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Objective: To identify barriers and motivators for reducing secondhand smoke exposure (SHSe) for families of African-American, lowincome, urban children. Method: Audiotaped intervention sessions of 52 African-American caregivers of Head Start children who reported being a smoker and/or had at least one smoker in the home were randomly sampled from a larger trial examining the effectiveness of a motivational- interviewing intervention in reducing child's SHSe. Counseling sessions were qualitatively coded to identify barriers and motivators to implementing a home smoking ban or quitting smoking. Results: African-American families identified several themes that were either or both barriers and motivators for SHSe reduction, including: asking others not to smoke, other family living in the home, neighborhood safety, absence of childcare, cost/availability of cessation tools, physician support and prevention of health problems. Discussion: Urban, low-income African- American families face numerous barriers to reducing SHSe. Families were able to identify many motivators for reducing SHSe, suggesting an awareness of the importance for SHSe reduction but uncertainty in their confidence to change behaviors. Counseling should include tailoring to be most effective in supporting health behavior change. Greater emphasis on motivators is needed, such as low-cost/free cessation tools, engagement from physicians and greater involvement of extended family members. [ABSTRACT FROM AUTHOR]

Introduction: This study determines if expenditures associated with implementing a combined motivational interviewing (MI) and Head Start-level education program (MI+Education), as compared to education alone, yield cost savings to society.Methods: Post hoc cost analyses were applied to a randomized controlled-trial of MI among predominantly African American, low-income caregivers of 330 Baltimore City Head Start students who reside with a smoker. The primary outcome was the cost savings of MI+Education from averted direct secondhand smoke exposure (SHSe)-related acute healthcare events and inferred indirect costs (work days lost, transportation and reduction in cigarettes smoked). The net direction of savings was defined by the sum of averted direct and indirect costs of the MI+Education intervention at 3, 6 and 12 months, benchmarked against the Education alone cohort at the equivalent time periods.Results: The costs saved by the MI+Education intervention, relative to Education alone, resulted in savings at solely the 12-month follow-up time point. Significant savings were appreciated from averted emergency department (ED) visits at 12 months ($4410; 95% simulation interval [SI]: $2241, $6626) for the MI+Education group. The total savings at 12 months ($2274; 95% SI: -3916, $8442) could not overcome additional program costs of implementing MI to Head Start-level education ($13 695; 95% SI: $11 250, $16 034).Conclusions: This study is the first to examine the cost of either intervention on SHSe-attributed pediatric healthcare costs from a population level relevant for federal and community decision makers. Intervention costs could not be offset by short-term savings but a trend towards positive savings was appreciated 1 year after implementation.Implications: Behavioral interventions are effective in reducing SHSe in children. However, many of these interventions are not implemented in community settings due to lack of resources and money. Behavioral strategies may be a cost-saving addition to the national initiatives to create smoke-free home environments. The long-term benefits of MI, as evidenced from cost savings from averted ED visits, appeared to show MI+Education to be a robust long-term strategy. The decrease of acute healthcare services at 12 months may be informative for policy decision makers seeking to allocate limited resources to reduce the usage of costly ED services and hospital readmissions. [ABSTRACT FROM AUTHOR]

The article cites a study which seeks to determine the relationship between depressive symptoms and electronically monitored adherence to asthma therapy after the discharge of inner-city adult patients who were hospitalized for asthma exacerbations in Baltimore, Maryland. Accordingly, the study reveals that depressive symptoms are usual in inner-city adults which are responsible in explaining poor adherence to asthma therapy.

