Among those still smoking, number of cigarettes smoked decreased significantly and most (88%) had made at least 1 serious quit attempt. Participation rates were excellent and no adverse effects on alcohol or illicit drug use were found. Although not a definitive test of the intervention, findings suggest that a multi-component approach to tobacco dependence is feasible and potentially effective in helping drug treatment patients achieve smoking cessation well beyond the end of treatment and that a large-scale randomized trial is warranted.