Nancy P. Chin

Understanding social conditions prior to intervention design can enhance tobacco control interventions. This paper describes formative research conducted in 2010 about tobacco use in eight economically disadvantaged Dominican Republic communities, four of which participated in a previous intervention study (2003–2008). A combined US-Dominican team used a rapid assessment process to collect qualitative social and cultural data on tobacco use, knowledge and attitudes; plus observations about social and policy factors, such as exposure to secondhand smoke (SHS), tobacco regulations, pregnancy, health care provider (HCP) practices and sustainability of the 2003–2008 intervention. This assessment found that tobacco use varied by age. While all ages typically used cigarettes, older adults used relatively more unprocessed tobacco, which is seen as less harmful and less addictive. Middle-aged smokers typically used commercial cigarettes, which are viewed as dangerous, addictive, expensive and offensive. Young adults reported avoiding smoking, but using relatively more smokeless tobacco. Smoking during pregnancy has reportedly decreased. SHS was viewed as harmful, although smoke-free homes were uncommon. HCPs discussed tobacco issues mostly for patients with tobacco-related conditions. Sustainability of the 2003–2008 intervention appeared to be linked to active Community Technology Centers with strong leadership, and community social capital. This information could be used to design better targeted interventions in these communities.

Engaging partners for tobacco control within low and middle income countries (LMICs) at early stages of tobacco control presents both challenges and opportunities in the global effort to avert the one billion premature tobacco caused deaths projected for this century. The Dominican Republic (DR) is one such early stage country. The current paper reports on lessons learned from 12 years of partnered United States (US)-DR tobacco cessation research conducted through two NIH trials (Proyecto Doble T, PDT1 and 2). The projects began with a grassroots approach of working with interested communities to develop and test interventions for cessation and secondhand smoke reduction that could benefit the communities, while concurrently building local capacity and providing resources, data, and models of implementation that could be used to ripple upward to expand partnerships and tobacco intervention efforts nationally. Lessons learned are discussed in four key areas: partnering for research, logistical issues in setting up the research project, disseminating and national networking, and mentoring. Effectively addressing the global tobacco epidemic will require sustained focus on supporting LMIC infrastructures for tobacco control, drawing on lessons learned across partnered trials such as those reported here, to provide feasible and innovative approaches for addressing this modifiable public health crisis.

This is a case study of one community's recovery after an 1814 landslide obliterated two hamlets in the Italian Dolomites, leaving only 44 escaping survivors. The study has two aims: to introduce the concept of taskscape to the recovery literature and to use survival narratives to identify community strengths. The concept of taskscape considers the social activities of people living within a specific, local landscape. Taskscapes may provide a more dynamic, locally developed understanding of social cohesion than do current notions such as social capital. Comparing pre-disaster taskscapes to post-disaster recovery across different cases may reveal new mechanisms for community resiliency.

Worksites provide multiple advantages to prevent and treat obesity and to test environmental interventions to tackle its multiple causal factors. We present a literature review of group-randomized and non-randomized trials that tested worksite environmental, multiple component interventions for obesity prevention and control paying particular attention to the conduct of formative research prior to intervention development. The evidence on environmental interventions on measures of obesity appears to be strong since most of the studies have a low (4/8) and unclear (2/8) risk of bias. Among the studies reviewed whose potential risk of bias was low, the magnitude of the effect was modest and sometimes in the unexpected direction. None of the four studies describing an explicit formative research stage with clear integration of findings into the intervention was able to demonstrate an effect on the main outcome of interest. We present alternative explanation for the findings and recommendations for future research.

The childhood obesity epidemic has raised national awareness about the need to improve school meals. Our research study partnered University of Rochester researchers with the Healthi Kids Coalition, a local health planning organization, to evaluate a newly instituted food service program in a metropolitan school district of western New York. Using the Centers for Disease Control and Prevention’s Program Evaluation stepwise framework, we focused on stakeholder accountability and student satisfaction. The first author collected data through informal, conversational group interviews with students, key informant interviews (with school board members, food service employees, and the food services management company), and participant-observations at 2 schools. Then, we sorted data across the categories of “accountability” and “satisfaction.” Analysis of stakeholder accountability data revealed 3 themes: (a) unsustainable program costs, (b) strained working relationships among stakeholders, and (c) student–staff interactions that could potentially encourage consumption, but often resulted in rushed, unfinished meals. Analysis of student satisfaction data also revealed 3 themes: (a) dissatisfaction with food quality, including taste, texture, and food preparation; (b) unappealing food presentation; and (c) tremendous food waste with large amounts of uneaten food thrown away. Our study identified a complex system of relationships between the school board, food services management company, and unionized food service workers, which ultimately affected the food quality and (non)consumption at the point of delivery. We recommend improving stakeholder relationships, training staff to reduce waste, reevaluating labor contracts pertaining to food services, continued program evaluation, and using an evaluation process that represents all relevant perspectives.

