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Background: Diverse, equitable and inclusive participation in clinical research is needed to ensure evidence-based clinical practice and lessen disparities in health outcomes. Yet, clinical trial participation remains critically low in minoritized communities, particularly among Blacks. The Louisiana Community Engagement Alliance against COVID-19 Disparities (LA-CEAL) was launched in response to the disproportionate impact of COVID-19 on Black Louisianans to understand community barriers and preferences and increase inclusive participation in research. This study aims to understand perceptions regarding COVID-19 trial participation among underrepresented Louisianans., Methods: A rapid assessment integrating cross-sectional, surveys among federally qualified health center (FQHC) patients and community residents, and focus group discussions (FGDs) from community representatives was conducted in 2020-2021. Factors and perceptions underlying trial participation were identified using logistic regression models and thematic analyses, respectively., Results: Quantitative findings (FQHC: N=908, mean age=46.6 years, 66.4% Black; community: N=504, mean age=54.2 years, 93.7% Black) indicated that 0.9% and 3.6%, respectively, ever participated in a COVID-19 trial. Doctors/Healthcare providers were most trusted (FQHC=55.1%; community=59.3%) sources of information about trials. Advancing age was associated with increased odds of being very willing to participate (OR FQHC =1.03, 95% CI 1.02-1.05; OR Community =1.02, 95% CI 1.00-1.04). Qualitative data (6 FGDs, 29 attendees) revealed limited awareness, experimentation/exploitation-based fears, and minimal racial/ethnic representation among trialists as barriers to participation., Conclusion: COVID-19 trial participation rates were low in our sample. Altruism was a key facilitator to participation; fear, mistrust, and low awareness were predominant barriers. Community-centered approaches, engaging informed providers and trusted community members, may facilitate inclusive trial participation., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2023. Published by Elsevier Inc.)

