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Residents in small urban and rural areas frequently depend on unreliable personal transportation to maintain their lifestyle and get to essential destinations within their society. Especially, vulnerable populations, such as seniors and low-income residents, have lower access to personal vehicles and therefore are mobility-challenged. Being challenged in terms of mobility has effects on the health of the population concerned as this constraint not only limits economic activity that leads to perpetuation of lower means and poverty but also social activity that leads to physical and mental isolation. In a study of Michigan public and nonprofit transit systems, the customer satisfaction, particularly of vulnerable populations, with transit services is analyzed through on-board intercept surveys. Results illustrate the significance of employment, age, income, disability, and demand-response services in public transit planning and ultimately public health. [ABSTRACT FROM AUTHOR]

Introduction: The CenteringPregnancy model has been demonstrated to improve birth outcomes for certain cultural and ethnic groups, but the literature lacks examples on how to modify their guidelines for socioculturally isolated women. Our aim is to examine the modifications we made to the CenteringPregnancy group prenatal care for Japanese women and to examine the implications for transcultural modification. Methods: Using a descriptive case study design, we examined the cultural fit and modifications of our Japanese prenatal group approach. We report the aspects that do not require modifications and the transcultural modifications that are needed. Based on this descriptive case, we discuss the lessons learned for making transcultural modifications that may apply to other cultural groups. Results: Many aspects of the CenteringPregnancy were readily adopted. We made 10 substantive transcultural modifications and articulate considerations for transcultural modifications. Discussion/Conclusion: This research illustrates transcultural considerations for modifying the CenteringPregnancy model and provides implications for use in other isolated populations of pregnant women. [ABSTRACT FROM AUTHOR]

Few studies have examined predictors of hospital readmission among high-using patients enrolled in a behaviorally oriented intensive care management program. The purpose of this case control study was to describe risk factors and the effectiveness of a complex care management program for hospital readmission among vulnerable patients at a large academic medical center. One hundred sixty-three patients enrolled in the University of Michigan Complex Care Management Program (UM CCMP) were hospitalized between January 2014 and March 2015. Sixty were readmitted within 30 days of discharge. Among all patients, the mean age was 51.1 years, 38.7% were non-White, 81.5% had Medicaid and/or Medicare, 50.3% were without stable housing, and 27.6% had significant psychiatric illnesses. Although mostly not statistically significant, multivariable risk of readmission was increased by having twice the mean number of hospitalizations in the last 6 months (odds ratio [OR] = 1.44, 95% CI [1.00, 2.06]), having chronic pain on a scheduled narcotic (OR = 1.49, 95% CI [0.67, 3.35]), and going to a primary care physician within 30 days of discharge (OR = 1.35, 95% CI [0.63, 2.89]). Risk was decreased by going to a specialist (OR = 0.54, 95% CI [0.23, 1.27]) and receiving moderate-intensity CCMP intervention (OR = 0.48, 95% CI [0.20, 1.19]). Among hospitalized high-using patients enrolled in the UM intensive care management program, readmission is likely significantly influenced by medical, behavioral, and social challenges. Care management appears most effective in preventing readmission among patients with mid- rather than high- or low-level needs. These findings at a single program should be explored in further, larger studies. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to explore low-income parents' perceptions of oral health and of mid-level dental providers as a means of improving access to care. As states increasingly consider adding mid-level providers to the dental workforce, understanding the views of potential patients toward such providers is important, since the success of this strategy will depend, in part, upon the willingness of potential patients to be treated by them. Methods: Because little is known about the social acceptability of mid-level dental providers, the researchers employed a qualitative methodology, conducting in-depth interviews with 20 low-income parents in order to assess their perceptions of oral health, access to and need for dental care, and potential acceptance of mid-level dental providers. Interview transcripts were analyzed by a team of researchers using interpretive research methods. Results: Respondents' descriptions of experiences with oral health and dental care demonstrate their strong desire to maintain their families' oral health, as well as their perception that they face significant barriers to receiving needed care. The vast majority of respondents expressed positive inclinations toward the introduction of mid-level dental providers, particularly once they understood that such providers would be fully trained professionals. Though in reality the cost to a patient would likely not vary, many respondents expressed increased interest in treatment by mid-level providers if it were less expensive than treatment by dentists, indicating the significant barrier that cost posed for many in the sample. Conclusion: The low-income parents in this sample would likely seek care from mid-level dental providers if such providers were introduced in the U.S. The success of mid-level providers in meeting the needs of this population would potentially be even greater if public education clearly explained their training and professionalism. [ABSTRACT FROM AUTHOR]

