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Although farmers experience lower overall cancer rates than the U.S. population, they are at increased risk for cancers of certain sites, such as brain, stomach, lymphatic and hematopoietic, lip, prostate, and skin. Little research has been done to determine the extent to which farmers and their families use cancer control services or hozo their utilization behaviors and cancer survival rates compare to those of nonfarmers in the United States. In 1989, recognizing the occupational uniqueness of farm populations and the limited cancer-related information about them, Congress mandated that the National Institute for Occupational Safety and Health (NIOSH) develop a program to promote cancer control among farming populations. Eight institutions were funded through cooperative agreements to collaborate with NIOSH and each other to develop the demonstration research and intervention projects. The projects are aimed at identifying barriers that prevent farmers, farmworkers, and their families from accessing the fill range of cancer control services, and then implementing interventions to mitigate those barriers. This paper illustrates some of the conceptual and methodological issues NIOSH researchers and their collaborators faced while developing the cancer control program. [ABSTRACT FROM AUTHOR]

Introduction: The majority of construction companies are small businesses and small business often lack the resources needed to ensure that their supervisors have the safety leadership skills to build and maintain a strong jobsite safety climate. The Foundations for Safety Leadership (FSL) training program was designed to provide frontline leaders in all sized companies with safety leadership skills. This paper examines the impact of the FSL training by size of business., Methods: Leaders, defined as foremen or other frontline supervisors, from small, medium, and large construction companies were recruited to participate in a study to evaluate the degree to which the FSL changed their understanding and use of the leadership skills, safety practices and crew reporting of safety-related conditions. We used linear mixed modeling methods to analyze pre-post training survey data., Results: Prior to the training, leaders from small and medium sized companies reported using safety leadership skills less frequently than those from large ones. After the training, regardless of business size, we observed that the FSL training improved leaders understanding of safety leadership skills from immediately before to immediately after the training. Additionally, leaders reported greater use of safety leadership skills, safety practices, and crew reporting of safety-related conditions from before to two-weeks after the training. However, those from small and medium sized companies reported the greatest improvement in their use of safety leadership skills., Conclusions: The FSL training improves safety leadership outcomes regardless of the size company for which the leader worked. However, the FSL may be even more effective at improving the safety leadership skills of leaders working for smaller sized construction companies or those with lower baseline levels of safety leadership skills. Practical applications: The majority of construction companies employ a small number of employees and therefore may not have the resources to provide their frontline leaders with the leadership training they need to be effective leaders who can create a strong jobsite safety climate. The Foundations for Safety Leadership (FSL) training can help fill this gap., (Copyright © 2020 National Safety Council and Elsevier Ltd. All rights reserved.)

Introduction: Construction foremen may lack the leadership skills needed to create a strong jobsite safety climate. Many construction companies address this by sending their lead workers to the OSHA 30-h course; however the course does not include a leadership training module. This article describes the development and pilot testing of such a module and evaluation surveys designed to address this training gap., Methods: A 17-member curriculum development team, numerous subject matter experts, and an instructional design company helped us develop a comprehensive set of teaching resources and a set of survey instruments for evaluating the materials' effectiveness on improving safety leadership and safety climate. All materials and surveys were pilot tested with representative members of the target population., Results: Pilot surveys showed high reliability and data collected on the resulting Foundations for Safety Leadership (FSL) module indicated that the majority of foremen thought the training was helpful or valuable, particularly the discussion questions. The majority said they intended to use the skills on the jobsite. With the exception of the role-play activities, the trainers rated highly all other components, especially the videos and discussion questions. Modifications were made to the training materials and surveys based on pilot test findings. The most important result of the development and pilot testing efforts is that the OSHA Training Institute (OTI) included the FSL as an elective in the OSHA 30-h course., Conclusions: The FSL module fills a needed skills gap by providing safety leadership training to all foremen who might otherwise not have access to it through their company or union. The continued success of the FSL training will be ensured by dissemination via the OSHA 30-h course, an established nationwide safety training program. Practical applications: The FSL training module has already been widely accepted by the construction industry as a useful approach for providing construction foremen/See new abstract lead workers with the knowledge and skills they need to become more effective jobsite safety leaders., (Copyright © 2019 Elsevier Ltd and National Safety Council. All rights reserved.)

Introduction: The 2.5 h Foundations for Safety Leadership (FSL) training program teaches construction supervisors the leadership skills they need to strengthen jobsite safety climate and reduce adverse safety-related outcomes., Methods: Using a quasi-experimental prospective switching replications study design, we examined (1) if FSL-trained jobsite safety leaders would report improved understanding and practice of the FSL leadership skills, safety practices and crew reporting of safety related conditions, and (2) if their crew perceived a change in (a) their supervisors' practices, (b) their own safety practices and reporting of safety-related conditions, and (c) overall jobsite safety climate. Twenty construction sub-contracting companies were recruited and randomly assigned to either an early or lagged-control training group. Participating supervisors and workers completed surveys at multiple time points before and after the FSL training. We used linear mixed modeling to test changes over time., Results: Only supervisors in the early group reported a statistically significant improvement in their understanding and practice of the leadership skills as well as safety practices from before to 2- and 4-weeks post-training. Overall, no significant change was detected in crew-reported outcomes from before to after their supervisors' participated in the FSL training., Conclusions: These results provide evidence that the FSL training can, at least in the short-term, improve construction frontline leaders' jobsite leadership skills. Future research could include an evaluation of FSL refresher activities and a longer-term follow-up. Practical applications: The Foundations for Safety Leadership (FSL) program fills an identified need for construction frontline supervisors to learn and practice critical safety leadership skills on the jobsite. It has already reached over 60,000 leaders and has the potential to reach over 100,000 each year during either an OSHA 30-h or a stand-alone course., (Copyright © 2019 Elsevier Ltd and National Safety Council. All rights reserved.)

Introduction: This paper presents the development and validation of a new rubric-based Safety Climate Assessment Tool (S-CAT). The S-CAT gives companies the opportunity to use rubric descriptors, rather than traditional Likert scale responses, to self-assess their level of safety climate maturity and receive a composite score benchmarked against others in the S-CAT database., Method: The S-CAT is composed of 37 separate indicators of 8 safety climate factors identified by construction industry subject matter experts. The eight factors have between three and six indicators each with its own rubric-based response-scale. The scales comprise descriptors for five levels of safety climate maturity ranging from "inattentive" to "exemplary." Nine hundred and eighty-five respondents working in the construction industry completed the S-CAT via our online safety climate website. We used company recordable incident rates (RIR) to assess the S-CAT's criterion-related validity., Results: Cronbach alphas for each factor ranged from 0.77 to 0.90 and a confirmatory factor analysis supported the hypothesized eight factor structure with a higher-order safety climate factor. Seven of the eight factor scores, as well as the overall S-CAT score, were significantly negatively correlated with RIR. Moreover, a relative weights analysis indicated that a weighted combination of the eight safety climate factors explained 27% of the variance in organizational RIR., Conclusions: These findings provide evidence that the S-CAT is a reliable tool allowing construction companies to self-assess their safety climate along eight different factors. Moreover, the S-CAT was significantly associated with organizational injury rates. Practical applications: We discuss how companies can use the rubric descriptors to strengthen their safety management systems and improve their safety climate maturity., (Copyright © 2019 Elsevier Ltd and National Safety Council. All rights reserved.)

