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Workplace violence is on the rise in health care. This problem contributes to medical errors, ineffective delivery of care, conflict and stress among health professionals, and demoralizing and unsafe work conditions. There is no specific federal statute that requires workplace violence protections, but several states have enacted legislation or regulations to protect health care workers. To address this problem in their state, the Massachusetts Health & Hospital Association developed an action plan to increase communication, policy development, and strategic protocols to decrease workplace violence. The purpose of this article is to report on the quality and safety improvement work that has been done statewide by the Massachusetts Health & Hospital Association and to provide a roadmap for other organizations and systems at the local, regional, or state level to replicate the improvement process. [ABSTRACT FROM AUTHOR]

Appropriate management by schools of all students with a concussion, regardless of the cause, has not received the same attention as sports-related concussions. Focus groups conducted with Massachusetts School Nurses in 2015 found that some had applied protocols required in the state's sports concussion regulations to all students with concussion, not just student athletes. We surveyed high school nurses in Massachusetts to examine (1) the extent of this practice and (2) the extent to which protocols for all students with concussion are included in school policies. Of 168 (74%) responding, 94% applied the return-to-learn and play, and medical clearance requirements to all students with concussion, regardless of how or where the concussion occurred and 77% reported their school's policy required these protocols for all students with concussion. A significant association (odds ratio: 13.3, 95% confidence interval [2.4, 72.8], p <.01) existed between the two measures. These findings have important clinical and academic implications.

Background and Purpose: Favorable organizational climate in primary care settings is necessary to expand the nurse practitioner (NP) workforce and promote their practice. Only one NP-specific tool, the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), measures NP organizational climate. We confirmed NP-PCOCQ's factor structure and established its predictive validity., Methods: A crosssectional survey design was used to collect data from 314 NPs in Massachusetts in 2012. Confirmatory factor analysis and regression models were used., Results: The 4-factor model characterized NP-PCOCQ. The NP-PCOCQ score predicted job satisfaction (beta = .36; p < .001) and intent to leave job (odds ratio = .28; p = .011)., Conclusion: NP-PCOCQ can be used by researchers to produce new evidence and by administrators to assess organizational climate in their clinics. Further testing of NP-PCOCQ is needed.

This article considers queer-driven student activism at Smith College, as well as admissions policy shifts at a number of prominent U.S. women's colleges for transgender women's inclusion. The author illustrates how student attempts to dismantle the transmisogyny at Smith as a purportedly feminist "women's" space, as well as some women's colleges' shifts in admissions policy, challenge divisions between transgender and cisgender women. This paradigmatic shift reflects the campuses as comparative havens for gender and sexual exploration, the influence of postmodern gender theory in understanding identity, and the growth of "queer" as an all-encompassing signifier for sexual and gender transgression.

We tested a theoretically trimmed model of union participation presented by Tetrick, Shore, McClurg, and Vandenberg (2007), in which perceived union instrumentality is expected to influence participation through perceived union support. This testing was accomplished as a precursor to testing a conditional indirect effect model of women's participation--in which perceived union tolerance for sexual harassment was expected to moderate the influence of perceived support on willingness to participate in union activities. In a sample of 326 women from multiple unions, we found support for the conditional model; the influence of perceived instrumentality on willingness to participate through perceived support was moderated by perceived tolerance for harassment; specifically, the influence through perceived support was weak when perceived tolerance was high. The implications of our results are discussed in reference to need support and women's participation.

