CHAPTER 11: APPLICATIONS IN THE HEALTH CARE SETTINGS
Table of Contents
Headlines, Timelines, & Milestones
Headlines, Timelines, &
Picking a Bone With Vitamin A. (Washington Post, Feb. 3, 2003) -
According to a newly published study in the New England Journal of Medicine,
high levels of vitamin A are linked to bone fractures.
New U.S. Guidelines Stress First Colon Screening. (Reuters
Health) - New U.S. guidelines on colon screening stress the importance of the
first screening after the 50th birthday, over 3 year follow-up screening after
the removal of polyps.
HMO Kaiser Plans to Put Its Medical Records Online. (Wall Street
Journal, February 4, 2003) - Kaiser Permanente has announced plans to spend $1.8
billion to automate its patient files.
Patients Switch Doctors After Shabby Treatment. (Wall Street
Journal - Harris Interactive Poll, February 5, 2003) - A poll conducted by the
Wall Street Journal sampled the public's views on bad experiences with doctors
and whether these experiences lead to a change in doctors.
SUPPLEMENTARY REFERENCES (some are annotated (with abstracts), or
provide links to journals)
Amery, W.K. (1999). Coming full circle in pharmacovigilance: Communicating
safety information to patients through patient packageinserts.
PHARMACOEPIDEMIOLOGY AND DRUG SAFETY 8 (2): 121-129.
Barner, J. C., Mason, H. L., & Murray, M. D. (1999). Assessment
of asthma patients' willingness to pay for and give time to an asthma self-management
program. CLINICAL THERAPEUTICS 21 (5): 878-894.
ABSTRACT: Optimal drug therapy requires that the patient should be
informed adequately, unequivocally and in timely fashion. Patient package inserts (PPIs)
have an important facilitating role to play in this respect. Patients' confidence in the
benefit of a drug treatment and their fear of its side effects are strong determinants of
their adherence to that treatment. Yet, the European PPI format does not allow a
discussion of the treatment's benefits, which results in an unbalanced focus on side
effects. This serious shortcoming may significantly interfere with a patient's compliance.
In addition, prescribers are often unaware of the content of the PPI of the products they
are prescribing. To rectify this situation, the development is proposed of annotated PPIs
providing the scientific background to the PPI message. In conclusion, European PPIs need
to be improved. The patient should be informed of the expected benefit of a drug
treatment, its likelihood and the expected time course of the effect, and not only of side
effects and interactions, which constitutes the present focus. Moreover, prescribers need
to be informed about the content of the PPIs for the medicines they prescribe.
ABSTRACT: Despite the success of health education programs for patients
with asthma, several researchers have found that patients are reluctant to enroll in and
complete a program designed to help them manage their condition. The purpose of this study
was to identify factors that influence asthma patients' willingness to pay (WTP) for and
willingness to give time (WTGT) to an asthma self-management program. The patient sample
consisted of 116 adult asthma patients (age range, 18 to 34 years) from 2 affiliated
sites: a county teaching hospital with ambulatory clinics and a staff-model health
maintenance organization. To determine WTP and WTGT, patients were presented with a
scenario in which the components of an 8-week asthma management program were described.
Patients were then asked how much they would be willing to pay for and how much time they
would be willing to spend on the program. Regression analyses were used to determine what
effect the following factors had on WTP and WTGT with respect to an asthma self-management
program: sociodemographic factors; predisposing, enabling, and reinforcing factors; level
of asthma self-management; and health care utilization. Mean patient WTP was $29.50 for an
8-week asthma education program. Several factors appeared to influence this amount.
Patients who were willing to pay more for a program that would help them manage their
asthma exhibited suboptimal behaviors during asthma attacks, had greater perceived access
to health care resources, received less educational information from health care
providers, had previously participated in a self-management program, and had indicated an
interest in participating in a self-management program. This model was statistically
significant (P <0.0001), with 35% of the variation in WTP scores explained by the
independent variables. Patients reported that they were willing to spend a mean of 5.8
hours per week on an 8-week asthma self-management program. Patients who were willing to
spend more time on an asthma self-management program had indicated an interest in
participating in such a program, had a higher number of comorbidities, or had more
emergency department visits. This model was statistically significant (P = 0.0018), with
18% of the variance explained. This study identified several factors that may affect WTP
and WTGT in relation to an asthma self-management program. This information may be helpful
in identifying candidates for educational programs.
Black, M. M. (1999). Commentary: feeding problems: an
ecological perspective. JOURNAL OF PEDIATRIC PSYCHOLOGY 24 (3): 217-219, June.
For this issue of the Journal, go to:
Braveman, P., Egerter, S., & Marchi, K. (1999). The prevalence of low
income among childbearing women in California: Implications for the private and public
sectors. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 868-874.
The Journals Home Page is at:
THE AMERICAN JOURNAL OF PUBLIC HEALTH.
ABSTRACT: Objectives. This study examined the income distribution of
childbearing women in California and sought to identify income groups at increased risk of
untimely prenatal care. Methods. A 1994/95 cross-sectional statewide survey of 10132
postpartum women was used. Results. Sixty-five percent of all childbearing women had low
income (0%-200% of the federal poverty level), and 46% were poor (0%-100% of the federal
poverty level). Thirty-five percent of women with private prenatal coverage had low
income. Most low-income women with Medi-Cal (California's Medicaid) or private coverage
received their prenatal care at private-sector sites. Compared with women with incomes
over 400% of the poverty level, both poor and near-poor women were at significantly
elevated risk of untimely care after adjustment for insurance, education, age, parity,
marital status, and ethnicity (adjusted odds ratios = 5.32 and 3.09, respectively).
Conclusions. This study's results indicate that low-income women are the mainstream
maternity population, not a "special needs" subgroup; even among privately
insured childbearing women, a substantial proportion have low income. Efforts to increase
timely prenatal care initiation cannot focus solely on women with Medicaid, the uninsured,
women in absolute poverty, or those who receive care at public-sector sites.
Brown, R., Butow, P.N., Boyer, M.J., & Tattersall, M.H.N. (1999). Promoting
patient participation in the cancer consultation: evaluation of a prompt sheet and
coaching in question asking. BRITISH JOURNAL OF CANCER 80 (1-2): 242-248.
ABSTRACT: Active participation in the medical consultation has been
demonstrated to benefit aspects of patients' subsequent psychological well-being. We
investigated two interventions promoting patient question-asking behaviour. The first was
a question prompt sheet provided before the consultation, which was endorsed and worked
through by the clinician. The second was a face to face coaching session exploring the
benefits of, and barriers to, question-asking, followed by coaching in question-asking
behaviour employing rehearsal techniques. Sixty patients with heterogeneous cancers,
seeing two medical oncologists for the first timer were randomly assigned to one of three
groups: two intervention groups and one control group. Sociodemographic variables and
anxiety were assessed prior to the intervention which preceded the consultation, The
consultations were audiotaped and subsequently analysed for question-asking behaviour.
Anxiety was assessed again immediately following the consultation. Questionnaires to
assess patient satisfaction, anxiety and psychological adjustment were sent by mail 2
weeks following the consultation. Presentation and discussion of the prompt sheet
significantly increased the total number of questions asked and the number of questions
asked regarding tests and treatment. Coaching did not add significantly to the effects of
the prompt sheet. Psychological outcomes were not different among the groups, We conclude
that a question prompt sheet addressed by the doctor is a simple, inexpensive and
effective means of promoting patient question asking in the cancer consultation.
Buetow, S.A. (1999). Unsolicited GP advice against smoking: To give or not to
give? JOURNAL OF HEALTH COMMUNICATION 4 (1): 67-74.