The construction industry is one of the largest and also most hazardous industries in the USA. It is affected more severely by the business cycle than most other industries. We examined industry trends during the last decade including the severe recession. During 2008 to 2010, as a result of the recession, 2.7 million workers and 20% of all employers left the industry. By 2010, the number and rate of traumatic fatalities had reached its lowest point ever, only to gradually increase again as the industry recovered from the recession. The risks of a fatality were disproportionate with employer size. The small employers (<20 employees), which account for 37.5% of employment, were responsible for 57% of all fatalities. These small employers are less likely to embrace essential safety culture practices and are slow to adopt new approaches to occupational safety and health. These employers-especially those which hire immigrant workers and self-employed workers-lag far behind in terms of adopting even essential elements of good safety cultures and management practices. Currently, there are no restrictions on going into business as a construction contractor or seeking employment as a construction worker. There is a great need to find ways to establish minimum qualifications for becoming a construction contractor and for becoming a construction worker. Some jurisdictions have established minimum occupational safety and health training. This is a good start, but qualifications must include greater emphasis on minimum skills requirements. State and local jurisdictions have good policy tools which could be deployed for this purpose but which have largely been neglected: licensing of both companies and workers could include skills qualifications; construction permits could include requirements for occupational safety and health; and greater use of criminal prosecution could be pursued where it is obvious that basic requirements for safety and health have been ignored.

Safety climate measurements can be used to proactively assess an organization's effectiveness in identifying and remediating work-related hazards, thereby reducing or preventing work-related ill health and injury. This review article focuses on construction-specific articles that developed and/or measured safety climate, assessed safety climate's relationship with other safety and health performance indicators, and/or used safety climate measures to evaluate interventions targeting one or more indicators of safety climate. Fifty-six articles met our inclusion criteria, 80% of which were published after 2008. Our findings demonstrate that researchers commonly defined safety climate as perception based, but the object of those perceptions varies widely. Within the wide range of indicators used to measure safety climate, safety policies, procedures, and practices were the most common, followed by general management commitment to safety. The most frequently used indicators should and do reflect that the prevention of work-related ill health and injury depends on both organizational and employee actions. Safety climate scores were commonly compared between groups (e.g. management and workers, different trades), and often correlated with subjective measures of safety behavior rather than measures of ill health or objective safety and health outcomes. Despite the observed limitations of current research, safety climate has been promised as a useful feature of research and practice activities to prevent work-related ill health and injury. Safety climate survey data can reveal gaps between management and employee perceptions, or between espoused and enacted policies, and trigger communication and action to narrow those gaps. The validation of safety climate with safety and health performance data offers the potential for using safety climate measures as a leading indicator of performance. We discuss these findings in relation to the related concept of safety culture and offer suggestions for future research and practice including (i) deriving a common definition of safety climate, (ii) developing and testing construction-specific indicators of safety climate, and (iii) focusing on construction-specific issues such as the transient workforce, subcontracting, work organization, and induction/acculturation processes., (© The Author 2016. Published by Oxford University Press on behalf of the British Occupational Hygiene Society.)

Background: Antenatal corticosteroids (ANCS) reduce complications of preterm birth; however, not all eligible women receive them. Many hospitals and providers do not have the right processes and conditions to enable ANCS administration with high reliability. The objective of this study was to understand conditions that enable delivery of ANCS with high reliability among hospitals participating in an Ohio Perinatal Quality Collaborative (OPQC) ANCS project., Methods: We conducted focus groups and semistructured interviews with members of the OPQC project team (n=27) and other care providers (n=70) using a purposeful sample of 6 sites involved in the OPQC ANCS project. Participants including nurses (n=57), attending obstetricians (n=17), physician trainees (n=21) and certified nurse midwives (n=2) were asked to reflect on their experiences and to identify factors contributing to optimal use of ANCS. Focus groups and interviews were transcribed verbatim and were analysed by a multidisciplinary team using an iterative approach that combined inductive and deductive methods to identify and categorise themes., Results: Six major themes supporting reliable implementation of ANCS at these hospitals emerged including: (1) presence of a high reliability culture, (2) processes that emphasise high reliability, (3) timely and efficient administration process, (4) multiple disciplines are involved, (5) evidence of benefit supports ANCS use and (6) benefit is recognised at all levels of the care team., Conclusions: Our findings identify the key processes and supports needed to ensure delivery of ASCS with high reliability and are reinforced by implementation and reliability science. They are useful for foundation of the successful implementation of other evidence-based practices at high levels of reliability., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Work-related Musculoskeletal Disorders (WMSD) account for approximately one-third of all injuries in the U.S. construction industry. Many companies have implemented stretch and flex (s/f) programs to reduce WMSD despite a lack of evidence showing effectiveness., Methods: We conducted a mixed-methods study to understand (a) why employers continue devoting resources to s/f programs; (b) how programs vary; and (c) any actual or perceived benefits., Results: Nineteen safety and health professionals were interviewed and 133 more (13.3% response rate) completed an on-line survey. Fifty-six percent had implemented an s/f program with the primary goal of reducing WMSDs; though most did not review data to determine goal achievement. Program structure varied in terms of duration, frequency, and type of stretches. There was strong agreement about mandating attendance but not participation, due primarily to liability issues. Cost was a factor when deciding to implement a program but not for sustaining one. The majority had not implemented other ergonomic prevention activities, but many had started conducting daily safety huddles for task and safety planning. Those reporting a reduction in WMSDs agreed that it was not due to the s/f program alone and that other benefits included increased worker camaraderie, communication, and collaboration., Conclusion: Although there is little to no scientific evidence showing that they work as intended, construction companies continue to implement s/f programs with the goal of reducing WMSDs. Bringing work crews together for s/f activities has prompted employers to also begin conducting daily safety huddles. Although employers may not be able to link reduced WMDS to an s/f program, the ancillary benefits may warrant the time and resources., Practical Applications: S/f programs should be only one component of a more comprehensive ergonomics prevention program. Conducting daily safety huddles at the same time also may enhance worker communication, camaraderie, collaboration and improve safety outcomes., (Copyright © 2015 Elsevier Ltd and National Safety Council. All rights reserved.)

