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Implementation of a Program to Teach Pediatric Residents and Faculty About Domestic Violence
Rachel P. Berger, MD, MPH;
Debra Bogen, MD;
Tina Dulani;
Elsie Broussard, MD, DrPH
Arch Pediatr Adolesc Med. 2002;156:804-810.
ABSTRACT
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Objectives To obtain information about pediatric resident and staff knowledge,
attitudes, and screening practices related to domestic violence (DV), to implement
a domestic violence education program, and to evaluate whether the program
resulted in changes in these 3 domains.
Design Interventional with before and after survey evaluation.
Setting A hospital-based, pediatric residency continuity clinic that serves
families in Pittsburgh, Pa.
Participants Pediatric residents (n = 51), medicine-pediatric residents (n = 6),
continuity clinic faculty (n = 22), and certified-registered nurse practitioners
(n = 5).
Results Prior to implementation of the DV education program, respondents correctly
answered questions about the prevalence of DV (74 participants [90%]), the
racial distribution of DV victims (66 participants [80%]), and the significant
overlap between child abuse and DV (75 participants [91%]). Seventy-nine participants
(96%) believed that screening for the presence of DV was part of their role
as pediatric health care providers. At baseline, 17 (21%) of the 82 participants
reported that they were routinely screening for signs of DV during well-child
care visits compared with 39 (46%) after attending the education program (P = .005).Among participants who attended both educational
session 25% (9/36) were routinely screening for the presence of DV prior to
the intervention, compared with 46% (16/35) after the intervention (P = .008). At baseline, 33 (40%) of the 82 participants
had identified at least 1 case of DV in the prior 6 months compared with 45
(53%) after training. Prior to training, 18 participants (22%) were aware
of resources for DV victims compared with 45 (53%) after training (P<.001).
Conclusions To our knowledge, this is one of the first pediatric studies to demonstrate
that using a short, multifaceted educational module, it is possible to change
DV screening practices and to increase identification of DV victims among
pediatric residents, continuity clinic faculty, and certified-registered nurse
practitioners at a pediatric teaching hospital.
INTRODUCTION
THE EFFECT of domestic violence (DV) on the health and well-being of
children is becoming more recognized.1-3
Between 3 and 10 million children witness DV each year4
and over time, many of these children become more directly and physically
involved. Children of battered mothers are 6 to 15 times more likely to be
abused than children of mother who are not victims of DV. Between 33% and
77% of mothers who are reported for child abuse are victims of DV.5
In response to the overwhelming evidence of the effects of DV on children,
the American Academy of Pediatrics issued a policy statement in June 1998
recommending that all pediatricians incorporate DV screening into their routine
anticipatory guidance.6 However, recent studies
suggest that there are numerous barriers to screening for the presence of
DV7-9 and that
fewer than 10% of pediatricians are routinely screening for the presence of
DV.10
Lack of education is one of the primary barriers to screening that is
consistently identified in prior studies.7-9
This finding is not surprising since most pediatricians were and perhaps still
are not educated about DV during their medical school or residency training.4, 9, 11-12 Although
the most effective way to educate physicians about DV is unknown, several
studies have evaluated the effect of different methods of education on physician
screening practices. The educational interventions in these studies ranged
from a single 20-minute videotape13 to 2 half-day
training sessions combined with 4 educational sessions, DV newsletters, and
various environmental enablers including cue cards for health care providers.14 The previously performed studies assessed change
using self-report,13 a preintervention and
postintervention survey,8, 15 or
a combination of surveys and medical records review.14
The variety of interventions, evaluation methods, and outcome variables makes
it difficult to compare these studies. However, none of the programs showed
a sustained influence on physician knowledge, comfort level, screening, and
identification of DV cases. Most were successful in improving at least one
of these variables. Thompson et al14 was the
most successful at increasing DV screening and DV case finding and at maintaining
this increase 9 months after the intervention. However, the intervention described
in this study required considerable time commitments on the part of the physicians
being trained as well as significant financial resources on the part of the
educators. In Kripke et al16 there was only
a 4-hour time commitment for the trainees, but there was no change in DV screening
or DV case finding, although self-reported attitudes, skills, and knowledge
improved.