Burnand, B. (1999). Editorial. Clinical practice
guidelines. A public health perspective. EUROPEAN JOURNAL OF PUBLIC HEALTH 9 (2):
ABSTRACT: This article discusses whether general practitioners (GPs)
should give unsolicited antismoking advice to patients who smoke. Patient preferences and
GP advice-giving are discussed,vith particular reference to professional roles. It is
suggested that gluing unsolicited advice against smoking at nearly every encounter is a
competitive rather than collaborative behavior. General practitioners should ascertain
patients' readiness for change before offering to help produce individualized agreements
of joint benefit on change. Three strategies for negotiation-bridging, trading, and
Chaney, J. M., Mullins, L. L., Uretsky, D. L., Pace, T. M.,
Werden, D, & Hartman, V. L. (1999). An experimental examination of learned
helplessness in older adolescents and young adults with long-standing asthma.
JOURNAL OF PEDIATRIC PSYCHOLOGY 24 (3): 259-270, June.
For this issue of the Journal, go to:
Cheng, T.L., DeWitt, T.G., Savageau, J.A., & O'Connor, K.G.
(1999). Determinants of counseling in primary care pediatric practice - Physician
attitudes about time, money, and health issues. ARCHIVES OF PEDIATRICS &
ADOLESCENT MEDICINE 153 (6): 629-635.
ABSTRACT: Objectives: To assess pediatrician goals and practice in
preventive counseling, and to use social learning theory to examine physician attitudes
about preventive health issues, time, and reimbursement to explain physician counseling
behavior. Design: Random sample survey of American Academy of Pediatrics fellows.
Participants: A total of 1620 pediatricians were surveyed with a return rate of 72%. The
556 pediatricians who had finished training and who currently performed child health
supervision were included. Methods: Pediatricians were asked about their goals in 6 areas
of health supervision: biomedical issues, development, behavior, family functioning,
safety education, and supportive interpersonal interaction. They were also asked about the
prevalence of counseling, importance of specific topics, their self-efficacy, outcome
expectation in these areas, and their concerns about time and reimbursement for preventive
counseling. Results: Assurance of physical health and normal development were the most
important goals of child health supervision among the pediatricians surveyed. Goals
involving behavioral, family, and safety issues were less important and less likely to be
addressed in practice. Most did not regularly discuss family stress, substance abuse, gun
safety, and television. In these areas, physicians had less confidence they could provide
guidance and lower expectation that they could prevent problems. Only 17% felt that they
receive adequate reimbursement for preventive counseling. Most have adequate time (53%)
and receive adequate respect (57%) for their preventive efforts. Physicians who were more
concerned about time for preventive counseling reported less overall counseling (r=-0.28,
P<.001). Concern about reimbursement was not associated with reported counseling.
Multiple regression analysis found that the primary predictors of physician counseling
were an issue's importance, a physician's perceived self-efficacy, and perceived
effectiveness of counseling, while concerns about time and reimbursement were secondary.
Conclusions: Physician goals in child health supervision were primarily biomedical, with
psychosocial and safety issues of lesser importance. Concern about time for preventive
counseling was associated with less reported counseling. Physician attitudes regarding the
importance of a health issue and their confidence and effectiveness in counseling were
more predictive of physician practice than their attitudes about time and reimbursement
for preventive care.
Desnick, L.., Taplin, S., Taylor, V., Coole, D., & Urban, N.
(1999). Clinical breast examination in primary care: Perceptions and predictors
among three specialties. JOURNAL OF WOMENS HEALTH 8 (3): 389-397.
ABSTRACT: To assess predictors of reported performance of screening
clinical breast examination (CBE) by internists, family physicians, and
obstetrician/gynecologists, we surveyed members of these specialties in four counties of
Washington State. We contacted all physicians in the counties and identified 334 providers
who saw women ages 50-75 and provided primary care as their principal activity.
Seventy-five percent (252 of 334) responded. Physicians were mailed a survey and contacted
for telephone completion if they did not respond in writing. The survey inquired about
their current performance of CBE and factors that might predispose, enable, or reinforce
its use. Differences across specialties were assessed using the chi-square statistic.
Factors associated with reported performance of screening CBE in greater than or equal to
90% of women were evaluated using logistic regression. Fifty-one percent of physicians
reported that they perform regular CBE on greater than or equal to 90% of their patients,
although the proportion varied across specialty type. Beliefs about the benefit of CBE
were positive and similar across specialties. Twelve percent of male physicians, but no
female physicians, reported that women's embarrassment affected their use of screening
CBE. In a multivariate model, male gender, family practice specialty, and the perception
of patient embarrassment were all associated with lower reported rates of performing
regular CBE (p <0.05). Work to increase the performance of CBE should consider the role
of male physician embarrassment and family physician training. Ways to facilitate delivery
of preventive care and factors influencing the women themselves may also be important to
increased use of CBE.
Diehr, P., Yanez, D., Ash, A., Hornbrook, M., & Lin, D.Y.
(1999). Methods for Analyzing Health Care Utilization and Costs. ANNUAL
REVIEW OF PUBLIC HEALTH 20: 125-158.
Durham, M. L. (1998). Mental health and managed care.
ANNUAL REVIEW OF PUBLIC HEALTH 19: 493-505. For abstract, go to:
Farmer, K. C. (1999). Methods for measuring and monitoring
medication regimen adherence in clinical trials and clinical practice. CLINICAL
THERAPEUTICS 21 (6): 1074-1090, June.
ABSTRACT: Researchers and clinicians have used numerous methods in
their attempts to adequately assess patient compliance (adherence) with medication
regimens and to identify noncompliant patients. Large variations have been reported in the
extent of noncompliance in individual patients and large populations. In addition,
nonadherence has often been poorly defined. Direct measures of adherence include drug
assays of blood or urine, use of drug markers with the target medication, and direct
observation of the patient receiving the medication. Indirect measures of adherence imply
that the medication has been used by the patient; these measures include various forms of
self-reporting by the patient, medication measurement (pill count), use of electronic
monitoring devices, and review of prescription records and claims. Compliance measures
should be assessed on the basis of their validity (sensitivity and specificity or
statistical correlation) and the reference standard used. Many early studies used pill
counts as a reference standard, but electronic monitoring devices such as the Medication
Event Monitoring System have replaced pill counts as the reference standard. The choice of
a method for measuring adherence to a medication regimen should be based on the usefulness
and reliability of the method in light of the researcher's or clinician's goals. Specific
methods may be more applicable to certain situations, depending on the type of adherence
being assessed, the precision required, and the intended application of the results.
Farris, K. B., & Schopflocher, D. P. (1999). Between intention and behavior: an
application of community pharmacists' assessment of pharmaceutical care. SOCIAL
SCIENCE & MEDICINE 49 (1): 55-66, July.
Fisher, L. D. (1999). Advances in Clinical Trails in the Twentieth Century.
ANNUAL REVIEW OF PUBLIC HEALTH 20: 109-124.
Fishman, P. A., & Wagner, E. H. (1998). Managed care data and public
health: The experience of group health cooperative of Puget Sound. ANNUAL REVIEW
OF PUBLIC HEALTH 19: 477-491. For abstract, go to:
Franche, R. L., & Mikail, S. F. (1999). The impact of
perinatal loss on adjustment to subsequent pregnancy. SOCIAL SCIENCE &
MEDICINE 48 (11): 1613-1623.
ABSTRACT: This study compares the emotional adjustment of pregnant
couples with and without a history of perinatal loss. We assessed thirty-one pregnant
women with a history of perinatal loss and 31 pregnant women with an unremarkable
reproductive history between their 10th and 24th week of gestation. Partners were
recruited. Twenty-eight men were in the loss group and 23 men in the comparison group.