This study evaluated feasibility, acceptability, and preliminary efficacy of a 12-week Guys/Girls Opt for Activities for Life (GOAL) intervention on 10- to 13-year-old adolescents' body mass index (BMI), percent body fat, physical activity (PA), diet quality, and psychosocial perceptions related to PA and healthy eating. Parent-adolescent dyads from two schools were enrolled. Schools were assigned to either GOAL (38 dyads) or control (43 dyads) condition. The intervention included an after-school club for adolescents 2 days/week, parent-adolescent dyad meeting, and parent Facebook group. Intervention adolescents had greater autonomous motivation for PA and self-efficacy for healthy eating than control adolescents (both p < .05). Although between-group differences were not significant, close-to-moderate effect sizes resulted for accelerometer-measured moderate-to-vigorous PA and diet quality measured via 24-hr dietary recall ( d = .46 and .44, respectively). A trivial effect size occurred for percent body fat ( d = -.10). No differences emerged for BMI. Efficacy testing with a larger sample may be warranted.

Introduction . The policing of identities through policies that restrict access to IDs issued by U.S. governmental entities disparately affects communities of color; communities who identify as low-income, immigrant, older, and/or transgender; and community members who experience chronic mental illness, housing instability, or incarceration. Yet government-issued IDs are increasingly needed to access health-promoting resources such as housing, banking, social services, and health care, and in interactions with law enforcement. Methods. Since 2012, the Washtenaw ID Project 's coalition-building process has involved communities affected by restrictive ID policies, advocates, and institutional stakeholders to enact community and systems change regarding inequities in government-issued IDs. We discuss the coalition-building process that culminated in the implementation of a photo ID issued by Washtenaw County government as a policy change strategy. We also highlight the community-academic research partnership evaluating the effectiveness of the Washtenaw ID in order to ensure equity in Washtenaw ID access and acceptance. Results. In 2015, 77% of Washtenaw ID holders reported having no other locally accepted ID. At follow-up, Washtenaw ID holders reported favorable Washtenaw ID acceptance rates in several domains (e.g., health care, school), but not when accessing banking services and housing. Additionally, community discussions suggested racial inequities in carding and ID acceptance. We discuss next steps for policy improvement to ensure equitable impact of the ID. Conclusions. Without national policy reform instating access to government-issued IDs for all, the social movement to establish local IDs may improve access to health-related resources contingent on having an ID. Careful attention must be paid to community organizing processes, policy implementation, and evaluation to ensure equity.

HIV risk perception and discrimination are important determinants of HIV prevention among vulnerable populations. Using Detroit's 2016 National HIV Behavioral Surveillance (NHBS) Survey, we evaluated demographic variables, risk behaviors, and perception of HIV stigma and discrimination stratified by perceived HIV risk (high, medium, low) in a sample of high-risk women. Significant variables were identified using Pearson Chi-squared tests and one-way analysis of variance tests. Among 541 females surveyed, 93.0% were black and 87.7% lived in poverty. Women's poverty (p = .010), employment (p = .012), insurance (p = .024) and homelessness status (p < .001) were all significantly associated with their level of HIV risk perception. Among women with low HIV risk perception (76.7%), the majority did not know their partner's HIV status at last intercourse (68.7%, p = .007), had unprotected anal/vaginal sex in the past year (86.7%, p = .025), participated in sex exchange (63.4%, p < .001), and did not use condoms with a partner with HIV-unknown status (87.2%, p < .001). Half of the women agreed or strongly agreed most people would not be friends with someone with HIV (50.4%), and 46.3% agreed or strongly agreed most people would support PLWH to live or work where they want. Compared to women with low HIV risk perception, women with high perceived HIV risk were more likely to agree or strongly agree most people would discriminate against someone with HIV (87.3% vs. 76.8%) and that people who got HIV via sex exchange or drugs got what they deserve (46.6% vs. 25.8%). Women's perceived HIV risk was not significantly associated with these discriminatory attitudes. Despite multiple risk behaviors significantly associated with the level of perceived HIV risk in the sample, the NHBS survey demonstrates many women with high-risk behaviors still perceive themselves to be at low risk. Our findings highlight a complex interaction of risk perception, risk behaviors and stigma surrounding HIV in high-risk women.