Background: Deaf mothers who use American Sign Language (ASL) consider themselves a linguistic minority group, with specific cultural practices. Rarely has this group been engaged in infant-feeding research. Objectives: To understand how Deaf mothers who use ASL learn about infant feeding and to identify their breastfeeding challenges. Methods: Using a community-based participatory research approach, we conducted 4 focus groups with Deaf mothers who had at least 1 child 0-5 years old. A script was developed using a social ecological model (SEM) to capture multiple levels of influence. All groups were conducted in ASL, filmed, and transcribed into English. Deaf and hearing researchers analyzed data by coding themes within each SEM level. Results: Fifteen mothers participated. All had initiated breastfeeding with their most recent child. Breastfeeding duration for 8 of the mothers was 3 weeks to 12 months. Seven of the mothers were still breastfeeding, the longest for 19 months. Those mothers who breastfed longer described a supportive social environment and the ability to surmount challenges. Participants described characteristics of Deaf culture such as direct communication, sharing information, use of technology, language access through interpreters and ASL-using providers, and strong self-advocacy skills. Finally, mothers used the sign for “struggle” to describe their breastfeeding experience. The sign implies a sustained effort over time that leads to success. Conclusion: In a setting with a large population of Deaf women and ASL-using providers, we identified several aspects of Deaf culture and language that support breastfeeding mothers across institutional, community, and interpersonal levels of the SEM.

More than 30% of the pregnancies in women aged 35 and over are unintended. This paper compares perceptions about contraceptive methods and use among women with and without an unintended pregnancy after turning age 35. Semi-structured, in-depth interviews were conducted with 17 women. They were all 35 to 49 years old, regularly menstruating, sexually active, not sterilized, not desiring a pregnancy in the near future, and at least 3 months postpartum. We purposely sampled for women who had had at least one unintended pregnancy after age 35 (n = 9) and women who did not (n = 8). We assessed partnership, views of pregnancy and motherhood, desired lifestyle, perceived advantages and disadvantages of using and obtaining currently available well-known reversible contraceptives in the U.S. ''We also assessed contraceptive methods used at any time during their reproductive years, including current method use and, if appropriate, circumstances surrounding an unintended pregnancy after age 35.'' Each interview was taped and transcribed verbatim. Data were analyzed using Grounded Theory. Analysis focused on partnership, views of pregnancy, motherhood, desired lifestyle and perceived advantages and disadvantages of various reversible contraceptive methods. The women without an unintended pregnancy after age 35 were more likely to (1) use contraceptive methods that helped treat a medical condition, (2) consider pregnancy as dangerous, or (3) express concerns about the responsibilities of motherhood. The women who experienced an unintended pregnancy after age 35 were more likely to (1) report unstable partnerships, (2) perceive themselves at lower risk of pregnancy, or (3) report past experiences with unwanted contraceptive side effects. There was a greater likelihood a woman would choose a contraceptive method if it was perceived as easy to use, accessible, affordable and had minimal side effects. Women's perspective on contraceptive use after age 35 varies. Public health messages and health providers' care can help women in this age group by reviewing their fertility risks, as well as all contraceptive methods and their associated side effects. The impact of such interventions on unintended pregnancy rates in this age group should be tested in other areas of evidence-based medicine.

Exclusive breastfeeding of infants for the first 6 months of life with continued breastfeeding for at least 6 more months occurs only 11.9% of the time in the United States. Efforts of the past 30 years to promote optimal breastfeeding practices have had little impact. In order to create significant change in the way we feed infants in this country, we need to change the way we look at this public health issue and examine the cultural logic that makes bottle feeding the preferred choice of most U.S. women. This article analyzes the term “inadequate” not just as self-description of a woman's milk supply, but also as a metaphor for the lives of low-income women in the United States, the group least likely to breastfeed. Low-income women in the United States not only have inadequate incomes as compared to the general population, but inadequate child care, education, preventive health services, inadequate lifespans, and lives saturated with violence, leaving them inadequately safe even in their own homes. Here we outline a research agenda to explore the relationship between socially determined inadequacies and the cultural logic that makes bottle feeding a preferred form of infant feeding.

Objectives: To understand patterns of decision making among families presenting to a pediatric emergency department (ED) for nonacute care and to understand pediatric ED staff responses. Methods: Cross-sectional qualitative study using in-depth interviews, direct observations, and nonidentifying demographic data. Results: Eleven percent of visits made during the study period were identified as nonacute. All were made by families from low-income areas. Three main themes emerged: (1) most families had been referred by their primary care providers; (2) the complexity of living in low-income areas makes the ED a choice of convenience for these stressed families; and (3) mistrust of primary health services was not identified by our respondents as a motivator for ED utilization, in contrast with other published data. Two themes emerged from ED staff: (1) actual nonurgent visit rates were lower than staff estimates; and (2) these visits produced frustration among staff members, although their degrees of insight and understanding of factors motivating these visits were variable. Conclusions: In this setting, nonacute visits occurred with lower than perceived frequency and caused disproportionate frustration among staff and families. These visits appear to be driven more by consequences of system design and structure than by family members' decision making. Mistrust of primary care services was not a strong family decision-making factor; the study's setting may have limited its ability to capture such data. Recommended system changes to lower barriers to primary care include expanded office hours, subsidized staffing for offices in medically underserved areas, and lowering barriers to sick care.