Couples with a history of loss reported significantly more depressive symptomatology and
pregnancy-specific anxiety than couples in the comparison group. Women reported more
depressive symptomatology than men. Results: Regression analyses revealed that for the
group with a previous loss. depressive symptomatology was significantly associated with
self-criticism, interpersonal dependency and number of previous losses. For the comparison
group, depressive symptomatology was significantly associated dyadic adjustment.
Pregnancy-specific anxiety of women with a previous loss was associated with their belief
that their behavior affects fetal health; for women in the comparison group,
pregnancy-specific anxiety was associated with the belief that health professionals'
behavior affects fetal health. Implications for practice of health care professionals: The
importance of early intervention to reduce distress is highlighted by the finding that
alterations in mood are apparent in the early stages of pregnancy for both women and men
who have experienced a previous perinatal loss. Carefully reducing personal responsibility
for fetal health in women with a previous loss may reduce their pregnancy-specific
anxiety, but women with an unremarkable obstetrical history may benefit from an approach
diminishing their perception of the power that medical staff has on fetal health.
Freund, D., Lave, J., Clancy, C., Hawker, G., Hasselblad, V.,
Keller, R., Schneiter, E., & Wright, J. (1999). Patient Outcomes Research
Teams: Contribution to Outcomes and Effectiveness Research. ANNUAL REVIEW OF
PUBLIC HEALTH 20: 337-360.
Goldberg, B. W. (1998). Managed care and public health departments: Who is
responsible for the health of the population? ANNUAL REVIEW OF PUBLIC HEALTH 19:
527-537. For abstract, go to: http://biomedical.annualreviews.org/current/16.shtml
Green, L. W. (1999). What can we generalize from research
on patient education and clinical health promotion to physician counseling on diet?
EUROPEAN JOURNAL OF CLINICAL NUTRITION 53 (Suppl. 2): S9-S18.
AUTHORS ABSTRACT: Objective: This paper explores the status of
knowledge development from clinical trials and other studies of patient education and
clinical health promotion. Design: It asks what this cumulative literature has to offer
dietary counseling of patients by family doctors. A series of meta-analyses of drug
education and preventive health education research in clinical settings provide a starting
framework for guidelines on dietary counseling. Conclusions: Smoking cessation studies, in
particular, have mounted in quantity and quality to the greatest extent and offer the
clearest statement on what can be achieved, under what conditions, and with what support
beyond the physician's counseling session or sessions. The Precede-Proceed Model offers a
further guide to assuring the comprehensiveness of approaches to dietary change - enabling
and reinforcing the change, not just predisposing it through admonitions and altering of
knowledge, attitudes and beliefs. The specific evidence supporting the application of a
patient counseling algorithm based on the Precede-Proceed model is reviewed here.
Griffin, J.F., Hogan, J.W., Buechner, J.S., Leddy, T. M. (1999). The
effect of a Medicaid managed care program on the adequacy of prenatal care utilization in
Rhode Island. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (4): 497-501.
Hale, J. F (1998). Application of the PRECEDE-PROCEED
Model for comprehensive community assessment, education programming, and evaluation in a
combat hospital community during the Gulf War. HOME HEALTH CARE MANAGEMENT &
PRACTICE 11(1): 52-65.
ABSTRACT: Objectives. The purpose of this study was to determine
whether adequacy of prenatal care utilization improved after the implementation of a
Medicaid managed care program in Rhode Island. Methods. Rhode Island birth certificate
data (1993-1995; n = 37021) were used to analyze pre- and post-program implementation
changes in adequacy of prenatal care utilization. Logistic regression models were used to
characterize the variation in prenatal care adequacy as a function of both time and the
various covariates. Results. Adequacy of prenatal care utilization for Medicaid patients
improved significantly after implementation of the program, from 57.1% to 62.1% (odds
ratio [OR] = 1.2, 95% confidence interval [CI] = 1.1, 1.3), After the program was
implemented, Medicaid patients who went to private physicians' offices for prenatal care
were 1.4 times as likely as before to receive adequate prenatal care (OR = 1.4, 95% CI =
1.2, 1.7). Conclusions. Unlike many other Medicaid expansions for pregnant women, the RIte
Care program in Rhode island has resulted in significant improvement in adequacy of
prenatal care utilization for its enrollees. This improvement has been due to specific
program interventions that addressed and changed organizational and delivery system
barriers to care.
ABSTRACT: "This article describes the Persian Gulf combat hospital
community of the 410th [Evacuation Hospital of the US Army Reserve] as it evolved,
dissolved, and was evaluated in terms of the PRECEDE-PROCEED model as a community that
attained and maintained a high quality of life for both community members and patients
during its 'life' in the barren desert of Saudi Arabia..."(p.52). The quality of life
of the 400 uprooted personnel is described in detail in the social diagnosis, including
stressors, fears, physiologic and physical strains such as sleep deprivation, sand storms,
extremes temperatures, and lack of privacy and control over personal life. The
epidemiologic diagnosis includes 9 "wounded in action" factors, 6 diseases and
nonbattle injuries, and battle fatigue. These analyses produced 12 desired social and
quality-of-life outcomes and 11 health goals. Phase 3 produced a list of 12 behavioral and
environmental concerns, with safety identified as the number one risk factor. Each of the
subsequent phases is described in graphic and fascinating detail. The author concludes
that the Precede-Proceed "model provides an excellent framework in which to organize
and document data in assessing a target population for any reason. It can then be applied
for planning, implementing and evaluating interventions, not only for health promotion
planning but also for any other types of interventions that could impact on the quality of
life and the health outcomes of a population, community, or home setting. This article
echoes previous ones in support of this framework for not only nursing interventions, but
also for interdisciplinary community-based interventions and interactions as well. The
author has found it to be invaluable in both an academic setting for teaching graduate
students a process for and application of an advanced level of community assessment,
planning, and evaluation both nationally and internationally when one needs to look at the
targeted population or setting from the 'ground up'. The readers are challenged to apply
this framework to home health care settings and further add to the diversity and
applicability of the model" (p. 64).
Haslam, C. (1999). Maternal factors, obstetric history and
smoking stage of change. Journal of Public Health Medicine 21(2): 185-191.
Helliwell, P.S.m, O'Hara, M., Holdsworth, J., Hesselden, A.,
King, T., Evans, P. (1999). A 12-month randomized controlled trial of patient
education on radiographic changes and quality of life in early rheumatoid arthritis.
RHEUMATOLOGY 38 (4): 303-308.
For abstract: http://www.oup.co.uk/pubmed/hdb/Volume_21/Issue_02/210185.sgm.abs.html
ABSTRACT: Objective. In rheumatoid arthritis, education programmes
successfully impart knowledge but, notwithstanding issues of empowerment, this knowledge
has to be translated into behavioural change to have a chance of improving disease
outcome. Arguably, behavioural change must also occur early if outcomes are to be
improved. For these reasons: we planned a study of patient education in early disease,
with radiological damage and quality of life as the main outcome variables. Methods. We
performed a randomized controlled trial in people with rheumatoid arthritis of <5 yr
duration. The main intervention was a 4 week education programme, each weekly session
lasting 2 h. Assessments were made at entry, at 4 weeks and at 12 months. The main outcome
variables were the modified Larsen radiological score for the hands and the SF-36 quality
of life questionnaire. Secondary outcome variables were the Health Assessment
Questionnaire (HAQ), Ritchie Articular Index (RAI), Patient Knowledge Questionnaire (PKQ),
Compliance Questionnaire (CQ), plasma viscosity (PV), pharmaceutical changes and
consulting behaviour. Results. The patient numbers were 34 (10 male, 24 female) for the
control group and 43 (16 male, 27 female) for the education group. The groups were matched
for age (56.5 yr for control, 55 yr for education), disease duration (3.5 yr vs 3.0 yr)
and duration of second-line drug therapy (14 months vs 12 months). We found no significant
difference between the groups for Larsen scores at 12 months, although scores for the
education group were lower (39.5 vs 43.0, P = 0.13). The 'social functioning' and 'general
health perception' subscales of the SF-36 showed a significant improvement in the
education group, but no significant differences between groups were seen. No significant
differences were found for the HAQ, RAI, PV and CQ, but the education group had more
disease-specific knowledge than the control group at 12 months (PKQ scores: 17 vs 21, P =
0.0002). No differences were found for out-patient visits and in-patient admissions, but
the education group had slightly more changes in second-line drugs during the study (0.43
changes/person in the control group, 0.51 changes/person in the education group).
