Few studies have empirically examined patient–clinician conversations to assess how intimate part... more Few studies have empirically examined patient–clinician conversations to assess how intimate partner violence (IPV) screening is performed. Our study sought to examine audio-recorded first obstetric encounters’ IPV screening conversations to describe and categorize communication approaches and explore associations with patient disclosure. We analyzed 247 patient encounters with 47 providers. IPV screening occurred in 95% of visits: 57% used direct questions, 25% used indirect questions, 17% repeated IPV screening later in the visit, 11% framed questions with a reason for asking, and 10% described IPV types. Patients disclosed IPV in 71 (28.7%) visits. There were no associations between disclosure and any categories of IPV screening.
Training in intimate partner violence (IPV) improves health professionals’ knowledge and comfort ... more Training in intimate partner violence (IPV) improves health professionals’ knowledge and comfort regarding IPV; the optimal training frequency and format is unknown. We assessed how various types and amounts of IPV education for medical students affected knowledge and attitudes. Medical students at a large, urban university completed a survey concerning IPV-related knowledge and attitudes and participation in didactic and experiential IPV training activities. This was a one-time assessment. Of 586 students, 279 (48%) completed the survey. IPV-related knowledge increased with increased number of training activities. Knowledge and attitude scores were higher ( p < .001) for respondents with experiential, versus only didactic, activities.
As managed care enrollment has increased, controversy has arisen about the role of internists (IM... more As managed care enrollment has increased, controversy has arisen about the role of internists (IM), family physicians (FP), and obstetrician/gynecologists (ob/gyns) in the provision of women's health care. Efforts to improve training in women's health needs have also increased. Yet it is unclear how these trends have affected practice. We used the National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of office-based medical visits, to examine by physician specialty a) trends in the proportion of visits for women's health care and b) the content of nonillness care. Between 1985 and 1997-98, market share of reproductive health services increased for IMs (e.g., from 3.7% to 10.5% of contraceptive visits, p <.05) and decreased for FPs (from 30.5% to 20.5% for contraceptive visits, p <.05). Ob/Gyns increased their share of women's health care visits, with reproductive health visits increasing from 56.2% to 65.9% (p <.0001). The trend in hormone replacement therapy visits differed, with nonsignificant gains in market share for IMs and decreases for ob/gyns. Nonillness care (1997-98 data only) differed predictably by specialty, with IMs and FPs more often providing cholesterol screening while ob/gyns more often provided reproductive health services. Compared with IMs and FPs, ob/gyns were more likely to counsel women on reproductive health topics and equally likely to counsel on general health topics, but additional time spent in counseling was lower. Specialty differences in the provision of women's health services continue, though the scope of care provided by IMs has broadened. Still, women are unlikely to obtain a full range of preventive services in a single nonillness visit. Ensuring adequate coordination among physicians providing primary care to women continues to be a critical concern.
To describe the types of services provided to women with disabilities at community-based domestic... more To describe the types of services provided to women with disabilities at community-based domestic violence programs in the state of North Carolina, the challenges faced, and strategies used to provide the services. We conducted a statewide cross-sectional survey of community domestic violence programs and had a response rate of 85%. Of the participating programs, 99% provided services to at least one woman with a physical or mental disability in the preceding 12 months; 85% offered shelter services to women with physical or mental disabilities. Most respondents (94%-99%) reported that their programs were either somewhat able or very able to provide effective services and care to women with disabilities. The respondents also described challenges to serving women with disabilities, including lack of funding, lack of training, and structural limitations of service facilities. Strategies used by the programs to overcome these challenges were networking and coordinating care with organizations that specifically serve disabled populations. Domestic violence programs in North Carolina provide services to women with disabilities but are faced with challenges stemming from limited funding, physical space, and training. Collaborations between domestic violence and disability service providers are necessary to improving the services and care delivered to women with disabilities who experience domestic violence.
