Search

Background.-Although national guidelines recommend controller medications for children with persistent asthma, adherence is poor. Prior studies have begun to explore parental beliefs regarding controller asthma medications and their effect on adherence. Objective.-To describe parental beliefs about controller medications among a community-based sample of urban children with persistent asthma and to examine the relationship between parental beliefs and adherence. Design/Methods.-Parents of 150 children with asthma completed a telephone survey as part of a larger asthma intervention. Parents of children using controller asthma medications were included in this study. A previously validated Beliefs About Medications Questionnaire (BMQ) was used, which included two subscales: necessity and concern. The relationship between parental beliefs about medications and medication adherence was assessed using bivariate linear regression and multivariate statistics. Results.-This study included 67 children with parental report of controller medication (54% male, 61% African American, 69% Medicaid). Overall, 75% of parents strongly believed that their child's medications were necessary for their health and 34% had strong concerns about the medications. Only 22% of parents reported being completely adherent with medications. Parents with greater concern about medications were more likely to have poor adherence (P < .05). In a multivariate analysis, including both BMQ subscales and asthma severity, concern about medications significantly predicted poor medication adherence (P = .03). Conclusions.-Parental concerns about controller medications were associated with poor medication adherence for this population of urban children with asthma. These findings highlight the importance of addressing parental concerns at the time of medication prescription. [ABSTRACT FROM AUTHOR]

There has been an increase in intimate partner violence (IPV) research regarding the deaf population; however, no studies to date obtained data directly from members of the deaf population who disclose IPV perpetration. This community-based participatory research study explored the social context of IPV perpetration involving the deaf population through interviews with deaf or hard-of-hearing individuals who self-identified as perpetrating either physical or sexual abuse in an intimate relationship where at least one partner was deaf. Through semi-structured interviews using video relay, an interdisciplinary research team, which included deaf investigators, explored questions which included IPV triggers, types of IPV, weapon use, childhood victimization, and interactions with first responders and response systems (e.g., criminal justice, medical). The types of IPV abuse, resulting injuries, and systems used are discussed. The team collectively identified key elements of abuse and their relationships to each other through concept mapping of each interview. Through a method of constant comparison, we identified several themes: intergenerational transmission of violence, fund of information concerns, communication barriers with family and friends and resulting frustration, and help-seeking challenges. Many of these themes are specific to the deaf population, illustrating the need for continued research to understand IPV in diverse communities. Findings are compared with IPV trends in the general (hearing) population, and prompt concerns that universal IPV interventions may not effectively address the needs of the deaf population. Recommendations for diversifying screening efforts, modifying screening tools, and tailoring interventions to better address IPV involving deaf and hard-of-hearing populations are discussed.

Objective: Quantitative studies have demonstrated that social capital can positively impact community health, but qualitative explorations of the factors mediating this relationship are lacking. Furthermore, while the world's poor are becoming increasingly concentrated in the cities of lower-middle income countries, most of the existing literature on social capital and health explores these variables in Western or rural contexts. Even fewer studies consider the impact of social constructs like race, gender, or class on the creation of social capital and its operationalization in health promotion.Our study aimed to address these gaps in the literature through an ethnographic exploration of social capital among women living in Kaula Bandar (KB) - a marginalized slum on the eastern waterfront of Mumbai, India. We then sought to identify how these women leveraged their social capital to promote health within their households., Methods: This was a mixed-method, qualitative study involving participant observation and 20 in-depth, semi-structured, individual interviews over a nine-month period. Field notes and interview transcripts were manually analyzed for recurring content and themes., Results: We found that women in KB relied heavily on bonding social capital for both daily survival and survival during a health crisis, but that the local contexts of gender and poverty actively impeded the ability of women in this community to build forms of social capital - namely bridging or linking social capital - that could be leveraged for health promotion beyond immediate survival., Conclusions: These findings illustrate the context-specific challenges that women living in urban poverty face in their efforts to build social capital and promote health within their households and communities. Community-based qualitative studies are needed to identify the macro- and micro-level forces, like gender and class oppression, in which these challenges are rooted. Directly addressing these structural inequalities significantly increases the potential for health promotion through social capital formation.