Conclusions. We found no significant difference between the groups in our primary outcome
measures, but a trend in favour of the education group was found in radiological
progression. Further studies of this kind, using larger patient numbers, are required
since the difference may result from improved self-care, better compliance with joint
protection strategies and, possibly, improved drug compliance.
Hiddink, G. J., Hautvast, J. G. A. J., van Woerkum, C. M. J.,
vant Hot, M. A., & Fieren, C. J. (1999). Cross-sectional and
longitudinal analyses of nutrition guidance by primary care physicians. EUROPEAN
JOURNAL OF CLINICAL NUTRITION 53 (Suppl. 2): S35-S43.
ABSTRACT: Objective: To investigate in primary care physicians (PCPs)
the determinants of a nutrition guidance practice ('noticing patients' overweight and
guidance of treatment'), as well as their mechanism of action, in a cross-sectional and a
longitudinal approach. Design: Mixed longitudinal design. Five years follow up study of a
previous cross-sectional study in October 1992. Subjects: A representative sample of 675
Dutch PCPs, in practice for 5 up to 20y. Interventions: A shortened version of the
Wageningen PCPs Nutritional Practices Questionnaire was mailed to the subjects in August
1997. Main outcome measure: To obtain with the LISREL-program a model of the mechanism of
action of determinants of the dependent variable 'noticing patients' overweight and
guidance of treatment' with an adequate fit of the empirical data, both in the
cross-sectional and in the longitudinal approach. Results: The same set of predisposing
factors and intermediary factors explains the dependent variable both in two different
representative cross-sectional study populations of PCPs, and in a cohort cross-sectional
study at two points in time. Two dynamic LISREL-models were developed (the
'determinant-longitudinal approach' and the 'early behavior longitudinal approach') which
explain the dependent variable. The latter model has, as added value, a gain in explained
variance. In 5 y time, the dependent variable decreased significantly (P < 0.001).
Conclusions: This study reconfirms that PCPs' nutritional guidance practices are
determined partly directly by predisposing factors, and indirectly via driving forces and
barriers. However this study also reveals that an important nutrition guidance practice of
PCPs, 'noticing patients' overweight and guidance of treatment', shows a significant
decrease over the last 5 y. At the same time, two of the four predisposing factors and two
of the three driving factors also decreased significantly. As research findings indicate
that the role of diet in health and disease becomes of greater influence PCPs need to be
activated to apply their responsibility in this field within a multi-faceted approach.
Holzemer, W.L., Corless, I.B., Nokes, K.M., Turner, J.G., Brown, M.A., Powell-Cope,
G.M., Inouye, J., Henry, S.B., Nicholas, P.K., Portillo, C.J. (1999). Predictors
of self-reported adherence in persons living with HIV disease. AIDS PATIENT CARE
AND STDs 13 (3): 185-197.
ABSTRACT: This study examined the relationships between the five
dimensions of the Wilson and Cleary model of health-related quality of life and three
self-reported adherence measures in persons living with HIV using a descriptive survey
design. Data collection occurred in seven cities across the United States, including
university-based AIDS clinics, private practices, public and for-profit hospitals,
residential and day- care facilities, community-based organizations, and home care. The
three dependent adherence measures studied were "medication nonadherence,"
"follows provider advice," and "missed appointments." The sample
included 420 persons living with HIV disease with a mean age of 39 years of which 20% were
women and 51% were white; subjects had a mean CD4 count of 321 mm(3). HIV-positive clients
with higher symptom scores, particularly depression, were more likely to be nonadherent to
medication, not to follow provider advice, and to miss appointments. Participants who
reported having a meaningful life, feeling comfortable and well cared for, using their
time wisely, and taking time for important things were both more adherent to their
medications and more likely to follow provider's advice. No evidence was found
demonstrating any relationship between adherence and age, gender, ethnicity, or history of
injection drug use. These findings support the need to treat symptoms, particularly
depression, and to understand clients' perceptions of their environment as strategies to
enhance adherence. A limitation of this study was that adherence was measured only by
self-report; however, the study did expand the concept of adherence in HIV care beyond
medication adherence to include following instructions and keeping appointments.
Horne, R., Weinman, J., & Hankins, M. (1999). The beliefs about medicines
questionnaire: The development and evaluation of a new method for assessing the cognitive
representation of medication.
Hulscher, M.E.J.L., Wensing, M., Grol, R.P.T.M., van der Weijden,
T., & van Weel, C. (1999). Interventions to improve the delivery of preventive
services in primary care. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (5): 737-746.
ABSTRACT: This paper presents a novel method for assessing cognitive
representations of medication: the Beliefs about Medicines Questionnaire (BMQ). The BMQ
comprises two sections: the BMQ-Specific which assesses representations of medication
prescribed for personal use and the BMQ-General which assesses beliefs about medicines in
general. The pool of test items was derived from themes identified in published studies
and from interviews with chronically ill patients. Principal Component Analysis (PCA) of
the test items resulted in a logically coherent, 18 item, 4-factor structure which was
stable across various illness groups. The BMQ-Specific comprises two 5-item factors
assessing beliefs about the necessity of prescribed medication (Specific-Necessity) and
concerns about prescribed medication based on beliefs about the danger of dependence and
long-term toxicity and the disruptive effects of medication (Specific-Concerns). The
BMQ-General comprises two 4-item factors assessing beliefs that medicines are harmful,
addictive, poisons which should not be taken continuously (General-Harm) and that
medicines are overused by doctors (General-Overuse). The two sections of the BMQ can be
used in combination or separately. The paper describes the development of the BMQ scales
and presents data supporting their reliability and their criterion-related and
ABSTRACT: Objectives. This review was conducted to determine the
effectiveness of different interventions to improve the delivery of preventive services in
primary care. Methods. MEDLINE searches and manual searches of 21 scientific journals and
the Cochrane Effective Professional and Organization of Care of trials were used to
identify relevant studies. Randomized controlled trials and controlled before-and-after
studies were included if they focused on interventions designed to improve preventive
activities by primary care clinicians. Two researchers independently assessed the quality
of the studies and extracted data for use in constructing descriptive overviews. Results.
The 58 studies included comprised 86 comparisons between intervention and control groups.
Postintervention differences between intervention and control groups varied widely within
and across categories of interventions. Most interventions were found to be effective in
some studies, but not effective in other studies. Conclusions. Effective interventions to
increase preventive activities in primary care are available. Detailed studies are needed
to identify factors that influence the effectiveness of different interventions.
Jelalian, E., & Saelens, B. E. (1999). Empirically
supported treatments in pediatric psychology: pediatric obesity. JOURNAL OF
PEDIATRIC PSYCHOLOGY 24 (3): 223-248, June.
For this issue of the Journal, go to:
Jirojwong, S., Dunt, D., & Goldsworthy, D. (1999). Social support and
antenatal clinic attendance among Thai pregnant women in Hatyai, a city in southern
Thailand. JOURNAL OF ADVANCED NURSING 29 (2): 395-406.