Despite the availability of effective treatments that aid in controlling asthma symptoms, inner-city children with asthma have high rates of morbidity and are frequent users of emergency department services. The goal of these studies was to pilot test an intervention that used social learning strategies (e.g., goal-setting, monitoring, feedback, reinforcement, and enhanced self-efficacy) and targeted known barriers to individualize a family-based asthma action plan. Participants were 15 children with asthma, aged 7-12 years, who had been prescribed at least one daily inhaled steroid. The children and their mothers lived in inner-city Baltimore and all were African-American. Participants received up to five visits in their home by a nurse. Electronic monitors were installed on the children's MDI to provide immediate feedback on medication adherence to the families and validate medication use. At baseline, only 28.6% of the children were using their medications as prescribed. Within four weeks, the number of children who were using their medications appropriately doubled from 28.6% at baseline to 54.1% (90% increase; p = 0.004), while underutilization decreased from 51.2% to 25.4% (100% decrease; p = 0.02). The number of children with no medication use at all dropped from 28.3% at baseline to 15.1% by week 5 (87% decrease; p = 0.009). Thus, within four weeks, more than half the children were using their inhaled steroids appropriately. In addition, the rate of underutilization decreased and that of nonutilization was cut in half. Our initial data suggest that an individualized, home-based intervention can significantly enhance adherence to the daily use of inhaled steroids in inner-city children with asthma. Nevertheless, adherence to daily inhaled steroid therapy remains a significant problem in this group. [ABSTRACT FROM AUTHOR]

Background: On-line tutorials are being increasingly used in medical education, including in teaching housestaff skills regarding end of life care. Recently an on-line tutorial incorporating interactive clinical vignettes and communication skills was used to prepare housestaff at Johns Hopkins Hospital to use the Maryland Orders for Life Sustaining Treatment (MOLST) form, which documents patient preferences regarding end of life care. 40% of housestaff who viewed the module felt less than comfortable discussing choices on the MOLST with patients. We sought to understand factors beyond knowledge that contributed to housestaff discomfort in MOLST discussions despite successfully completing an on-line tutorial., Methods: We conducted semi-structured telephone interviews with 18 housestaff who completed the on-line MOLST training module. Housestaff participants demonstrated good knowledge of legal and regulatory issues related to the MOLST compared to their peers, but reported feeling less than comfortable discussing the MOLST with patients. Transcripts of interviews were coded using thematic analysis to describe barriers to using the MOLST and suggestions for improving housestaff education about end of life care discussions., Results: Qualitative analysis showed three major factors contributing to lack of housestaff comfort completing the MOLST form: [1] physician barriers to completion of the MOLST, [2] perceived patient barriers to completion of the MOLST, and [3] design characteristics of the MOLST form. Housestaff recommended a number of adaptations for improvement, including in-person training to improve their skills conducting conversations regarding end of life preferences with patients., Conclusions: Some housestaff who scored highly on knowledge tests after completing a formal on-line curriculum on the MOLST form reported barriers to using a mandated form despite receiving training. On-line modules may be insufficient for teaching communication skills to housestaff. Additional training opportunities including in-person training mechanisms should be incorporated into housestaff communication skills training related to end of life care., Competing Interests: The authors have declared that no competing interests exist.

Purpose: To understand the role of Maryland Head Start (HS) programs in asthma care and identify resources and needs to improve health outcomes., Methods: A qualitative needs assessment was conducted with Maryland HS staff (n = 35) and parents/caregivers of enrolled children with asthma (n = 16) from all 14 grantee programs in Maryland. Focus group discussions and interviews addressed strengths and challenges in current asthma control and opportunities for integration of an asthma care program into HS services. Transcripts were thematically analyzed using a modified Framework approach., Results: HS programs actively communicate with families about asthma management and facilitate communication between families and primary care providers (PCPs). Both HS staff and families reported a strong trusting relationship allowing HS staff to provide asthma management support. HS needs strong linkages with supportive services and PCP offices to engage families, address environmental triggers, and educate staff. While families across the state report interest in peer education on asthma through HS, there were some region-specific asthma care barriers for urban and rural programs., Conclusion: This needs assessment confirmed interest among all stakeholders in integrating asthma care through HS and identified communication strategies, supportive infrastructure, and addressing regional access to care as key elements for program design., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: Seasonal influenza is a significant cause of morbidity and mortality in the United States each year. Healthcare worker (HCW) influenza vaccination is associated with both decreased absenteeism among employees and improved outcomes among patients. However, HCW influenza vaccine uptake remains suboptimal. The objective of this study was to characterize HCWs' understanding of and response to a stringent vaccination policy., Design, Setting, and Participants: A survey of 928 hospital staff at a tertiary academic medical center in Baltimore during the 2008-2009 influenza season., Results: Of those surveyed, 75% (n = 695) completed the survey; 623 respondents reported regular patient contact, and 91% of those reported vaccination in the current influenza season. However, only 60% reported consistently receiving the vaccine every year. Of those who were vaccinated, 8% (n = 48) reported being vaccinated for the first time during that influenza season. A significant proportion (42%) of respondents were unaware of the major change in hospital policy regarding vaccination. Influences on the decision to be vaccinated varied significantly between those who are regularly vaccinated and those with inconsistent vaccination habits. Attitudes toward hospital policy varied significantly by race and clinical role., Conclusions: Although 91% of respondents with regular patient contact reported being vaccinated for influenza in the 2008-2009 season, only 60% reported consistent annual vaccination. Misinformation regarding hospital policies is widespread. Improvements in vaccination rates will likely require multifaceted, targeted efforts focused on specific influences on less adherent groups. The identified variability in influences on the decision to be vaccinated suggests possible targets for future interventions.