Background: Situation awareness (SA)-the perception of data elements, comprehension of their meaning and projection of their status in the near future-has been associated with human performance in high-risk environments, including aviation and the operating room. The influences on SA in inpatient medicine are unknown., Methods: We conducted seven focus groups with nurses, respiratory therapists and resident physicians using a standardised semistructured focus group guide to promote discussion. Recordings of the focus groups were transcribed verbatim, and transcripts were qualitatively analysed by two independent reviewers to identify convergent and divergent themes., Results: Three themes emerged: (1) team-based care, (2) availability of standardised data and (3) standardised processes and procedures. We categorised these into social, technological and organisational influences on SA. Subthemes that emerged from each focus group were shared language to describe at-risk patients, provider experience in critical care/deterioration and interdisciplinary huddles to identify and plan for at-risk patients. An objective early warning score, proactive assessment and planning, adequate clinician staffing and tools for entering, displaying and monitoring data trends were identified by six of seven groups. Our data better reflected the concepts of team SA and shared SA than individual SA., Conclusions: Team-based care and standardisation support SA and the identification and treatment of patient risk in the complex environment of inpatient care. These findings can be used to guide the development and implementation of targeted interventions such as huddles to proactively scan for risk and electronic health record displays of data trends.

Objectives: To examine healthcare worker's perceptions, expectations, and experiences regarding how work processes, patient-related safety, and care were affected when a quaternary care center transitioned from one computerized provider order entry (CPOE) system to a full electronic health record (EHR)., Methods: The I-SEE survey was administered prior to and 1-year after transition in systems. The construct validity and reliability of the survey was assessed within the current population and also compared to previously published results. Pre- and 1-year post-implementation scale means were compared within and across time periods., Results: The majority of respondents were nurses and personnel working in the acute care setting. Because a confirmatory factor analysis indicated a lack of fit of our data to the I-SEE survey's 5-factor structure, we conducted an exploratory factor analysis that resulted in a 7-factor structure which showed better reliability and validity. Mean scores for each factor indicated that attitudes and expectations were mostly positive and score trends over time were positive or neutral. Nurses generally had less positive attitudes about the transition than non-nursing respondents, although the difference diminished after implementation., Conclusions: Findings demonstrate that the majority of responding staff were generally positive about transitioning from CPOE system to a full electronic health record (EHR) and understood the goals of doing so, with overall improved ratings over time. In addition, the I-SEE survey, when modified based on our population, was useful for assessing patient care and safety related expectations and experiences during the transition from one CPOE system to an EHR., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: Studies show that implementing huddles in healthcare can improve a variety of outcomes. Yet little is known about the mechanisms through which huddles exert their effects. To help remedy this gap, our study objectives were to explore hospital administrator and frontline staff perspectives on the benefits and challenges of implementing a tiered huddle system; and propose a model based on our findings depicting the mediating pathways through which implementing a huddle system may reduce patient harm., Methods: Using qualitative methods, we conducted semi-structured interviews and focus groups to obtain a deeper understanding of the huddle system and its outcomes as implemented in an academic tertiary care children's hospital with 539 inpatient beds. We recruited healthcare providers representing all levels using a snowball sampling technique (10 interviews), and emails, flyers, and paper invitations (six focus groups). We transcribed recordings and analysed the data using established techniques., Results: Five themes emerged and provided the foundational constructs of our model. Specifically we propose that huddle implementation leads to improved efficiencies and quality of information sharing, increased levels of accountability, empowerment, and sense of community, which together create a culture of collaboration and collegiality that increases the staff's quality of collective awareness and enhanced capacity for eliminating patient harm., Conclusions: While each construct in the proposed model is itself a beneficial outcome of implementing huddles, conceptualising the pathways by which they may work allows us to design ways to evaluate other huddle implementation efforts designed to help reduce failures and eliminate patient harm.

Background: A learning health system enables patients, clinicians, and researchers to work together to choose care based on the best evidence, drive discovery as a natural outgrowth of patient care, and ensure innovation, quality, safety, and value in health care; all in a more real-time fashion., Objective: Our paper describes how goal-directed design (GDD) methods were employed to understand the context and goals of potential participants in such a system as part of a design process to translate the concept of a learning health system into a prototype collaborative chronic care network (C3N), specifically for pediatric inflammatory bowel disease., Methods: Thirty-six one-on-one in-depth interviews and observations were conducted with patients (10/36, 28%), caregivers (10/36, 28%), physicians/researchers (10/36, 28%), and nurses (6/36, 17%) from a pediatric gastroenterology center participating in the ImproveCareNow network. GDD methods were used to determine the context and goals of participants. These same methods were used in conjunction with idealized design process techniques to help determine characteristics of a learning health system for this pediatric health care ecology. Research was conducted in a clinic and, in the case of some patients and caregivers, at home., Results: Thematic analysis revealed 3 parent-child dyad personas (ie, representations of interviewees' behavior patterns, goals, skills, attitudes, and contextual information) that represented adaptation to a chronic illness over time. These were used as part of a design process to generate scenarios (potential interactions between personas and the learning health system under design) from which system requirements were derived. These scenarios in turn helped guide generation, prioritization, design, measurement, and implementation of approximately 100 prototype interventions consistent with the aim of C3N becoming a learning health network., Conclusions: GDD methods help ensure human goals and contexts inform the design of a network of health care interventions which reflect the shape and purpose of a C3N in pediatric chronic illness care. Developing online and in-person interventions according to well-documented context and motivations of participants increases the likelihood that a C3N will enable all participants to act in ways that achieve their goals with grace and dignity. GDD methods complemented quality-improvement methods to generate prototypes consistent with clinical and research aims, as well as the goals of patient disease management.

Background: Recent efforts to increase insurance coverage have revealed limits in primary care capacity, in part due to physician maldistribution. Of interest to policymakers and educators is the impact of nontraditional curricula, including global health education, on eventual physician location. We sought to measure the association between graduate medical education in global health and subsequent care of the underserved in the United States., Methods: In 2005, we surveyed 137 graduates of a family medicine program with one of the country's longest-running international health tracks (IHTs). We compared graduates of the IHT, those in the traditional residency track, and graduates prior to IHT implementation, assessing the anticipated and actual involvement in care of rural and other underserved populations, physician characteristics, and practice location and practice population., Results: IHT participants were more likely to practice abroad and care for the underserved in the United States in the first 5 years following residency than non-IHT peers. Their current practices were more likely to be in underserved settings and they had higher percentages of uninsured and non-English-speaking patients. Comparisons between pre-IHT and post-IHT inception showed that in the first 5 years following residency, post-IHT graduates were more likely to care for the underserved and practice in rural areas and were likely to offer volunteer community health care services but were not more likely to practice abroad or to be in an academic practice., Conclusions: Presence of an IHT was associated with increased care of underserved populations. After the institution of an IHT track, this association was seen among IHT participants and nonparticipants and was not associated with increased long-term service abroad.