ABSTRACT: Many studies in western countries have shown that persons who
have a high level of social support are likely to have better health behaviors, including
use of preventive health services, than those who have low support. The present study aims
to investigate the impact of level of social support among Thai pregnant women on their
attendance at antenatal care (ANC) clinics. The study was conducted in Hatyai, a city in
Southern Thailand, between 1990 and 1991. Relationships between various measures of the
women's social support and their use of antenatal clinics were assessed. Open ended and
closed ended questions were used to gather information relating to these women's level of
social support, including the number of supporters and their age, the percentage of
females among the supporters, the sources of support (spouse, kin, friend and health
professionals), the frequency of contact, the types of support and the sufficiency of
support. Social support indices were constructed: sources of support indices, a social
network index, a subjective support index, and a social support index. One hundred and
seventy-seven postpartum women were interviewed at their homes. Spouses, relatives and
friends were important sources of the four principle types of support, namely emotional,
instrumental, information and appraisal supports. Less than 10% of the women studied
identified health personnel as providing support. The majority of supporters were women
who had daily, face-to-face communication with the women studied. Approximately 76% of the
women studied had sufficient support. The majority of supporters, except health personnel,
provided all four types of support. Only 47% of the women studied made four or more
antenatal clinic visits as recommended by the Thai government. No significant relationship
between the indices of social support and the use of ANC clinics was identified, The Thai
extended family by its nature generates large numbers of supporters. Little variation in
support levels among all the women therefore occurred. Support to the women could have
positive and/or negative effects on the women's use of ANC clinics. It was concluded that
in Thai communities, social support is not an important determinant of the use of ANC
clinics and the indices of social support were not the most appropriate techniques to use
in the communities.
Kegler, M.C., Malcoe, L.H., Kegler, S.R., Lynch, R.A., Tolliver, R. (1999). Caregiver
beliefs and behaviors in the prevention of childhood lead poisoning. FAMILY &
COMMUNITY HEALTH 22 (1): 50-65.
Kerwin, M. L. E. (1999). Empirically supported treatments
in pediatric psychology: severe feeding problems. JOURNAL OF PEDIATRIC PSYCHOLOGY
24 (3): 193-214, June.
ABSTRACT: Caregivers living in areas with environmental lead problems
are often advised to engage in behaviors to protect their children from lead. This study
investigates caregiver knowledge, beliefs, and barriers associated with lead poisoning
prevention behaviors. Interviews were conducted with 332 caregivers of children ages 1
through 6 living in a mining area with large quantities of lead-contaminated soil.
Findings indicated low to moderate levels of preventive behaviors. Of the health beliefs
examined, self-efficacy and barriers most consistently predicted the preventive behaviors.
Applications of the findings are discussed for both family and community-based lead
poisoning prevention programs.
For this issue of the Journal, go to:
Kok, G. (1999). Targeted prevention for people with HIV/AIDS:
feasible and desirable? PATIENT EDUCATION AND COUNSELING 36 (3): 239-246.
Korenbrot, C.C., Miller, G., & Greene, J. (1999). The
impact of medicaid managed care on community clinics in Sacramento County, California.
AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 913-917.
ABSTRACT: People with HIV/AIDS are rarely chosen as a target group for
prevention activities. In this paper we look at empirical and theoretical evidence for the
feasibility and desirability of directing preventive interventions at HIV-positives.
Research data on the behavior and motivation of HIV-positives suggests that the
differences between HIV-positives and HIV-negatives and those who are unaware of their
HIV-status are not large. However, specific determinants of behavior, such as
responsibility for others or the risk of superinfection, have seldom been measured.
Effective interventions targeting at HIV-positives and focussing on prevention are
lacking. Fear of increased stigmatization has been used as an argument against focussing
prevention activities at HIV-positives. Theoretically that argument is probably not
correct: positive coping with HIV may invite positive reactions. The conclusion is that
HIV- positives should be chosen as a special target group for additional planned
preventive interventions. Because people need to be aware of their HIV status, testing and
treatment sites are adequate settings. Effective interventions should be developed on the
basis of theory and evidence about the specific determinants of risk behavior of HIV-
positives: protecting oneself for superinfection and protecting one's partner.
The Journals Home Page is at:
THE AMERICAN JOURNAL OF PUBLIC HEALTH.
ABSTRACT: Objectives. The purpose of this study was to determine the
impact of countywide Medicaid managed care on service use at community clinics. Methods.
Clinic use before and after introduction of Medicaid plans in one county was compared with
that in a group of comparable counties without such plans. Results. There were significant
declines of 40% to 45% in the volumes of Medicaid clients, encounters, and revenues at
clinics with the introduction of Medicaid plans. Declines of 23% in uninsured clients and
encounters did not differ significantly. Conclusions. The introduction of Medicaid managed
care with multiple commercial plans can have significant negative effects on nonprofit
Krieger, J., Collier, C., Song, L., & Martin, D. (1999). Linking
community-based blood pressure measurement to clinical care: A randomized controlled trial
of outreach and tracking by community health workers. AMERICAN JOURNAL OF PUBLIC
HEALTH 89 (6): 856-86.
The Journals Home Page is at:
THE AMERICAN JOURNAL OF PUBLIC HEALTH.
ABSTRACT: Objectives. This study assessed the effectiveness of enhanced
tracking and follow-up services provided by community health workers in promoting medical
follow-up of persons whose elevated blood pressures were detected during blood pressure
measurement at urban community sites. Methods. In a randomized controlled trial, 421
participants received either enhanced or usual referrals to care. Participants were 18
years or older; were either Black or White, and had blood pressure greater than or equal
to 140/90 mm fig and income equal to or less than 200% of poverty. The primary outcome
measure was completion of a medical follow-up visit within 90 days of referral. Results.
The enhanced intervention increased follow-up by 39.4% (95% confidence interval [CI] =
14%, 71%; P = .001) relative to usual can. Follow-up visits were completed by 65.1% of
participants in the intervention group, compared with 46.7% of those in the usual-care
group. The number needed to treat was 5 clients (95% CI = 3, 13) per additional follow-up
visit realized. Conclusions. Enhanced tracking and outreach increased the proportion of
persons with elevated blood pressure-detected during community measurement who followed up
with medical care.
Lipton, H. L., Kreling, D. H.; Collins, T., & Hertz, K. C. (1999). Pharmacy
Benefit Management Companies: Dimensions of Performance. ANNUAL REVIEW OF PUBLIC
HEALTH 20: 361-402.
Loffler, W., & Hafner, H. (1999). Ecological pattern of
first admitted schizophrenics in two German cities over 25 years. SOCIAL SCIENCE &
MEDICINE 49 (1): 93-108, July.
Luft, H.S. (1998). Medical and managed care. ANNUAL REVIEW OF
PUBLIC HEALTH 19: 459-475.
Maiburg, H. J. S., Hiddink, G. J., vant Hof, M. A.,
Rethans, J. J., & van Ree, J. W. (1999). The NECTAR-Study: development of
nutrition modules for general practice vocational training; determinants of nutrition
guidance practices of GP-trainees. EUROPEAN JOURNAL OF CLINICAL NUTRITION 53
(Suppl. 2): S83-S88.
ABSTRACT: Objective: To identify determinants of nutrition guidance
practices of general practitioner-trainees (GP-trainees), to investigate whether these
determinants differ from those found by experienced general practitioners; to reveal
educational directions towards the development of computer-based instruction on nutrition.
Design: Cross-sectional study by means of validated questionnaires. Subjects: All
CTP-trainees in training at the eight university departments for vocational training in
the Netherlands in September, 1998 (n = 985). Main outcome measures: Reliability of
determinants of nutrition guidance practices was calculated by means of Crohnbach's alpha.
The mechanism of action of determinants was identified by means of linear structural
relationship analysis (LISREL) using a model developed for GPs. Results: Crohnbach's
alphas for factors ranged from 0.58-0.90. The empirical GP-trainee-data fitted with the
corresponding GP-model on the mechanism of action. Conclusions: The same predisposing
factors, driving forces and barriers as found with GPs were identified with GP-trainees.
