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PubMed1996

Radiation exposure to patients and personnel during interventional ERCP at a teaching institution.

BACKGROUND: This study was designed to determine the radiation dose to patients and personnel during ERCP procedures. METHODS: Phantom studies were performed to compare dosimetry for two image capture systems and to determine the effectiveness of shielding in reducing stray radiation. Radiation techniques and dosimetry were recorded in 72 patients undergoing ERCP. RESULTS: Phantom studies indicated that increasing fluoroscopy voltage from 75 to 96 kV decreased entrance dose by 50%. Image capture by digital radiography decreased radiation exposure by 66%. Shielding decreased stray radiation exposure by 93%. All patients underwent cholangiography (n = 71) and/or pancreatography (n = 53). The mean number of interventional ERCP procedures performed per patient was 1.8 (range, 0 to 6). The mean measured patient entrance dose was 80 mGy (8 R; range, 0.2 to 73 R); however, the calculated mean entrance dose (based on measured intensifying screen doses) may have been as high as 3000 mGy (30 R; range, 0.8 to 300 R). Measured patient exposure increased with fluoroscopy time (r = 0.9) and with the number of interventions performed (r = 0.3). The mean dose to personnel was estimated at 0.04 mR. CONCLUSIONS: The patient radiation dose depended most on fluoroscopy time. The dose may be lowered by minimizing fluoroscopy time, using higher voltage and lower current for fluoroscopy, and using digital radiography for documentation. Personnel were adequately protected.

Adult↗

PubMed2006

Pollution prevention--occupational safety and health in hospitals: alternatives and interventions.

An integrated pollution prevention (P(2)) and occupational safety and health (OSH) worksite intervention and alternatives assessment strategy was developed in hospitals. It was called the Pollution Prevention-Occupational Safety and Health (P(2)OSH) assessment for the "Sustainable Hospitals Project." Methods included (a) developing a participatory intervention model for introducing more environmentally sound, healthy, and safe materials and work practices for specific hospital procedures; (b) developing an integrated P(2)OSH survey to evaluate environmental and occupational impacts of the intervention; and (c) conducting and evaluating interventions by applying the P(2)OSH assessment pre- and post-intervention. Eleven interventions were performed in six hospitals: an aliphatic fixative replaced xylene in three histology laboratories; a mercury reduction plan was implemented in three clinical laboratories; digital imaging replaced wet chemical film processing in three radiology departments; a less toxic aldehyde replaced formaldehyde in one hospital histopathology laboratory; and conventional mopping was replaced by microfiber mopping in one hospital. Occupational and environmental health and safety impacts were observed for all interventions. The alternatives generally were beneficial, although each had limitations that resulted in process and task changes with potentially negative P(2) and/or OSH impacts. When these were identified in the pilot phase they could be addressed before full-scale implementation. The P(2)OSH method shifts the focus of occupational and environmental hygiene from hazard control to substitution. Because few ideal alternatives exist, the emphasis is on a continuous process to identify, implement, and evaluate alternatives, rather than on a particular alternative. Occupational and environmental health and safety professionals have an important role as agents in hospital organizational change and in the search for healthier and safer alternatives. Through these activities they can become involved in the design/redesign of products, materials, and processes, thus expanding their traditional role.

Air Pollution, Indoor↗

PubMed2004

Physical activity promotion in primary care: bridging the gap between research and practice.

BACKGROUND: While a growing literature supports the effectiveness of physical activity interventions delivered in the primary care setting, few studies have evaluated efforts to increase physician counseling on physical activity during routine practice (i.e., outside the context of controlled research). This paper reports the results of a dissemination trial of a primary care-based physical activity counseling intervention conducted within the context of a larger, multi-strategy, Australian community-based, physical activity intervention, the 10,000 Steps Rockhampton Project. METHODS: All 23 general practices and 66 general practitioners (GPs, the Australian equivalent of family physicians) were invited to participate. Practice visits were made to consenting practices during which instruction in brief physical activity counseling was offered, along with physical activity promotion resources (print materials and pedometers). The evaluation, guided by the RE-AIM framework, included collection of process data, as well as pre- and post-intervention data from a mailed GP survey, and data from the larger project's random-digit-dialed, community-based, cross-sectional telephone survey that was conducted in Rockhampton and a comparison community. RESULTS: Ninety-one percent of practices were visited by 10,000 Steps staff and agreed to participate, with 58% of GPs present during the visits. General practitioner survey response rates were 67% (n =44/66 at baseline) and 71% (n =37/52, at 14-month follow-up). At follow-up, 62% had displayed the poster, 81% were using the brochures, and 70% had loaned pedometers to patients, although the number loaned was relatively small. No change was seen in GP self-report of the percentage of patients counseled on physical activity. However, data from the telephone surveys showed a 31% increase in the likelihood of recalling GP advice on physical activity in Rockhampton (95% confidence interval [CI]=1.11-1.54) compared to a 16% decrease (95% CI=0.68-1.04) in the comparison community. CONCLUSIONS: This dissemination study achieved high rates of GP uptake, reasonable levels of implementation, and a significant increase in the number of community residents counseled on physical activity. These results suggest that evidence-based primary care physical activity counseling protocols can be translated into routine practice, although the initial and ongoing investment of time to develop partnerships with relevant healthcare organizations, and the interest generated by the overall 10,000 Steps program should not be underestimated.