Colorectal cancer (CRC) screening has been shown to decrease CRC mortality, yet significant disparities persist among those living in rural areas, from minority backgrounds, and those having low income. The purpose of this two-arm randomized controlled trial is to test the effectiveness and fidelity of a stepped care (increasing intensity as needed) approach to promoting 3-year adherence to CRC screening via fecal immunochemical testing (FIT) or colonoscopy in rural community clinics serving high rates of low-income and minority patients. We hypothesize that, compared to enhanced usual care (EUC), patients receiving the multifaceted CRC screening intervention will demonstrate higher rates of CRC screening completion over 3 years. Participants from six federally qualified health centers (FQHCs; N = 1200 patients) serving predominately low-income populations in rural Louisiana will be randomized to the intervention or EUC arm. All participants will receive health literacy-directed CRC counseling, simplified materials about both the FIT and colonoscopy procedures, and motivational interviewing to aid in the determination of test preference. Participants in the intervention arm will also receive motivational reminder messages from their primary care provider (via audio recording or tailored text) for either a scheduled colonoscopy or return of a completed FIT. Participants in the EUC arm will receive the standard follow-up provided by their clinic or colonoscopy facility. The primary outcome will be completion of either colonoscopy or annual FIT over 3 years. Results will provide evidence on the effectiveness of the intervention to decrease disparities in CRC screening completion related to health literacy, race, and gender. Trial registration:Clinicaltrials.gov Identifier NCT04313114., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The role pharmacies play in addressing the opioid crisis and drug-related risks such as injection drug use is evolving. Estimating the prevalence of injection drug use at the community level is challenging because of the stigma of drug use. Many community pharmacies sell nonprescription sterile syringes; thus, pharmacy-level sales of injection equipment may be an indicator of drug-related harms and unmet needs of high-risk populations., Objectives: To describe, compare, and assess the convergent validity of staff-reported nonprescription syringe (NPS) sales volume and NPS administrative sales data from community pharmacies in Massachusetts (MA) and Rhode Island (RI)., Methods: This study employed both prospective cross-sectional survey data collection and utilization of administrative pharmacy sales data. Between November 2017 and January 2018, we administered a telephone-based survey to estimate average weekly NPS type and volume for 191 chain pharmacies (CVS Health) located in communities experiencing fatal opioid overdoses above the state's 2015 annual median rate. For the same time period, we obtained NPS sales data from surveyed pharmacies and all CVS Health pharmacies in the 2 states. We calculated Spearman correlations to assess convergence of average weekly volume between pharmacy staff reports and sales data., Results: All pharmacies responded to the survey. Most (98.4%) pharmacies surveyed sold NPS, but 42.0% reported running out of stock monthly or more frequently. Pharmacy staff tended to under-report syringe sales. Staff-reported weekly NPS sales volume was 67,922 versus 70,962 syringes from administrative pharmacy sales data. Spearman correlation between reported and actual NPS sales was 0.40 (95% CI 0.27-0.51)., Conclusion: The counts of administrative pharmacy syringe sales data in MA and RI indicate high need, substantial volume, and notable access at community pharmacies. Future research should use NPS sales data rather than self-report data to track emerging trends and tailor local responses., (Copyright © 2021 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Pimodivir exerts an antiviral effect on the early stages of influenza A virus replication by inhibiting the cap-binding function of polymerase basic protein 2 (PB2). In this study, we used a combination of sequence analysis and phenotypic methods to evaluate pimodivir susceptibility of influenza A viruses collected from humans and other hosts. Screening PB2 sequences for substitutions previously associated with reduced pimodivir susceptibility revealed a very low frequency among seasonal viruses circulating in the U.S. during 2015-2020 (<0.03%; 3/11,934) and among non-seasonal viruses collected in various countries during the same period (0.2%; 18/8971). Pimodivir potently inhibited virus replication in two assays, a single-cycle HINT and a multi-cycle FRA, with IC 50 values in a nanomolar range. Median IC 50 values determined by HINT were similar for both subtypes of seasonal viruses, A(H1N1)pdm09 and A(H3N2), across three seasons. Human seasonal viruses with PB2 substitutions S324C, S324R, or N510K displayed a 27-317-fold reduced pimodivir susceptibility by HINT. In addition, pimodivir was effective at inhibiting replication of a diverse group of animal-origin viruses that have pandemic potential, including avian viruses of A(H5N6) and A(H7N9) subtypes. A rare PB2 substitution H357N was identified in an A(H4N2) subtype poultry virus that displayed >100-fold reduced pimodivir susceptibility. Our findings demonstrate a broad inhibitory activity of pimodivir and expand the existing knowledge of amino acid substitutions that can reduce susceptibility to this investigational antiviral., (Published by Elsevier B.V.)

As the population grows and shifts demographically, the resulting increase in demand for beef and milk necessitates improvements in the sustainability of ruminant livestock production systems. Ruminant livestock contribute to ensuring global food security because they have the ability to up-cycle non-human-edible products into meat and milk products with notable nutritional value. However, ruminant livestock also pose a challenge to global food sustainability because they are resource-intensive to produce and contribute substantially to agricultural greenhouse gas emissions. As such, improving environmental impacts of ruminant livestock production globally is an essential goal. There are a number of strategies that can be employed to enhance sustainability of ruminant production systems; however, improving reproductive efficiency is among the more efficient, because an increase in reproductive success will reduce the number of cows needed to produce a target quantity of beef. This reduction in the cow herd size helps limit the number of unproductive animals retained in the herd, thereby reducing the environmental maintenance cost of livestock production. Additionally, proper application of reproductive technologies enables faster and more targeted advances in genetic gains, which can be leveraged to produce phenotypes that are resource-use-efficient and well-adapted to their production environment. Optimizing reproductive efficiency can be accomplished through improved genetic selection for fertility and fecundity; applying more effective use of assisted reproductive technologies; and coupling reproductive and nutritional management to optimize likelihood of reproductive success. Collectively, applying these approaches will be essential when working to ensure ruminant livestock's contribution to global food security., (Copyright © 2020. Published by Elsevier Inc.)