Comparing the GP-and GP-trainee-models, only minor differences were found in the path
coefficients between factors. Lack of nutrition training and education proved to be of
great influence on the extent of nutrition information given. The GP-trainee-model will be
of use in developing computer-based instruction on nutrition. It is expected that GPs may
also benefit from this instruction.
Mainous, A. G. III, Hueston, W. J., Love, M. M., & Griffith, C. H.
III. (1999). Access to care for the uninsured: Is access to a physician enough?
AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 910-912.
The Journals Home Page is at:
THE AMERICAN JOURNAL OF PUBLIC HEALTH.
ABSTRACT: Objectives. This study examined a private-sector, statewide
program (Kentucky Physicians Care) of care for uninsured indigent persons regarding
provision of preventive services. Methods. A survey was conducted of a stratified random
sample of 2509 Kentucky adults (811 with private insurance, 849 Medicaid recipients, 849
Kentucky Physicians Care recipients). Results. The Kentucky Physicians Care group had
significantly lower rates of receipt of preventive services. Of the individuals in this
group, 52% cited cost as the primary reason fur not receiving mammography, and 38% had not
filled prescribed medicines in the previous year. Conclusions. Providing free access to
physicians fills important needs but is not sufficient for many uninsured patients to
receive necessary preventive services.
McDonnell, R., Johnson, Z., Doyle, A. & Sayers, G. (1999). Determinants
of folic acid knowledge and use among antenatal women. Journal of Public Health
Medicine 21(2): 145-149.
Morrell, S., Taylor, R., Slaytor, E., & Ford, P. (1999). Urban
and rural suicide differentials in migrants and the Australian-born, New South Wales,
Australia 1985-1994. SOCIAL SCIENCE & MEDICINE 49 (1): 81-91, July.
Nawaz, H., Adams, M.L., & Katz, D.L. (1999). Weight loss
counseling by health care providers. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (5):
Nichol, M. B., Venturini, F., & Sung, J. C. Y. (1999). A
critical evaluation of the methodology of the literature on medication compliance.
ANNALS OF PHARMACOTHERAPY 33 (5): 531-540.
ABSTRACT: Objectives. This study explores the pattern of weight loss
counseling by health care providers in Connecticut and the associated weight loss efforts
by patients. Methods. Data from the 1994 Connecticut Behavioral Risk Factor Surveillance
system survey were analyzed to determine (1) the frequency of weight management counseling
by health care providers of overweight adults with and without additional cardiovascular
risk factors and (2) the current weight loss practices of overweight subjects. Results.
Only 29% of all overweight respondents, and fewer than half with additional cardiovascular
risk factors, reported that they had been counseled to lose weight. Conclusions. the
findings suggest need for more counseling of overweight persons, especially those with
cardiovascular disease risk factors.
ABSTRACT: OBJECTIVE: To develop a simple evaluation tool to assess
methodological rigor of the literature on patient compliance with medications, and to
apply the tool to a sample of the literature. METHODS: A computerized search of the
MEDLINE database (January 1980-December 1996) was performed. All English-language articles
on compliance with medications were identified, using the MeSH terms patient-compliance
and drug-therapy. A 10% sample was then randomly selected for review, Methodological rigor
was assessed on eight standards: study design, specification of patient sample, power
analysis, specification of disease, specification of therapeutic regimen, duration of
follow-up, definition of compliance, and compliance measurement. The raw scores of the
eight standards were then combined in three summary scores, standardized from 0 to 100:
study design, disease-related features, and compliance issues. RESULTS: Seventy-two
articles from 719 identified were reviewed. The majority of the research articles were
descriptive (63.9%), and patients in these studies were selected mainly from a convenience
sample (41.7%). Just nine studies were multicenter studies, and three employed power
analysis. The compliance definition was replicable in 41.7% of the studies. In 22 articles
neither the compliance measure nor the criteria were stated. One-quarter of the studies
(18) used a nonvalidated measure of compliance. Only two studies reached a score of 6 in
the compliance measure, and eight studies used two different measures of compliance
simultaneously. The median values in the summary scores were: study design 8.3, disease
42.9, compliance issues 50. CONCLUSIONS: The quality of the compliance research was
generally poor. These low scores reflect very important shortcomings in the methodology,
such oversights make it difficult for the reader to critically assess the validity of the
Powell-Griner, E., Bolen, J., & Bland, S. (1999). Health
care coverage and use of preventive services among the near elderly in the United States.
AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 882-886.
The Journals Home Page is at:
THE AMERICAN JOURNAL OF PUBLIC HEALTH.
ABSTRACT: Objectives. It has been proposed that individuals aged 55 to
64 years be allowed to buy into Medicare. This group is more likely than younger adults to
have marginal health status, to be separating from the workforce, to face high premiums,
and to risk financial hardship from major medical illness. The present study examined
prevalence of health insurance coverage by demographic characteristics and examined bow
lack of insurance may affect use of preventive health services. Methods. Data were
obtained from the Behavioral Risk Factor Surveillance System, an ongoing telephone survey
of adults conducted by the 50 states and the District of Columbia. Results. Many
near-elderly adults least likely to have health care coverage were Black or Hispanic, had
less than a high school education and incomes less than $15 000 per year, and were
unemployed or self-employed. Health insurance coverage was associated with increased use
of clinical preventive services even when sex, race/ethnicity, marital status, and
educational level were controlled. Conclusions. Many near-elderly individuals without
insurance will probably not be able to participate in a Medicare buy-in unless it is
subsidized in some way.
Ratner, P., Johnson, J., Bottorf, J. (1999). Smoking cessation
in the clinical setting. Chap. 1 in Green, L.W., Frankish, C.J., McGowan, P.,
Ratner, P., Bottorff, J., Lovato, C.Y., Shoveller, J., Johnson, J., Williamson, D. (Eds.),
SMOKING CESSATION: A SYNTHESIS OF THE LITERATURE ON PROGRAM EFFECTIVENESS. Vancouver:
University of British Columbia Institute of Health Promotion Research, for the BC Ministry
Raube, K., & Merrell, K. (1999). Maternal
minimum-stay legislation: Cost and policy implications. AMERICAN JOURNAL OF
PUBLIC HEALTH 89 (6): 922-923.
A systematic review of the research literature on smoking cessation
effectiveness in clinical settings. http://www.commhealth.ihpr.ubc.ca/mohscr/Ch1clin.PDF.
ABSTRACT: Recently, most state legislatures and Congress have passed
laws mandating insurance coverage for a minimum period of inpatient care following
delivery. This study analyzed the likely cost implications of one state's law. To view the
complete abstract, go to:
The Journals Home Page is:
Riekert, K. A., & Drotar, D. (1999). Who participates
in research on adherence to treatment in insulin-dependent diabetes mellitus? Implications
and recommendations for research. JOURNAL OF PEDIATRIC PSYCHOLOGY 24 (3):
For this issue of the Journal, go to:
Rimer, B. K., Conaway, M., Lyna, P., Glassman, B., Yarnall, K. S.
H., Lipkus, I., & Barber, L. T. (1999). The impact of tailored interventions
on a community health center population. PATIENT EDUCATION AND COUNSELING 37 (2):
Rosenbach, M. L., & Gavin, N. I. (1998). Early and
periodic screening, diagnosis, and treatment and managed care. ANNUAL REVIEW OF
PUBLIC HEALTH 19: 507-525. For abstract, go to:
Rowland, D., Salganicoff, A., & Keenan, P. S. (1999). The
Key to the Door: Medicaid's Role in Improving Health Care for Women and Children. ANNUAL
REVIEW OF PUBLIC HEALTH 20: 403.