Women with substance use disorders (SUDs) often experience inadequate health care, mental and physical health problems, trauma, lack of social support, and undermining of support for psychological needs of autonomy, competence, and relatedness needed for motivation and well-being. For women with SUD trying to reclaim sobriety and a healthy life, family can present both barriers and support. The aim of this study is to gain a deeper understanding of the intersection of family relationships with motivation of women in Drug Treatment Court (DTC) to attain their health goals. Data consist of transcribed intervention sessions between trained peer interventionists and 15 DTC participants from The Women's Initiative Supporting Health DTC Intervention Study. This analysis uses a qualitative framework approach to analyze the data. The Self-determination Theory of human motivation and Family Systems Theory provide the conceptual framework to understand how participants' expressions of motivation-related basic needs of autonomy, competence, and relatedness and change-related behaviors interfaced with family support. Analysis revealed more mentions of family in motivation-supportive contexts than in motivation-thwarting contexts, but highlighted complex roles families can play in health of women in recovery from SUD. Providers may be able to incorporate this knowledge to address the needs of this challenging population., Competing Interests: Declaration of conflicting interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

While in recent years, intimate partner violence (IPV) has attracted considerable research attention, the experiences of IPV affecting the Deaf community have been understudied. As a linguistic and cultural minority, Deaf victims of IPV encounter significant barriers in accessing information and services designed to address the medical and legal consequences of victimization. The number of Deaf Americans who communicate via American Sign Language (ASL) may well exceed a half-million, yet little is known about Deaf IPV victims' experiences and the characteristics of persons who perpetrate IPV with ASL users. This study addressed both topics. The current study is based on interviews in ASL with 14 Deaf IPV victims (participants). We explored: the types of abuse participants experienced; characteristics of victims and perpetrators; participants' help-seeking behaviors; and the availability, use, and helpfulness of various resources. These findings were compared to what is known about IPV in the hearing community. Our findings include that lack of information regarding IPV and lack of access to specialized IPV services were pervasive problems affecting Deaf victims. For some victims, the close-knit nature of the Deaf community was a barrier for discussing IPV and accessing information and support. It was common for Deaf victims to receive services or information about IPV from providers who were not IPV specialists. Communication abuse was prevalent in our study. The nature of communication abuse is unique for Deaf victims compared to hearing victims.

Objectives: We assessed the effects of a worksite multiple-component intervention addressing diet and physical activity on employees' mean body mass index (BMI) and the percentage of employees who were overweight or obese., Methods: This group-randomized trial (n = 3799) was conducted at 10 worksites in the northeastern United States. Worksites were paired and allocated into intervention and control conditions. Within- and between-groups changes in mean BMIs and in the percentage of overweight or obese employees were examined in a volunteer sample., Results: Within-group mean BMIs decreased by 0.54 kilograms per meter squared (P = .02) and 0.12 kilograms per meter squared (P = .73) at the intervention and control worksites, respectively, resulting in a difference in differences (DID) decrease of 0.42 kilograms per meter squared (P = .33). The within-group percentage of overweight or obese employees decreased by 3.7% (P = .07) at the intervention worksites and increased by 4.9% (P = .1) at the control worksites, resulting in a DID decline of 8.6% (P = .02)., Conclusions: Our findings support a worksite population strategy that might eventually reduce the prevalence of overweight and obesity by minimizing environmental exposures to calorically dense foods and increasing exposures to opportunities for energy expenditure within worksite settings.