Background: Current training practices and teaching methods for critical care medicine education during internal medicine residency have not been well described. This study explored critical care medicine education practices and environments for internal medicine residents in the United States., Methods: A web-based survey recruited Pulmonary and Critical Care Medicine fellowship program directors involved with internal medicine residency programs at academic institutions in the United States., Results: Of 127 accredited Pulmonary and Critical Care Medicine programs in 2007, 63 (50%) responded. Demographics of the intensive care units varied widely in size (7-52 beds), monthly admissions (25-300 patients), and presence of a "night float" (22%) or an admissions "cap" (34%). All programs used bedside teaching, and the majority used informal sessions (91%) or didactic lectures (75%). More time was spent on resident teaching in larger (≥20 bed) medical intensive care units, on weekdays, in programs with a night-float system, and in programs that suspended residents' primary care clinic duties during their intensive care unit rotation., Conclusions: Although similar teaching methods were used within a wide range of training environments, there is no standardized approach to critical care medicine education for internal medicine residents. Some survey responses indicated a correlation with additional teaching time.

Background: Resident interest in global health care training is growing and has been shown to have a positive effect on participants' clinical skills and cultural competency. In addition, it is associated with career choices in primary care, public health, and in the service of underserved populations. The purpose of this study was to explore, through reflective practice, how participation in a formal global health training program influences pediatric residents' perspectives when caring for diverse patient populations., Methods: Thirteen pediatric and combined-program residents enrolled in a year-long Global Health Scholars Program at Cincinnati Children's Hospital Medical Center during the 2007-2008 academic year. Educational interventions included a written curriculum, a lecture series, one-on-one mentoring sessions, an experience abroad, and reflective journaling assignments. The American Society for Tropical Medicine and Hygiene global health competencies were used as an a priori coding framework to qualitatively analyze the reflective journal entries of the residents., Results: Four themes emerged from the coded journal passages from all 13 residents: (1) the burden of global disease, as a heightened awareness of the diseases that affect humans worldwide; (2) immigrant/underserved health, reflected in a desire to apply lessons learned abroad at home to provide more culturally effective care to immigrant patients in the United States; (3) parenting, or observed parental, longing to assure that their children receive health care; and (4) humanitarianism, expressed as the desire to volunteer in future humanitarian health efforts in the United States and abroad., Conclusions: Our findings suggest that participating in a global health training program helped residents begin to acquire competence in the American Society for Tropical Medicine and Hygiene competency domains. Such training also may strengthen residents' acquisition of professional skills, including the Accreditation Council for Graduate Medical Education competencies.

Five hundred and nineteen members of the Movement Disorder Society completed a 22-item questionnaire probing diagnostic and management issues in psychogenic movement disorders (PMD). When patients showed definite evidence of PMD with no other unexplained clinical features, approximately 20% said they informed patients of the diagnosis and requested no further neurological testing. The 51% who reported conducting standard neurological investigations to rule out organic causes before presenting the diagnosis to such patients had fewer years of fellowship training and fewer PMD patients seen per month. A non-PMD diagnosis was correlated with patients' normal social or personal functioning, little or no employment disruption, lack of non-physiologic findings, and lack of psychiatric history. Ongoing litigation was more predictive of the PMD diagnosis for US compared to non-US respondents. Two thirds of respondents, more commonly younger and academic clinician researchers, refer PMD patients to a psychiatrist or mental health specialist while also providing personal follow up. Physician reimbursement, insurability of PMD patients, and ongoing litigation interfered with managing PMD patients to a greater extent in the US compared to non-US countries. Acceptance of the diagnosis by the patient and identification and management of psychological stressors and concurrent psychiatric disorders were considered most important for predicting a favorable prognosis. These findings suggest that expert opinions and practices related to diagnosing and managing PMD patients differ among movement disorders neurologists. Some of the discrepancies may be accounted for by factors such as training, type of practice, volume of patients, and country of practice, but may also reflect absence of practice guidelines., (2009 Movement Disorder Society.)

Purpose: In the intensive care unit (ICU), critically ill patients are often unable to participate in discussions about cardiopulmonary resuscitation (CPR), and decisions on CPR are often made by surrogate decision makers. The objective of this study is to determine the prevalence, content, and perceptions of CPR discussions between critically ill patients' surrogates and ICU physicians and their effect on resuscitation decisions., Materials and Methods: Eligible patients' surrogates were interviewed using a structured questionnaire more than 24 hours after admission to the medical ICUs at 2 university-affiliated medical centers. Data from surrogates who did and did not participate in a CPR discussion were compared and correlated with patient characteristics and outcomes., Results: Of 84 surrogates interviewed, 54% participated in more than 1 CPR discussion. Although most (73%) recalled discussing endotracheal intubation, 49% and 44% recalled discussing chest compressions or electrical cardioversion, respectively, and 68% to 84% stated they understood these components. Mortality was higher in the discussion group compared to the no-discussion group (37% vs. 8%; P < .05), although changes in CPR decisions were similar in both groups (25% vs 18%, P = .5)., Conclusions: Only half of critically ill patients' surrogates participated in CPR discussions. For those who did participate, most reported good understanding of resuscitation techniques, but less than half recalled the core components of CPR.

Little is known regarding patient preferences for method of delivery despite concern about rising cesarean section rates. We hypothesize that the majority of pregnant women desire a vaginal birth. An anonymous survey was distributed to pregnant women assessing demographics, pregnancy history, delivery preference, and concern for outcomes. Five-hundred fifty respondents completed the survey; 43% were nulliparous. The majority preferred vaginal delivery (89.6%). Reasons included reduced recovery pain (72%), scars (68%), and bleeding (48%). Cesarean deliveries were believed to cause more maternal injuries (39%), but affect sexual function less (35%). Nulliparas were more concerned about vaginal support damage (p = .005), sexual function changes (p < or = 0.001), and need for episiotomy (p < or = .001). Despite this, 93% of nulliparas chose vaginal birth. Increased parity was associated with preference for cesarean delivery (r = 0.108, p = 0.013). Despite nulliparas' concerns about complications of vaginal delivery, the majority of pregnant women would choose vaginal birth.

