Feedback on a multimedia violence prevention program

The objective of this study is to describe feedback on a multimedia violence prevention program. Professionals and laypersons provided feedback regarding a multimedia CD program by completing an anonymous form. Feedback was obtained from 66% of participants (314). In general, participants felt more comfortable managing childhood aggression after the program (p<0.001). Pediatric residents felt more comfortable counseling parents (p<0.001). Approximately 90% of participants would either strongly or very strongly recommend the program to others. Multimedia programs can increase comfort level with managing childhood aggression, suggesting that they hold promise for use as adjunctive violence prevention tools.     

Voluntary or required viewing of a violence prevention program in pediatric primary care

Participants were parents of children less than 7 years of age who presented with their child for a well child visit. Viewed in the waiting room, the intervention was Play Nicely, which teaches childhood aggression management skills. A total of 138 parents were invited to view the program; 57 (41%) accepted (voluntary group). A second group of 35 parents viewed the program as part of the clinic visit (required group); all 35 (100%) accepted. There were no differences between the groups in the proportion of parents who were pleased that the program was offered by their pediatrician (100%) and the proportion who felt more comfortable managing aggression after the viewing experience (94%). Approximately 75% of both groups reported an increased willingness to discuss child behavior and discipline strategies with their pediatrician. These findings have implications for how providers can more routinely introduce educational material into the well child visit that relates to childhood aggression, discipline, and violence prevention.     

Cost-effectiveness of a school-based tobacco-use prevention program

OBJECTIVE: To determine the cost-effectiveness of a school-based tobacco-use prevention program. DESIGN: Using data from the previously reported 2-year efficacy study of the Project Toward No Tobacco Use (TNT), we conducted a decision analysis to determine the cost-effectiveness of TNT. The benefits measured were life years (LYs) saved, quality-adjusted life years (QALYs) saved, and medical care costs saved, discounted at 3%. The costs measured were program costs. We quantified TNT's cost-effectiveness as cost per LY saved and cost per QALY saved. INTERVENTION: A 10-lesson curriculum designed to counteract social influences and misconceptions that lead to tobacco use was delivered by trained health educators to a cohort of 1234 seventh-grade students in 8 junior high schools. A 2-lesson booster session was delivered to the eighth-grade students in the second year. The efficacy evaluation was based on 770 ninth-grade students who participated in the program in the seventh and eighth grades and in both the baseline and the 2-year follow-up survey. RESULTS: Under base case assumptions, at an intervention cost of $16 403, TNT prevented an estimated 34.9 students from becoming established smokers. As a result, we could expect a saving of $13 316 per LY saved and a saving of $8482 per QALY saved. Results showed TNT to be cost saving over a reasonable range of model parameter estimates. CONCLUSIONS: The TNT is highly cost-effective compared with other widely accepted prevention interventions. School-based prevention programs of this type warrant careful consideration by policy makers and program planners.     

Parents with low literacy report higher quality of parent-provider relationships in a residency clinic.

OBJECTIVE: Quality of care in pediatrics is suboptimal for many children from families of low socioeconomic status. Literacy is one aspect of socioeconomic status. We hypothesized that low parental literacy would be associated with low-quality well-child care. METHODS: We performed a cross-sectional study of caregivers of 1- to 4- year-old children in a pediatric resident clinic. To assess parental literacy, we used the Rapid Estimate of Adult Literacy in Medicine. To assess the quality of well-child care, we used 5 subscales from the Promoting Healthy Development Survey relevant to either provider-parent relationships or content of discussions in the well-child visit. RESULTS: We enrolled 157 caregivers. The mean age of the respondents was 30 years, 55% were African American, 69% received Medicaid, and 85% had graduated high school. A total of 34% of the respondents scored below a ninth-grade reading level (low literacy). Parents with low literacy were more likely than those with higher literacy to report Family-centered care (79% vs 61%, P = .03), and Helpfulness and Confidence building (79% vs 57%, P = .01). There was no difference, by literacy level, in the percentage of parents who reported reaching established threshold levels for discussion of Psychosocial issues, Safety issues, or Anticipatory guidance topics. CONCLUSIONS: The lower-literacy respondents reported higher-quality parent-provider relationships; there was no difference in quality of content of discussions by literacy level. Parents with low literacy may have lower expectations regarding relationships with their health care provider or may be less likely to be critical. Alternatively, pediatric residents may be more effective at relationship building with low-literacy families.     