Fetal alcohol spectrum disorders (FASD) impact 2-5% of the US population and are associated with life-long cognitive and behavioral impairments. Individuals with FASD have high rates of secondary conditions, including mental health problems, school disruptions, and trouble with the law. This study focuses on systems-level barriers that contribute to secondary conditions and interfere with prevention and treatment. Using a phenomenological methodology, semi-structured interviews and focus groups were conducted with parents of children with FASD and service providers. Data were analyzed using a framework approach. Participants emphasized the pervasive lack of knowledge of FASD throughout multiple systems. This lack of knowledge contributes to multi-system barriers including delayed diagnosis, unavailability of services, and difficulty qualifying for, implementing, and maintaining services. FASD is a major public health problem. Broad system changes using a public health approach are needed to increase awareness and understanding of FASD, improve access to diagnostic and therapeutic services, and create responsive institutional policies to prevent secondary conditions. These changes are essential to improve outcomes for individuals with FASD and their families and facilitate dissemination of empirically supported interventions.

Worksites provide multiple advantages to prevent and treat obesity and to test environmental interventions to tackle its multiple causal factors. We present a literature review of group-randomized and non-randomized trials that tested worksite environmental, multiple component interventions for obesity prevention and control paying particular attention to the conduct of formative research prior to intervention development. The evidence on environmental interventions on measures of obesity appears to be strong since most of the studies have a low (4/8) and unclear (2/8) risk of bias. Among the studies reviewed whose potential risk of bias was low, the magnitude of the effect was modest and sometimes in the unexpected direction. None of the four studies describing an explicit formative research stage with clear integration of findings into the intervention was able to demonstrate an effect on the main outcome of interest. We present alternative explanation for the findings and recommendations for future research.

Background: Fetal alcohol spectrum disorders (FASD) are a major public health problem that affects 2 to 5 percent of the population. Individuals with FASD are at high risk for secondary conditions, such as mental health problems, school disruptions, and trouble with the law. Evidence-based intervention programs are needed to prevent and treat secondary conditions in this population., Objectives: The purpose of this study was to identify intervention program characteristics for preventing secondary conditions in individuals with FASD from the perspectives of parents and service providers., Methods: This qualitative study utilized a phenomenological approach to identify program characteristics for preventing secondary conditions. Twenty-five parents of children (ages 3 to 33) with FASD and 18 service providers participated in focus groups or individual interviews. Data was systematically analyzed using a framework approach. Themes did not differ by participant type., Results: Participants emphasized five primary characteristics of intervention programs for individuals with FASD. Programs need to 1) be available to individuals across the lifespan, 2) have a prevention focus, 3) be individualized, 4) be comprehensive, and 5) be coordinated across systems and developmental stages. Participants discussed a variety of specific intervention strategies for each developmental stage and setting., Conclusions: Program characteristics identified in this study are consistent with a positive behavior support framework. This framework is discussed in the context of research on existing interventions for individuals with FASD, and recommendations for future intervention development and evaluation are highlighted.

Background: Deaf mothers who use American Sign Language (ASL) consider themselves a linguistic minority group, with specific cultural practices. Rarely has this group been engaged in infant-feeding research., Objectives: To understand how Deaf mothers who use ASL learn about infant feeding and to identify their breastfeeding challenges., Methods: Using a community-based participatory research approach, we conducted 4 focus groups with Deaf mothers who had at least 1 child 0-5 years old. A script was developed using a social ecological model (SEM) to capture multiple levels of influence. All groups were conducted in ASL, filmed, and transcribed into English. Deaf and hearing researchers analyzed data by coding themes within each SEM level., Results: Fifteen mothers participated. All had initiated breastfeeding with their most recent child. Breastfeeding duration for 8 of the mothers was 3 weeks to 12 months. Seven of the mothers were still breastfeeding, the longest for 19 months. Those mothers who breastfed longer described a supportive social environment and the ability to surmount challenges. Participants described characteristics of Deaf culture such as direct communication, sharing information, use of technology, language access through interpreters and ASL-using providers, and strong self-advocacy skills. Finally, mothers used the sign for "struggle" to describe their breastfeeding experience. The sign implies a sustained effort over time that leads to success., Conclusion: In a setting with a large population of Deaf women and ASL-using providers, we identified several aspects of Deaf culture and language that support breastfeeding mothers across institutional, community, and interpersonal levels of the SEM.