These published programs were designed for physicians who provide medical
care to adults; none focused on pediatric health care providers. The distinction
is important since pediatric health care providers screen their patients'
parents, not their own patients, for DV. The only exception is pediatric health
care providers who care for adolescents. For the pediatric health care provider,
the reasons for screening for the presence of DV, the way in which the screening
is actually performed, the goals of screening, and even the documentation
of screening, may all be different than for the adult health care provider.
As a result, educating pediatric health care providers about DV whether in
the form of a videotape, a didactic session, a role play, or a combination
of these, needs to focus on DV as it relates to children.
The goal of our study was, therefore, to design a DV education program
for pediatric health care providers using the available literature from adult
studies to guide the educational design. This program was designed to consider
the limited time available in our residency program for DV training and our
lack of funding to design, establish, or sustain such a program.
SUBJECTS, MATERIALS, AND METHODS
SITE DESCRIPTION
Children's Hospital of Pittsburgh (CHP) is a university-based teaching
hospital in Pittsburgh, Pa, with between 17 and 24 pediatric and pediatric-medicine
residents in each residency class. Seventy-five percent of these residents
in each class (ie, between 13 and 18 in each residency class) have a weekly
half-day outpatient continuity clinic on-site during which they are precepted
by CHP faculty (CHP group). The other 25% of the residents in each class (ie,
between 4 and 6 in each residency class) have their weekly continuity clinic
in private pediatric offices in the greater Pittsburgh area (community group).
These residents are taught by pediatricians in these offices who have admitting
privileges at CHP, but are not faculty. Patients seen in the private practices
are generally of a higher socioeconomic class than the patients at CHP, and
have insurance from a third-party payer rather than from Medicaid. At the
time this program was implemented, neither residents at CHP nor in the community
had an established DV curriculum.
SURVEYS
After receiving approval from the CHP institutional review board, a
17-question preintervention survey was distributed to all pediatric and medicine-pediatric
residents (n = 57), continuity clinic faculty (n = 22), and certified-registered
nurse practitioners (n = 5) in December 2000. The survey was divided into
questions about DV knowledge (n = 7), attitudes, and barriers to screening
(n = 4) and screening practices (n = 2). There was also a single question
about prior training (n = 1), prior identification of DV cases (n = 1) as
well as 2 internal reliability questions on important anticipatory guidance
issues (discipline and guns) that were not specifically discussed during the
educational sessions (n = 2).
At the time this survey was designed, we were unaware of any validated,
reliable instruments for assessing the pediatric health care providers' knowledge
of DV. However, in the time between our preintervention survey and our intervention,
Maiuro et al17 described the development of
a 39-item validated and reliable survey instrument. Since we were unaware
of the work of Maiuro et al at the time we began our study, our survey was
designed based on surveys used in previously published work.18-20
Like Maiuro et al, our survey was divided into 3 categories—knowledge,
attitudes, and beliefs and behaviors.
Our survey used a 5-point Likert scale to assess attitudes and barriers
to screening (1, strongly disagree with statement; 5, strongly agree with
statement). Questions about screening practices had 4 possible responses:
"never," "less than half the time," "more than half the time," and "always."
Respondents who reported that they screened "always" or "more than half the
time" were classified as "routine" screeners.
The 18-question postintervention survey repeated the same questions
about attitudes and barriers to screening (n = 4), screening practices (n
= 2), identification of cases (n = 1), and the internal reliability questions
(n = 2). Only one (n = 1) question about knowledge was repeated in the postintervention
survey. The remaining questions in this survey were related to the effect
of the intervention, continued barriers to screening, physician perception
of their competence in the field of DV, and suggestions for future educational
sessions (n = 8).
Surveys were distributed to all pediatric and medicine-pediatric residents
and to the certified-registered nurse practitioners and pediatric faculty
who precept and work with residents in the primary care center. Surveys were
not sent to the community physicians (n = 14) who precept the community group.
Distribution was performed through a combination of hand delivery, interoffice
mail, and the US mail. The survey was sent with a cover letter describing
the purpose of the study and stating that the responses to the survey would
be confidential, but not anonymous. The second survey was distributed in June
2001 using similar distribution techniques.
INTERVENTION
Residents and faculty were invited to attend one 30-minute didactic
session given by one of us (R.P.B.) on 4 separate occasions in January 2001.