Proper diabetes self-care requires patients to have considerable knowledge, a range of skills, and to sustain multiple health behaviors. Self-management interventions are needed that can be readily implemented and sustained in rural clinics with limited resources that disproportionately care for patients with limited literacy. Researchers on our team developed an evidence-based, patient-centered, low literacy intervention promoting diabetes self-care that includes: 1) the American College of Physicians (ACP) Diabetes Guide that uses plain language and descriptive photographs to teach core diabetes concepts and empower patients to initiate behavior change; 2) a brief counseling strategy to assist patients in developing short-term, explicit and attainable goals for behavior change ('action plans'); and 3) a training module for health coaches that prepares them to assume educator/counselor roles with the Diabetes Guide as a teaching tool. While the intervention has previously been field tested and found to significantly improve patient knowledge, self-efficacy, and engagement in related health behaviors, its optimal implementation is not known. This project took advantage of a unique opportunity to modify and disseminate the ACP health literacy intervention among patients with type 2 diabetes cared for at rural clinics in Arkansas that are Patient-Centered Medical Homes (PCMH). These practices all had health coaches that could be leveraged to provide chronic disease self-management mostly via phone, but also at the point-of-care. Hence we conducted a patient-randomized, pragmatic clinical trial in 6 rural PCMHs in Arkansas, targeting individuals with uncontrolled type 2 diabetes., (Published by Elsevier Inc.)

Underserved and minority populations suffer from a disproportionately high prevalence of obesity and related comorbidities. Effective obesity treatment programs delivered in primary care that produce significant weight loss are currently lacking. The purpose of this trial is to test the effectiveness of a pragmatic, high intensity lifestyle-based obesity treatment program delivered within primary care among an underserved population. We hypothesize that, relative to patients who receive usual care, patients who receive a high-intensity, health literacy- and culturally-appropriate lifestyle intervention will have greater percent reductions in body weight over 24 months. Eighteen clinics (N = 803 patients) serving low income populations with a high proportion of African Americans in Louisiana were randomized to the intervention or usual car. Patients in the intervention participate in a high-intensity lifestyle program delivered by health coaches employed by an academic health center and embedded in the primary care clinics. The program consists of weekly (16 in-person/6 telephone) sessions in the first six months, followed by sessions held at least monthly for the remaining 18 months. Primary care practitioners in usual care receive information on weight management and the current Centers for Medicare and Medicaid Services reimbursement for obesity treatment. The primary outcome is percent weight loss at 24 months. Secondary outcomes include absolute 24-month changes in body weight, waist circumference, blood pressure, fasting glucose and lipids, health-related quality of life, and weight-related quality of life. The results will provide evidence on the effectiveness of implementing high-intensity lifestyle and obesity counseling in primary care settings among underserved populations., Trial Registration: ClinicalTrials.gov Identifier NCT02561221., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: We examined patient beliefs about provider awareness of medication use, patient-reported prevalence and nature of provider counseling about medications, and the impact of health literacy on these outcomes., Methods: Structured interviews were conducted at academic general internal medicine clinics and federally qualified health centers with 500 adult patients. Interviewer-administered surveys assessed patients' beliefs, self-reported prevalence and nature of provider counseling for new prescriptions, and medication review., Results: Most patients believed their physician was aware of all their prescription and over the counter medications, and all medications prescribed by other doctors; while a minority reported disclosing over the counter and supplement use. Among those receiving new prescriptions (n=190): 51.3% reported physician medication review, 77.4% reported receiving instructions on use from physicians and 43.3% from pharmacists. Side effects were discussed 42.9% of the time by physicians and 25.8% by pharmacists. Significant differences in outcomes were observed by health literacy, age, and clinic type., Conclusions: There is a sizable gap between what patients believe physicians know about their medication regimen and what they report to the physician., Practice Implications: Discordance between patient beliefs and physician knowledge of medication regimens could negatively impact patient safety and healthcare quality., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: To create a brief assessment tool, the Medication Understanding and Use Self-Efficacy Scale (MUSE)., Methods: An existing scale (Communication and Attitudinal Self-Efficacy Scale) was modified, augmented, and piloted among 267 primary care patients in Chicago, New York City, and Shreveport, LA. Participant sociodemographics, literacy, current medication use, understanding medication instructions, and medication self-efficacy were measured., Results: Using principal components analysis, two scales emerged: taking medication and learning about medication; these two factors accounted for 55% of the total variance of understanding medication instructions. Performance on the MUSE differed by literacy level; multivariate analysis detected no interaction between literacy level and MUSE score. Regression analysis, adjusted for age, education, literacy level and number of current prescription medications indicated that participants' MUSE scores predicted patient understanding of common medication instructions (beta=0.07, 95% CI 0.001-0.14, p=0.04)., Conclusion: The MUSE is a valid and reliable tool measuring self-efficacy of understanding and using prescription medication. This scale differs from existing medication-specific self-efficacy scales as it addresses both learning about one's medications and adherence to the prescribed regimen., Practice Implications: The MUSE is an effective and brief research tool that can be utilized among participants with varying literacy levels., (Copyright (c) 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: To evaluate the usefulness of a diabetes self-management guide and a brief counseling intervention in helping patients set and achieve their behavioral goals., Methods: We conducted a quasi-experimental study using a one group pretest posttest design to assess the effectiveness of a goal setting intervention along with a self-management guide. English- and Spanish-speaking patients with diabetes had one in-person session and two telephone follow-up calls with a non-clinical provider over a 12-16-week period. At each call and at the end of the study, we assessed success in achieving behavioral goals and problem solving toward those goals. Satisfaction with the self-management guide was assessed at the end of the study., Results: We enrolled 250 patients across three sites and 229 patients completed the study. Most patients chose to set goals in diet and exercise domains. 93% of patients achieved at least one behavioral goal during the study and 73% achieved at least two behavioral goals. Many patients exhibited problem solving behavior to achieve their goals. We found no significant differences in reported achievement of behavior goals by literacy or language. Patients were very satisfied with the guide., Conclusions: A brief goal setting intervention along with a diabetes self-management guide helped patients set and achieve healthy behavioral goals., Practice Implications: Non-clinical providers can successfully help a diverse range of patients with diabetes set and achieve behavioral goals.