Ryan, A. A. (1999). Medication compliance and older people: a
review of the literature. INTERNATIONAL JOURNAL OF NURSING STUDIES 36 (2):
ABSTRACT: This critical review of the literature pertaining to
medication compliance among older people included (a) a critique of the more commonly
cited compliance theories, (b) an analysis of the key variables influencing medication
compliance among older people and (c) a critical evaluation of the literature that
examines these phenomena. Additional studies that explore the benefits of
Self-Administration of Medication Schemes are examined for their coverage of the
educational component as well as the behavioral component of a well-organized patient
education program. The review covers material published in English since 1980 excluding
literature on compliance theories that originated in previous decades. Search terms
included medication, compliance, older people, self-medication and education. The
literature was then critically reviewed using the criteria identified by Roe (1993) [Roe,
B., 1993. Undertaking a critical review of the literature. Nurse Researcher 1(1), 35-46.]
which emphasizes the need for clarity in key areas such as research design, sample
selection, research methods, results, discussion and conclusions. Empirical studies that
met these criteria were included in the review and in the main, were found in academic
rather than professional journals. The review concludes with a summary of the main points
and a discussion of the implications for nursing practice, education and research.
Schwartz, M.D., Rimer, B.K., Daly, M., Sands, C., & Lerman, C.
(1999). A randomized trial of breast cancer risk counseling: The impact on
self-reported mammography use. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 924-926.
The Journals Home Page is:
THE AMERICAN JOURNAL OF PUBLIC HEALTH.
ABSTRACT: Objectives. We evaluated the impact of individualized breast
cancer risk counseling on mammography use among women at risk for breast cancer. Methods.
Participants (n = 508) were randomized to the breast cancer risk counseling intervention
or a general health education control intervention, and 85% completed follow-up. Results.
in multivariate modeling, a significant group-by-education interaction demonstrated that
among less-educated participants, standardized breast cancer risk counseling led to
reduced mammography use. There was no intervention effect among the more-educated
participants. Conclusions. These results suggest that standard breast cancer risk
counseling could have an adverse impact on the health behaviors of less-educated women.
Shannon, W., Buller-Taylor, T., Green, L.W. (1999). BC Doctors
Stop Smoking Program: Results of the Spring 1998 retrospective evaluation. Chap.
7 in Green, L.W., Frankish, C.J., McGowan, P., Ratner, P., Bottorff, J., Lovato, C.Y.,
Shoveller, J., Johnson, J., Williamson, D. (Eds.), SMOKING CESSATION: A SYNTHESIS OF THE
LITERATURE ON PROGRAM EFFECTIVENESS. Vancouver: University of British Columbia Institute
of Health Promotion Research, for the BC Ministry of Health.
Shiboski, C.H., Palacio, H., Neuhaus, J.M., & Greenblatt,
R.M. (1999). Dental care access and use among HIV-infected women.
AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 834-839.
A systematic review of the research literature on smoking cessation
effectiveness of a program designed to instruct and support physicians in their efforts to
help their patients stop smoking. http://www.commhealth.ihpr.ubc.ca/mohscr/Ch7BCDoc.PDF
ABSTRACT: This study sought to identify predictors of dental care use
in HIV-infected women. For the complete abstract, go to:
The Journals Home Page is at:
SjÖstrom, M., Karlsson, A. B., Katti, G., Yngve, A., Green, L.
W., Bygren, L. O. (1999). A four week residential program for primary health care
patients to control obesity and related heart risk factors: Effective application of
principles of learning and lifestyle change. EUROPEAN JOURNAL OF CLINICAL
NUTRITION 53 (Suppl. 2): S72-S77.
ABSTRACT: Objective: To test the short and long-term effectiveness of a
four week residential program for primary health care patients to control obesity and
related risk factors for card-vascular disease (CVD), especially blood pressure (BP).
Design: Prospective clinical study, with follow up after 1 and 5 y. Setting: Vindeln
Patient Education Centre, Vindeln, and Department of Social Medicine, University of Umea,
Sweden. Subjects: Approximately 2500 individuals, with two or more of the traditional risk
factors for CVD, participated in the program. This report describes a subsample of 100
consecutive patients, 52+/-9 y, 53 men, with obesity and/or high BP. Intervention: Four
week residential program with lectures and group discussions as well as practical sessions
in smaller groups (meal preparations, physical exercise, etc). The patients were
followed-up medically in their home area. Outcome measures: Weight and blood pressure.
Results: Dramatic reductions of weight and, especially, of blood pressure (BP) occurred
during the residential weeks, and the reductions were pronounced also after 1 y. After 5
y, the total mean weight among men with initial BMI greater than or equal to 30 kg/m(2)
was still 5 kg lower, and diastolic and systolic BP among those with hypertension was 15
and 20 mm Hg lower, respectively, than before the program. Conclusions: The full-time
participation in the residential program and the enrollment and commitment of the patients
may explain the clinical outcome. A level of predisposition greater than that required of
most weight- and BP-control programs was confirmed and a great preventive or therapeutic
potential was indicated. The study illustrates an effective application of the
Precede-Proceed model of health promotion planning.
Stark, L. J. (1999). Commentary: beyond feeding problems:
the challenge of meeting dietary recommendations in the treatment of chronic diseases in
pediatrics. JOURNAL OF PEDIATRIC PSYCHOLOGY 24 (3): 221-222, June.
For this issue of the Journal, go to:
Svikis, D.S., Pickens, R.W., Schweitzer, W., Johnson, E., Haug,
N. (1999). Weekly patterns of drug treatment attendance. AMERICAN JOURNAL
OF PUBLIC HEALTH 89 (5): 752-755.
ABSTRACT: Objectives. This study examined weekly patterns of drug treatment
attendance in relation to date of welfare payment receipt and reason for treatment
absence. Methods. Treatment attendance by Medicaid-eligible pregnant women who were drug
dependent was examined by calendar week over a 29-month period. Results. Time series
analyses showed that attendance was lower during week 1 than week 4. Drug use was the most
frequently reported reason for treatment absence during week 1 (25%) but was not reported
as a reason during week 3. Conclusion. Drug-dependent out-patients had increased absences
associated with illicit drug use during the first week of the month when welfare payments
were received. The generalizability of the findings is unknown.
Sword, W. (1999). A socio-ecological approach to
understanding barriers to prenatal care for women of low income. JOURNAL OF
ADVANCED NURSING 29 (5): 1170-1177.
ABSTRACT: This paper critically examines the notion of barriers as
conceptualized in the literature and suggests an expanded orientation to more fully
appreciate its complexity. This alternative approach not only takes into account factors
and processes relevant to the individual that create constraints to utilization, but also
acknowledges influences on the design and delivery of health care. These latter
considerations determine the availability and characteristics of programmes and services
that may or may not encourage or enable participation by persons of law income. A
socio-ecological model is proposed that compels health care practitioners and researchers
to acknowledge the many influences on utilization behaviour. The literature on barriers to
prenatal care is subsequently reviewed and evaluated, with consideration given to the
range of behavioural determinants suggested by the model. Finally, a case is made for
qualitative methods for inquiry to further enhance knowledge about factors and processes
influencing use of the health care system, including prenatal care. It is argued that
these approaches lead to enhanced appreciation of behaviour as: a social product and are
consistent with the ideology of health promotion.
Ulmi, S., McGowan, P., Gray, D., & Savoy, D. (1999). Moving
beyond information: Evaluation of a nutrition education tool based on a theoretical model.
EUROPEAN JOURNAL OF CLINICAL NUTRITION 53 (Suppl. 2): S49-S53.