This study investigated hydroxyurea use in people with sickle cell disease (SCD) outside of a research setting. Pharmacy data, outpatient visits, hospital admissions, and length of stay were assessed for all patients with SCD enrolled in a Medicaid managed care organization in Maryland. Three hundred and ninety (390) people with SCD were covered between the years 2001-2005. A large majority (85.9%) never had a claim for a hydroxyurea refill. Hydroxyurea users had higher admission rates than non-hydroxyurea users (5 vs. 1.5, p=.004). Patients who were in the highest tertile of refills of hydroxyurea had significantly fewer hospital admissions than patients in the lowest tertile (2.44 vs. 7.57, p=.043). Patients with the lowest hydroxyurea refill usage had significantly higher mean costs per month enrolled than those with the highest number ($4,553 vs. $2,017, p=.031). Hydroxyurea was underutilized in this patient population. Patients with more regular refills of hydroxyurea had fewer admissions to the hospital and markedly decreased costs.

The environment is suspected to play an important role in the prevalence and severity of asthma in inner-city children. This paper describes the implementation and baseline data of an inner-city community-based participatory research clinical trial designed to test the effectiveness of a pollutant and allergen control strategy on children's asthma morbidity. Participants were 100 elementary-school-aged children with asthma, graduates of a school-based asthma education program in East Baltimore. The intervention for half of the randomly assigned families consisted of environmental control education, allergen-proof encasements, pest extermination, and a HEPA air cleaner at the beginning of the study. Controls received the same at the end of the study. Participants visited a clinic for questionnaires, allergy skin testing, spirometry, and blood sample at baseline and 12 months. Home environments, NO(2), O(3), airborne particulates, and allergens were evaluated at baseline and at 6 and 12 months. Asthma morbidity and adherence was assessed quarterly. Collaboration with the community proved very beneficial in creating a study design and procedures acceptable to an inner-city community.

Background: Environmental tobacco smoke (ETS) is a frequent exposure and is linked to asthma among inner-city children., Objective: We sought to examine the relationship among ETS exposure, select asthma symptoms, and consequences among inner-city children with asthma., Methods: Data from interviews with primary caregivers of inner-city elementary school children with asthma were evaluated (n = 590). Caregiver reports of child asthma symptoms, exercise limitations, asthma management, health care use, and ETS exposure were examined., Results: Smoking in the home was reported by 29.4% of primary caregivers. ETS exposure (yes/no) was not related to frequency of child nocturnal symptoms or other select asthma morbidity markers. However, among children exposed to ETS, the frequency and severity of child nocturnal symptoms were highest among children exposed to moderate-to-heavy levels of ETS. After controlling for child age, anti-inflammatory medication use, asthma primary care, and caregiver's education, exposure to higher levels of ETS was associated with nearly a 3-fold increase in nocturnal symptoms in children (odds ratio, 2.83; 95% CI, 1.22-6.55)., Conclusion: Among elementary school inner-city children with asthma, exposure to higher levels of ETS was associated with increased frequency of nocturnal symptoms. Reducing the exposure of children with asthma to ETS should be a clear priority in developing effective asthma management plans for inner-city families.