Objective: To determine whether literacy mediates the association between education, hypertension knowledge and control., Methods: In-person interviews with a literacy assessment and chart review were conducted with 330 hypertensive patients from six primary care safety net clinics. Mediational analysis was used to test the role of literacy skills in explaining the relationship between education and hypertension knowledge and control., Results: In multivariate analyses that did not make an adjustment for the other variable, both lower educational attainment and more limited literacy were found to be significant independent predictors of poorer hypertension knowledge and control. When literacy was entered into models that included education only, the association between education and knowledge was fully attenuated and no longer significant (Grades 1-8: beta=-0.30, 95% CI=-1.44-0.83), while the relationship between education and blood pressure control was only minimally reduced (AOR 2.46, 95% CI 2.10-2.88). More limited literacy skills also was associated with hypertension control in the final model (AOR 2.68, 95% CI 1.54-4.70)., Conclusion: Patient literacy mediated the relationship between education and hypertension knowledge. Literacy was a significant independent predictor of blood pressure control, but only minimally explained the relationship between education and blood pressure., Practice Implications: Health literacy is critical to the design of educational tools to improve knowledge acquisition. However, in order to impact health outcome, future health literacy studies should also address other psychosocial factors that impact motivation and capability to manage disease.

Objective: In this pilot study, we evaluated the impact of providing patients with a literacy-appropriate diabetes education guide accompanied by brief counseling designed for use in primary care., Methods: We provided the Living with Diabetes guide and brief behavior change counseling to 250 English and Spanish speaking patients with type 2 diabetes. Counseling sessions using collaborative goal setting occurred at baseline and by telephone at 2 and 4 weeks. We measured patients' activation, self-efficacy, diabetes distress, knowledge, and self-care at baseline and 3-month follow-up., Results: Statistically significant (p