Background: Cardiovascular disease leads in overall mortality and morbidity in the United States. Cardiovascular disparities remain high among minority and underserved groups. Deaf American Sign Language (ASL) users are an underserved and understudied group that receives little attention from researchers due to language and communication barriers. A recent ASL survey in Rochester, NY, indicated greater cardiovascular risk among Deaf participants. The study objective was to investigate risk perceptions of cardiovascular disease among Deaf ASL users, linking perceptions to features of Deaf culture and communication. This information will be used to inform future strategies to promote cardiovascular health among Deaf adults., Methods and Participants: Four focus groups were conducted in Rochester, New York, with 22 Deaf participants in ASL. Videotaped sessions were translated and transcribed by a bilingual researcher. A team of investigators coded, analyzed, and identified key themes from the data., Main Results: Themes centered on five major domains: knowledge, barriers, facilitators, practices, and dissemination. The majority of themes focused on barriers and knowledge. Barriers included lack of health care information access due to language and communication challenges, financial constraints, and stress. Inconsistent knowledge emerged from many key areas of cardiovascular health., Conclusions: The study outlines key themes for improving cardiovascular health knowledge and perceptions among Deaf ASL users. Findings suggest the importance of providing health educational programs and information in ASL to maximize understanding and minimize misconceptions. When caring for Deaf ASL users, providers should take extra effort to ask about cardiovascular risk factors and confirm patients' understanding of these factors., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: More than 30% of the pregnancies in women aged 35 and over are unintended. This paper compares perceptions about contraceptive methods and use among women with and without an unintended pregnancy after turning age 35., Methods: Semi-structured, in-depth interviews were conducted with 17 women. They were all 35 to 49 years old, regularly menstruating, sexually active, not sterilized, not desiring a pregnancy in the near future, and at least 3 months postpartum. We purposely sampled for women who had had at least one unintended pregnancy after age 35 (n = 9) and women who did not (n = 8). We assessed partnership, views of pregnancy and motherhood, desired lifestyle, perceived advantages and disadvantages of using and obtaining currently available well-known reversible contraceptives in the U.S. ''We also assessed contraceptive methods used at any time during their reproductive years, including current method use and, if appropriate, circumstances surrounding an unintended pregnancy after age 35.'' Each interview was taped and transcribed verbatim. Data were analyzed using Grounded Theory. Analysis focused on partnership, views of pregnancy, motherhood, desired lifestyle and perceived advantages and disadvantages of various reversible contraceptive methods., Results: The women without an unintended pregnancy after age 35 were more likely to (1) use contraceptive methods that helped treat a medical condition, (2) consider pregnancy as dangerous, or (3) express concerns about the responsibilities of motherhood. The women who experienced an unintended pregnancy after age 35 were more likely to (1) report unstable partnerships, (2) perceive themselves at lower risk of pregnancy, or (3) report past experiences with unwanted contraceptive side effects. There was a greater likelihood a woman would choose a contraceptive method if it was perceived as easy to use, accessible, affordable and had minimal side effects., Conclusions: Women's perspective on contraceptive use after age 35 varies. Public health messages and health providers' care can help women in this age group by reviewing their fertility risks, as well as all contraceptive methods and their associated side effects. The impact of such interventions on unintended pregnancy rates in this age group should be tested in other areas of evidence-based medicine.