Aims: The aim of this study to examine the level of access to dental care in Michigan for individuals with DD and explore the dentists' practices, attitudes, and perceived barriers to providing care to this vulnerable population., Methods and Results: A survey was mailed to a random sample of 1250 general dental practitioners with an active license in the State of Michigan. The survey included questions related to dentists' demographic information, opinion about willingness, barriers, and training needs associated with delivering care to children and adults with developmental disabilities. Descriptive statistics were computed and chi-squared tests and logistic regression models analyzed the association between predictor and key outcome variables. Results show that most dentists treated individuals with developmental disabilities (80.3%). Respondents who indicated that they currently do not treat these patients identified behavior management of patient (67.9%), inadequate training and experiences (52.4%) and severity of patient's condition (41.7%) as the most common reasons for not providing care to individuals with developmental disabilities., Conclusion: A majority of Michigan general dentists treat patients with developmental disabilities. Addressing barriers like training and improved reimbursements might help in increasing the number of dentists willing to treat patients with developmental disabilities., (© 2018 Special Care Dentistry Association and Wiley Periodicals, Inc.)

Fine particulate matter is associated with adverse health outcomes. Exposure to fine particulate matter may disproportionately affect urban communities with larger numbers of vulnerable residents. We used multilevel logistic regression models to estimate the joint effects of fine particulate matter (PM 2.5 ) and population vulnerabilities on cardiopulmonary mortality (CPM). We estimated the health benefits of reductions in PM 2.5 across census tracts in the Detroit metropolitan area with varying levels of population vulnerability, using cluster-specific odds ratios scaled to reflect PM 2.5 -attributable cardiopulmonary risk. PM 2.5 and population vulnerability were independently associated with odds of CPM. Odds of CPM and the number of deaths attributable to PM 2.5 were greatest in census tracts with both high PM 2.5 exposures and population vulnerability. Reducing PM 2.5 in census tracts with high PM 2.5 would lead to an estimated 18% annual reduction in PM 2.5 -attributable CPM. Between 78⁻79% of those reductions in CPM would occur within census tracts with high population vulnerabilities. These health benefits of reductions in PM 2.5 occurred at levels below current U.S. reference concentrations. Focusing efforts to reduce PM 2.5 in the Detroit metropolitan area in census tracts with currently high levels would also lead to greater benefits for residents of census tracts with high population vulnerabilities.

The objectives of this study were to explore 1) how students across the four years of a dental curriculum differed in attitudes towards underserved patients and community service at the beginning and end of each school year; 2) how these attitudes changed as a function of participating in required vs. voluntary community-based activities; and 3) what attitudes faculty members held about the effects of community service-learning on students. Surveys were distributed to 440 students at one dental school at the beginning and end of the school year. The overall response rate for those surveys was 75 percent, with variations among classes: first year, 94 percent; second year, 92 percent; third year, 69 percent; and fourth year, 43 percent. Survey data were also collected from twenty-two students (out of a possible forty-seven) who participated in voluntary service-learning and from fifty-four faculty members (out of approximately 150). The results showed that, at the beginning of the year, the first-year students' attitudes were more positive than the responses of students in all other cohorts. However, at the end of the year, their attitudes were less positive. Participating in voluntary service-learning improved students' attitudes towards treating underserved patients only in the short run, and experiencing ten weeks of community-based dental education did not improve their attitudes. The faculty respondents' attitudes, however, were quite positive. The decrease in students' positive attitudes towards treating underserved patients and participating in community service should raise questions about why this loss of idealism occurred.