Although many professional and accrediting bodies have identified competencies for medical students pertaining to caring for older patients, including understanding the basics of the healthcare delivery system, the highly structured curriculum in medical school provides few opportunities for these competencies to be achieved. One possible solution is to let students participate in geriatrics-related extracurricular educational and clinical activities and ask them to reflect on their experiences. This article presents the results of a qualitative analysis of student reflections from participating in such a program implemented at the University of Cincinnati College of Medicine. One hundred thirty of 321 student journal entries (collected over 3 academic years) containing any mention of the healthcare system were qualitatively analyzed. The themes and resulting model that emerged from the data includes three distinct levels of healthcare delivery: individual, organizational, and systems. Each level is presented and explained using illustrative student quotes. As a whole, the model indicates that students in this innovative extracurricular experience gained important knowledge about how medical care is provided to elderly people. The model developed may provide additional structure for future medical students as they reflect on their early encounters with the complex health and social forces affecting the quality of care received by older adults.

The Intervention Evaluation Competition at the Work, Stress, and Health conference in Miami (March 2006) highlighted the importance of intervention evaluation studies that promote safety and health at work. A retitled, "Best Practices Evaluation Competition," has been included in the March, 2008, Work, Stress, and Health conference, in Washington, DC. This brief note describes the development of the criteria used to evaluate the manuscripts. The criteria are discussed with respect to (a) improving the science of evaluation methodology, (b) promoting the highest ethical standards in intervention evaluation, and (c) using the current criteria as a starting point for continuing to raise the bar for evaluation methodology. The policy implications of the evaluation criteria are discussed as well.

Objective: To assess acting interns' (AI's) experience with and perceived level of competency performing 6 basic medical procedures., Design: Fourth-year medical students at the University of Cincinnati (UCCOM) are required to complete 2 AI rotations in Internal Medicine. All AIs in 2003-2004 (n = 150) and 2004-2005 (n = 151) were asked to complete a survey about whether during each of their rotations they had performed and felt competent performing the following procedures: phlebotomy, intravenous (IV) catheter insertion, arterial blood gas (ABG), nasogastric (NG) tube insertion, lumbar puncture (LP), and Foley catheter insertion., Results: Four hundred sixty-seven of 601 possible surveys (across both years and both rotations) were completed (78% response rate). During both rotations, relatively few students performed the procedures, ranging from 9% for Foley catheter insertion (24/208) to 50% for both ABG and NG tube insertion (130/259). The two procedures most often performed were ABG (range 46-50%) and NG tube insertion (range 42-50%). Feelings of competency varied from 12% (LP) to 82% (Foley catheter). Except for LP, if students performed a procedure at least once, they reported feeling more competent (range 85% for ABG to 96% for Foley catheter insertion). Among the students who performed LP during a rotation, many still did not feel competent performing LPs: 23 (74%) in rotation 1 and 20 (40%) in rotation 2., Conclusion: Many fourth-year students at UCCOM do not perform basic procedures during their acting internship rotations. Procedural performance correlates with feelings of competency. Lumbar puncture competency may be too ambitious a goal for medical students.

Background and Objectives: While medical students' interest in family medicine declines, and residency programs face recruiting challenges, interest in international health is increasing. We studied the influence of offering an international health track (IHT) on residency recruitment., Methods: We surveyed all graduates between the years 1994--2003 of a family medicine residency program offering an optional IHT (n=90). Descriptive and bivariate analyses characterized and compared the geographic scope and residency selection criteria of IHT participants and nonparticipants., Results: The response rate was 77%. Compared to nonparticipants in the IHT, residents who participated in the IHT reported coming a significantly greater median distance from their medical school training site (250--499 miles versus 0--99) and from their "home" (500--999 miles versus 100--249) for residency training. Participants reported that the factor most positively influencing their choice of this residency training site over others was the IHT (mean=+2.5, standard deviation [SD]=0.90), outscoring, on average, location, faculty quality, resident quality, and spousal preference. Nonparticipants' choices were influenced most by the traditionally reported selection factors location (mean=+2.37, SD=1.14) and faculty quality (mean=+2.29, SD=0.97)., Conclusions: One program's experience suggests that the presence of international health training opportunities may influence the residency selection choices of family medicine residents. As family medicine moves to reinvent residency education and to recapture student interest, attractive training models that integrate clinical, community, and public health should be evaluated further.

Objective: This article discusses how formative feedback to medical students during their clinical rotations facilitates their successfully meeting the rotation's educational objectives. To help students initiate mid-rotation feedback and to help preceptors structure that feedback, the authors designed the Instant Feedback Card (IFc). The goal of this study was to examine the degree to which the IFc facilitated the formative feedback process from the perspectives of both students and faculty., Method: The IFc contains a checklist of the 13 clinical competencies that are also used to provide summative evaluations to students. One hundred and sixty-five medical students completing a 6-week psychiatry clerkship between January and December 2004 were given an IFc to present to their inpatient preceptor at one of their two inpatient sites. At the end of each 3-week inpatient rotation, all students were e-mailed a brief questionnaire about the formative feedback received during the preceding rotation. At the end of the 12-month study period, faculty were e-mailed a brief questionnaire about how useful the IFc was in helping to facilitate the feedback process., Results: One hundred thirty-eight students (80%) participated in the study and returned 267 questionnaires (1.9/student, 97% response rate). Two hundred five students indicated on 77% of the questionnaires returned that they received mid-rotation feedback and of those, 84% revealed that feedback was helpful. Eighty-five percent of the students received mid-rotation feedback when they used the IFc and only 69% received mid-rotation feedback without the IFc. A majority of the 14 faculty serving as inpatient preceptors during the study period found the cards useful for stimulating feedback discussions, for reducing the stress of providing feedback, and for getting students to request feedback., Conclusions: The results of this pilot study are not definitive, but they do indicate that the Instant Feedback card (IFc) did facilitate the process and structure of providing and receiving formative feedback as indicated by a significantly greater number of students receiving formative feedback when they used the IFc., (Copyright (C) 2006 Academic Psychiatry.)

In 2003, the University of Cincinnati College of Medicine initiated a 4-year Geriatric Medical Student Scholars (GMSS) program in which a selected group of 14 medical students participated in a variety of extracurricular geriatrics-related activities such as one-on-one mentoring and discussion groups. These students were also required to compose journal entries describing GMSS program-related activities using a semistructured on-line computer program designed specifically for this purpose. The reflective journals, in combination with the American Geriatrics Society (AGS) competencies, were used to evaluate the degree to which the GMSS program achieved its goal of enhancing students' understanding of the complex health and social challenges facing older adults. Using a confirmatory qualitative analysis strategy, the AGS competencies served as an a priori codebook to evaluate the student journal entries. Of the original 53 AGS competencies identified as being relevant for a first- or second-year medical student, 74% were used at least one time, and only 26% were never used. These findings strongly suggest that the GMSS program successfully moved this group of first- and second-year medical students closer to at least understanding the content of many of the AGS competencies by providing them with geriatrics-related experiences and a geriatrics-related framework they could draw on when participating in curricular and extracurricular activities. The findings also point to the potential value of using reflective journaling as a tool for conducting process evaluation of medical education interventions.

