Publications

BACKGROUND

Secondhand smoke is a major cause of morbidity in young children, and exposure to smoking parents is the principal source. Physician visits for young children present an opportunity to effect behavioral change among smoking parents.

OBJECTIVE

To survey pediatricians and family physicians in their knowledge and practice of smoking cessation counseling with parents.

DESIGN

Cross-sectional mail survey.

SETTING

Urban California.

PARTICIPANTS

Pediatricians and family physicians in urban areas of California, younger than 65 years, practicing in an ambulatory setting, and randomly selected from the American Medical Association Physician Masterfile.

MAIN OUTCOME MEASURES

Reported frequency of asking about tobacco use, using cessation counseling techniques with smokers, and perceived barriers to providing cessation services.

RESULTS

Of the 1000 mailed surveys, 899 were eligible and 499 (56% response rate) were returned and completed. A higher proportion of pediatricians compared with family physicians were women (44% vs 29%; P<.01) and nonwhite (44% vs 32%; P =.01). Family physicians compared with pediatricians were more likely to report referring a parent to a smoking cessation program (41% vs 30%), giving pamphlets on smoking cessation (40% vs 28%), asking for a quit date (41% vs 18%), scheduling a follow-up visit to discuss quitting (27% vs 5%), and recommending nicotine replacement therapy (41% vs 13%) (for each comparison, P<.001). Pediatricians were more likely to report recording in the medical record smoking by a parent as a problem for the child (65% vs 48%; P<.001), but a higher proportion of pediatricians perceived that parents would ignore the advice (39% vs 24%; P<.001) and lacked interest in quitting smoking (45% vs 27%; P<.001). Pediatricians were more likely to agree that they lacked smoking cessation counseling skills (26% vs 7%; P<.001). Multivariate models showed that pediatricians were less likely to report performing 5 of 14 smoking cessation techniques in at least 50% of smoking parents.

CONCLUSIONS

Pediatricians appear to lack training to implement smoking cessation counseling with smoking parents. Physicians in private practice are less likely to counsel smoking parents. Educational interventions for pediatricians are needed to decrease secondhand smoke exposure for young children.

BACKGROUND

Sexually transmitted infections (STI) are common in developing countries. The World Health Organisation (WHO) estimates that in 1995, 333 million new cases of syphilis, gonorrhoea, chlamydial infection and trichomoniasis occurred. Human immunodeficiency virus (HIV) infection is also common in developing countries. UNAIDS estimates that over 90% of the 33 million people infected with HIV by December 1999 live in developing countries (UNAIDS 1999). The STI and HIV epidemics are interdependent. Similar behaviours, such as frequent unprotected intercourse with different partners, place people at high risk of both infections, and there is clear evidence that conventional STIs increase the likelihood of HIV transmission. Several studies have demonstrated a strong association between both ulcerative and non-ulcerative STIs, and HIV infection (Cameron 1989, Laga 1993) and there is biological evidence that the presence of an STI increases shedding of HIV and that STI treatment reduces HIV shedding (Cohen 1997, Robinson 1997). Therefore, STI control may have the potential to contribute substantially to HIV prevention.

OBJECTIVES

To determine the impact of population-based STI interventions on the frequency of HIV infection, frequency of STIs and quality of STI management.

SEARCH STRATEGY

The following electronic databases were searched for relevant randomised trials or reviews: 1) MEDLINE for the years 1966 to current using the search terms sexually transmitted diseases and human immunodeficiency virus infection 2) The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness and the Cochrane Clinical Trials Register in the most recent issue of the Cochrane Library 3) The specialist register of trials maintained by the Cochrane Infectious Diseases Group. 4) EMBASE The abstracts of relevant conferences were searched and reference lists of all review articles and primary studies were scanned. Finally, authors of included trials and other experts in the field were contacted as appropriate.

SELECTION CRITERIA

Randomised controlled trials in which the unit of randomisation is either a community or a treatment facility. Studies where individuals are randomised were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied the inclusion criteria to potential studies with any disagreements resolved by discussion. Trials were examined for completeness of reporting. The methodological quality of each trial was assessed by the same two reviewers with details recorded of randomisation method, blinding, use of intention-to-treat analysis and the number of patients lost to follow-up using standard guidelines of the Cochrane Infectious Diseases Group.