Objective: To use a patient-centered approach to refine warning labels promoting the safe use of prescription drugs among patients, regardless of literacy level., Methods: Ten discussion groups were conducted among adults recruited from a general internal medicine clinic and four adult education classes. Participants completed face-to-face cognitive interviews with literacy assessment to determine comprehension of the 10 most commonly used drug warning labels, followed by a discussion group that solicited feedback for revising text and icons., Results: In all, 85 adults participated; 56% had limited literacy skills. Feedback from discussion groups indicated that the majority of icons were confusing, used difficult language, and text and icons were often discordant. Participants sought actionable language in the most simple and concise manner. In comprehension testing, five of the warning labels reached a set standard of >80% comprehension; the remaining labels were revised and three others modified on patients' request. A universal icon that conveyed 'Caution' was used for one label ("use only on your skin") as patients were unable to agree on an acceptable visual representation., Conclusion: A patient-centered approach to designing consumer medication information could improve the comprehensibility of existing warning labels., Practice Implications: Pharmacies should review existing drug warnings to assess adequacy among patients, particularly those with limited literacy. Pharmacists should confirm patients understand auxiliary warnings to support safe and effective use.

Objective: To assess the efficacy of a literacy-appropriate weight loss intervention targeting providers and patients in improving physicians' weight loss counseling and patients' self-reported beliefs, and self-efficacy., Methods: The study took place in a public hospital nephrology clinic. The intervention included two physician workshops and a small group patient education. Physician-patient communication was observed and coded. Structured interviews assessed patient recall of weight loss recommendations, weight-related beliefs, and self-efficacy., Results: 64 patient visits were observed before and after the intervention. 75% of patients were African American, 96% lacked private insurance, 71% had low literacy skills; mean body mass index (BMI) of 35 kg/m(2). Physician counseling improved significantly post-intervention, particularly in assessing, supporting and advising patients about weight loss and exercise. Patients reported increases in recall of weight loss recommendations and were more likely to report greater confidence about losing weight (52% vs. 70%, p<0.01)., Conclusions: This pilot study offers promising directions to address provider and patient barriers to weight loss education and counseling in a public hospital., Practice Implications: Hospital-based weight loss interventions need to target both physicians and patients.

Objective: To examine the nature and cause of patients' misunderstanding common dosage instructions on prescription drug container labels., Methods: In-person cognitive interviews including a literacy assessment were conducted among 395 patients at one of three primary care clinics in Shreveport, Louisiana, Jackson, Michigan and Chicago, Illinois. Patients were asked to read and demonstrate understanding of dosage instructions for five common prescription medications. Correct understanding was determined by a panel of blinded physician raters reviewing patient verbatim responses. Qualitative methods were employed to code incorrect responses and generate themes regarding causes for misunderstanding., Results: Rates of misunderstanding for the five dosage instructions ranged from 8 to 33%. Patients with low literacy had higher rates of misunderstanding compared to those with marginal or adequate literacy (63% versus 51% versus 38%, p<0.001). The 374 (19%) incorrect responses were qualitatively reviewed. Six themes were derived to describe the common causes for misunderstanding: label language, complexity of instructions, implicit versus explicit dosage intervals, presence of distractors, label familiarity, and attentiveness to label instructions., Conclusion: Misunderstanding dosage instructions on prescription drug labels is common. While limited literacy is associated with misunderstanding, the instructions themselves are awkwardly phrased, vague, and unnecessarily difficult., Practice Implications: Prescription drug labels should use explicit dosing intervals, clear and simple language, within a patient-friendly label format. Health literacy and cognitive factors research should be consulted.

Objective: We examined the relationship between patient literacy level and self-reported HIV medication adherence, while estimating the mediating roles of treatment knowledge and self-efficacy on this relationship., Methods: Structured patient interviews with a literacy assessment, supplemented by medical chart review, were conducted among 204 consecutive patients receiving care at infectious disease clinics in Shreveport, Louisiana and Chicago, Illinois. Literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM), while the Patient Medication Adherence Questionnaire (PMAQ) was used to assess medication self-efficacy and adherence to antiretroviral regimens in the past 4 days., Results: Approximately one-third of patients (30.4%) were less than 100% adherent to their regimen, and 31.4% had marginal to low literacy skills. In multivariate analyses, low literate patients were 3.3 times more likely to be non-adherent to their antiretroviral regimen (p < 0.001). Patients' self-efficacy, but not knowledge, mediated the impact of low literacy on medication adherence (AOR 7.4, 95% CI 2.7-12.5)., Conclusion: While low literacy was a significant risk factor for improper adherence to HIV medication regimens in our study, self-efficacy mediated this relationship., Practice Implications: Comprehensive intervention strategies that go beyond knowledge transfer may be needed to address self-efficacy among patients across all literacy levels to be successful in the management of difficult medication schedules.