The sessions were given immediately before continuity clinic during a time
slot reserved for resident education. The content of these sessions was based
on the University of Pittsburgh Medical Center Health Systems curriculum on
the appropriate health care response to DV, which was developed at the Magee-Women's
Hospital Domestic Violence Resource Center in Pittsburgh.21
Attendance was taken at each session and attendees were given 2 articles
about DV and its effect on children3, 6
an Office Reference Manual for Recognition and Referral
of Victims of Domestic Violence (an 8-page pocket-sized pamphlet published
by the DV Resource Center at Magee-Women's Hospital), and a list of local
DV resources. After the lectures, a laminated copy of this list was placed
in an accessible location in the primary care center. Simultaneously, DV posters
ordered from The Family Violence Protection Fund (available at: http://www.endabuse.org) were hung in the waiting area and hallways around the clinic; signs
about DV were hung in each of the women's bathrooms near the clinic.
Three months after the initial didactic session, residents were required
and faculty was invited to attend a 90-minute teaching session consisting
of a 15-minute didactic, 12-minute videotape of testimony from DV victims,
and 45-minute role-play session. During the role playing, residents and faculty
were divided into groups of 4 or 5 and given common scenarios during which
they would ask a parent or adolescent about DV. They practiced posing these
questions to actors (social workers from the clinic who had been involved
in designing the educational sessions) and then addressing the actors' responses.
The small group size ensured that each physician had multiple opportunities
to practice. Attendance was taken at these sessions.
Our education program was specifically tailored to pediatric health
care providers. For example, in the didactic sessions, we did not focus on
the affect of DV on adults, but on the short-term and long-term affects of
witnessing DV on children. When we discussed community resources, we discussed
resources for women as well as for children who have witnessed DV. We discussed
the logistical issue of how to arrange for older children and male caregivers
to leave the examining room to provide pediatricians with the opportunity
to ask women about DV. The pediatric-specific issue of documentation of DV
questioning was also discussed since a male DV perpetrator has access to the
child's medical record. Perhaps most importantly, since many of the standard
questions that adult physicians use to screen for DV often seem out of place
in a pediatric visit, we discussed different approaches to integrating questions
about DV into the pediatric visit, Participants were given examples of how
to integrate questions about DV into discussions of behavior, discipline,
television, guns, and family life.
DATA ANALYSIS
Data analysis was performed using SPSS version 10.1. (SPSS Inc, Chicago,
Ill). The McNemar test was used to compare dichotomized responses before and
after intervention. For questions designed on a 5-point Likert scale (1, strongly
disagree with the statement; 5, strongly agree with the statement), responses
were evaluated as continuous variables and a paired t
test was used. For dichotomous data, differences between groups were determined
by either the Pearson  2 or Fisher exact test. The Spearman
rank correlation was used for comparison of ordinal variables. P .05 was considered statistically significant. No adjustment was
made for multiple comparisons. Ninety-five percent confidence intervals (CIs)
for differences were used to display the precision between the preintervention
and postintervention responses. For statistical analysis, pediatric (n = 51)
and medicine-pediatric residents (n = 6) were grouped together and referred
to as trainees. Certified-registered nurse practitioners (n = 5) and continuity
clinic faculty (n = 22) were grouped together and referred to as staff. Trainees
and staff are collectively referred to as pediatric health care providers.
RESULTS
The distribution of trainees and staff, the response rates for each
survey, and the attendance rates are summarized in Table 1. Overall, 82 preintervention (98%) and 77 postintervention
(92%) surveys were completed. Survey response and attendance rates of trainees
and staff were similar. However, compared with trainees in the CHP group (n
= 41), trainees in the community (n = 16) had lower survey response rates
(surveys 1 and 2 combined 40 participants [98%] vs 13 participants [81%])
(P = .005) and lower attendance rates at the 2 educational
sessions (session 1: 30 participants [73%] vs 0 participants, P<.001; session 2: 31 participants [76%] vs 7 participants [44%], P<.001).