Attitude of Health Personnel↗

PubMed1987

Videodensitometric determination of minimum coronary artery luminal diameter before and after angioplasty.

Quantitative measurements of coronary stenoses were made from digital coronary angiograms in 19 patients before and after percutaneous transluminal coronary angioplasty (PTCA). Two methods of measurement were compared. Mean stenosis before PTCA was 67 +/- 10% by the edge detection method and 67 +/- 12% by videodensitometry (difference not significant). After PTCA, the mean stenosis was 32 +/- 14% by edge detection and 30 +/- 13% by videodensitometry (difference not significant). In addition, a new method was developed to rapidly calculate the absolute minimum luminal area and diameter by videodensitometry. The minimum luminal diameter before PTCA was 1.0 +/- 0.5 mm and after PTCA increased to 2.4 +/- 0.5 mm (p less than 0.001). The validity of the videodensitometric method was analyzed in a series of Lucite phantom studies, which suggested that when there is an irregular angiographic appearance, the densitometric method may be more accurate than standard edge detection methods. Digital acquisition of coronary angiograms provides a means for rapid application of quantitative analysis during coronary interventional procedures.

Angioplasty, Balloon↗

PubMed2003

Physician advice about smoking and drinking: are U.S. adults being informed?

BACKGROUND: Population-based estimates for the prevalence of smokers receiving advice from a health professional to quit smoking and the prevalence of binge drinkers being talked to about alcohol use are lacking for U.S. adults. This information is useful for clinicians and public health professionals. METHODS: Data are from the Behavioral Risk Factor Surveillance System, a continuous random-digit-dial telephone survey of U.S. adults. In 1997, 10 states collected data on these health interventions for tobacco and alcohol use. The prevalence of professional advice to quit smoking and about alcohol use was calculated and examined by demographic characteristics. The number of at-risk adults who had a routine checkup in the last year and had not received these interventions was also estimated. RESULTS: By self-report, 70% of smokers were advised to quit, and 23% of binge drinkers were talked to about their alcohol use. Using multivariate logistic regression analyses, we found among smokers that women and older persons were more likely to receive advice; among binge drinkers, health intervention was more likely to occur for men and non-Hispanic blacks. Across the 10 states, approximately 2 million smokers and 2 million binge drinkers with a routine checkup in the past 12 months were not advised to quit smoking or talked to about their alcohol use. CONCLUSIONS: Many opportunities to intervene with smokers and binge drinkers are lost. Efforts to increase physician education and to identify and reduce other barriers may help.

Adult↗

PubMed2003

Digital subtraction angiography assisted ultrasound puncture in a pelvic kidney.

A new technique for percutaneous nephrostomy needle guidance is presented. It was applied in a patient with a solitary pelvic kidney, where ultrasound guidance was not feasible because of a very narrow puncture window. Typical intravenous urography was not useful, owing to poor opacification of the collecting system. We describe how the use of digital subtraction imaging eventually permitted us to establish a percutaneous nephrostomy tube safely, avoiding the intestine and blood vessels.

Aged↗

PubMed2003

Intrapartum ultrasound for the examination of the fetal head position in normal and obstructed labor.