Objective: To investigate whether consumer-directed, FDA-approved Medication Guides issued for potentially harmful medications are likely to be useful to patients with limited literacy., Methods: Lexile analysis and the suitability assessment of materials (SAM) were conducted on the 40 currently issued Medication Guides to evaluate reading difficulty, content, and format. Structured interviews with a literacy assessment were also conducted among 251 primary care patients at a public hospital clinic in Louisiana to determine if patients directed attention to Medication Guides and other accompanying patient information materials., Results: The average Lexile score estimated an 11th-12th grade reading level for the guides (M=1223, S.D.=200). None of the 40 Medication Guides met federal recommendations (6th-8th grade level). Most Medication Guides were deemed unsuitable because they did not provide a summary of content (90.0%) or limit the scope of information (77.5%). Only 23.0% of patients reported having looked at Medication Guides or accompanying patient information materials; patients with low literacy were less likely to have looked at them (16.7% versus 32.9%, p=0.03)., Conclusion: Medication Guides in their current form are not likely to be useful to patients with limited literacy skills., Practice Implications: Reading level of text in Medication Guides should be reduced, summaries or "highlights" provided, and the scope of information limited to increase the likelihood of use among individuals with limited literacy. Consumers should be involved in their development.

Introduction: The National Childhood Vaccine Injury Act (NCVIA) requires that physicians distribute the appropriate Vaccine Information Statements (VIS) at each immunization visit and discuss the risks/benefits of every vaccine given. In a national study, 31% of pediatricians reported not using the VIS and 56% indicated that time was a barrier to vaccine risk/benefit communication. Parents, however, indicated they want their primary providers to personally tell them about risks/benefits., Objective: To test the feasibility of an Immunization Education Package (IEP) intervention to improve compliance with the federal mandate and to improve physician/parent vaccine risk/benefit communication., Setting: Two multi-physician private pediatric practices in Shreveport, La., Design: A before-after trial with comparison of 130 pre-intervention and 78 post-intervention visits. Research assistants recorded content and duration of immunization discussions during well-baby visits during which immunizations were scheduled. Clinic staffs were masked as to variables recorded., Intervention: The IEP was a multifaceted intervention, involving a practice-based in-service and distribution and discussion of ready-to-use materials including an exam room poster entitled "7 Questions Parents Need To Ask About Baby Shots.", Results: Patients were 90% white and 96% privately insured. Pre and post results revealed a significant increase in VIS distribution (33% vs 91%, P <.001) and physician and nurse initiation of verbal teaching about the vaccine (65% vs 100%, 32% vs 72%, respectively; P <.001 for both), and parent initiation of questions (0% vs 32%, P <.001). A significant increase was found in the discussion of 6 of 8 major immunization IEP topics: contraindications, common side effects, treatment of common side effects, severe side effects, management of severe side effects, and schedule of the next vaccination. These vaccine communication improvements were made with a very small (20-s) increase in physician time. In post-intervention focus groups, provider staff endorsed the IEP method., Conclusions: This IEP was a feasible way to facilitate compliance with the NCVIA. A significant amount of additional information was provided to parents with only a slight increase in time.