Incarcerated women have had limited access to health care prior to their arrest. Although their i... more Incarcerated women have had limited access to health care prior to their arrest. Although their incarceration presents an opportunity to provide them with health care, their reproductive health needs have been overlooked. We performed a cross-sectional study of a nationally representative sample of 950 correctional health providers who are members of the Academy of Correctional Health Providers. A total of 405 surveys (43%) were returned, and 286 (30%) were eligible for analysis. Most ineligible surveys were from clinicians at male-only facilities. Of eligible respondents, 70% reported some degree of contraception counseling for women at their facilities. Only 11% provided routine counseling prior to release. Seventy percent said that their institution had no formal policy on contraception. Thirty-eight percent of clinicians provided birth control methods at their facilities. Although the most frequently counseled and prescribed method was oral contraceptive pills, only 50% of providers rated their oral contraceptive counseling ability as good or very good. Contraception counseling was associated with working at a juvenile facility, and with screening for sexually transmitted infections. Contraception does not appear to be integrated into the routine delivery of clinical services to incarcerated women. Because the correctional health care system can provide important clinical and public health interventions to traditionally marginalized populations, services for incarcerated women should include access to contraception.
The way clinicians communicate with parents during pregnancy about congenital heart disease (CHD)... more The way clinicians communicate with parents during pregnancy about congenital heart disease (CHD) can significantly influence parental understanding of and psychological response to the diagnosis. A necessary first step to improving communication used in fetal cardiology consultations is to understand and describe the language currently used, which this paper aims to do. Nineteen initial fetal cardiology consultations with parents were audio-recorded, transcribed verbatim, and coded by two independent coders. A codebook was inductively developed and applied to all transcripts. The finalized coding was used to characterize fetal cardiologists’ language. We identified four discourse styles employed in fetal cardiology consultations: small talk, medical, plain, and person-centered. Plain language was used to define and emphasize the meaning of medical language. Person-centered language was used to emphasize the baby as a whole person. Each consultation included all four discourse style...
INTRODUCTION: Postpartum care can be fragmented, especially among women with premature infants in... more INTRODUCTION: Postpartum care can be fragmented, especially among women with premature infants in the Neonatal Intensive Care Unit (NICU). We aimed to explore women's goals for and experiences with postpartum care. METHODS: We conducted a qualitative study using semi-structured interviews to ask women between 2 and 8 weeks after delivery of preterm infants in the NICU about their preferred topics of discussion at the postpartum visit and experiences with postpartum care. We analyzed transcripts using thematic analysis. IRB approval obtained. RESULTS: We enrolled 16 mothers who delivered between 25 and 34 weeks gestation (11 by Cesarean). At interview time (14-55 days postpartum), 4 women had attended a postpartum visit, 2 had missed their visit, and 10 had an upcoming appointment scheduled. Reasons for not attending a visit included distance of clinic from NICU, a desire to focus on their infant's health, and insurance changes. Participants identified several topics of impor...
To explore initial pregnancy intentions and postmiscarriage family planning needs and counseling ... more To explore initial pregnancy intentions and postmiscarriage family planning needs and counseling preferences of women experiencing spontaneous abortion. We conducted semistructured qualitative interviews with women who recently experienced spontaneous abortion to explore their feelings about conception, pregnancy, and miscarriage; their future family planning goals; and contraceptive counseling preferences. Two trained coders utilized an inductive, iterative approach to code transcripts and identify themes using Atlas.ti software to organize the analysis. We interviewed 26 women reporting varied intentions in their recent pregnancies: 54% were trying to conceive, 27% were not trying but not preventing, and 19% were attempting to avoid pregnancy. Participants reported a range of feelings about the pregnancy diagnoses and eventual miscarriages with some relatively unemotional ("a little disappointed…suffering for two months for nothing") and others feeling devastated by thei...
To assess how obstetric health care providers counsel patients regarding prenatal genetic screeni... more To assess how obstetric health care providers counsel patients regarding prenatal genetic screening and how these conversations influence patients' screening decisions. This cohort study analyzed transcripts and audio recordings of 210 first prenatal visits collected as part of a larger study on patient-provider communication. Conversations were coded in an iterative process to determine compliance with American College of Obstetricians and Gynecologists (College) prenatal genetic screening recommendations and to identify recurrent themes. χ, nonparametric tests, and logistic regression were used to determine the effects of discussion elements on screening decisions. Qualitative analysis was performed for genetic screening content. The study included 210 patients and 45 health care providers. Health care providers offered genetic screening at 90% of visits; 78% of women chose genetic screening. Few conversations (1.5%) included all College-recommended topics. Inclusion of Colleg...