Objective: To identify emergency medical services (EMS) provider perceptions of factors that may affect the occurrence, identification, reporting, and reduction of near misses and adverse events in the pediatric EMS patient., Methods: This was a subgroup analysis of a qualitative study examining the nature of near misses and adverse events in EMS as it relates to pediatric prehospital care. Complementary qualitative methods of focus groups, interviews, and anonymous event reporting were used to collect results and emerging themes were identified and assigned to specific analytic domains., Results: Eleven anonymous event reports, 17 semistructured interviews, and two focus groups identified 61 total events, of which 12 were child-related. Eight of those were characterized by participants as having resulted in no injury, two resulted in potential injury, and two involved an ultimate fatality. Three analytic domains were identified, which included the following five themes: reporting is uncommon, blaming errors on others, provider stress/discomfort, errors of omission, and limited training. Among perceived causes of events, participants noted factors relating to management problems specific to pediatrics, problems with procedural skill performance, medication problems/calculation errors, improper equipment size, parental interference, and omission of treatment related to providers' discomfort with the patient's age. Few participants spoke about errors they had committed themselves; most discussions centered on errors participants had observed being made by others., Conclusions: It appears that adverse events and near misses in the pediatric EMS environment may go unreported in a large proportion of cases. Participants attributed the occurrence of errors to the stress and anxiety produced by a lack of familiarity with pediatric patients and to a reluctance to cause pain or potential harm, as well as to inadequate practical training and experience in caring for the pediatric population. Errors of omission, rather than those of commission, were perceived to predominate. This study provides a foundation on which to base additional studies of both a qualitative and quantitative nature that will shed further light on the factors contributing to the occurrence, reporting, and mitigation of adverse events and near misses in the pediatric EMS setting.

Introduction: Cardiovascular disease is the leading cause of deaths and illnesses in US adults, and the prevalence is disproportionately high in underserved populations. In this study, we assessed respondents' understanding of context-specific differences in knowledge and perceptions of disease, risk, and prevention in 6 underserved communities, with the longer-term goal of developing appropriate interventions., Methods: Thirty-nine small-group sessions and 14 interviews yielded data from 318 adults. Each site's researchers coded, analyzed, and extracted key themes from local data. Investigators from all sites synthesized results and identified common themes and differences., Results: Themes clustered in 3 areas (barriers to cardiovascular health, constraints related to multiple roles, and suggestions for effective communications and programs). Barriers spanned individual, social and cultural, and environmental levels; women in particular cited multiple roles (eg, competing demands, lack of self-care). Programmatic suggestions included the following: personal, interactive, social context; information in language that people use; activities built around cultural values and interests; and community orientation. In addition, respondents preferred health-related information from trusted groups (eg, AARP), health care providers (but with noticeable differences of opinion), family and friends, and printed materials., Conclusion: Interventions to decrease barriers to cardiovascular health are needed; these strategies should include family and community context, small groups, interactive methods, culturally sensitive materials, and trusted information sources. New-immigrant communities need culturally and linguistically tailored education before receiving more substantive interventions.

Exclusive breastfeeding of infants for the first 6 months of life with continued breastfeeding for at least 6 more months occurs only 11.9% of the time in the United States. Efforts of the past 30 years to promote optimal breastfeeding practices have had little impact. In order to create significant change in the way we feed infants in this country, we need to change the way we look at this public health issue and examine the cultural logic that makes bottle feeding the preferred choice of most U.S. women. This article analyzes the term "inadequate" not just as self-description of a woman's milk supply, but also as a metaphor for the lives of low-income women in the United States, the group least likely to breastfeed. Low-income women in the United States not only have inadequate incomes as compared to the general population, but inadequate child care, education, preventive health services, inadequate lifespans, and lives saturated with violence, leaving them inadequately safe even in their own homes. Here we outline a research agenda to explore the relationship between socially determined inadequacies and the cultural logic that makes bottle feeding a preferred form of infant feeding.

A Dominican Republic (DR)-based multi-community trial of smoking cessation viewed health care workers (HCWs) as potential interventionists. Effectively engaging them requires a clear understanding of their attitudes and practices regarding smoking. A Rapid Assessment Procedure, conducted among HCWs in six economically disadvantaged communities, included physicians, nurses, other health professionals, paraprofessionals, and lay workers. Attitudes and practices about smoking were consistent across the 82 HCWs and mostly reflected community views. HCWs lacked proactiveness related to smoking cessation and had a limited view of their role, attributing clients' quitting successes to personal will. Prior cessation training was limited, although interest was generally high. Material resources about smoking cessation were virtually absent. DR HCWs' views represented features both distinct from and common to HCWs elsewhere. Any intervention with HCWs must first raise awareness before addressing their role in smoking cessation, discussing implementation barriers, and include training and materials about risks and effective interventions.