A multimedia violence prevention program increases pediatric residents' and childcare providers' knowledge about responding to childhood aggression

A pre-post knowledge test using alternate forms was used to determine if a multimedia violence prevention program can increase knowledge about management of childhood aggression. The participants were pediatric residents and childcare workers who attended lectures about aggression management in young children. The intervention was a presentation of a 30 minute CD-ROM program, Play Nicely, which teaches how to manage aggression in young children ages 1 to 7 years. A pretest and posttest multiple-choice knowledge assessment that focused on the program's most important recommendations was administered. Childcare workers and pediatric residents had significantly increased knowledge scores after viewing the CD-ROM demonstration (F=6.8, p = 0.01). Childcare workers' scores improved by 2.6 points (p< 0.001) and residents' scores by 3.8 points (p< 0.001). A relatively short CD-ROM can improve knowledge about how to manage aggression in young children, indicating its usefulness as a violence prevention resource.     

Emerging strategies in the prevention of domestic violence

Responses to domestic violence have focused, to date, primarily on intervention after the problem has already been identified and harm has occurred. There are, however, new domestic violence prevention strategies emerging, and prevention approaches from the public health field can serve as models for further development of these strategies. This article describes two such models. The first involves public health campaigns that identify and address the underlying causes of a problem. Although identifying the underlying causes of domestic violence is difficult--experts do not agree on causation, and several different theories exist--these theories share some common beliefs that can serve as a foundation for prevention strategies. The second public health model can be used to identify opportunities for domestic violence prevention along a continuum of possible harm: (1) primary prevention to reduce the incidence of the problem before it occurs; (2) secondary prevention to decrease the prevalence after early signs of the problem; and (3) tertiary prevention to intervene once the problem is already clearly evident and causing harm. Examples of primary prevention include school-based programs that teach students about domestic violence and alternative conflict-resolution skills, and public education campaigns to increase awareness of the harms of domestic violence and of services available to victims. Secondary prevention programs could include home visiting for high-risk families and community-based programs on dating violence for adolescents referred through child protective services (CPS). Tertiary prevention includes the many targeted intervention programs already in place (and described in other articles in this journal issue). Early evaluations of existing prevention programs show promise, but results are still preliminary and programs remain small, locally based, and scattered throughout the United States and Canada. What is needed is a broadly based, comprehensive prevention strategy that is supported by sound research and evaluation, receives adequate public backing, and is based on a policy of zero tolerance for domestic violence.     

Parents in the observer-position: a psychoanalytically informed use of video in the context of a brief parent-child intervention

The paper investigates the possibility of integrating psychoanalytic observation with video-feedback technique in the framework of a brief parent-child intervention, using case illustrations from work with two different boys and their parents. The intervention also includes the clinical use of the Adult Attachment Interview. The paper suggests that the experience of being observed, being listened to, and of watching the video helps some parents to take on the observer-position providing a new perspective on the relationship which in turn enhances their capacity for reflective functioning.     