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Table 1. Survey Response Rates and Attendance at Training Sessions
About Domestic Violence
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Sixty-three (77%) of the 82 pediatric health care providers reported
having received at least 1 hour of DV training in the prior year. Before the
intervention, respondents correctly answered questions about the prevalence
of DV (74 participants [90%]), the racial distribution of DV victims (66 participants
[80%]), and the significant overlap between child abuse and DV (75 participants
[91%]). Fifty-three (67%) of the 79 respondents were aware that physicians
are not mandated reporters of DV in Pennsylvania. Staff was more likely than
trainees to be aware of this (88% [23 of 26 staff] vs 58% [31 of 53 trainees], P = .004). There was no difference in baseline knowledge
between CHP and community residents. Given the high rate of correct responses
to the knowledge questions in all groups, we felt it would be unlikely to
see significant improvement after the educational sessions. As a result, the
only knowledge-based question in the postintervention survey was related to
mandated reporting. After the educational sessions, there was no overall change
in the number of correct responses to this question among the staff or trainees,
although the number of interns who correctly answered this question increased
from 64% (14/22) to 100% (22 ± 22) (P<.001).
Despite the strong preintervention knowledge, 46 (60%) of the 77 respondents
felt that the educational sessions improved their DV knowledge. There was
no change in the responses to the 2 internal reliability questions before
and after the educational sessions.
Attitudes and beliefs of trainees and faculty before and after intervention
were measured on a 5-point Likert scale and are summarized in Table 2. Overall, there was no change in whether respondents felt
comfortable discussing DV or whether they felt they had adequate time to screen
for DV. However, respondents were more aware of DV resources after the intervention.
The preintervention responses to these questions did not differ between trainees
and staff or within the trainee group. The postintervention responses did
not differ between trainees and staff except that staff was more likely to
feel that they had time to screen for DV (mean [SD], 3.54 [1.104] vs 2.65
[0.844], P<.001). When asked to choose all of
the barriers to screening during a given well-child visit, respondents most
frequently cited lack of time (75%) followed by the presence of adult males
(49%) or older siblings in the examination room (40%), and the feeling that
the topic of DV did not fit in with certain well-child visits (44%).
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Table 2. Attitudes and Beliefs About Domestic Violence (DV)*
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Reported screening practices improved after the intervention as given
in Table 3. Overall, among pediatric
health care providers who attended both educational sessions, 46% (16/35)
reported that they were routinely screening for the presence of DV at the
time of the postintervention survey compared with 25% (9/36) prior to the
educational sessions (P = .008). As a subgroup, staff
was not more likely to be screening after attendance at both educational sessions,
although this is most likely the result of a small sample size. Overall, 22%
(17/77) of the respondents reported that they had changed their screening
practices; 7 respondents changed from never screening to screening less than
half the time, and 10 changed from screening less than half the time to screening
more than half the time. Ninety-five percent (61/64) of the pediatric health
care providers who attended at least 1 educational session believed that the
session(s) had influenced their screening practices. The proportion of pediatric
health care providers who reported that they had identified at least 1 case
of DV was greater in the 6 months after the intervention compared with the
6 months before the intervention (53% [41/77] vs 38% [31/82], P = .02). Both before and after the educational sessions, respondents
who reported that they routinely screened for DV were more likely to have
identified at least 1 case of DV compared with those who did not routinely
screen (before intervention, 65% [11/17] vs 31% [20/65], P = .01; after intervention, 79% [19/24] vs 42% [22/53], P = .002).
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Table 3. Change in Routine Screening* Practices Before and After Intervention
by the Number of Sessions Attended
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After the educational sessions, 52% (40/77) of the pediatric health
care providers rated their DV competence as poor or fair. Perceived competence
was significantly correlated to routine screening ( = 0.538, P<.001) and to the pediatric health care providers' comfort with
the topic of DV ( = 0.560, P = .001).
Except as noted previously, responses to the surveys did not vary by
sex, year of residency training, or classification as trainee or staff. Because
attendance among trainees in the community group was so low, it was impossible
to determine if the educational session had an equivalent effect on screening
practices in the community and CHP groups.
COMMENT
This brief education program demonstrated that it is possible to improve
the frequency with which pediatricians screen for DV during well-child care
visits. The strong correlation between attendance at the educational sessions
and change in reported DV screening practices points to the educational sessions
as the most likely cause of the change.
The change in screening practices is based on physician report only.
Ideally, physician report would be substantiated by 1 of a variety of techniques
including direct observation, videotaping of patient encounters, or medical
record review. The cost and time associated with these activities were prohibitive.