OBJECTIVE: To assess the feasibility of transabdominal ultrasound for determining fetal head position in laboring women and compare it to digital examination, and to study ultrasonographically the rotation of the fetal head in normal and obstructed labor. DESIGN: This was an observational prospective study of 148 women in active labor. Ultrasound examinations were performed longitudinally in the first and second stages of labor. RESULTS: Assessment of the fetal head position by digital examination was not possible in 60.7% (122/201) of cases in the first stage and 30.8% (41/133) in the second stage of labor. Difficulty in assessing the position was more likely if the occiput was posterior in comparison to anterior and in the maternal right in comparison to the left side. In the second stage, it was three times more likely for the assessment not to be possible digitally if the occiput was posterior. In the cases when assessment by vaginal examination was possible, the correlation with ultrasound was average in the first stage (kappa = 0.59) and good in the second stage (kappa = 0.77). Overall fetal head position assessment by digital examination was accurate in 31.28% of the cases in the first stage and 65.7% of the cases in the second stage of labor. Rotation of the fetal head is highly unlikely when labor begins in the occipital anterior position. Persistent occipital posterior position developed through failure to rotate from an initial occipital posterior or transverse position. Duration of the first stage of labor was independently related to parity and position of the fetal spine at presentation, and duration of the second stage of labor was independently related to parity, birth weight, position of the fetal head at the beginning of the second stage, rotation and position of the head at delivery. CONCLUSION: Ultrasound assessment of the fetal head position in labor is feasible in a busy labor ward. Digital examination is less accurate than ultrasound, in particular in cases of obstructed labor when medical intervention is more likely to be needed. Ultrasound assessment may prove useful in the prediction and diagnosis of difficult and prolonged labor.

Adolescent↗

PubMed1993

Arterial reconstruction of vessels in the foot and ankle.

OBJECTIVE: This study demonstrated that arterial reconstruction of vessels of the foot and ankle can preserve the majority of ischemic extremities with extensive tibial and peroneal occlusive disease and patent pedal arteries. SUMMARY BACKGROUND DATA: There are successful reports of bypass procedures to the ankle and foot, but despite this, these procedures have not gained widespread acceptance among surgeons performing infra-inguinal revascularization. Primary amputation is often offered for such patients. For this reason, the authors have reviewed their experience with bypasses to the foot and ankle. METHODS: A retrospective review was done of 75 arterial bypasses (5 bilateral), done since 1985, to the ankle and foot in 70 patients (38 males and 32 females). Fifty-four (77%) of the patients were diabetic. The age ranged from 55 to 95 years. Twenty-six (37%) were older than 80 years. The patients were selected for operative intervention because of severe tibioperoneal occlusive disease with ischemic rest pain or gangrene of the foot. Digital subtraction arteriography facilitated visualization of distal vessels. Operative principles included regional anesthesia, autogenous graft material, short bypass, non-traumatic vessel occlusion, selective operative arteriography, tension free ankle and foot skin closure, and concomitant conservative debridement of infected devitalized tissue. Incomplete pedal arch did not influence decision for operation. Indications for operation were: gangrene, 42 (56%); non-healing ulcer, 21 (28%); and rest pain, 12 (16%). Graft material was in situ greater saphenous vein, 40 (53%); translocated greater saphenous vein, 19 (25%); reversed greater saphenous vein, 11 (15%); and arm vein, lesser saphenous vein or vein patch, 5 (7%). Donor artery was popliteal, 30 (41%); common femoral, 26 (35%); and superficial femoral, 17 (23%). Recipient vessel was dorsalis pedis, 43 (57%); posterior tibial, 18 (24%); distal anterior tibial, 9 (12%); and distal peroneal, plantar or tibial endarterectomy, 5 (7%). RESULTS: There were four (5.7%) deaths and three (4.2%) graft failures within 30 days. Early graft failure led to transmetatarsal amputation (1), below knee amputation (1), and conversion of graft to femoral (1), popliteal bypass graft with limb salvage (1). In one patient, significant tissue necrosis with infection necessitated a below knee amputation within 30 days, despite a patent graft. Long-term follow-up revealed 10 graft failures, 4 major amputations, 3 graft revisions, and 15 deaths. Cumulative primary and secondary patency was 79.0% and 81.6% at 36 months. Limb salvage was 87.5% at 36 months. CONCLUSIONS: These results support an aggressive approach to limb salvage in patients with threatened limb loss, unreconstructable tibio-peroneal occlusive disease, and patent pedal arteries. Bypasses to the ankle and foot will maintain a functional extremity in the majority of these patients.

Aged↗

PubMed1991

Endothelial function in human coronary arteries in vivo. Focus on hypercholesterolemia.