Background: Organ donation after cardiac death is increasingly implemented, with outcomes similar to those of organ donation after brain death. Many hospitals hesitate to implement a protocol for donation after cardiac death because of the potential negative reactions among health care providers., Objectives: To determine the acceptance of a protocol for donation after cardiac death among multidisciplinary staff in a pediatric intensive care unit., Methods: An anonymous, 15-question, Likert-scale questionnaire (scores 1-5) was used to determine the opinions of staff about donation after brain death and after cardiac death in a pediatric intensive care unit of a tertiary-care university hospital., Results: Survey response rate was 67% (n = 60). All physicians, 89% of nurses, and 82% of the remaining staff members stated that they understood the difference between donation after brain death and donation after cardiac death; staff supported both types of donation, at rates of 90% and 85%, respectively. Staff perception was the same for each type of donation (ρ = 0.82; r = 0.92; P < .001). The 20 staff members who provided care directly to patients who were donors after cardiac death considered such donation worthwhile. However, 60% of those providers offered suggestions to improve the established protocol for donation., Conclusions: The multidisciplinary staff has accepted organ donation after cardiac death and has fully integrated this kind of donation without reported differences from their acceptance of donation after brain death.

Background: The Centers for Disease Control and Prevention recommend hospitals develop guidelines for the appropriate use of vancomycin as part of comprehensive antimicrobial stewardship. The objective of this study was to evaluate the effectiveness and safety of a guideline to restrict vancomycin use in the neonatal intensive care unit (NICU)., Methods: A vancomycin use guideline was introduced in 2 tertiary care NICUs with low incidences of methicillin-resistant Staphylococcus aureus infections. We compared all infants >72 hours of age who were evaluated for late-onset infection before and after implementation of this guideline., Results: Vancomycin start rates were reduced from 6.9 to 4.5 per 1000 patient-days (35% reduction; P = 0.01) at Brigham and Women's Hospital, and from 17 to 6.4 per 1000 patient-days (62% reduction; P < 0.0001) at Massachusetts General Hospital. The number of infants exposed to vancomycin decreased from 5.2 to 3.1 per 1000 patient-days (40% reduction; P = 0.008) at Brigham and Women's Hospital, and 10.8 to 5.5 per 1000 patient-days (49% reduction; P = 0.009) at Massachusetts General Hospital. Causes of infection, duration of bacteremia, and incidence of complications or deaths attributable to late-onset infection did not change significantly at either institution., Conclusions: Implementation of a NICU vancomycin use guideline significantly reduced exposure of newborns to vancomycin without adversely affecting short-term patient safety. Further studies are required to evaluate the long-term effect of vancomycin restriction on NICU patient safety and microbial ecology, particularly among institutions with higher rates of methicillin-resistant Staphylococcus aureus infections.

Background: Heavy alcohol use among U.S. college students is a major contributor to young adult morbidity and mortality. The aim of this study was to examine whether college alcohol policy enforcement levels predict changes in student drinking and related behaviors in a state system of public colleges and universities, following a system-wide change to a stricter policy., Methods: Students and administrators at 11 Massachusetts public colleges/universities completed surveys in 1999 (N of students = 1252), one year after the policy change, and again in 2001 (N = 1074). We calculated policy enforcement scores for each school based on the reports of deans of students, campus security chiefs, and students, and examined the correlations between perceived enforcement levels and the change in student drinking rates over the subsequent two year period, after weighting the 2001 data to adjust for demographic changes in the student body., Results: Overall rates of any past-30-days drinking, heavy episodic drinking, and usual heavy drinking among past-30-days drinkers were all lower in 2001 compared to 1999. School-level analyses (N = 11) found deans' baseline reports of stricter enforcement were strongly correlated with subsequent declines in heavy episodic drinking (Pearson's r = -0.73, p = 0.011). Moreover, consistently high enforcement levels across time, as reported by deans, were associated with greater declines in heavy episodic drinking. Such relationships were not found for students' and security chiefs' reports of enforcement. Marijuana use did not rise during this period of decline in heavy drinking., Conclusions: Study findings suggest that stronger enforcement of a stricter alcohol policy may be associated with reductions in student heavy drinking rates over time. An aggressive enforcement stance by deans may be an important element of an effective college alcohol policy.