Furthermore, since some pediatricians do not document DV screening because
of confidentiality issues (a child's medical record can be legally accessed
by both parents, thus opening the door for a DV perpetrator to learn of his
partner's disclosure), medical record review might not have helped verify
screening. The fact that the surveys were confidential decreases the possibility
of false reporting. Though anonymous surveys might have further decreased
this possibility, this would have made it impossible to compare preintervention
and postintervention responses. The success of this education program may
lie in the fact that in contrast to a prior survey that suggested that pediatric
health care providers do not feel that DV is within the purview of pediatrics,4 the pediatric health care providers at CHP overwhelmingly
considered screening for and discussing DV part of their role as pediatricians.
The high survey response rate and the high percentage of respondents who reported
routine DV screening prior to the training session suggest that CHP may not
be a typical pediatric hospital. The high survey response rate is most likely
because of the ease of distribution—it was distributed in the resident
continuity clinic—and the rapidity with which the survey could be completed
(approximately 4 minutes). There is also a significant amount of institutional
support for resident and fellow research, and the principal investigator (R.B.)
was a fellow at the time this study was performed. The high rate of routine
screening at baseline may be an indication of increasing public awareness
about DV, increased baseline education (77% [63/82] of pediatric health care
providers reported that they had had at least 1 hour of DV training in the
prior year), or inaccurate self-report by respondents. However, since the
surveys were confidential, the respondents should not have felt a need to
falsely report their screening rates. At the time of this intervention there
was no hospital-based DV advocacy program and no local DV awareness raising
activities at CHP that might have influenced the preintervention responses
or confounded the affect of the intervention program.
It is not surprising that the staff was more likely than trainees to
know that there is no mandated reporting of DV in Pennsylvania; most of the
staff has practiced medicine in Pennsylvania for many years, while many of
the trainees had only lived there for a few months when this survey was taken.
Even in a hospital such as ours where the atmosphere seemed ripe to
introduce a DV screening program, there were significant barriers to successful
implementation of the program. There was significant institutional concern
about whether the hospital social workers would be able to appropriately respond
to and provide needed resources to women who would presumably be identified
as DV victims. Offers of support from leaders of local DV shelters and programs
helped to alleviate these concerns. Another barrier was the ability to maintain
the DV signs in the women's bathrooms—for the first several weeks, the
signs disappeared every few hours. After numerous discussions with all housekeeping
staff on all shifts, this problem improved, although it never completely resolved.
The attendance at the training sessions was lower than expected, although
comparable to attendance rates at both the "communications course" and the
"family-systems curriculum," 2 other resident and faculty education programs
at CHP that are conducted at similar times of the day and for similar amounts
of time. The low attendance at our training sessions by residents in the community
group was particularly disappointing. The community residents received the
same notification about each of the sessions as residents in the CHP group.
Residents in both groups were relieved of their other responsibilities so
that they could attend 1 of the 90-minute educational sessions. The community
residents have also had low attendance at the 2 curriculum blocks mentioned
earlier. As a result, we believe that their low attendance is more likely
a more general problem with integration of the community residents into the
primary care curriculum rather than a selection bias. The lack of a selection
bias among the residents and faculty is supported by that fact that the preintervention
knowledge, attitudes, or screening rates did not differ between those who
attended the sessions and those who did not.
The lack of change in the pediatric health care providers' comfort level
is not surprising. Improving a physician's comfort with a topic, particularly
ones as complex as DV, requires far more than 2 hours of education. However,
the significant relationship between comfort level and routine screening implies
that improved comfort should be one of the key goals of a DV training session.
Interestingly, though the survey respondents had a strong knowledge base in
the issues of DV, this did not result in perceived comfort or competence in
the topic of DV. The difficulty in changing physician comfort related to DV
has been documented previously.15
Of the 46% (16/35) of pediatric health care providers who attended both
educatonal sessions and reported screening for the presence of DV during more
than half of their well-child visits, 66% (23/35) reported that they had identified
at least 1 case of DV in the prior 6 months. Forty-eight percent (11/23) had
identified 1 case, 43% (10/23) had identified between 2 and 4 cases, and 9%
(2/23) had identified more than 10 cases. If the average resident provides
primary care to 6 children each week, each resident would care for just over
150 patients in the course of 6 months. If the prevalence of DV is estimated
to be 35% and each resident screened for DV during half of their well-child
visits, one would expect that each resident would identify more than 20 cases
of DV over a 6-month period. There are several explanations for why this was
not observed. Many women do not admit to current or past DV the first time
they are asked about it, so although the pediatric health care providers may
have asked, they may have received a false-negative response. It may also
be related to interpretation of the survey question. Respondents may have
interpreted the word "identified" to mean that they were the first person
with whom the DV victim had discussed DV. Using this definition, identification
of DV in a woman who had already revealed the information to another person
would not count as a case of DV. Informal questioning of several faculty and
residents confirmed this hypothesis and revealed that they would have answered
the question differently if asked how many cases they became "aware of" during
the prior 6 months. It is also possible that if pediatric health care providers
were not screening as frequently as they reported, they would be expected
to identify fewer cases. The confounding effect of the patients on identification
of DV victims cannot be overlooked. Because of the changes that were made
in the clinic as part of this program, patients saw DV posters on the walls
of the waiting room and saw signs every time they used a bathroom near the
clinic. This may have increased the number of patients who were willing to
discuss the topic of DV with their physician, thus helping to increase the
number of identified cases of DV.