Introduction: Climate change is increasing the frequency of heat waves and hot weather in many urban environments. Older people are more vulnerable to heat exposure but spend most of their time indoors. Few published studies have addressed indoor heat exposure in residences occupied by an elderly population. The purpose of this study is to explore the relationship between outdoor and indoor temperatures in homes occupied by the elderly and determine other predictors of indoor temperature., Materials and Methods: We collected hourly indoor temperature measurements of 30 different homes; outdoor temperature, dewpoint temperature, and solar radiation data during summer 2009 in Detroit, MI. We used mixed linear regression to model indoor temperatures' responsiveness to weather, housing and environmental characteristics, and evaluated our ability to predict indoor heat exposures based on outdoor conditions., Results: Average maximum indoor temperature for all locations was 34.85°C, 13.8°C higher than average maximum outdoor temperature. Indoor temperatures of single family homes constructed of vinyl paneling or wood siding were more sensitive than brick homes to outdoor temperature changes and internal heat gains. Outdoor temperature, solar radiation, and dewpoint temperature predicted 38% of the variability of indoor temperatures., Conclusions: Indoor exposures to heat in Detroit exceed the comfort range among elderly occupants, and can be predicted using outdoor temperatures, characteristics of the housing stock and surroundings to improve heat exposure assessment for epidemiological investigations. Weatherizing homes and modifying home surroundings could mitigate indoor heat exposure among the elderly., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Poor feeding practices during infancy contribute to obesity risk. As infants transition from human milk and/or formula-based diets to solid foods, these practices interfere with infant feeding self-regulation and healthy growth patterns. Compared with other socioeconomic groups, lower-income mothers are more likely to experience difficulty feeding their infants. This may include misinterpreting feeding cues and using less-than-optimal feeding styles and practices, such as pressuring infants during mealtimes and prematurely introducing solid food and sweetened beverages. The Healthy Babies trial aims to determine the efficacy of a community-based randomized controlled trial of an in-home intervention with economically and educationally disadvantaged mother-infant dyads. The educational intervention is being conducted during the infant's first 6 months of life to promote healthy transition to solids during their first year and is based on the theory of planned behavior., Methods/design: We will describe our study protocol for a multisite randomized control trial being conducted in Colorado and Michigan with an anticipated sample of 372 economically and educationally disadvantaged African American, Hispanic, and Caucasian mothers with infants. Participants are being recruited by county community agency staff. Participants are randomly assigned to the intervention or the control group. The intervention consists of six in-home visits by a trained paraprofessional instructor followed by three reinforcement telephone contacts when the baby is 6, 8, and 10 months old. Main maternal outcomes include a) maternal responsiveness, b) feeding style, and c) feeding practices. Main infant outcome is infant growth pattern. All measures occur at baseline and when the infant is 6 and 12 months old., Discussion: If this project is successful, the expected outcomes will address whether the home-based early nutrition education intervention is effective in helping mothers develop healthy infant feeding practices that contribute to improving infant health and development and reducing the risk of early-onset childhood obesity., Trial Registration: Current Controlled Trials ACTRN126100000415000.

Little research has been done to examine the cost-effectiveness of REC review, or the components of review that make the greatest contributions to the protection of human subjects. We describe a process used to obtain consensus on the important categories and outcomes of REC review using the Delphi method and an array of stakeholders in a limited domain of research (biomedical). Study participants recruited from the University of Michigan Medical School's RECs, REC council, and principal investigators identified the following six categories as being the most important aspects of REC review: (1) A favorable risk/benefit ratio; (2) minimization of risk to subjects; (3) clarity of consent; (4) protection of vulnerable populations; (5) protection of privacy and confidentiality; and (6) review time. We believe that this kind of information can be used to assist in the development of a metric to assess the effectiveness and efficiency of REC review in the various research domains.

Background: Community-academic partnerships are an increasingly popular approach to addressing community health problems and engaging vulnerable populations in research. Despite these altruistic foci, however, partnerships often struggle with fundamental issues that thwart sustainability, effectiveness, and efficiency., Objectives: We adapted a synergy-promoting model to guide the development and evaluation of a community-academic partnership and share lessons learned along the way., Methods: We analyzed the partnership process over time to determine the interaction of trust, collaboration, and engagement in creating partnership synergy and promoting sustainability., Lessons Learned: Few community-academic partnerships use a conscious and systematic approach to guide and evaluate their progress. We argue that this is an important first step in creating a partnership, sustaining a milieu of open dialogue, and developing strategies that promote trust and equalize power dynamics. Still, as we learned, the best laid plans can go awry, challenging partnership synergy throughout its lifespan.