Skin cancer is highly preventable, but clearly there is a critical need to focus on better ways to disseminate information about known skin cancer prevention. The U.S. Environmental Protection Agency's (EPA) SunWise Program is one channel for reaching children, teachers, and school nurses. In a pilot study designed to increase adoption of school-based sun protection policies, 28 schools were randomly assigned to one of three groups: Control, which included the EPA's original SunWise curriculum toolkit; SunWise Policy, which included a revised toolkit emphasizing policy; and SunWise Policy plus Technical Assistance, which included the policy toolkit and 3 technical assistance phone calls. The enhanced SunWise Policy plus Technical Assistance intervention led to more new sun protection policies. Use of study interventions for improving sun protection practices such as policy toolkits or brief counseling can be easily interwoven into school hours by school nurses and other health educators.

Hospitals, associations agree that the policy is 'the right thing to do'. CMS announcement it would not reimburse for specified errors may have impacted timing of policies. Not paying for adverse events likely a trend to spread to other states.

Background: Hospital policies and practices related to breastfeeding may have long-term health effects. The Ten Steps to Successful Breastfeeding (WHO/UNICEF) provide an evidence-based standard, which may be used to assess individual hospitals. We assessed implementation, and factors related to implementation, of the Ten Steps in Massachusetts hospitals., Methods: We surveyed postpartum nurse managers at 43 (88%) of the 49 Massachusetts maternity hospitals by telephone. Survey items characterized hospital policies, breastfeeding education, and support practices. We classified hospital implementation of the Ten Steps as high, moderately high, partial, or low and used Massachusetts Department of Public Health hospital data to analyze factors related to implementation., Results: Levels of implementation of the Ten Steps ranged from high to partial. Overall, we classified implementation of 2% of hospitals as high, 58% moderately high, 40% partial, and 0% as low. Hospitals with high/moderately high levels of implementation significantly differed from hospitals with partial implementation with respect to pacifier usage (p=0.0017) and postpartum breastfeeding instruction (p=0.0001). Requirement of a physician order for formula was a statistically significant (p=0.02) predictor of Step 1 implementation but did not reach significance (p=0.14) overall. Acceptance of free formula was significantly associated (p=0.03) with overall Ten Steps implementation., Conclusion: Rates of self-reported implementation of the Ten Steps are relatively high in Massachusetts. Step 1 implementation is significantly associated with formula availability, and overall implementation with acceptance of free formula. Continued assessment is needed to confirm these results in larger samples and to examine the relationship of implementation of individual steps, breastfeeding rates, and health outcomes.

Objective: To determine the relationship of providing explanatory information regarding resuscitation to DNR status for parents and guardians of young people who reside in a pediatric skilled nursing facility., Design: Retrospective, quasi-experimental study of policy change, with each individual serving as his or her own control. Interval comparisons were made between resuscitation choices before and after information was provided to families. For those who were originally in the full resuscitation group, comparisons were also made between those who changed to DNR and those who did not., Setting: Pediatric skilled nursing facility in Massachusetts., Participants: Sixty individuals with severe mental retardation and complex medical problems, between the ages of approximately 2 and 32 years., Measurements: Review of records regarding resuscitation choices and changes, with each person serving as his or her own control. Both univariate and multivariate analyses were performed on individuals who were in the full resuscitation group at the initiation of the study to determine distinguishing characteristics between those who remained in that group from those who changed to DNR., Results: The families of 11 (18%) of 60 patients had requested DNR orders prior to requirement of written preference for resuscitation or DNR in the event of cardiopulmonary arrest. After provision of informative material, there was an increase to 26 patients (43%) who were designated DNR (P < . 001). There was no significant difference in characteristics between the groups that changed to DNR and those that remained full resuscitation, although there was a marginal trend of children in the group with an acquired etiology for their developmental disabilities were more apt to have their resuscitation status changed than those with congenital diagnoses (P = .053)., Conclusion: When families are provided with explanatory information regarding resuscitation in a nonacute, pediatric skilled nursing home setting, there is a significant increase in request for DNR.