To examine whether and to what extent hypercholesterolemia may affect the vasoactive role of the endothelium before the onset of angiographically visible atherosclerosis in the coronary circulation, we studied normal subjects (group 1, n = 11), individuals with elevated low density lipoprotein plasma values but angiographically smooth coronary arteries (group 2, n = 8), and patients with hypercholesterolemia and minimal disease of the vessel under study (group 3, n = 8). Coronary vasomotor function was evaluated by three interventions: subselective intracoronary infusion of acetylcholine (0.036, 0.36, and 3.6 micrograms/min) with a 3F Doppler catheter in the left anterior descending artery, 0.3 mg intracoronary nitroglycerin ("endothelium-independent"), and increase in blood flow (assessment of flow-dependent, endothelium-mediated coronary dilation). In group 1, all interventions caused coronary dilation of the left anterior descending artery as assessed by automatic quantification of digitized cineframes. However, in group 2, acetylcholine elicited substantial coronary vasoconstriction, and the vasodilator response to nitroglycerin and to increases in flow (flow-dependent dilation) was preserved. In group 3, the acetylcholine-induced coronary vasoconstriction was even more pronounced, and the flow-dependent dilation was impaired (+5.1 +/- 1% versus +10.5 +/- 1.1% [group 1], p less than 0.05). The coronary flow reserve (derived from Doppler flow velocity measurements) in response to papaverine was not significantly different in normal and hypercholesterolemic individuals (groups 2 and 3). However, the increase in coronary flow exerted by acetylcholine was substantially depressed in patients with hypercholesterolemia (groups 2 and 3) as compared with normal individuals (+48 +/- 8.3% and +49 +/- 25% versus +220 +/- 28.5%, respectively, p less than 0.01). Thus, hypercholesterolemia elicits endothelial dysfunction in coronary conduit and resistance vessels in humans that precedes angiographically visible atherosclerotic lesions in large coronary arteries. Conceivably, these vascular alterations contribute to increased coronary vasomotor tone within the coronary circulation and may predispose these patients to myocardial ischemia.

Acetylcholine↗

PubMed2004

Assessing computer skills in Tanzanian medical students: an elective experience.

BACKGROUND: One estimate suggests that by 2010 more than 30% of a physician's time will be spent using information technology tools. The aim of this study is to assess the information and communication technologies (ICT) skills of medical students in Tanzania. We also report a pilot intervention of peer mentoring training in ICT by medical students from the UK tutoring students in Tanzania. METHODS DESIGN: Cross sectional study and pilot intervention study. PARTICIPANTS: Fourth year medical students (n = 92) attending Muhimbili University College of Health Sciences, Dar es Salaam, Tanzania. MAIN OUTCOME MEASURES: Self-reported assessment of competence on ICT-related topics and ability to perform specific ICT tasks. Further information related to frequency of computer use (hours per week), years of computer use, reasons for use and access to computers. Skills at specific tasks were reassessed for 12 students following 4 to 6 hours of peer mentoring training. RESULTS: The highest levels of competence in generic ICT areas were for email, Internet and file management. For other skills such as word processing most respondents reported low levels of competence. The abilities to perform specific ICT skills were low - less than 60% of the participants were able to perform the core specific skills assessed. A period of approximately 5 hours of peer mentoring training produced an approximate doubling of competence scores for these skills. CONCLUSION: Our study has found a low level of ability to use ICT facilities among medical students in a leading university in sub-Saharan Africa. A pilot scheme utilising UK elective students to tutor basic skills showed potential. Attention is required to develop interventions that can improve ICT skills, as well as computer access, in order to bridge the digital divide.

Adult↗

PubMed2001

Three-dimensional gadolinium-enhanced magnetic resonance venography in suspected thrombo-occlusive disease of the central chest veins.