Objective: To assess the relationship between African-American caregivers' and children's caries levels adjusting for sociodemographic factors., Methods: A representative sample of 1021 children (0-5 years) and their caregivers were recruited using a stratified two-stage area probability sample of households in Detroit. The response rate was 73.7%. Caries was measured using the International Caries Detection and Assessment System. Caries was defined as D1S/d1s (noncavitated) or D2S/d2s (cavitated lesions) for both caregivers and children. Sociodemographic data included caregivers' employment status, sex, age, income and education. Negative binomial regression techniques were used for the multivariable analyses because of the highly skewed distribution of caries among the children., Results: 48% of the children were male, 39% had employed caregivers, 46% had caregivers with less than a high school education and 44% had family incomes less than $10,000. A total of 47% of the children had at least one noncavitated lesion and 31% had a cavitated lesion. Younger children (ages 0-3 years) had lower caries rates with 24% having one or more noncavitated lesion,18% having a cavitated lesion and 31% with any lesion compared with 78%, 51% and 81%, respectively, among the 4- to 5-year olds. Because of these differences in prevalence in the age groups, subsequent analyses were conducted separately for the two age groups. Multivariable analyses found that the number of cavitated surfaces among the caregivers was significantly related to the number of cavitated and noncavitated lesions among their children for both age groups. The prevalence of children's caries increased with increasing caregivers' caries score when demographic characteristics of caregivers were controlled. Younger children with family incomes of less than $10,000 had a significantly increased risk of higher caries prevalence compared with children in families with incomes greater than or equal to $20,000., Conclusions: Caregivers' caries levels were modestly correlated with children's caries. However, higher caries prevalence among caregivers significantly increased the risk of caries prevalence among their children. Thus, efforts aimed at improving caregiver's oral health could result in reducing caries risk among their children, regardless of whether the mechanism was biologically or behaviorally based. Efforts also should be aimed directly at reducing caries risk among children by increasing fluoride exposure among children and improving access to preventive dental care. Finally, even the poorest of the poor experienced additional health disadvantages associated with income suggesting even small increases in family income raising families could have a significant effect on reducing caries risk among young children.

This article reports the outcomes of an evaluation conducted to determine if an academic skills training program for undergraduate predental students from underrepresented minority backgrounds increased the students' standardized academic skills test scores for vocabulary, reading comprehension, reading rates, spelling, and math as well as subject-specific test results in biology, chemistry, and physics. Data from standardized academic skill tests and subject-specific tests were collected at the beginning and end of the 1998 to 2006 Pipeline Programs, six-week summer enrichment programs for undergraduate predental students from disadvantaged backgrounds. In total, 179 students (75.4 percent African American, 7.3 percent Hispanic, 5.6 percent Asian American, 5 percent white) attended the programs during these nine summers. Scores on the Nelson-Denny Reading Test showed that the students improved their vocabulary scores (percentile ranks before/after: 46.80 percent/59.56 percent; p<.001), reading comprehension scores (47.21 percent/62.67 percent; p<.001), and reading rates (34.01 percent/78.31 percent; p<.001) from the beginning to the end of the summer programs. Results on the Wide Range Achievement Test III showed increases in spelling (73.58 percent/86.22 percent; p<.001) and math scores (56.98 percent/81.28 percent; p<.001). The students also improved their subject-specific scores in biology (39.07 percent/63.42 percent; p<.001), chemistry (20.54 percent/51.01 percent; p<.001), and physics (35.12 percent/61.14 percent; p<.001). To increase the number of underrepresented minority students in the dental school admissions pool, efforts are needed to prepare students from disadvantaged backgrounds for this process. These data demonstrate that a six-week enrichment program significantly improved the academic skills and basic science knowledge scores of undergraduate predental students. These improvements have the potential to enhance the performance of these students in college courses and thus increase their level of competitiveness in the dental school admissions process.

Pap smear is a screening test that detects abnormal cells before they advance to cancer. Unfortunately, not all women obtain routine screening. The method used was a qualitative study exploring personal influences regarding Pap smears. Face-to-face interviews with 7 low-income African American women who do and do not obtain Pap smears (between 21 and 37 years of age) were conducted at a health department about their social influence, previous health care experience, and cognitive appraisal regarding Pap smears and cervical cancer. Women were found to be socially influenced by their family and their physician. Previous health care experience with the Pap and pelvic was perceived as negative. Cognitively, Pap smears were believed to test for sexually transmitted diseases, including HIV, and the women also felt that if one took good care of oneself it reduced the risk for cervical cancer. It was concluded that exploring beliefs associated with Pap smears and perceptions of vulnerability to cervical cancer and giving correct information and counseling may increase Pap smear screening in women.