Objectives: Our goal was to determine whether school-level variability in implementation of immunization requirements is associated with the likelihood of a child having received an exemption to school immunization requirements., Methods: We surveyed 1000 school immunization personnel in Colorado, Massachusetts, Missouri, and Washington. We explored associations between school implementation of immunization requirements and the likelihood of a child having an exemption using logistic regression models., Results: School policies associated with an increased likelihood of children having exemptions included lack of provision of written instructions for completing the school immunization requirement before enrollment, administrative procedures making it easier to claim an exemption, and granting of philosophical exemptions. In the 2 states we surveyed where philosophical exemptions are not authorized (Massachusetts and Missouri), 17.0% and 18.1% of schools reported permitting philosophical exemptions., Conclusions: Inconsistencies in the interpretation and implementation of school immunization laws contribute to variability in rates of exemptions. School policies should be reviewed to ensure consistency with the intent of state laws.

Background: Within the challenging healthcare environment are nurses, patients, and patients' families. Families want proximity to their loved ones, but the benefits of such proximity depend on patients' conditions and family-patient dynamics., Objectives: To describe patients' preferences for family visiting in an intensive care unit and a complex care medical unit., Methods: Sixty-two patients participated in a structured interview that assessed patients' preferences for visiting, stressors and benefits of visiting, and patients' perceived satisfaction with hospital guidelines for visiting., Results: Patients in both units rated visiting as a nonstressful experience because visitors offered moderate levels of reassurance, comfort, and calming. Patients in the intensive care unit worried more about their families than did patients in the complex care medical unit but valued the fact that visitors could interpret information for the patients while providing information to assist the nurse in understanding the patients. Patients in the intensive care unit were more satisfied with visiting practices than were patients in the complex care medical unit, although both groups preferred visits of 35 to 55 minutes, 3 to 4 times a day, and with usually no more than 3 visitors., Conclusions: These data provide the input of patients in the ongoing discussion of visiting practices in both intensive care units and complex care medical units. Patients were very satisfied with a visiting guideline that is flexible enough to meet their needs and those of their family members.

Background: Children who attend day care are high consumers of antibiotics. Studies suggest that physicians prescribe unnecessary antibiotics for upper respiratory tract infections (URIs) for children who attend day care on the basis of perceived pressure from parents and/or day care centers., Objective: To determine both parental and day care-level predictors of acute care and antibiotic seeking for children who attend day care., Methods: We conducted a day care center-based cross-sectional survey of parents and day care center staff. Two hundred eleven parents of children attending 36 day care centers in Massachusetts completed a survey. Day care center staff completed a separate survey addressing their day care center's policies for ill children., Results: Few parents reported day care staff pressure to seek care from a physician (3.9%) or antibiotics (1.9%). In multivariate models, higher parental knowledge about URIs was related to decreased acute care seeking for 3 upper respiratory symptoms (clear rhinorrhea, green rhinorrhea, and cough) in the absence of fever (odds ratios and 95% confidence intervals: 0.45 [0.31-0.65], 0.66 [0.52-0.85], and 0.57 [0.45-0.72], respectively). Parent-reported acute care seeking was not related to a day care center's polices for exclusion or physician clearance for these illnesses. Similar results were also found for the parental belief that antibiotics expedite return to day care for these symptoms., Conclusion: Although it has been suggested that inappropriate day care center policies for exclusion motivate parental acute care and antibiotic seeking, this study suggests that parental knowledge is a more important predictor of these reported behaviors than are day care center policies.

Students who violate school smoking policies present a difficult health and disciplinary issue for school officials. Professionals know little about the characteristics of students who smoke at school. In a prospective study of 679 students in two cities in central Massachusetts, researchers examined how nicotine dependence contributes to the problem of smoking at school. After three years of follow up, smoking at school was reported by 10.3% of students. Among subjects who admitted to smoking at school, 63% reported that symptoms of nicotine dependence preceded their smoking at school. After adjusting for other variables, student smokers with symptoms of nicotine dependence were nine times more likely to report smoking in school (OR 9.1, 95% CI 2.9-28.5) than were student smokers without symptoms. Smoking at school was more common among daily smokers and those who paid for their own cigarettes. Age, gender, race, and parental smoking status were not significantly associated with students' reports of smoking at school. These data suggest nicotine dependence as an important contributor to the problem of smoking at school, but not the only reason why students violate school smoking policies. Disciplinary action against students caught violating school smoking policies should be supplemented with an offer of treatment for nicotine dependence.