Since the postintervention survey was administered only 3 months after
the second educational session, it is possible that the changes in screening
practice were only transient. However, had we waited longer to complete the
follow-up survey, the possibility of the pediatric health care providers receiving
DV information from other sources would have increased, thus decreasing the
ability to directly correlate attendance at training sessions and changes
in practice. In particular, 1 month after the pediatric health care providers
completed the second survey, the newly formed Collaborative Domestic Violence
Working Group at CHP presented a grand rounds that focused on many of the
same issues as in the educational sessions. Since many of the the pediatric
health care providers in this study attend grand rounds, a survey given subsequent
to it would be unable to discriminate whether the grand rounds or our intervention
had been the cause of any changes. To decrease the possibility that the change
in screening practices will be transient, the educational module described
in this article will be integrated into the residency program. As a result,
there will never be more than a 6-month period without some type of resident
or faculty DV education. Since the staff members are stable and have attended
the DV training sessions, we hypothesize that when they precept residents,
they will prompt residents to screen for DV. We also plan to provide similar
training to the community preceptors and residents with the goal of improving
DV screening in the community.
| What This Study Adds
Domestic violence has a profound effect on children. The American Academy
of Pediatrics has recommended that pediatricians screen for DV as part of
routine anticipatory guidance. However, very few pediatricians routinely screen
for DV and previous studies have identified a lack of education as one of
the most important barriers. Several interventional studies have been done
to assess ways to affect physician practice, although these studies focused
on training physicians who care for adult patients. This article describes
a focused, goal-driven, brief educational intervention designed specifically
for pediatric residents, continuity clinic faculty, and certified-registered
nurse practitioners at a large teaching hospital. Using a preintervention
and postintervention survey to evaluate knowledge, attitudes, beliefs, and
screening practices related to DV, there was a significant increase in the
number of pediatric health care providers who reported screening for and identifying
cases of DV after the intervention.
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AUTHOR INFORMATION
Accepted for publication April 11, 2002.
This study was supported in part by an Administration Faculty Development
Grant in General Pediatrics, 5-D08-HP-50102-03-01, from the Human Resources
Services, Bethesda, Md (Dr Berger).
We thank the following people for designing and implementing the 90-minute
teaching session described in this article: Kate DeAntonis, MD, Sara Hamel,
MD, Dianna Ploof, EdD, Julie Spangler, RN, Tahniat Syed, MD, Janet Syphan,
BS, Joan Williams, MSW, and Barbara Williams, MSW. We would also like to thank
Frank D'Amico, PhD, and Lorraine Ettarl, MPH, for their statistical advice
and expertise, Lorraine Douthett for her administrative assistance, Deb Moss,
MD, for her review of the manuscript, and Heidi Feldman, MD, PhD, for her
support of the project.
Corresponding author and reprints: Rachel P. Berger, MD, MPH, Department
of Pediatrics, Pittsburgh Child Advocacy Center, Children's Hospital of Pittsburgh,
3705 Fifth Ave, Pittsburgh, PA 15213 (e-mail: rberger{at}pitt.edu).
From the Departments of Pediatrics, Pittsburgh Child Advocacy Center
(Dr Berger) and General Academic Pediatrics (Dr Bogen), Children's Hospital
of Pittsburgh, Pittsburgh, Pa; Mount Holyoke College, South Hadley, Mass (Ms
Dulani); and Department of Health Services Administration, Graduate School
of Public Health, Department of Psychiatry, University of Pittsburgh School
of Medicine (Dr Broussard), Pittsburgh, Pa.
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