Adolescent violence prevention practices among California pediatricians

OBJECTIVES: To examine pediatricians' provision of violence prevention services to their adolescent patients and to identify factors associated with pediatricians' implementation of these services. DESIGN: A cross-sectional sample of California pediatricians completed a self-report questionnaire. The "Precede/Proceed" theoretical model guided the questionnaire in identification of factors associated with pediatricians' screening and intervening practices in preventing adolescent violence. RESULTS: Two hundred twenty pediatricians (54% female, 66% white, 24% Asian, 5% Latino, and 5% other) participated in the study. On average, participants screened their patients for violence-related risk factors 31% of the time for fighting, 39% of the time for violence in the home, and 29% of the time for weapon carrying. Participants provided their at-risk patients with violence-related interventions less than 50% of the time (on average) implementing the following interventions: written materials, follow-up appointments, discipline counseling, or referral to a community organization, Child Protective Services, or a specialized adolescent clinic. Factors associated with violence prevention screening practices included the following: positive attitudes and beliefs regarding screening for violence, familiarity with violence prevention guidelines, use of prompts in medical records, perceptions of greater skills, and positive reinforcement from patients and colleagues for providing violence prevention services (R(2)=0.44; P<.001). Factors associated with violence prevention intervention practices included: positive attitudes and beliefs in screening for violence, availability of resources, and positive reinforcement from patients and colleagues for providing violence prevention services (R(2)=0.37; P<.001). CONCLUSIONS: California pediatricians are not widely screening their adolescent patients for risk factors associated with adolescent violence, nor are they providing interventions to their adolescent patients who may be at risk for violence. The factors associated with pediatricians' implementation of violence prevention services may assist in the development of effective interventions designed to enhance their delivery of these services to their adolescent patients.     

Longitudinal growth patterns of Pakistani infants in a clinic based growth promotion program

OBJECTIVE: To describe the operation of growth monitoring and promotion (GMP) clinic and longitudinal growth patterns of children. DESIGN: Prospective observation and intervention. SETTING: Outpatient department of a teaching hospital. METHODS: Less than 6 months old infants were registered at GMP clinic and followed for up to two years of age. Mothers were provided information, education and counselling about healthy growth of their infants. The outcome measure was change in weight after follow-up. RESULTS: We enrolled a cohort of 553 children in the first 6 months of life, of which 318 were males. Mean follow up period was 15.7 (SD+/-6.4) months. At enrollment 207 were underweight [weight-for-age Z score (WAZ<-2], of which 153 were from low-income families. The children from poorer families also gained weight regularly, although it was less than the higher income families. Of 346 infants with normal weight at registration, 305 maintained their weight gain by last follow-up visit. Of 207 underweight infants at enrollment 128 improved their weight gain by the last follow-up visit. Overall 433 infants followed-up at our GMP clinic either maintained or improved their weight gain. CONCLUSIONS: Children at risk of undernutrition should be identified at an early age and through effective interaction between health workers and the family, their growth can be improved. Children of poor families can also benefit from this activity, provided a comprehensive approach is made available.     

School-based violence prevention programs: systematic review of secondary prevention trials

OBJECTIVE: To quantify the effectiveness of school-based violence prevention programs for children identified as at risk for aggressive behavior. DESIGN: Systematic review and meta-analysis of randomized controlled trials. Electronic databases and bibliographies were systematically searched and authors and organizations were contacted to identify randomized controlled trials. Standardized, weighted mean effect sizes were assessed by meta-analysis. SETTING: Elementary, middle, and high schools. PARTICIPANTS: Children at risk for aggressive behavior. MAIN OUTCOME MEASURES: Violent injuries, observed or reported aggressive or violent behaviors, and school or agency responses to aggressive behaviors. RESULTS: Of the 44 trials identified, none reported data on violent injuries. For the 28 trials that assessed aggressive behaviors, the pooled difference between study groups was -0.36 (95% confidence interval, -0.54 to -0.19) in favor of a reduction in aggression with intervention. For the 9 trials that reported data on school or agency responses to aggression, the pooled difference was -0.59 (95% confidence interval, -1.18 to 0.01). Subgroup analyses suggested greater effectiveness in older students and when administered to mixed-sex groups rather than to boys alone. CONCLUSIONS: School-based violence prevention programs may produce reductions in aggressive and violent behaviors in children who already exhibit such behavior. These results, however, need to be confirmed in large, high-quality trials.     