Purpose: To investigate the relationship between inadequate literacy and violent behavior among adolescents., Methods: This descriptive study involved a convenience sample of 386 adolescents who participated in a summer track and field and literacy program serving youths in low-income neighborhoods in Shreveport, Louisiana, during 1994-1996. Self-reported violence was measured using the Youth Risk Behavior Survey (YRBS) and reading grade levels were measured by the Slosson Oral Reading Test-Revised (SORT-R)., Results: Youths ranged in age from 11 to 18 years; 66% were male, and 86% were African-American. Forty-three percent of adolescents tested had below-grade reading levels (> or = 2 grades). Participants with below-grade reading skills had higher rates of self-reported violent behaviors compared with those reading at grade level. When gender, race, and age were controlled for, adolescents reading below grade level were significantly more likely to report carrying weapons [odds ratio (OR) = 1.9; 95% confidence interval (CI) 1.1-3.5], carrying guns (OR = 2.6; CI 1.1- 6.2), to have been in a physical fight at school (OR = 1.7; CI 1.1-2.6), and to have been in a physical fight resulting in injuries requiring treatment (OR = 3.1; CI 1.6-6.1). In addition, youths reading below grade level were significantly more likely to be threatened at school with a weapon (OR = 2.1; CI 1.2-3.7) and to report missing days of school in the previous 30 days because they felt unsafe at school (OR = 2.3; CI 1.3-4.3). In characterizing the violence related behaviors, we found that low reading-level adolescents were more likely to be both aggressor/perpetrator and victim (44% vs. 32%; p = .02) and less likely to be only a victim (6% vs. 12%; p = .04) compared to adolescents with grade-appropriate reading skills., Conclusions: Below-grade-level reading was significantly related to violence behaviors among adolescents who volunteered for a summer track and field program. Longitudinal studies are needed to further investigate the relationship of below-grade-level reading and aggressive/perpetrator and victim behaviors.

Purpose: The purpose of this study was to compare attitudes toward violence and weapon-carrying among seventh-grade students in three dissimilar U.S. communities. A second focus was to determine students' understanding of their parents' violence-related guidance and behavior., Methods: Five hundred sixty-seven seventh-grade students (48% male, 46% white, 35% African-American, 13% Latino) completed a self-administered questionnaire in May or October 1991., Results: Thirty-four percent of the students had fought at least once, and 7% more than four times during the previous month. Also, within that period, 5% had skipped school owing to fear of violence. Students whose parents used nonviolent disciplinary techniques fought less frequently than those whose parents relied on hitting and more violent disciplinary methods (p < 0.001). Fighting was significantly more common among students who believe their parents want them to fight if insulted (p = 0.001). Students who reported that they try to stay out of fights usually succeeded (p = 0.001). Those students who more frequently participated in and observed fighting were more likely to carry a weapon (p = 0.001)., Conclusions: Fighting is a frequent occurrence in the lives of seventh-grade students. Students' understanding of their parents' attitudes and behavior correlate strongly with violent behavior. While many students feel that weapons confer safety, those students who actually carry weapons are much more likely to fight.

Purpose: To determine the characteristics of recent fights among seventh-grade students at public middle schools in three dissimilar U.S. communities., Methods: The study sample was composed of 289 seventh-grade students at public middle schools in three U.S. communities who participated in fights during the previous 6 months. Students at each site completed a self-administered two-part questionnaire (developed for this study) in May or October 1991. Pearson Chi-square test was performed to determine the association among characteristics of the fights, weapon use, and injury severity., Results: One or more weapons were present at 43% of the fights, weapons were used to threaten or injure in 23%, and stab or gunshot wounds were reported in 10%. Fights with five or more participants or with participants who were intoxicated or gang members involved more weapon use and more severe injury (p < 0.02). There was more frequent weapon use occurring away from home and school (p < 0.01). Spectators were present at 87% of the fights, and when they attempted to mediate or end the fighting, injury severity was lower. Students who often carry a weapon were much more likely to report involvement in fights in which weapons were used and to suffer more severe injuries (p < 0.02)., Conclusions: Seventh-graders' fights frequently involve the threat and actual use of weapons. The large number of participants and spectators at many of the fights with the most severely injurious outcomes implies that social factors and not exclusively poor conflict resolution skills are important factors precipitating fights among seventh-grade students.

We used a randomized trial to compare two polio vaccine pamphlets written on a sixth grade level--the vaccine information statement prepared by the Centers for Disease Control (CDC) and an easy-to-read pamphlet we developed (LSU)--for reading ability, comprehension and preference among 610 parents with a broad range of demographic characteristics. Parents at all reading levels and incomes preferred LSU (76% vs. 21%, P < 0.001). Although readers of LSU achieved significantly higher comprehension (65% vs. 60%, P < 0.05) this difference may not be clinically significant. The information items presented with instructional graphics were the only items on which differences in comprehension levels achieved both clinical and statistical significance. Comprehension was lowest for the CDC mandated information on risks and the National Injury Compensation. Our findings demonstrate that simplifying written immunization material and making it more suitable will increase appeal, but such modification may not raise comprehension to an acceptable level without use of instructional graphics. Health education materials intended for general parent populations, which are written on a sixth grade reading level, may not adequately educate parents or prepare them for a discussion with their physicians.