To describe obstetric health care providers' responses and counseling approaches to patients&... more To describe obstetric health care providers' responses and counseling approaches to patients' disclosures of marijuana use during first prenatal visits. We performed a content analysis of audio-recorded patient-health care provider first prenatal visits for obstetrics health care providers' responses to patients' disclosure of marijuana use. The study was conducted at five urban outpatient clinics located in Pittsburgh, Pennsylvania. Among 468 audio-recorded first obstetric encounters, 90 patients (19%) disclosed marijuana use to 47 health care providers; mean number of recoded encounters containing marijuana disclosures for participating health providers was 1.8±1.4. In 48% of these 90 visits, obstetric health care providers did not respond to marijuana use disclosures or offer counseling. When counseling was offered, it consisted of general statements without specific information on the risks or outcomes related to marijuana use in pregnancy, discussions regarding ...
Background: Illicit drug use during pregnancy is associated with negative pregnancy, infant and m... more Background: Illicit drug use during pregnancy is associated with negative pregnancy, infant and maternal outcomes. Past illicit drug use is a predictor of perinatal drug use. However, little is know whether obstetric care providers screen for past drug use during clinic visits. Objective: To examine patient-provider discussions during the first obstetric visit for screening of past drug use. Methods: First obstetric visits between obstetric care providers and pregnant patients were audio-recorded. Conversations were qualitatively analyzed for drug screening questions; these questions were then categorized by whether the provider specifically asked about past or present use. Results: Two-hundred fifty patients and 56 obstetric care providers participated. In 224 visits (89.6%) providers screened for illicit drug use in some manner. Providers asked specifically about current use in 78 visits (31.2%), and about past use in 60 visits (24.0%). In 143 (57.2%) visits, questioning about dru...
Few studies have empirically examined patient–clinician conversations to assess how intimate part... more Few studies have empirically examined patient–clinician conversations to assess how intimate partner violence (IPV) screening is performed. Our study sought to examine audio-recorded first obstetric encounters’ IPV screening conversations to describe and categorize communication approaches and explore associations with patient disclosure. We analyzed 247 patient encounters with 47 providers. IPV screening occurred in 95% of visits: 57% used direct questions, 25% used indirect questions, 17% repeated IPV screening later in the visit, 11% framed questions with a reason for asking, and 10% described IPV types. Patients disclosed IPV in 71 (28.7%) visits. There were no associations between disclosure and any categories of IPV screening.
Training in intimate partner violence (IPV) improves health professionals’ knowledge and comfort ... more Training in intimate partner violence (IPV) improves health professionals’ knowledge and comfort regarding IPV; the optimal training frequency and format is unknown. We assessed how various types and amounts of IPV education for medical students affected knowledge and attitudes. Medical students at a large, urban university completed a survey concerning IPV-related knowledge and attitudes and participation in didactic and experiential IPV training activities. This was a one-time assessment. Of 586 students, 279 (48%) completed the survey. IPV-related knowledge increased with increased number of training activities. Knowledge and attitude scores were higher ( p < .001) for respondents with experiential, versus only didactic, activities.