MAIN RESULTS

Four trials were included. Frequency of HIV infection: In Rakai, after 3 rounds of treatment of all community members for STIs the rate ratio of incident HIV infection was 0.97 (95%CI 0.81 to 1.16), indicating no effect of the intervention. In Mwanza, the incidence of HIV infection in the intervention groups (strengthened syndromic management of STIs in primary care clinics) was 1.2% compared with 1.9% in the control groups (OR=0.58, 95% CI 0.42-0.70), corresponding to a 38% reduction (95%CI 15% to 55%) in HIV incidence in the intervention group. Frequency of STIs: In both Mwanza and Rakai, there was no significant reduction in gonorrhoea, chlamydia, urethritis, or reported STI symptoms among intervention communities. The prevalence ratio of syphilis between intervention and control groups in Rakai was 0.8 (95%CI 0.71-0.89), of trichmoniasis was 0.59 (0.38-0.91), and of bacterial vaginosis was 0.87 (0.74-1.02). In Mwanza, the prevalence of serologically diagnosed syphilis in the intervention community was 5% compared with 7% in the control community at the end of the trial (adjusted relative risk 0.71 (95%CI 0.54-0.93). Quality of treatment: In Lima, following training of pharmacy assistants in STI syndromic management, symptoms were recognised as being due to an STI in 65% of standardised simulated patients (SSPs) visiting intervention and 60% of SSPs visiting control pharmacies (p=0.35). Medication was offered without referral to a doctor in most cases (83% intervention and 78% control, p=0.61). Of those SSPs offered medication, only 1.4% that visited intervention pharmacies and only 0.7% of those that visited control pharmacies (p=0.57) were offered a recommended regimen. Similarly in only 15% and 16% of SSP visits respectively was any recommended drug offered. However, education and counseling were more likely to be given to SSPs visiting intervention pharmacies (40% vs 27%, p=0.01). No SSPs were given partner cards or condoms. In Hlabisa, following the intervention targeting primary care clinic nurses (strengthened STI syndromic management and provision of STI syndrome packets containing recommended drugs, condom, partner cards and patient information leaflets), SSPs were more likely to be given recommended drugs in intervention clinics (83% vs 12%, p <0.005) and more likely to be correctly case managed [given correct drugs, partner cards and condoms] (88% vs 50%, p <0.005). There were no significant difference in the proportions adequately counseled (68% vs 46%, p=0.06), experiencing good staff attitude (84% vs 58%, p=0.07), and being consulted in privacy (92% vs 86%, p=0.4). There was no strong evidence of any impact on treatment seeking behaviour, utilisation of services, or sexual behaviour in any of the four trials.

REVIEWERS' CONCLUSIONS

There is limited evidence from randomised controlled trials for STI control as an effective HIV prevention strategy. Improved STI treatment services have been shown to reduce HIV incidence in an environment characterised by an emerging HIV epidemic (low and slowly rising prevalence), where STI treatment services are poor and where STIs are highly prevalent. There is no evidence for substantial benefit from treatment of all community members. There are however other compelling reasons why STI treatment services should be strengthened and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided. Further community based randomised controlled trials that test a range of alternative STI control strategies are needed in a variety of different settings. Such trials should aim to measure a range of factors that include health seeking behaviour and quality of treatment as well as HIV, STI and other biological endpoints.

OBJECTIVE

There has been insufficient research on the influence of ethno-cultural and language differences in public health surveys. Using data from three independent studies, the authors examine methods to assess data quality and to identify causes of problematic survey questions.

METHODS

Qualitative and quantitative methods were used in this exploratory study, including secondary analyses of data from three baseline surveys (conducted in English, Spanish, Cantonese, Mandarin, and Vietnamese). Collection of additional data included interviews with investigators and interviewers; observations of item development; focus groups; think-aloud interviews; a test-retest assessment survey; and a pilot test of alternatively worded questions.

RESULTS

The authors identify underlying causes for the 12 most problematic variables in three multiethnic surveys and describe them in terms of ethnic differences in reliability, validity, and cognitive processes (interpretation, memory retrieval, judgment formation, and response editing), and differences with regard to cultural appropriateness and translation problems.

CONCLUSIONS

Multiple complex elements affect measurement in a multiethnic survey, many of which are neither readily observed nor understood through standard tests of data quality. Multiethnic survey questions are best evaluated using a variety of quantitative and qualitative methods that reveal different types and causes of problems.

Inhalation of ozone by Rhesus monkeys results in epithelial injury and granulocyte influx in both conducting airways and respiratory bronchioles. We have reported that ozone-induced neutrophil recruitment and subsequent epithelial repair can be inhibited in vivo with a CD18 antibody. The antibody-mediated effect is abrogated by local instillation of C5a (a CD18-independent neutrophil chemoattractant), thereby demonstrating a role for neutrophils in lung epithelial repair processes. As an extension of this study, we examined the effect of ozone and neutrophil influx on epithelial expression of the beta6 integrin, an adhesion molecule associated with proliferation and repair. Expression of beta6 integrin was determined by immunohistochemistry for ozone-exposed monkeys treated with either control immunoglobulins or a CD18 antibody. The tracheal epithelium of ozone-exposed monkeys treated with control immunglobulins expressed the beta6 integrin. In contrast, the tracheal epithelium of ozone-exposed monkeys treated with CD18 antibody exhibited very low to undetectable expression of beta6 integrin. In association with C5a instillation and neutrophil influx, beta6 integrin was also observed in respiratory bronchiolar epithelium from both control and ozone-exposed animals. These findings cumulatively suggest that lung epithelial cell expression of beta6 integrin is associated with sites of neutrophil recruitment.