A survey of Massachusetts companies reporting use of methylene chloride between 1995 and 1999 was conducted to assess the status of industrial use of the chemical in 2000. Methylene chloride has had wide use in industry although it has been identified as potentially hazardous to exposed workers and the environment. New and tightened occupational and environmental regulations taking effect in the 1990s were hypothesized to have reduced use of the chemical in Massachusetts. Substitute technologies, especially aqueous cleaning, were expected to have replaced methylene chloride in many industries. Seventeen of the 21 Massachusetts manufacturing companies reporting use of over 10,000 lb/y of methylene chloride between 1995 and 1999 were surveyed by telephone regarding their experiences of methylene chloride use and elimination and/or replacement. Fifteen of the 17 companies had either eliminated (10) or reduced to below 10,000 lbs/yr (5) their use of methylene chloride at the time of the survey in 2000. Many of the surveyed companies moved to aqueous cleaning from methylene chloride degreasing operations. Environmental concerns were the most popular reason given for eliminating or reducing use of methylene chloride. Worker health and safety concerns, especially concern about compliance with the 1997 Occupational Safety and Health Administration methylene chloride standard, were also a motivation. In general, the companies associated many benefits and few problems with eliminating or reducing use of methylene chloride. Exposure reduction strategies based on toxics use reduction techniques appear to be feasible for many manufacturing companies. However, research should be conducted to assess the introduction of new hazards as a result of tightened regulations on methylene chloride.

Objective: Physician attitudes may be a key factor in effective managed care for older patients. We sought to explore physicians' views of the influence of health maintenance organization (HMO) policies on the care of their older patients., Design: A self-administered one-page questionnaire consisting of questions about physician demographics, the impact of HMOs on physician practice, patient care, HMO policies, and respondents' personal use of managed health care plans., Participants: The survey was mailed to 838 randomly selected primary care physicians affiliated with two large, nonprofit, academically-oriented, Medicare HMOs in Massachusetts., Results: Completed surveys were received from 516 of 797 eligible primary care physicians, affiliated with either Secure Horizons (Tufts Associated Health Plan) or First Seniority (Harvard Pilgrim Health Care). About half (55%) of the physician respondents reported they had sufficient time to spend with their older patients. Most (81%) respondents indicated that overall, patients aged 65 and older received either better care or no change in care after joining an HMO. The majority of physicians reported that HMO affiliation had increased the frequency with which they addressed geriatric issues with their older patients. There were several patterns of response that emerged with respect to beliefs about key HMO policies., Conclusions: The majority of physicians working in two nonprofit, academically oriented Medicare HMOs in Massachusetts believed that the overall quality of care that older patients received after joining an HMO either did not change or improved.

Smoking policies and smoking practices of residents and employees in a state-supported residential system were investigated. Smoking policies existed in almost every agency, although state- and vendor-operated programs had vastly different policies. State-operated programs prohibited employees from smoking in residences and restricted residents who smoked to designated areas. One third of vendor-operated agencies allowed residents and staff members to smoke in designated areas, whereas one quarter stipulated that residences be smoke-free. Smoking among employees was higher and among residents lower than in the general population. The feasibility of specific approaches to reduce passive smoking and attitudes and beliefs about human rights issues related to smoking are presented.