Objectives: The objectives were to examine the perceptions of emergency medical services (EMS) providers regarding near-misses and adverse events in out-of-hospital care., Methods: This study uses qualitative methods (focus groups, interviews, event reporting) to examine the perceptions of EMS providers regarding near-misses and adverse events in out-of-hospital care. Results were reviewed by five researchers; analytic domains were assigned and emerging themes were identified. Descriptive statistics were calculated., Results: Fifteen in-depth interviews (73% advanced life support [ALS], 40% volunteer, and 87% male) resulted in 50 event descriptions. Eleven additional event reports were obtained from the anonymous reporting system. Of the 61 total events, 27 (44%) were near-misses and 34 (56%) were adverse events. Fourteen (23%) involved a child (< 19 years). Types of error included 33 clinical judgment (54%), 13 skill performance (21%), 9 medication event (15%), 3 destination choice (5%), and 3 others (5%). For the 21 cases where the provider discussed the event, 10 (48%) were reported to a physician, and 9 (43%) to a supervisor; 4 (19%) were not reported, and none were reported to the patient. Focus groups supported interview and event report data. Emerging themes included a focus on the errors of others and a "blame-and-shame" culture., Conclusions: Adverse events and near-misses were common among the EMS providers who participated in this study, but the culture discourages sharing of this information. Participants attributed many events to systems issues and to inadequacies of other provider groups. Further study is necessary to investigate whether these hypothesis-generating themes are generalizable to the EMS community as a whole.

This study assessed knowledge regarding the harm of environmental tobacco smoke (ETS) exposure and barriers to reducing ETS from the point-of-view of urban parents of asthmatic children. We conducted in-depth interviews with 15 mothers of children with asthma. All parents had good knowledge regarding the harmful effects of ETS. While all children of smoking parents were exposed to ETS, parents described using various strategies to keep ETS away from children. Many parents experienced significant stress in their lives and used smoking to relieve their stress. Barriers to a smoke-free home included stress, addiction, and the use of ineffective strategies to reduce ETS exposure.

Objectives: To understand the role of trust of medical institutions in the decision by elderly black Americans to receive pneumococcal and influenza vaccinations., Design: Cross-sectional, qualitative study, using semistructured in-depth interviews., Participants: Twenty black Americans age > or = 65 years from two different socioeconomic groups., Results: Six main themes were identified: prevention, vaccine-caused illnesses, vaccines as irrelevant to health, experience with healthcare, self-advocacy and attitudes toward childhood vaccinations. The majority of vaccinated participants viewed vaccines as a preventive measure, while the unvaccinated group viewed vaccines as irrelevant to their health. In addition, the majority of the participants in the unvaccinated group believed vaccines caused illness. Mistrust of medical institutions or the knowledge of the historical medical injustices was not a significant influence in participant's willingness to be vaccinated against pneumococcal or influenza disease., Conclusion: Mistrust of medical institutions was not a key concern affecting willingness to be vaccinated in this black community of elderly adults. Participant's willingness to be vaccinated was largely influenced by prior positive or negative experiences with healthcare systems.

