Objective The objective of this study was to determine whether patients' families' violence-prevention behaviors would be affected by their primary care practitioner's use of a violence-prevention clinical intervention during the routine well-child examination. Methods In this cluster-randomized, controlled trial (2002–2006), 137 Pediatric Research in Office Settings practices were randomly assigned and initiated patient recruitment for either an office-based violence-prevention intervention or a control group (educational handout on literacy promotion provided). Primary caregivers of children who were aged 2 to 11 years and presented for a well-child visit were surveyed at baseline and 1 and 6 months. Practitioners were trained to (1) review a parent previsit summary regarding patient-family behavior and parental concern about media use, discipline strategies, and children's exposure to firearms, (2) counsel using brief principles of motivational interviewing, (3) identify and provide local agency resources for anger and behavior management when indicated, and (4) instruct patient-families on use of tangible tools (minute timers to monitor media time/timeouts and firearm cable locks to store firearms more safely where children live or play). Main outcomes were change over time in self-reported media use < 120 minutes per day, use of timeouts, and use of firearm cable locks. Results Generalized estimating equation analysis revealed a significant effect at 6 months for decreased media use and safer firearm storage. The intervention group compared with the control group showed an increase in limiting media use to < 120 minutes per day. There was no significant effect for timeout use. There was a substantial increase in storing firearms with cable locks for the intervention group versus a decrease for the control group. Conclusions This randomized, controlled trial demonstrated decreased media exposure and increased safe firearm storage as a result of a brief office-based violence-prevention approach.
WHAT'S KNOWN ON THIS SUBJECT: Young adult smokers frequently encounter the health care system as parents coming in for their child' s medical visit. Child health care clinicians, however, do not typically provide smoking cessation assistance to parents. WHAT THIS STUDY ADDS:This national cluster-randomized trial demonstrates that a tobacco dependence intervention for parents can be effectively implemented in routine pediatric outpatient practice.abstract OBJECTIVE: To test whether routine pediatric outpatient practice can be transformed to assist parents in quitting smoking. METHODS:Cluster RCT of 20 pediatric practices in 16 states that received either CEASE intervention or usual care. The intervention gave practices training and materials to change their care delivery systems to provide evidence-based assistance to parents who smoke. This assistance included motivational messaging; proactive referral to quitlines; and pharmacologic treatment of tobacco dependence. The primary outcome, assessed at an exit interview after an office visit, was provision of meaningful tobacco control assistance, defined as counseling beyond simple advice (discussing various strategies to quit smoking), prescription of medication, or referral to the state quitline, at that office visit.RESULTS: Among 18 607 parents screened after their child' s office visit between June 2009 and March 2011, 3228 were eligible smokers and 1980 enrolled (999 in 10 intervention practices and 981 in 10 control practices). Practices' mean rate of delivering meaningful assistance for parental cigarette smoking was 42.5% (range 34%-66%) in the intervention group and 3.5% (range 0%-8%) in the control group (P , .0001). Rates of enrollment in the quitline (10% vs 0%); provision of smoking cessation medication (12% vs 0%); and counseling for smoking cessation (24% vs 2%) were all higher in the intervention group compared with the control group (P , .0001 for each). CONCLUSIONS:A system-level intervention implemented in 20 outpatient pediatric practices led to 12-fold higher rates of delivering tobacco control assistance to parents in the context of the pediatric office visit.
WHAT'S KNOWN ON THIS SUBJECT: Tobacco smoke exposure is associated with increased morbidity in children, and exposure in cars can be particularly intense. The American Academy of Pediatrics policy statement recommends that pediatricians assist families in adopting smoke-free car policies. WHAT THIS STUDY ADDS:In this study, few smoking parents had a strictly enforced smoke-free car policy. Low rates of pediatric health care providers addressing smoking in the car highlights the need for improved pediatric interventions to protect children from tobacco smoke toxins. abstract OBJECTIVE: To determine prevalence and factors associated with strictly enforced smoke-free car policies among smoking parents. METHODS:As part of a cluster, randomized controlled trial addressing parental smoking, exit interviews were conducted with parents whose children were seen in 10 control pediatric practices. Parents who smoked were asked about smoking behaviors in their car and receipt of smoke-free car advice at the visit. Parents were considered to have a "strictly enforced smoke-free car policy" if they reported having a smoke-free car policy and nobody had smoked in their car within the past 3 months. RESULTS:Of 981 smoking parents, 817 (83%) had a car; of these, 795 parents answered questions about their car smoking policy. Of these 795 parents, 29% reported having a smoke-free car policy, and 24% had a strictly enforced smoke-free car policy. Of the 562 parents without a smoke-free car policy, 48% reported that smoking occurred with children present. Few parents who smoke (12%) were advised to have a smoke-free car. Multivariable logistic regression controlling for parent age, gender, education, and race showed that having a younger child and smoking #10 cigarettes per day were associated with having a strictly enforced smoke-free car policy. CONCLUSIONS:The majority of smoking parents exposed their children to tobacco smoke in cars. Coupled with the finding of low rates of pediatricians addressing smoking in cars, this study highlights the need for improved pediatric interventions, public health campaigns, and policies regarding smoke-free car laws to protect children from tobacco smoke.
Objective-To measure impact of pediatricians' perceived self-efficacy and confidence on current practices and attitudes regarding four violence prevention (VP) topics (gun storage, gun removal, limiting exposure to media violence, discipline techniques) during health supervision for children ages 2-11.Methods-Random sample survey of American Academy of Pediatrics Fellows (n = 486; 53% response rate) providing health supervision for children ages 2-11. Participants surveyed about VP issues regarding: (1) current counseling practices for 2-5 and 6-11 year olds; (2) amount of time spent addressing; (3) confidence in addressing; and (4) perceived self-efficacy at changing patients' behaviors. Multivariate analyses explored relationships between pediatricians' perceived self-efficacy and confidence versus VP counseling frequency.Results-VP topics were not routinely discussed during health supervision. Most pediatricians (64%) reported spending too little time addressing these topics. Although most pediatricians felt confident discussing and effective at changing behaviors regarding limiting exposure to media violence (89% vs. 50%) and discipline techniques (91% vs. 76%), they were less so for safe gun storage (54% vs. 35%) and gun removal (51% vs. 17%). Perceived self-efficacy was the mediating factor on self-reported VP counseling frequencies for all topics. Author Manuscript confident discussing than effective at changing behaviors. Since pediatricians' self-efficacy was related to counseling practices, boosting self-efficacy could ultimately improve counseling frequencies. Further research is needed to identify methods to build providers' perceived selfefficacy regarding these VP areas. Conclusions-Pediatricians HHS Public Access
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