Available technology allows for the capture and rebroadcast of lectures via computer-based tools. Such tools have the potential to enhance medical education. Medical schools are beginning to offer such services, but little is known about end-user preferences. We surveyed students at one US medical school to gather their preferences for the availability and use of computer-based lecture presentation. These findings add to the limited literature regarding use of such tools for medical education.

Objective: This study compares the instruments and interventions utilized to identify and remediate unprofessional behaviors in medical students across U.S. psychiatry clerkships., Methods: A 20-item questionnaire was distributed to 120 psychiatry clerkship directors and directors of medical student education, in the U.S., inquiring into the procedures utilized for identifying, monitoring, and remediating unprofessional behaviors among medical students during their psychiatry clerkship., Results: Fifty seven (47.5%) clerkship directors responded to the questionnaire. Professionalism is evaluated by 96% of the clerkships with the most frequent goals being to provide feedback to students and to specifically identify problematic behaviors. Seventy percent of the clerkships identify one to three students per year with unprofessional behaviors that warrant intervention. The majority (86%) of the respondents note that unprofessional behaviors may impede the advancement of students during their medical education. A recommendation for a mental health evaluation occurs in at least 76% of cases. Dismissal from medical school for unprofessional behaviors is most likely recommended based on the severity and/or repetitiveness of the acts., Conclusions: There is concordance among clerkship directors regarding the importance of identifying unprofessional behaviors among medical students although there exists a range of modalities for monitoring, remediating, and disciplining such behaviors.

The purpose of the study was to evaluate practice patterns of members of the American Urogynecologic Society (AUGS) with respect to female sexual dysfunction (FSD). A brief self-administered survey of 20 questions was mailed to 966 physician members of the AUGS in the United States of America and Canada; 471 surveys were returned (49% response rate). The majority of responders see urogynecology (19%) or urogynecology and general gynecology patients (43%). Sixty-eight percent of physicians were familiar with questionnaires to assess FSD; however, only 13% said they use these for screening purposes. Most said they believed screening for FSD was somewhat (47%) or very important (42%). Despite having these beliefs, only 22% of the responding physicians stated they always screen for FSD, while 55% do so most of the time and 23% admitted they never or rarely screen. Similar results were obtained regarding screening following urogynecologic surgery. Several barriers to screening for FSD existed, the most common being lack of time. The majority of respondents (69%) underestimated the prevalence of FSD in their patient population. Finally, although more than half of responders had received post-residency training in urogynecology (59%), 50% of them stated the training with respect to FSD was unsatisfactory, while only 10% were satisfied. Overall, many urogynecologists do not consistently screen for FSD, underestimate its prevalence, and feel they received unsatisfactory training.

Purpose: New concise tools must be developed to assess reliably and validly the core residency competencies identified by the Accreditation Council for Graduate Medical Education., Participants: Eighteen content experts (residency program directors)., Methods: A 1-page Ophthalmic Clinical Exercise Examination (OCEX) checklist, for use during observed resident-patient interactions, was developed by an American Board of Ophthalmology taskforce. The OCEX checklist was sent to 18 content experts for their review and constructive comments., Results: Experts' comments were incorporated, establishing face and content validity., Conclusions: The OCEX has face and content validity. It can be used to assess a resident's patient care skills, medical knowledge, and interpersonal skills. Reliability and predictive validity still need to be determined.

Objectives: The dramatic increase in the U.S. elderly population expected over the coming decades will place a heavy strain on the current health care system. General internal medicine (GIM) residents need to be prepared to take care of this population. In this study, we document the current and future trends in geriatric education in GIM residency programs., Design, Setting, Participants: An original survey was mailed to all the GIM residency directors in the United States (N = 390)., Results: A 53% response rate was achieved (n = 206). Ninety-three percent of GIM residencies had a required geriatrics curriculum. Seventy one percent of the programs required 13 to 36 half days of geriatric medicine clinical training during the 3-year residency, and 29% required 12 half days or less of clinical training. Nursing homes, outpatient geriatric assessment centers, and nongeriatric ambulatory settings were the predominant training sites for geriatrics in GIM. Training was most often offered in a block format. The average number of physician faculty available to teach geriatrics was 6.4 per program (2.8 full-time equivalents). Conflicting time demands with other curricula was ranked as the most significant barrier to geriatric education., Conclusions: A required geriatric medicine curriculum is now included in most GIM residency programs. Variability in the amount of time devoted to geriatrics exists across GIM residencies. Residents in some programs spend very little time in specific, required geriatric medicine clinical experiences. The results of this survey can guide the development of future curricular content and structure. Emphasizing geriatrics in GIM residencies helps ensure that these residents are equipped to care for the expanding aging population.

This report documents the development and growth of geriatric medicine fellowship training in the United States through 2002. A cross-sectional survey of geriatric medicine fellowship programs was conducted in the fall 2001. All allopathic (119) and osteopathic (7) accredited geriatric medicine fellowship-training programs in the United States were involved. Data were collected using self-administered mailed and Web-based survey instruments. Longitudinal data from the American Medical Association (AMA) and the Association of American Medical Colleges' (AAMC) National Graduate Medical Education (GME) Census, the Accreditation Council for Graduate Medical Education (ACGME), and the American Osteopathic Association (AOA) were also analyzed. The survey instrument was designed to gather data about faculty, fellows, program curricula, and program directors (PDs). In addition, annual AMA/AAMC data from 1991 to the present was compiled to examine trends in the number of fellowship programs and the number of fellows. The overall survey response rate was 76% (96 of 126 PDs). Most (54%) of the PDs had been in their current position 4 or more years (range: <1-20 years), and 59% of PDs reported that they had completed formal geriatric medicine fellowship training. The number of fellowship programs and the number of fellows entering programs has slowly increased over the past decade. During 2001-02, 338 fellows were training in allopathic programs and seven in osteopathic programs (all years of training). Forty-six percent (n = 44) of responding programs offered only 1-year fellowship-training experiences. PDs reported that application rates for fellowship positions were stable during the academic years (AYs) 1999-2002, with the median number of applications per first year position available in AY 2000-01 being 10 (range: 1-77). In 2001-02, data from the AMA/AAMC National GME Census indicated a fill rate for first-year geriatric medicine fellowship positions of 69% (259 first-year fellows for 373 positions). During 2001-02, more than half of programs (53%) reported having two or fewer first-year fellows, whereas 31% had three or four first-year fellows. Thirty-three programs (36%) reported having no U.S. medical school graduate first-year fellows, and another 25 (28%) reported having only one. Of the 51 programs offering second-year fellowship training, PDs reported 61 post-first-year fellows (median 1, range: 0-7). During the past 10 years, 27 new allopathic geriatric medicine fellowship programs opened; there are now 119 programs. There are also seven osteopathic programs. The recruitment of high-quality U.S. medical school graduates into these programs remains a challenge for the discipline. Furthermore, the retention of first-year fellows for additional years of academic training has been difficult. Incentives will be needed to attract the best graduates of U.S. family practice and internal medicine training programs into academic careers in geriatric medicine.