Objective: To conduct formative research on the landscape of tobacco use to guide survey and subsequent intervention development in the Dominican Republic (DR)., Design: Rapid Assessment Procedures, systematic qualitative methods (participant-observations, in-depth interviewing, focus groups) using bilingual mixed age and gendered teams from the United States and DR., Subjects: Over 160 adults (men and women), ages 18 to 90 years, current, former and never smokers, community members and leaders from six underserved, economically disadvantaged DR communities., Main Outcome Measures: Key domains: tobacco use patterns and attitudes; factors affecting smoking initiation, continuation, quitting; perceived risks/benefits/effects of smoking; and awareness/effects of advertising/regulations., Results: Perceptions of prevalence varied widely. While "everybody" smokes, smokers or ex-smokers were sometimes difficult to find. Knowledge of health risks was limited to the newly mandated statement "Fumar es prejudicial para la salud" [Smoking is harmful to your health]. Smokers started due to parents, peers, learned lifestyle, fashion or as something to do. Smoking served as an escape, relaxation or diversion. Quit attempts relied on personal will, primarily for religious or medical reasons. Social smoking (custom or habit) (< 10 cigarettes per day) was viewed as a lifestyle choice rather than a vice or addiction. Out of respect, smokers selected where they smoked and around whom. Health care providers typically were reactive relative to tobacco cessation, focusing on individuals with smoking related conditions. Tobacco advertising was virtually ubiquitous. Anti-tobacco messages were effectively absent. Cultures of smoking and not smoking coexisted absent a culture of quitting., Conclusions: Systematic qualitative methods provided pertinent information about tobacco attitudes and use to guide subsequent project steps. Integrating qualitative then quantitative research can be replicated in similar countries that lack empirical data on the cultural dimensions of tobacco use.

Low-acuity (LA) use of emergency departments (EDs) is often viewed as misuse or abuse. We designed a program to help users access services more efficiently. Community health workers (CHWs) functioned as health educators, screeners, and liaisons to care. A participatory curriculum emphasized medical problems. Qualitative ethnographic methods were used for formative evaluation. Ninety families received regular visits from CHWs. Original system-oriented objectives and methods did not fit community needs. Instead, information was gathered regarding service utilization patterns: (1) families mistrusted primary and preventive care, reporting frequent discrimination and humiliation; (2) a primarily biomedical prioritization did not match families' need hierarchies; (3) complex demands of poverty made other uses of the system challenging; (4) primary care services were frequently avoided; and (5) the ED was often preferred. Intangible psychosocial factors and practical complexities of poverty were powerful promoters of LA visits. Families were creative strategists, viewing LA visits as rational use, not misuse, of a challenging system.

Purpose: To evaluate the extent to which a community pediatrics rotation in disadvantaged neighborhoods provided residents with a self-assessed change in knowledge, attitudes, and skills useful for improving the health of children at the community level., Method: All pediatrics and medicine-pediatrics residents at the University of Rochester Medical Center participate in a two-week community-based rotation. At the end of each rotation, residents were asked to write a short essay on what they learned during the experience. An interdisciplinary team conducted a retrospective, qualitative analysis of residents' essays looking for recurring themes. Essays were also examined for narrative plot elements that would indicate a causal sequence of events indicating some transformation of the learner., Results: Of the 25 essays reviewed, each gave evidence of at least one of three themes: increased knowledge of lives in poverty, renewed enthusiasm for advocacy, and increased skill in making referrals. Although many residents expressed initial skepticism of the value of a community rotation, none noted any negative final impression. The narrative structure of residents' essays also showed evidence of some transformation of the learner., Conclusions: A community pediatrics rotation can be a successful educational experience for providing residents with knowledge of how pervasive poverty impacts children and families. Reported changes in attitudes and skills require further evaluation to demonstrate that they can be applied in practice.

Medical education has historically relied on the rational choice model as a vehicle for promoting health behavior change, and has largely overlooked the powerful relationships between social class and health behaviors. The rational choice model, which assumes that people can choose to pursue behaviors that are needed for their health, has some clinical utility, especially in some circumstances, but it runs the risk of missing key sources of influence and of blaming the victim. The biopsychosocial model provides an alternative basis for teaching about health behavior change. Health behavior needs to be understood in a broad social context, in which social class is recognized as playing a large part in shaping many people's health behaviors through multiple pathways, including limited opportunities for self-fulfillment, financial constraints, health beliefs, self-efficacy, stress, and social support. In addition to highlighting the limitations of the rational choice model, we illustrate how to integrate the socio-cultural context into teaching about behavior change. Specific curricular suggestions include exercises for: (1) increasing students' awareness of their own biases regarding unhealthy behaviors and individual responsibility for change; (2) enhancing knowledge of social factors that impact health; (3) building advocacy skills; (4) learning from patients; and (5) practicing counseling skills through role-plays.