Expenditures for growth hormone (GH) in the United States approximates 400 million dollars annually. There is considerable controversy and variation around both the indications for GH treatment and insurance coverage decisions involving GH treatment. To address these issues, Harvard Community Health Plan (HCHP), now merged with Pilgrim Health Care to form Harvard Pilgrim Health Care (HPHC), developed a policy and implementation plan in 1992 which limited access to GH to those conditions for which GH has been shown to be effective. The 4-year experience of the HPHC Growth Hormone Review Committee, which determines by case review whether criteria for GH coverage are met, is described. The result has been a more rational, equitable approach to decisions about GH treatment coverage, and significant cost reductions. Caution is warranted in expanding access to GH because the potential for serious side effects has not been completely eliminated. Four years after the inception of the policy and approval process (1992-1995), it is estimated that savings have exceeded 1 million dollars. Growth hormone prescribing costs decreased from 13.4% of total to 4.4% of total drug costs 4 years after the new policy was implemented. This approach to policy development and implementation may be applicable to managing high-cost pharmaceuticals and advanced technology in other settings.

The implementation, monitoring, and impact of a program to restrict vancomycin use are described. A vancomycin restriction program was implemented in February 1995 at an acute care teaching hospital after guidelines for vancomycin use were established by a multidisciplinary group. Pharmacists reviewed each vancomycin order, suggested alternative treatments when vancomycin use did not comply with the guidelines, and set duration limits for all orders. Orders requiring greater clinical experience for review were referred to a pharmacist or a physician in the division of infectious diseases. The program was monitored by an infectious diseases pharmacist. Data collected after the program was established showed that the volume of vancomycin use decreased substantially. Problems in enforcing the restriction program included administration of vancomycin for surgical prophylaxis before the order reached the pharmacy, continuing use of vancomycin for initial empirical treatment of febrile neutropenic and immunocompromised patients, inadequate tracking of the evaluations, and deficiencies in the evaluations related to a need for continuing education of the pharmacists about the program. Use of vancomycin decreased after a pharmacy-enforced restriction program was implemented.

The main objectives of this study are to analyze the Massachusetts Health Maintenance Organizations (HMOs) in order to determine their standard definition of an emergency, the HMOs instructions for seeking emergency care, and distribution of such instructions for the pediatric population. A 15-question survey concerning pediatric emergency care policies and procedures was asked of each of the 20 HMOs contacted. Quarterly statements of each of the 20 HMOs were obtained from the Division of Insurance as well as the HMO's written materials distributed to the enrollees as member handbooks. Ninety percent of the HMOs had a definition of emergency care for the adult population, whereas 0% had a definition of emergency care specifically for the pediatric population. One hundred percent of the HMOs had instructions for emergency care, but 0% had specific provisions for pediatric emergency care. All 20 HMOs inform their enrollees about emergency policies through a member handbook. The results of this study reveal the lack of a standard definition of an emergency for HMOs. The current definitions of "urgent," "emergency," and "life-threatening emergency" care do not reflect the pediatric population, rather, these definitions are based on the adult population. The lack of specific pediatric guidelines could compromise the health of the children in HMOs.

Managed care has emerged as the centerpiece of the health care industry's efforts to control costs and ensure appropriate use of hospital services. This study assesses the impact of managed care by preadmission approval and/or continued stay review on length of psychiatric hospitalization and clinical outcome of children and adolescents. The sample included 277 cases hospitalized in nine psychiatric specialty hospitals in 1990. Demographic and clinical characteristics, hospital ownership type, and preadmission approval or continued stay review were used as independent variables in a multiple regression model to predict length of stay and clinical outcome. Results indicate that the model accounted for 27% of the variance in length of stay. Previous psychiatric hospitalization and for-profit hospital status predicted longer hospitalization. Clinical outcome was not significantly predicted by the model. Managed care did not predict either length of stay or clinical outcome. Implications for health care reform are discussed.