The primary prevention of asthma in children study: Design of a multifaceted prevention program

The PREVASC study addresses the primary prevention of asthma in infants and small children. The objective of this study is to investigate whether a multifaceted prenatally started intervention strategy in high-risk infants leads to a decrease in the occurrence of (severe) asthma and whether a refinement of the prevention strategy leads to an increase in the adherence to the prevention program. The primary prevention program includes house dust mite impermeable bed coverings, education on breast feeding, hypoallergenic feeding, timing of introduction of solid food and smoking cessation. A total of 888 infants were prenatally included. By the time of inclusion the mothers were 3-7 months pregnant. About 27 infants were excluded from the study and 18 dropped out. Of the remaining 843 infants 535 had a first-degree familial predisposition of asthma (high-risk group), whereas a reference group of 308 (162 boys) infants was not predisposed for asthma in the first-degree (low-risk group). To evaluate the (cost-)effectiveness of the preventive intervention, 222 (118 boys) infants of the high-risk group allocated to the intervention group and 221 (112 boys) allocated to a control group are followed up. The low-risk infants served as controls to evaluate the predictive value of high risk (first-degree familial predisposition of asthma). The infants are followed from the prenatal stage until they reach the age of 6 yr. The remaining 92 high-risk infants were included in an optimized randomized-clinical adherence trial (RCAT). Of these 92 infants, 45 (20 boys) were allocated to an intervention group and 47 (24 boys) to a control group. Until now all infants have been followed for at least 1 yr.     

Controlled evaluation of a community based injury prevention program in Australia

OBJECTIVE: To evaluate the effects of a community based, all age, all injury prevention program, the Safe Living Program, on injury risk and injury rates. DESIGN: A quasiexperimental population based evaluation using an intervention and comparison community design. SETTING: The intervention community (Shire of Bulla, n = 37,257) is an outer metropolitan area of Melbourne, Australia. The demographically matched comparison community (Shire of Melton, n=33,592) is located nearby. SUBJECTS AND METHODS: The Safe Living Program in the Shire of Bulla targeted injury reduction in all settings with a focus on high risk groups. Strategies included program publicity, education and training, injury hazard reduction, and environmental change. Baseline and follow up measures of program reach, risk factors, and injury rates in both communities were used to evaluate program process, impact, and outcome. RESULTS: Increase in program awareness was moderate and similar to other community based programs. The program achieved injury hazard reduction on the road, in schools, and, to a more limited extent, in the home. Other changes in injury risk factors could not necessarily be attributed to the program as similar changes were observed in the comparison community. No significant changes were found in rates of injury deaths, hospitalisations, or emergency department presentations in the Shire of Bulla after six years. Self reported household injuries, mostly minor, were reduced in the intervention community, but had been higher at program launch than in the comparison community. CONCLUSIONS: The Safe Living Program was unable to replicate the significant reductions in injuries reported in other community based interventions. Replication of apparently successful community based injury prevention programs in different settings and populations requires evidence based interventions, sustained and effective program penetration, reliable data systems to measure change, at least one control community, and sufficient budget and time for effects to be observable.     

Implementation of a program to teach pediatric residents and faculty about domestic violence