Objective: The authors document the development and growth of geriatric psychiatry fellowship training in the United States (U.S.) through 2002., Methods: A cross-sectional survey of the 62 U.S. geriatric psychiatry fellowship programs was conducted in Fall 2001. They also analyzed longitudinal data from the American Medical Association (AMA) and the Association of American Medical Colleges' (AAMC) National Graduate Medical Education (GME) Census, along with data from the Accreditation Council for Graduate Medical Education (ACGME)., Results: Forty-six (74%) of 62 training directors (TDs) responded. The number of fellowship programs has slowly increased over the past 7 years. During 2001-2002, a total of 94 fellows were in training (all years of training). Seventy-eight percent (N=36) of responding programs offered only 1-year fellowship training experiences. TDs reported that application rates for fellowship positions were stable during the academic years 1999-2002, with a median number of eight applications per program for first-year positions in 2001-2002. The fill-rate for first-year geriatric psychiatry fellowship positions dropped from 84% in 1999-2000 to 61% in 2001-2002. During 2001-2002, 73% of programs reported having two or fewer first-year fellows, and 16% had no first-year fellows. Seventeen programs reported having no U.S. medical school graduates (USMGs) as first-year fellows., Conclusion: Recruiting high-quality USMGs into geriatric psychiatry fellowship programs remains a challenge. Furthermore, retaining first-year fellows for additional years of academic training has been difficult. Findings indicate that specific strategies need to be developed to stimulate undergraduate and graduate interest in careers in clinical and academic geriatric psychiatry., ((c)2003 American Association for Geriatric Psychiatry.)

Problem: Little research exists on the relationship between working overtime and possible adverse health and safety outcomes for construction workers., Method: Five focus-group discussions were conducted with construction workers from around the United States. From the analyzed transcripts, a model of overtime was developed., Results: The model includes three dominant themes: (1) work organization issues [(a) definitions of overtime, (b) scheduling, and (c) economic conditions], (2) why workers choose to work overtime [(a) management expectations, (b) career, and (c) money], and (3) the effects of working overtime [(a) health and safety, including sleep deprivation, injury, fatigue, and stress, and (b) productivity]., Discussion: Health and safety is only one of the adverse outcomes related to working too much overtime. A list of worker-inspired recommendations for addressing overtime issues is provided., Impact on the Industry: Both employers and workers need to better understand the potential adverse effects of working too much overtime.

The effectiveness of commercially available interventions for reducing workers' perchloroethylene exposures in three small dry-cleaning shops was evaluated. Depending upon machine configuration, the intervention consisted of the addition of either a refrigerated condenser or a closed-loop carbon adsorber to the existing dry-cleaning machine. These relatively inexpensive (less than $5000) engineering controls were designed to reduce perchloroethylene emissions when dry-cleaning machine doors were opened for loading or unloading. Effectiveness of the interventions was judged by comparing pre- and postintervention perchloroethylene exposures using three types of measurements in each shop: (1) full-shift, personal breathing zone, air monitoring, (2) next-morning, end-exhaled worker breath concentrations of perchloroethylene, and (3) differences in the end-exhaled breath perchloroethylene concentrations before and after opening the dry-cleaning machine door. In general, measurements supported the hypothesis that machine operators' exposures to perchloroethylene can be reduced. However, work practices, especially maintenance practices, influenced exposures more than was originally anticipated. Only owners of dry-cleaning machines in good repair, with few leaks, should consider retrofitting them, and only after consultation with their machine's manufacturer. If machines are in poor condition, a new machine or alternative technology should be considered. Shop owners and employees should never circumvent safety features on dry-cleaning machines.

The goal of occupational safety and health intervention effectiveness research is to determine whether specific interventions work to prevent work-related injury and illness. But that is not the whole story. It is also important that the development and implementation of the intervention be evaluated. All three phases (development, implementation, and effectiveness) are central to a model of intervention research proposed by the National Occupational Research Agenda Intervention Effectiveness Research team. Areas for future research are also presented.

Construction is one of the largest industries in the United States, employing 7.6 million workers, or about 5% of the US work force. More women have taken jobs in the construction industry over the last two decades, as they have in other nontraditional industries. In 1997, there were 8.1 million construction workers, of whom 781,000 (9%) were women. Approximately 2% of those were employed as skilled tradeswomen. There is no disputing that construction work is dangerous. Seventeen percent of all fatal on-the-job injuries occur in construction, which is about three times its 6% share of total employment. In this paper, we review the medical literature on the safety and health hazards for women working in the construction industry. Women have a different pattern of fatal injuries and some differences in patterns of nonfatal injuries than men and report unique problems and concerns related to working in this industry.

Background: Occupational scientists agree there are hazards associated with dry-cleaning, but do dry-cleaning owners and workers concur? Knowledge of owners' and workers' perceptions can help guide intervention efforts to reduce worker exposure. To better understand these issues, a qualitative study was conducted using focus group methodology and constant comparative analysis., Methods: Two owner and four worker focus groups were held., Results: Findings suggest that overall, health and safety issues were not of great concern. Owners were primarily concerned with the economic impact of regulations. Workers did express some anxiety about solvent exposure and burns, but most felt that these hazards were "just part of the job." Also, other than the installation of air-conditioning in the shops and the provision of health benefits, workers could not think of ways health and safety on the job could be improved., Conclusions: These findings will be used to develop comprehensive safety and health interventions (e.g., engineering plus education and training) in dry-cleaning shops.

The authors examined the impact of a number of job stressors, including sexual harassment and gender-based discrimination, on female construction workers' level of job satisfaction and psychological and physical health. Results from a telephone survey with 211 female laborers indicated that having responsibility for others' safety and having support from supervisors and male coworkers was related to greater job satisfaction. Increased reported psychological symptoms were also related to increased responsibility, as well as skill underutilization, experiencing sexual harassment and gender-based discrimination from supervisors and coworkers, and having to overcompensate at work. Perceptions of overcompensation at work and job uncertainty were positively associated with self-reports of insomnia. Finally, sexual harassment and gender discrimination were positively related to reports of increased nausea and headaches.