As managed care enrollment has increased, controversy has arisen about the role of internists (IM... more As managed care enrollment has increased, controversy has arisen about the role of internists (IM), family physicians (FP), and obstetrician/gynecologists (ob/gyns) in the provision of women's health care. Efforts to improve training in women's health needs have also increased. Yet it is unclear how these trends have affected practice. We used the National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of office-based medical visits, to examine by physician specialty a) trends in the proportion of visits for women's health care and b) the content of nonillness care. Between 1985 and 1997-98, market share of reproductive health services increased for IMs (e.g., from 3.7% to 10.5% of contraceptive visits, p <.05) and decreased for FPs (from 30.5% to 20.5% for contraceptive visits, p <.05). Ob/Gyns increased their share of women's health care visits, with reproductive health visits increasing from 56.2% to 65.9% (p <.0001). The trend in hormone replacement therapy visits differed, with nonsignificant gains in market share for IMs and decreases for ob/gyns. Nonillness care (1997-98 data only) differed predictably by specialty, with IMs and FPs more often providing cholesterol screening while ob/gyns more often provided reproductive health services. Compared with IMs and FPs, ob/gyns were more likely to counsel women on reproductive health topics and equally likely to counsel on general health topics, but additional time spent in counseling was lower. Specialty differences in the provision of women's health services continue, though the scope of care provided by IMs has broadened. Still, women are unlikely to obtain a full range of preventive services in a single nonillness visit. Ensuring adequate coordination among physicians providing primary care to women continues to be a critical concern.
To describe the types of services provided to women with disabilities at community-based domestic... more To describe the types of services provided to women with disabilities at community-based domestic violence programs in the state of North Carolina, the challenges faced, and strategies used to provide the services. We conducted a statewide cross-sectional survey of community domestic violence programs and had a response rate of 85%. Of the participating programs, 99% provided services to at least one woman with a physical or mental disability in the preceding 12 months; 85% offered shelter services to women with physical or mental disabilities. Most respondents (94%-99%) reported that their programs were either somewhat able or very able to provide effective services and care to women with disabilities. The respondents also described challenges to serving women with disabilities, including lack of funding, lack of training, and structural limitations of service facilities. Strategies used by the programs to overcome these challenges were networking and coordinating care with organizations that specifically serve disabled populations. Domestic violence programs in North Carolina provide services to women with disabilities but are faced with challenges stemming from limited funding, physical space, and training. Collaborations between domestic violence and disability service providers are necessary to improving the services and care delivered to women with disabilities who experience domestic violence.
Incarcerated women have had limited access to health care prior to their arrest. Although their i... more Incarcerated women have had limited access to health care prior to their arrest. Although their incarceration presents an opportunity to provide them with health care, their reproductive health needs have been overlooked. We performed a cross-sectional study of a nationally representative sample of 950 correctional health providers who are members of the Academy of Correctional Health Providers. A total of 405 surveys (43%) were returned, and 286 (30%) were eligible for analysis. Most ineligible surveys were from clinicians at male-only facilities. Of eligible respondents, 70% reported some degree of contraception counseling for women at their facilities. Only 11% provided routine counseling prior to release. Seventy percent said that their institution had no formal policy on contraception. Thirty-eight percent of clinicians provided birth control methods at their facilities. Although the most frequently counseled and prescribed method was oral contraceptive pills, only 50% of providers rated their oral contraceptive counseling ability as good or very good. Contraception counseling was associated with working at a juvenile facility, and with screening for sexually transmitted infections. Contraception does not appear to be integrated into the routine delivery of clinical services to incarcerated women. Because the correctional health care system can provide important clinical and public health interventions to traditionally marginalized populations, services for incarcerated women should include access to contraception.
The way clinicians communicate with parents during pregnancy about congenital heart disease (CHD)... more The way clinicians communicate with parents during pregnancy about congenital heart disease (CHD) can significantly influence parental understanding of and psychological response to the diagnosis. A necessary first step to improving communication used in fetal cardiology consultations is to understand and describe the language currently used, which this paper aims to do. Nineteen initial fetal cardiology consultations with parents were audio-recorded, transcribed verbatim, and coded by two independent coders. A codebook was inductively developed and applied to all transcripts. The finalized coding was used to characterize fetal cardiologists’ language. We identified four discourse styles employed in fetal cardiology consultations: small talk, medical, plain, and person-centered. Plain language was used to define and emphasize the meaning of medical language. Person-centered language was used to emphasize the baby as a whole person. Each consultation included all four discourse style...