OBJECTIVES: To obtain information about pediatric resident and staff knowledge, attitudes, and screening practices related to domestic violence (DV), to implement a domestic violence education program, and to evaluate whether the program resulted in changes in these 3 domains. DESIGN: Interventional with before and after survey evaluation. SETTING: A hospital-based, pediatric residency continuity clinic that serves families in Pittsburgh, Pa. PARTICIPANTS: Pediatric residents (n = 51), medicine-pediatric residents (n = 6), continuity clinic faculty (n = 22), and certified-registered nurse practitioners (n = 5). RESULTS: Prior to implementation of the DV education program, respondents correctly answered questions about the prevalence of DV (74 participants [90%]), the racial distribution of DV victims (66 participants [80%]), and the significant overlap between child abuse and DV (75 participants [91%]). Seventy-nine participants (96%) believed that screening for the presence of DV was part of their role as pediatric health care providers. At baseline, 17 (21%) of the 82 participants reported that they were routinely screening for signs of DV during well-child care visits compared with 39 (46%) after attending the education program (P =.005).Among participants who attended both educational session 25% (9/36) were routinely screening for the presence of DV prior to the intervention, compared with 46% (16/35) after the intervention (P =.008). At baseline, 33 (40%) of the 82 participants had identified at least 1 case of DV in the prior 6 months compared with 45 (53%) after training. Prior to training, 18 participants (22%) were aware of resources for DV victims compared with 45 (53%) after training (P<.001). CONCLUSIONS: To our knowledge, this is one of the first pediatric studies to demonstrate that using a short, multifaceted educational module, it is possible to change DV screening practices and to increase identification of DV victims among pediatric residents, continuity clinic faculty, and certified-registered nurse practitioners at a pediatric teaching hospital.     

A pilot program to identify and reverse childhood obesity in a primary care clinic

This pilot study is an innovative approach to addressing the issue of childhood obesity that starts with the primary care physician and involves group education with peers. The primary care physician assesses the child's well-being at each interaction, whether for a scheduled well-child visit or for an acute illness. At each office visit the vital signs are taken, including the height, weight, and the calculated body mass index (BMI). The BMI is a tool that helps the provider identify children who are overweight or obese. Using the patient empowerment readiness model, the provider addresses obesity with the patient and the parent to determine if they are ready to implement behavioral changes. During a 10-month period, 68 patients were enrolled in the pilot program. The initial results after the 10 months showed that when the provider identified the issue of obesity and the child was assessed for readiness and integrated in the behavioral modification program the outcome was 63% of the group reduced their BMI. It was also noted that asthma was the most frequent comorbidity in the overweight/obese children. Whereas BMI increased in a matched control group, participants in the pilot program succeeded in reducing BMI.     

National survey of pediatricians' violence prevention counseling.

BACKGROUND: Recommendations for child health care providers to counsel patients and their families on violence prevention have been issued by a number of major health care organizations. OBJECTIVE: To assess the knowledge, attitudes, training, and practices of pediatricians concerning violence prevention counseling in the areas of family violence, discipline, television viewing, peer violence, and guns in the home. DESIGN: Survey. PARTICIPANTS: A national random sample of 1350 pediatricians, divided equally among residents in their final year of training, practitioners who had completed their residency training within the last 5 years, and those who had completed their training more than 5 years ago. MAIN OUTCOME MEASURES: Knowledge, attitudes, training, and current practices regarding violence prevention counseling. RESULTS: The overall response rate was 41%. When providing health supervision to patients, most pediatricians never or rarely screen for family and community violence, peer violence, and weapons. For example, 68% of residents and 73% of practitioners never or rarely screen for domestic violence, 56% of residents and 67% of practitioners never or rarely ask adolescents about their involvement in physical fighting, and 54% of residents and 56% of practitioners never or rarely identify families who have guns in the home. Regarding preparation for providing violence prevention counseling, 76% of residents and 83% of practitioners rated their training as inadequate. Receiving training in the prevention of child/adolescent violence in medical school (P<.001), residency (P<.001), or fellowship/continuing medical education (P=.002) were major determinants of more frequent violence prevention counseling. Pediatricians who believed that parents rarely or never follow through on a physician's advice about safe gun storage, switching to nonviolent disciplining techniques, or limiting their child's television viewing were less likely to ask or advise patients in these areas. CONCLUSIONS: Pediatricians are not adequately prepared to provide violence prevention counseling, and few currently screen for exposure to family and community violence, peer violence, and access to weapons. Comprehensive information about violence prevention should be integrated into medical education, and the efficacy of violence prevention counseling strategies should be evaluated.