Purpose: The purpose of this study was to compare tobacco use among high school male athletes with their nonathlete counterparts. We hypothesized that there was an inverse correlation between the intensity level of the sport and frequency of tobacco use., Methods: Students were surveyed at seven high schools in northwest Louisiana using a 109-item questionnaire. Of the 1,200 males tested, 83% participated in one or more sports. The mean age was 15.8, and mean grade level was 10th. Sixty-seven percent were white, 27% African-American (AA), and 6% other., Results: Forty-one percent of the adolescent males tested were one or more tobacco products, 31% reported cigarette smoking, 21% chewed tobacco, and 18% used snuff. Eleven percent reported using all three tobacco products. Race was a significant determinant of tobacco use, with whites being more likely to use each of the three tobacco products (P < .001). Medium- and high-intensity athletes were significantly (P < .01) less likely to be heavy smokers than athletes participating in low-intensity sports and nonathletes. However, athletes of each intensity sport used chewing tobacco and snuff at significantly higher rates (P < .001) than nonathletes. When race and grade point average were controlled, sports intensity was a significant predictor of smokeless tobacco use but not overall smoking behavior. Both AA and white high school male athletes at all sport intensity levels were using chewing tobacco and snuff at a rate higher at least 1.5 times that of their nonathlete counterparts., Conclusions: In our study, high school males' sports participation was a predictor of smokeless tobacco use but not overall smoking behavior. Although the probability of AA high school athletes using smokeless tobacco was low compared to whites, the pattern of use was similar across intensity levels of sports.

To participate effectively in their health care, older patients often are expected to read a wide variety of materials, including written instructions, brochures, and consent forms. This study quantitates the reading ability of older patients and compares it to that of younger patients. Two hundred seventy-two patients 30 and older were selected from five outpatient clinics at a public teaching hospital and tested for objective reading ability using the Peabody Individual Achievement Test--Revised. The 76 patients 60 and older read significantly worse (grade level 2.9) than the 196 patients younger than 60 (grade level 5.8) (P < 0.0001). Older patients also completed significantly fewer years of school than younger patients (7.3 years versus 10.6 years). Analysis of variance for age categories 30-44, 45-59, 60-74, and 75 and older confirmed declining reading ability and educational status with advancing age. Multiple regression analysis helped show that an equation could be derived to predict reading ability from age, educational status, race, and sex, but the coefficient of determination was so low (r2 = 0.39) that it cannot be considered clinically useful for individual patients. In this study, older patients read significantly worse than younger patients, and a formula that combines age, race, sex, and educational status cannot reliably predict reading ability for individual patients. Most older patients read on a level so low that they cannot be expected to read most commonly used written materials. Routine testing of reading ability may allow more appropriate design and use of written materials.

The purpose of this study was to determine the prevalence of forced sex among high school students and to assess student attitudes about it. The questionnaires were given in conjunction with a presentation on date rape to 9th through 12th grade students in health and science classes in three large metropolitan Louisiana public high schools. The first questionnaire, given before the presentation, elicited demographic information and attitudes about forced sex in 11 scenarios; the second, given after the program, asked if the student had ever been in a situation involving forced sex and, if so, whether he or she had told anyone. The two questionnaires were completed by all 237 students. Although one out of five students (20%) reported they had experienced forced sex, only half had told about the experience. A majority of boys (60%) found it acceptable in one or more situations for a boy to force sex on a girl. Male, black, and older students were significantly more likely (p < 0.05) to indicate that it was acceptable for a boy to force sex on a girl in certain circumstances. These findings should alert physicians to the risk of acquaintance rape among their high school student patients. Student attitudes, particularly those of males, may provide an important focus of preventive sex education in the physician's office, the classroom, and the community.