STUDY OBJECTIVE: To determine the usefulness of high-resolution three-dimensional (3D) gadolinium-enhanced magnetic resonance venography (MRV) in the evaluation of central venous thrombo-occlusive disease of the chest. DESIGN: Prospective study. SETTING: University hospital. PATIENTS: Sixteen consecutive patients with clinically suspected thrombosis of the superior vena cava, subclavian, brachiocephalic/innominate, internal jugular, or axillary veins. Thirteen patients had a neoplasm, two patients had a connective tissue disease, and one patient had a history of strenuous exercise. Twelve of 16 patients had prior central venous catheter placement. MRI was correlated with color-coded duplex sonography (CCDS) in 7 of 16 patients, digital subtraction angiography (DSA) in 3 of 16 patients, and CT in 2 of 16 patients. INTERVENTION: Contrast-enhanced MRV was performed in a total of 20 examinations. A 3D data set (gradient echo; time to repeat, 4.6 ms; time to echo, 1.8 ms; flip angle, 30 degrees; time of acquisition, 23 s; 512 matrix/64 partitions; slice thickness, 1.5 mm) was acquired in the arterial and venous phase. Overall image quality was assessed on a 5-point scale. The presence, site, and extent of thrombus, as well as presence of an intravascular device, were determined. MEASUREMENTS AND RESULTS: Overall image quality was rated very good (1 point) in 7 of 16 cases (44%) and good (2 points) in 9 of 16 cases (56%). Thrombus was detected in 16 of 16 patients, and complete extent of disease could be determined in 15 of 16 patients (94%). MRV did not miss any finding obtained by CCDS, DSA, or CT, and provided additional information in 6 of 16 examinations (38%). CONCLUSION: Contrast-enhanced MRV is a fast and reliable noninvasive procedure with excellent results regarding detection and determination of the extent of thrombo-occlusive disease of the chest veins.

Adult↗

PubMed2000

Managing drug costs: the perception of managed care pharmacy directors.

OBJECTIVE: To examine the perceptions of health plan pharmacy directors about drug costs and utilization drivers, interventions the plans use to control drug expenditures, and strategies considered necessary to permit continued provision of a comprehensive drug benefit. STUDY DESIGN/METHODS: A multipart survey developed and mailed to 500 pharmacy directors of managed care organizations across the country. RESULTS: The survey respondents (response rate = 18%) represented managed care health plans in the following percentages: 49% of respondents were from network/independent practice associations; mixed-model health maintenance organizations (HMOs), 20%; group HMOs, 15%; and staff-model HMOs and network/preferred provider organizations, 8% each. Drug mix and utilization were reported to be the primary drivers of drug expenditures. Half the respondents rated inflation as a somewhat strong cost driver. Interventions the health plans use to control drug expenditures include formularies, generic substitution, preauthorization, manufacturers' rebates, drug benefit design, physician profiling, target drug programs, academic detailing, and tiered copays. With the exception of formulary use, generic substitution, and manufacturers' rebates, which all the plans have instituted, the types of interventions used by the different model types vary widely. More than half the pharmacy directors reported generic substitution, drug benefit design, and differential copays as very effective interventions used to control drug costs. CONCLUSIONS: The majority of pharmacy directors predict continued double-digit increases in drug expenditures over both the short term and the long term. Of the respondents, 91% reported that additional limits and/or exclusions to the benefit design would be necessary to control these increases. To continue providing a comprehensive drug benefit, 54% indicated that they would have to achieve sufficient cost savings in other areas to offset increases in drug costs.

Attitude of Health Personnel↗

PubMed1998

[Using superselective digital subtraction angiographic localization and embolization to control vascular pulsative tinnitus].

Treating two cases of vascular palsative tinnitus with digital subtraction angiographic and superselective embolization was reported in this paper. The etiology pathogenesis, clinical sign and its treatment were also discussed.

Adult↗

PubMed1989

[Videometry and videodensitometry: possibilities within the scope of clinical angiocardiography].

Videometry and videodensitometry was developed more than 20 years ago by the groups of E. H. Wood in Rochester, New York, USA and P. H. Heintzen in Kiel, West Germany. These techniques allow the extraction of quantitative parameters such as dimensions and volumes (videometry) and the concentration and distribution of contrast material (videodensitometry) from videoangiograms. Whereas videometric techniques have, in between, been implemented world-wide into clinical practice (e.g., for geometric measurement of heart chamber volume or the quantitative assessment of coronary morphology), videodensitometry has still been restricted to a small number of laboratories, mainly due to the technical requirements. Videodensitometry, however, offers an on-line frame-to-frame analysis of left and right ventricular volumes throughout the cardiac cycle, the measurement of valvular regurgitant fraction, the estimation of intracardiac shunts, as well as the measurement of blood flow and velocity in coronary arteries and the assessment of changes in myocardial perfusion due to interventions form clinical videoangiograms. Since the basic principles of these techniques can easily be applied to digital image processing, videodensitometry has gained new interest in a time of increasing distribution of digital cardiac imaging.