ABSTRACT: Objective: This study investigated the relative effectiveness
of a nutrition education brochure based on a theoretical model versus a more traditional
information-based brochure in getting subjects to accurately assess daily calcium intake,
make a plan to increase intake if needed, and to implement the plan. Design: A randomized
trial involving 216 women between the ages of 19-49y. Subjects were randomly assigned to a
group which received educational materials containing an interactive brochure designed
using the Motivation Generating model (Calcium Calculator(R)), or to a group which
received a calcium information brochure (An Appetite for Good Health). Within a two week
period the women were contacted by telephone to assess use of materials, calcium intake
assessment information, and plans for dietary change. Setting: Subjects were recruited at
five fitness centers in the Vancouver area. The research was conducted by the Institute of
Health Promotion Research at the University of British Columbia. Results: Results
indicated significantly greater numbers of subjects conducting self- assessment and
increased group accuracy for calcium intake assessment in subjects using the interactive
brochure. Conclusion: Use of a theoretical model designed to create behavior change such
as the Motivation Generating Model can increase specific behaviors which may lead to
improvements in dietary consumption.
Venturini, F., Nichol, M.B., Sung, J.C.Y., Bailey, K.L., Cody, M., &
McCombs, J.S. (1999). Compliance with sulfonylureas in a health maintenance
organization: A pharmacy record-based study. ANNALS OF PHARMACOTHERAPY 33 (3):
Williams, P.L., Innis, S.M., Vogel, A.M.P., & Stephen, L.J.
(1999). Factors influencing infant feeding practices of mothers in Vancouver.
CANADIAN JOURNAL OF PUBLIC HEALTH-REVUE CANADIENNE DE SANTE PUBLIQUE 90 (2): 114-119.
ABSTRACT: OBJECTIVE: To determine which factors affect compliance with
sulfonylureas in a population served by a health maintenance organization in Southern
California. METHODS: Retrospective analysis of pharmacy records and healthcare utilization
data for two years (April 1993-March 1995), and a sun;survey mailed to patients, Patients
treated with sulfonylureas were selected for analysis on the basis of their prescription
profile, Compliance was measured from the pharmacy records as the proportion of days the
patient was in possession of the prescribed medications, patient compliance with
sulfonylureas was modeled as a function of four clusters of determinants: patient-related
attributes, drug regimen characteristics and complexity, health status and disease-related
variables, and characteristics of the interaction with healthcare providers. RESULTS: 786
patients were identified for analysis (49.1% women, mean age 59 y). The mean compliance
rate was 83% +/- 22% SD. Compliance was significantly positively related with age and
self-reported level of medication-taking compliance at baseline. Factors shown to have an
inverse relationship with compliance were treatment complexity, perception of general
health, and being a newly treated patient (adjusted R-2 for the final model = 0.148).
CONCLUSIONS: Our results suggest that factors found to be associated with noncompliant
behavior (e.g,, being a newly treated patient, self-reported compliance, regimen
complexity) can be assessed by physicians and pharmacists as a routine practice.
ABSTRACT: This study describes factors influencing infant feeding
choices of 434 mothers with 9-month-old infants in Vancouver. Consistent with Social
Cognitive Theory, both internal personal and socio-environmental factors influence infant
feeding choices. Mothers attributed the choice to breastfeed primarily to personal choice,
whereas the choice to formula feed was attributed to socio-environmental factors. Among
mothers who breastfed <3 months, the choice to ean was primarily attributed to concern
for baby's nutrition; compared to returning to work, concern about milk supply and concern
for baby's nutrition among those who breastfed greater than or equal to 3 to <6 months;
and returning to work and personal choice among those who breastfed greater than or equal
to 6 months. Among Caucasian mothers, the choice to wean was primarily attributed to
returning to work, compared to concern for baby's nutrition among non-Caucasian mothers.
Initiatives to facilitate further advances in breastfeeding promotion could address three
areas; 1) prenatal intentions, 2) early postpartum concerns, and 3) later issues
surrounding returning to work and infant nutrition.
McCraig, L. F. (1999). National Hospital Ambulatory
Medical Care Survey: 1997 Outpatient Department Summary. Advance data from vital
and health statistics; no. 307. Hyattsville, MD: National Center for Health Statistics.
Describes ambulatory care visits to hospital outpatient departments in
the United States. Presents statistics on selected hospital, clinic, patient, and visit
Prenatal Discussion of HIV Testing and Maternal HIV Testing ---
14 States, 1996--1997. Morbidity and Mortality Weekly Reports 48(19), May 21,
In July 1995, the Public Health Service recommended that health-care
providers counsel all pregnant women about human immunodeficiency virus (HIV) prevention
and encourage testing for HIV infection (1) and, if indicated, initiate zidovudine therapy
(2). To evaluate compliance with these recommendations, CDC analyzed population-based data
on HIV counseling and testing during 1996-1997 from 14 states participating in the
Pregnancy Risk Assessment Monitoring System (PRAMS). This report presents an analysis of
survey data collected from 1996 through 1997; results indicate that HIV counseling and
testing of pregnant women were common but varied by state, type of prenatal health-care
provider, Medicaid status, and maternal demographic characteristics. References cited:
1. CDC. US Public Health Service recommendations for human immunodeficiency virus
counseling and voluntary testing for pregnant women. MMWR 1995;44(no. RR-7):1-14.
2. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of
human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med
Clinical Trials Posting, an Internet service providing information about national and
local clinical trials and support services. E.g., Asthma Research START (Inhaled Steroid
Treatment as Regular Therapy in Early Asthma) clinical trial was posted at this site.
Wired health http://www.hc-sc.gc.ca/hppb/wired/
"Remembering the Victims of AIDS" is the first installment in HealthPromotion
Online's new monthly magazine, Wired Health. Every month, new articles will feature
different programs and events about health promotion. If you have any questions or
comments, or you would like to contribute a story idea, contact the editor.
Web sites on smoking cessation:
Action on Smoking & Health
The American Cancer Society
American Heart Association
American Lung Association
Americans for Nonsmokers Rights
Arizona Tobacco Education & Prevention Program
Breed's Tobacco Activism Guide (annotated links)
Campaign for Tobacco Free Kids
Centers for Disease Control & Prevention
Cable News Network (CNN) - Tobacco
Environmental Protection Agency (EPA)
Florida Tobacco Education Resources
Food and Drug Administration
Friends of Tobacco
International Union Against Cancer - Globalink
House Committee on Commerce
Investor Responsibility Research Center
Maryland Dept of Health
Mass. Tobacco Control Program
Minnesota Attorney General - Tobacco Trial
Minnesota Blue Cross - Tobacco Trial
Reuters News Service
Save Lives, Not Tobacco
Smokescreen Action Network
State Tobacco Information Center (STIC)
Tobacco BBS (extensive links)
Tobacco Control Resource Center
Tobacco Control Supersite (links by topic)
Tobacco Resolution (tobacco industry documents)
Univ Calif SF - Tob Archives
USA Today - Tobacco
Washington Doctors Ought to Care (DOC)
World Health Organization
Interactive web site
Interactive kiosk-based smoking cessation program in English and Spanish. Tailors
itself to the user on many characteristics (incl. gender, race/ethnicity, and age). You
can see a glimpse at
Kick the Smoking Habit -
- This publication is part of a set of booklets that present key steps that Latinos can
take to reduce their chances of having a heart attack or stroke. Written in a friendly
English/Spanish side-by-side style, the booklets present facts and dispel myths. The set
includes the following titles: Take Steps--Prevent High Blood Pressure; Cut Down on Salt
and Sodium; Learn Your Cholesterol Number; Protect Your Heart--Lower Your Blood
Cholesterol; Watch Your Weight; Cut Down on Fat--Not on Taste; Stay Active and Feel
Better; Kick the Smoking Habit.
The US DHHS Agency for Health Care Policy and Research has Clinical Practice Guidelines
for smoking cessation.