INTRODUCTION: Postpartum care can be fragmented, especially among women with premature infants in... more INTRODUCTION: Postpartum care can be fragmented, especially among women with premature infants in the Neonatal Intensive Care Unit (NICU). We aimed to explore women's goals for and experiences with postpartum care. METHODS: We conducted a qualitative study using semi-structured interviews to ask women between 2 and 8 weeks after delivery of preterm infants in the NICU about their preferred topics of discussion at the postpartum visit and experiences with postpartum care. We analyzed transcripts using thematic analysis. IRB approval obtained. RESULTS: We enrolled 16 mothers who delivered between 25 and 34 weeks gestation (11 by Cesarean). At interview time (14-55 days postpartum), 4 women had attended a postpartum visit, 2 had missed their visit, and 10 had an upcoming appointment scheduled. Reasons for not attending a visit included distance of clinic from NICU, a desire to focus on their infant's health, and insurance changes. Participants identified several topics of impor...
To explore initial pregnancy intentions and postmiscarriage family planning needs and counseling ... more To explore initial pregnancy intentions and postmiscarriage family planning needs and counseling preferences of women experiencing spontaneous abortion. We conducted semistructured qualitative interviews with women who recently experienced spontaneous abortion to explore their feelings about conception, pregnancy, and miscarriage; their future family planning goals; and contraceptive counseling preferences. Two trained coders utilized an inductive, iterative approach to code transcripts and identify themes using Atlas.ti software to organize the analysis. We interviewed 26 women reporting varied intentions in their recent pregnancies: 54% were trying to conceive, 27% were not trying but not preventing, and 19% were attempting to avoid pregnancy. Participants reported a range of feelings about the pregnancy diagnoses and eventual miscarriages with some relatively unemotional ("a little disappointed…suffering for two months for nothing") and others feeling devastated by thei...
To assess how obstetric health care providers counsel patients regarding prenatal genetic screeni... more To assess how obstetric health care providers counsel patients regarding prenatal genetic screening and how these conversations influence patients' screening decisions. This cohort study analyzed transcripts and audio recordings of 210 first prenatal visits collected as part of a larger study on patient-provider communication. Conversations were coded in an iterative process to determine compliance with American College of Obstetricians and Gynecologists (College) prenatal genetic screening recommendations and to identify recurrent themes. χ, nonparametric tests, and logistic regression were used to determine the effects of discussion elements on screening decisions. Qualitative analysis was performed for genetic screening content. The study included 210 patients and 45 health care providers. Health care providers offered genetic screening at 90% of visits; 78% of women chose genetic screening. Few conversations (1.5%) included all College-recommended topics. Inclusion of Colleg...
To describe obstetric health care providers' responses and counseling approaches to patients&... more To describe obstetric health care providers' responses and counseling approaches to patients' disclosures of marijuana use during first prenatal visits. We performed a content analysis of audio-recorded patient-health care provider first prenatal visits for obstetrics health care providers' responses to patients' disclosure of marijuana use. The study was conducted at five urban outpatient clinics located in Pittsburgh, Pennsylvania. Among 468 audio-recorded first obstetric encounters, 90 patients (19%) disclosed marijuana use to 47 health care providers; mean number of recoded encounters containing marijuana disclosures for participating health providers was 1.8±1.4. In 48% of these 90 visits, obstetric health care providers did not respond to marijuana use disclosures or offer counseling. When counseling was offered, it consisted of general statements without specific information on the risks or outcomes related to marijuana use in pregnancy, discussions regarding ...
Background: Illicit drug use during pregnancy is associated with negative pregnancy, infant and m... more Background: Illicit drug use during pregnancy is associated with negative pregnancy, infant and maternal outcomes. Past illicit drug use is a predictor of perinatal drug use. However, little is know whether obstetric care providers screen for past drug use during clinic visits. Objective: To examine patient-provider discussions during the first obstetric visit for screening of past drug use. Methods: First obstetric visits between obstetric care providers and pregnant patients were audio-recorded. Conversations were qualitatively analyzed for drug screening questions; these questions were then categorized by whether the provider specifically asked about past or present use. Results: Two-hundred fifty patients and 56 obstetric care providers participated. In 224 visits (89.6%) providers screened for illicit drug use in some manner. Providers asked specifically about current use in 78 visits (31.2%), and about past use in 60 visits (24.0%). In 143 (57.2%) visits, questioning about dru...
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Papers by Judy Chang