Objective: To examine the effectiveness of three modalities for delivery of nutrition education., Design: Between-subjects, repeated-measures design., Setting: Data were collected at community agencies or during home visits., Participants: Low-income, European American and African American mothers (N = 155)., Intervention: Participants were exposed to nutrition education material in 1 of 3 modalities (a computer game, The Fantastic Food Challenge; Web site; or pamphlet). Likeability, nutrition knowledge, intention to use, and demographic measures followed the intervention at T1 and T2., Main Outcome Measures: 5-point Likert-type scales measured likeability (5 items), and 33 multiple-choice questions measured knowledge., Analysis: Data were analyzed using analysis of variance (ANOVA) and analysis of covariance (ANCOVA) procedures using SPSS version 15.0 (SPSS Inc., Chicago, IL) software, P < .05., Results: Overall, the Web site was liked more than the other conditions with this audience of women. Significant differences in attention, understanding, and intent to use the information existed across modalities. The Web site performed better than other modalities on knowledge outcomes, with no differences in knowledge retention from T1 to T2., Conclusions and Implications: The Web site modality performed best with this audience of women, indicating that interactive computer games may not confer greater benefits than traditional modes of information delivery for all audiences, particularly those with low computer skills.

Objective: To examine the prevalence of depressive symptoms in mid-pregnancy and their relation to life circumstances across the life course in a community-based sample., Methods: The Pregnancy Outcomes and Community Health (POUCH) Study enrolled women at 16-26 weeks' gestation from 52 clinics in five Michigan communities. At enrollment women completed a screening instrument for depressive symptoms (CES-D) and questions about life circumstances covering three "periods," i.e. previous 6 months, adulthood, and childhood. Questions were grouped into sub-constructs (e.g., abuse, economic, substance use, loss, and legal) for each "period" and evaluated in relation to CES-D scores. Analyses included 1321 POUCH participants divided into three subgroups: teens; women > or =20 years insured by Medicaid (disadvantaged); and women > or =20 years not insured by Medicaid (advantaged)., Results: A positive CES-D screen (> or =16) was more common in teens (46%) and disadvantaged women (47%) than in advantaged women (23%). Recent problems (previous 6 months) with abuse, economics, and substance use in someone close were each associated with higher adjusted mean CES-D scores (2.3-7.5 increase) in the three subgroups of women. In life course analyses, abuse and substance use in teens, and abuse and economic problems in disadvantaged and advantaged women were strongly linked to higher adjusted mean CES-D scores when these problems occurred both in childhood and adulthood (range 2.2-7.1 increase), whereas the associations were more modest when problems were confined to childhood., Conclusions: Strategies for addressing the public health problem of depressive symptoms in mid-pregnancy will benefit from a life course perspective.

An especially vulnerable population is the disadvantaged and underserved older adult population residing in urban communities. This article describes a hospital-sponsored program in an urban community developed to improve access to health promotion and chronic disease control services for older adults. As part of the newly designed service, the hospital also sought to change its image from simply that of a "hospital" to that of a "community setting" dedicated to serving the comprehensive needs of older adults.

Background: Exposure to environmental tobacco smoke (ETS) is a global public health problem which is particularly acute in groups where smoking rates are higher than in the general population. A study was undertaken to investigate knowledge, attitudes and preventive efforts with regard to exposure to ETS in a sample of economically disadvantaged women residing in Michigan, USA., Methods: Analysis-of-variance techniques were used to investigate how knowledge, attitudes and preventive efforts regarding exposure to ETS relate to demographic variables such as smoking status, ethnicity, education, employment, and income; and analysis-of-covariance techniques were applied to determine the degree to which knowledge, attitudes, age, smoking status, ethnicity, education, employment, income and home environment predict these women's preventive efforts regarding exposure to ETS., Results: Generally, women with no high school diploma and women who were smokers were less knowledgeable about the adverse health effects of exposure to ETS, had worse attitudes concerning exposure to ETS and were less likely to take preventive steps to limit their exposure to ETS than were women who had more formal education or who were nonsmokers, respectively. The primary predictors of preventive efforts were knowledge, attitudes and smoking status., Conclusions: The results suggest that educational efforts focusing on increasing knowledge and improving attitudes regarding exposure to ETS, as well as providing practical strategies for limiting exposure to ETS, should be developed and delivered to at-risk populations.