Patient Education and Counseling - Articles in Press

Outcome of parent–physician communication skills training for pediatric residents - Corrected Proof

2010-02-08

Abstract: Objective: Communication skills represent an essential component of clinical competence. In the field of pediatrics, communication between physicians and patients’ parents is characterized by particular difficulties. To investigate the effects of a parent–physician communication skills training program on OSCE performance and self-efficacy in a group control design.Methods: Parallel to their daily work in the outpatient department, intervention-group experienced clinicians in practice (n=14) participated in a communication training with standardized parents. Control-group physicians (n=14) did not receive any training beyond their daily work. Performance was assessed by independent video ratings of an OSCE. Both groups rated their self-efficacy prior to and following training.Results: Regarding OSCE performance, the intervention group demonstrated superior skills in building relationships with parents (p<.024) and tended to perform better in exploring parents’ problems (p<.081). The communication training program led to significant improvement in self-efficacy with respect to the specific training objectives in the intervention group (p<.046).Conclusion: Even in physicians with considerable experience, structured communication training with standardized parents leads to significant improvement in OSCE performance and self-efficacy.Practise implications: Briefness and tight structure make the presented communication training program applicable even for experienced physicians in daily clinical practice.

The physical examination in telecardiology and televascular consultations: A study using conversation analysis - Corrected Proof

Yannis Pappas, Clive Seale — 2010-02-08

Abstract: Objective: This paper describes communication in the physical examination phases of telemedicine consultations.Methods: Using the method of conversation analysis, we draw on 10 telemedicine consultations (five telecardiology and five televascular) between primary and tertiary care in the UK.Results: Physical examination is absent in telecardiology consultations. In televascular consultations the professionals try to compensate for the lack of physical proximity by getting involved in a form of collaboration that constitutes a novel environment for all. Separated from the patient by physical space, the specialist orchestrates the positioning of the patient, the camera and the primary care nurse's activity via the use of a video-link.Conclusion: Telemedicine offers primary care nurses a unique opportunity to engage in active collaboration with hospital specialists. The nurses’ examination skills are recruited because physical examination is conducted from distance and the specialist cannot touch the patient or see parts of the body with ease. We speculate that difficulties with the physical examination may have contributed to the relatively slow adoption of telemedicine.Practice implications: The analysis reveals some new communication practices that participants in telemedicine are called to adopt. This can be used to inform training interventions that focus both on patient and professional.

Coping with infertility online: An examination of self-help mechanisms in an online infertility support group - Corrected Proof

Sumaira H. Malik, Neil S. Coulson — 2010-02-08

Abstract: Objective: To examine communication within an online infertility support group.Methods: A content analysis of 3500 messages posted to infertility bulletin boards.Results: The most frequently used self-help mechanisms were support or empathy (45.5%) and sharing personal experiences (45.4%), followed by the provision of information and advice (15.9%), gratitude (12.5%), friendship (9.9%), chit-chat (9.4%), requests for information or advice (6.8%) and universality (4.8%), with negative statements (0.3%) and creative expressions (0.2%) being the least frequent categories.Conclusion: These findings suggest that online support groups can provide a viable alternative source of support for couples dealing with infertility.Practice implications: Health care professionals interested in developing online support interventions should look to tailor support resources to the specific needs of patients at different stages of the infertility journey.

Did I really want to know this? Pregnant women's reaction to detection of a soft marker during ultrasound screening - Corrected Proof

Annika Åhman, Karin Runestam, Anna Sarkadi — 2010-01-18

Abstract: Objective: To investigate women's expectations of routine ultrasound and experiences when soft markers were discovered: what the disclosure meant, how it affected them, how they experienced the information given and why they did or did not choose amniocentesis.Design: Semi-structured, in-depth interviews were conducted with 11 women 25–30 weeks into the pregnancy, 7–13 weeks after the discovery of a soft marker.Findings: Women lacked knowledge about the potential of the scan and detection of soft markers created strong emotional reactions that women thought could have been alleviated by prior information about potential findings. Information in connection with the scan was perceived as insufficient. Decision about amniocentesis was affected by attitudes to disability, anxiety about fetal loss due to the procedure, need for certainty by a diagnostic test, and partner's opinion.Conclusions: Women were shocked by the unexpected and sometimes unwanted information on elevated risk for a chromosomal aberration for which they lacked any preparation. Because this event often has long-lasting effects on the pregnancy, models of information that are efficient in promoting informed decisions are imperative.Practice implications: Both women and their partners need relevant information before and in connection with ultrasound scan to be able to make informed choices.