Objectives: In 1990, the American Academy of Pediatrics (AAP) Committee on Injury and Poison Prevention issued a policy statement which recommended that all infants born at less than 37 weeks gestational age be monitored in their car seat before discharge to identify infants at risk for apnea associated with car seat use. The objective of this report is to summarize the experience of a community hospital in implementing this recommendation, including: education of health professionals about the problem and its management, development of an effective hospital policy and procedure for testing at-risk infants, overcoming logistical difficulties for nursing staff who implement the policy, overcoming liability concerns, and summarizing the clinical results which we observed during a 15-month period., Methods: MetroWest Medical Center, Framingham Union Campus is a community hospital with a Level II Neonatal Unit with approximately 2200 deliveries annually. Hospital procedures and policies were developed to implement the AAP policy for safe transportation of premature infants. Consequently, infants less than 37 weeks gestation at birth were monitored for a 90-minute observation period for oxygen saturation, apnea, or bradycardia in the car seat that they would be going home in from the nursery., Results: Policies and procedures for car seat monitoring were instituted successfully during 15-month period. Sixteen of 87 (18.4%) monitored infants 26 to 36 weeks gestation had abnormal results. In addition, one 37-week gestational newborn who was monitored because of duskiness during feeds also became apneic and bradycardic in the car seat., Conclusions: A car seat monitoring program can be incorporated effectively into a Level II community hospital nursery discharge plan provided that appropriate medical staff policies, nursing procedures, and administrative support to deal with the logistics of the program is established. Our monitoring results are consistent with previous reports that premature infants are at risk of desaturation in a car seat. In addition, we have demonstrated that a full-term neonate may also be at risk if other evidence of desaturation (eg, duskiness during feedings) is observed.

Objectives: Laws restricting smoking in public places and workplaces can protect the public only if they are obeyed. We sought to assess compliance with a Cambridge, Mass, no-smoking ordinance., Methods: We prospectively observed 174 retail stores 1 month before and 3, 11, and 24 months after the law took effect. At 24 months, we interviewed one employee per store., Results: Full compliance with the law was low; at 24 months, only 4% of stores displayed the mandated sign and were free of smokers and smoke. Fewer than half the stores posted any no-smoking sign. Sign prevalence increased over 2 years (22% to 41%, P < .001), but the frequency of smoke or smokers (13% and 10%, respectively, at baseline) did not change. According to employees interviewed at 24 months, 38% of stores illegally permitted customers or employees to smoke. These stores had more smoke and fewer signs than did stores prohibiting smoking. Compliance was poor in liquor and convenience stores. Employees who had been told how to handle customers' smoking were more likely to enforce the law., Conclusions: Compliance with a no-smoking law is not guaranteed. For retail stores, compliance may improve if stores adopt no-smoking policies, post signs, and teach employees to enforce the law.

Massachusetts ranks 10th in the nation in numbers of reported AIDS cases. The state had 3,877 AIDS cases reported through June 1991. The Southeastern Massachusetts region consisting of 70 cities and towns totaling approximately 1,735 square miles has the second highest incidence of HIV infection of regions in the state. Total cumulative cases of full-blown AIDS in the region have numbered 406, approximately 14 percent of the state total. This article describes the experience of Southeastern Massachusetts Area Health Education Center, Inc. (SMAHEC) in implementing AIDS educational efforts.

Despite the increasing participation of women in medicine over the past few decades, hindrances to professional advancement for women physicians and medical students persist. The present study sought to assess the prevalence of gender bias and sexual harassment in a sample of women physicians and medical students. Within a one-year period, 54% of respondents encountered some form of sex discrimination. In addition, approximately one-fourth experienced sexual harassment (27%) and/or discrimination related to parenthood (24%). Unwanted sexual attention not viewed as sexual harassment was experienced by more than twice as many respondents (55%). Other forms of discrimination were reported as well: age (22%), sexual preference (20%), and race (7%). Perceptions of the extent of sex discrimination and sexual harassment, of their impact on professional commitment, and of the adequacy of solutions at institutions varied directly with whether or not respondents had experienced some form of employment discrimination within the past 12 months. This study points to the need for clarification of what constitutes sexual harassment and for the creation of safe, effective mechanisms to remedy and prevent all forms of gender bias.