Angiocardiography↗

PubMedDate not supplied

Effect of ageing on the relationship between early diastolic left ventricular function and mitral valve motion.

OBJECTIVE: The relationships between age and diastolic left ventricular function, and age and mitral valve motion were studied. DESIGN: The maximum velocity of circumferential fibre lengthening (negative peak Vcf) of left ventricular function and mitral valve motions, such as mitral valve E and A wave amplitude, D-E and E-F slopes, and their relationships were assessed. SUBJECTS: Twenty young, healthy persons (10 males and 10 females) from 20 to 47 years old (mean 34.5), and 26 older healthy subjects (five males and 21 females) from 62 to 94 years old (mean 80.0) were studied. INTERVENTION: M-mode echocardiography of left ventricular function and mitral valve motion were recorded and digitized for the assessment. MAIN RESULTS: Age showed a significant (P = 0.0001) correlation with negative peak Vcf (r = -0.62), with E wave amplitude (r = -0.83), with D-E slope (r = -0.71) and with E-F slope (r = -0.83). Negative peak Vcf was correlated with E wave amplitude (r = 0.51, P = 0.0007), with D-E slope (r = 0.31, P = 0.058), with E-F slope (r = 0.53, P = 0.0005). Its relations with mitral valve A wave amplitude was r = -0.30, P = 0.17 in the elderly group and r = 0.003, P = 0.99 in the younger group. A significant (P < 0.001) positive, linear correlation was observed between age and mitral A/E ratio (r = 0.82). CONCLUSIONS: The easily measurable mitral valve E-F slope and E wave amplitude can be used to assess early diastolic left ventricular function in ageing. Left atrial contraction appears to play a more important role in the elderly, compensating for the decline in early diastolic left ventricular function.

Adult↗

PubMed1976

On a non linear describing function for bio-data.

The behaviour and handling of a flexible three variable--parameter function is presented, which is suitable for unbiased regression analysis. The function is defined by an intercept, a slope or coefficient and an exponent on the independent variable. Analog and digital problems and solutions are defined. Handling is simple and the program is run without operator intervention. The range of curves include linear, convex, concave and asymptotic forms and can be extended to include sigmoid and parabolic forms. Some application results are presented for different situations.

Computers↗

PubMed1995

Carbon dioxide in vascular imaging and intervention.

Angiography with iodinated contrast agents is bound up with the risks of contrast-induced nephrotoxicity and hypersensitivity, which led to the idea of using carbon dioxide (CO2) gas as a negative contrast medium to eliminate these drawbacks. During the last decade, refinements and experiences have proved carbon dioxide digital subtraction angiography (CO2-DSA) to be an accurate, safe, and clinically promising vascular imaging modality, with the advantages of no hypersensitivity and no nephrotoxicity as well as minimal patient discomfort. In this article, we have reviewed the history, physical and chemical aspects, techniques, and pathophysiologic changes with the use of CO2-DSA as well as some clinical trials. Applications of CO2 gas in vascular interventions and other imagings, and the advantages and limitations of using CO2 gas in DSA are also discussed.

Angiography↗

PubMed1999

Evaluation of a child sexual abuse prevention program.

A half-million children are believed to be sexually abused each year in the United States. In 1995, the American Medical Association declared sexual assault "a silent violent epidemic." The majority of efforts to stop child sexual abuse have focused on punishing abusers and treating victims and their families; prevention programs are uncommon and rely on educating children to report sexual abuse. This case study describes the evaluation of the first public health campaign designed to target adults for prevention. A baseline assessment of attitudes, awareness, knowledge, and policies was conducted in Vermont to identify facilitators and barriers to adult prevention of child sexual abuse. These included predisposing factors (50% of Vermont residents did not know the characteristics of an abuser), enabling factors (60% of Vermont residents did not know where to refer someone who may have sexual behavior problems), and reinforcing factors (when focus group participants knew an abuser, they were less likely to take action). This process guided the intervention, which included a broad-based media campaign targeting adults; a one-to-one communications strategy that provided information to agencies working with families at risk and a toll-free helpline for adults in an abuse situation; and a systems change strategy designed to educate decision-makers and leaders. Program evaluation measures included a random-digit dial survey, focus groups, a survey of Vermont decision-makers, and other data sets. The successes and limitations of these interventions, both as strategies in themselves and as data sources for evaluation, are discussed.

Adult↗