The authors present an overarching conceptual model of occupational stress, safety, and health, incorporating multiple factors from diverse disciplines. They examine specific implications of the model for the development of prevention interventions (e.g., context-specific interventions and primary, secondary, and tertiary prevention). They review prevention interventions and describe and analyze 4 case studies that address exposure to environmental, ergonomic, and psychosocial stressors and a combination of physical-environmental and psychosocial stressors. The authors examine lessons learned from these interventions in light of the conceptual model (e.g., role of top management and integrating research and intervention).

This article describes how the protection motivation theory (PMT) was used to inform the production of video curriculum for a bloodborne pathogens training program for hospital nurses. Although hospital nurses are well acquainted with the work practices designed to prevent bloodborne pathogen exposures (universal precautions), there is evidence that they do not always follow them. First, the original PMT is adapted to reflect what is currently known about the role of affect in health behavior prediction. Second, the authors show how the four PMT message constructs-probability of occurrence, magnitude of noxiousness, response efficacy, and self-efficacy-guided the planning, shooting, and editing of the videotapes. Incidental to this process was the operationalization of these message constructs in such a way that affective reactions would result. The results show that this video curriculum successfully aroused negative affect in the target audience. Only by carefully planning and documenting how message constructs are operationalized in health education materials can one be sure of achieving theory-based (and thus the most replicable) message design.

Qualitative research methods were used to determine the health and safety concerns of women employed in the construction trades. Major categories of concern were identified, including: 1) exposure to chemical and physical agents; 2) injuries from lifting/bending/ twisting, falling, and lacerations; 3) lack of proper education and training; and 4) the health and safety risks related specifically to tradeswomen. Many of the issues identified by the workers are amenable to change through either engineering, behavioral, or administrative interventions.

This article presents a brief summary of the nature and extent of intervention research being conducted in the area of occupational safety and health. Articles were classified either as engineering, administrative, or behavioral, according to the type(s) of interventions that were evaluated. Findings suggest that many of the intervention studies conducted lacked a theoretical basis, used small samples, and tested interventions lacking the intensity to cause the desired change. Most study designs were either nonexperimental or quasi-experimental. Recommendations for conducting future research are presented.

Despite a rich history of etiological research, the field of occupational safety and health does not have a rigorous history of research on what works and does not work to prevent and control occupational diseases and injuries. National and global transformations of economies and workplaces with enhanced competitiveness require more attention to options for interventions. A three-pronged approach to building a body of knowledge on intervention research in occupational health and safety is identified in this paper. The approach focuses on the science, skills, and strategies that can be useful in intervention research. Scientifically, researchers can draw on constructs and techniques from epidemiology, evaluation practice, and clinical trials. Experimental and nonexperimental approaches have value for occupational studies. The skills needed represent a range of disciplines beyond those traditional of health and safety; social scientists, economists, and organizational theorists often need to be part of research teams. Strategic approaches involve more labor-management partnerships, prospective study designs, and the use of intermediate and surrogate indicators. The strategic challenge will be to conduct intervention research against a backdrop of overriding political and economic pressures.

This paper reviews occupational health and safety intervention studies published between 1988 and 1993 to gauge the nature and extent of research in this area. Generally, the studies often lacked a theoretical basis, used small samples, and tested interventions lacking the intensity to cause the desired change. Most designs were either nonexperimental or quasi-experimental with uncontrolled sources of bias. Recommendations for future research include methods of minimizing the problems and biases caused by these weaknesses. Nonmethodological issues such as the costs of implementing interventions and the cultural and political dimensions of the workplace are also addressed. Although many methodological issues associated with field-based research are not easily addressed, researchers should make a stronger attempt to address these issues if the field of occupational health and safety intervention research is to be productive.

The goal of this study was to evaluate the relationship between acculturation and psychological distress in three groups of older adults who have immigrated from Mexico, Cuba, and Puerto Rico. Financial strain and social isolation are specified as intervening mechanisms that are thought to link acculturation with well-being in late life. Data from a recent nationwide survey of older Hispanics suggest that levels of psychological distress tend to vary across Hispanic groups and that these differences may be attributed in part to the complex interplay between educational attainment, language acculturation, financial strain, and social isolation.

Background: Health professionals have charged that magazines that depend on revenues from cigarette advertising are less likely to publish articles on the dangers of smoking for fear of offending cigarette manufacturers. Special concern has focused on magazines directed to women. Restricted coverage of smoking hazards could lead readers to underestimate the risks of smoking in relation to other health risks., Methods: Using logistic-regression analysis of a sample of 99 U.S. magazines published during 25 years (1959 through 1969 and 1973 through 1986), we analyzed the probability that the magazines would publish articles on the risks of smoking in relation to whether they carried advertisements for cigarettes and in relation to the proportion of their advertising revenues derived from cigarette advertisements. We controlled for other factors that might influence coverage., Results: The probability of publishing an article on the risks of smoking in a given year was 11.9 percent for magazines that did not carry cigarette advertisements, as compared with 8.3 percent for those that did publish such advertisements (adjusted odds ratio, 0.73; 95 percent confidence interval, 0.42 to 1.30). For women's magazines alone, the probabilities were 11.7 percent and 5.0 percent, respectively (adjusted odds ratio, 0.13; 95 percent confidence interval, 0.02 to 0.69). When the proportion of revenues derived from cigarette advertising was the independent variable, the probability of publishing an article on the risks of smoking in a given year was reduced by 38 percent (95 percent confidence interval, 18 percent to 55 percent) for magazines with the average proportion of total advertising revenues derived from cigarette advertising for the entire sample of magazines (6 percent) as compared with magazines with no cigarette advertising. This relation was particularly strong in the case of women's magazines. An increase of 1 percent in the share of advertising revenue derived from cigarette advertisements decreased the probability of covering the risks of smoking by three times as much as in other magazines., Conclusions: This study provides strong statistical evidence that cigarette advertising in magazines is associated with diminished coverage of the hazards of smoking. This is particularly true for magazines directed to women.

At the time of the cigarette broadcast advertising ban, which took effect in 1971, cigarette manufacturers rapidly shifted advertising expenditures from the broadcast media to the print media. In the last year of broadcast advertising and the first year of the ban, cigarette ad expenditures in a sample of major national magazines increased by 49 and then 131 percent in constant dollars. From an 11-year period preceding the ban to an 11-year period following it, these magazines decreased their coverage of smoking and health by 65 percent, an amount that is statistically significantly greater than decreases found in magazines that did not carry cigarette ads and in two major newspapers. This finding adds to evidence that media dependent on cigarette advertising have restricted their coverage of smoking and health. This may have significant implications for public health, as well as raising obvious concerns about the integrity of the profession of journalism.