Telephone nurse counseling for medication adherence in ulcerative colitis: A preliminary study - Corrected Proof

Paul F. Cook, Suzie Emiliozzi, Dana El-Hajj, Mishcha M. McCabe — 2010-01-15

Abstract: Objective: Adherence is challenging in episodic chronic conditions that require medication during both symptomatic and quiescent periods, such as ulcerative colitis (UC). Adherence for these conditions is under-studied. This study was a preliminary test of telephone nurse counseling to address cognitive and emotional barriers to adherence in UC.Methods: 524 people taking mesalamine for UC were referred by their health care providers, and 278 (53%) enrolled. There were no demographic differences between program participants and nonparticipants. Participants reported multiple comorbidities and concomitant medications. All participants received telephone follow-up (M=2.1 calls) from a registered nurse who used cognitive-behavioral and motivational interviewing counseling techniques. Adherence measured by structured interview was compared to a population baseline using a binomial test.Results: Attrition was 51% over 6 months but was unrelated to adherence. Participants had better adherence than the expected population rate, with a significant dose–response effect. Reasons for nonadherence were primarily psychological or efficacy-related.Conclusion: Adherence following intervention was better than typical mesalamine adherence. Self-efficacy predicted adherence, but demographic and clinical variables did not. Adherent participants reported more adverse events.Practice implications: Attention to patients’ cognitive and emotional reactions may help to improve adherence in episodic chronic diseases such as UC.

Promoting engagement with a Stop Smoking Service via pro-active telephone calls - Corrected Proof

A. McEwen, L. Condliffe, A. Gilbert — 2010-01-14

Abstract: Objectives: What proportion of smokers in a deprived area of London, contacted by telephone, are interested in quitting and accept a referral for cessation support?Methods: Current smokers from records of general practitioners (GPs) were telephoned; if interested in quitting they were offered a referral to the local Stop Smoking Service (SSS) and smoking status was assessed after 6 months.Results: Over half of current smokers (53%) were interested in receiving help to stop and 39% accepted a referral to the SSS. Six months later 21% of those contacted reported not smoking. Over one-quarter (28%) of those referred set a quit date with the service and 39% of these were recorded as abstinent four weeks after their quit date.Conclusion: Calling smokers from GP lists appears to offer promise as a means of prompting quit attempts and ensuring that the chances of these quit attempts succeeding are maximized through attendance at NHS SSS.Practice implications: GP records need to be accurate and maintained. Smoking patients can be contacted by telephone, informed about the availability of local cessation services and referred directly.

Being a patient in your own department - Corrected Proof

Jette Ammentorp, Poul-Erik Kofoed — 2010-01-14

“I had just arrived at my job when my wife phoned. Our teenage daughter had been admitted to the hospital due to severe stomach pain. My wife seemed very upset and asked me to come to the hospital immediately. It was extremely inconvenient, but of course I cancelled all my appointments and drove as quickly as possible to the hospital.

Averting adverse events in communication skills training: A case series - Corrected Proof

Tomer Levin, Jennifer Horner, Carma Bylund, David Kissane — 2010-01-14

Abstract: Objective: To document cases of adverse or near adverse events in communication skills training (CST) and to identify risk factors and strategies to reduce the likelihood of their occurrence.Methods: Six physician CST cases meeting criteria for an adverse or near adverse collected from experienced facilitators are analyzed and discussed.Results: Three types of adverse CST events are described: traumatic personal experiences or losses evoked by training; perception that feedback is not empathic; and where trainees are referred for remedial CST as a risk management strategy.Conclusion: Early identification of risk factors and emotional cues of trainees is a key first step that facilitates implementation of remedial strategies to avert potential adverse events. Consideration of ways that physicians’ personal experiences impact communication and good feedback techniques are vital. The implications of physicians sent to CST for risk management purposes is a new scenario that deserves special consideration.Practice implications: To make CST safer and to optimize learning, early recognition of potential adverse events is essential. Specific feedback techniques should be mastered by all CST facilitators.

Somali prenatal education video use in a United States obstetric clinic: A formative evaluation of acceptability - Corrected Proof

Christopher C. DeStephano, Priscilla M. Flynn, Brian C. Brost — 2010-01-13

Abstract: Objective: Because of low health literacy and low priority in seeking prenatal information, health education videos were explored for acceptability by Somali refugee women in a clinical setting.Methods: Focus groups led to the development of six targeted Somali prenatal education videos. Topics include: preparation for pregnancy, nutrition and exercise, pregnancy myths/facts, the father's role, episiotomies, and caesarean sections. Somali participants were recruited to view programs, and completed an 8-item survey prior to regularly scheduled prenatal appointments. Following the clinical visit, providers completed a 4-item survey indicating the video's helpfulness in facilitating client–provider communication.Results: All study participants “strongly recommended” and rated the videos as “appropriate for Somali clients”, 57% indicated the information was “just the right amount,” and 60% found the videos “extremely helpful.” The primary language spoken at home was Somali (72.7%) and 54.5% indicated Somali as the preferred language to receive health information. Providers indicated 24% of appointments were “more interactive” with 72% finding videos “somewhat” or “extremely helpful.”Conclusion: Preliminary results from this pilot study suggest that a video format for prenatal education is acceptable to Somali clients with most clients preferring video health education materials presented in the Somali language.Practice implications: Culturally tailored health education video series for Somali women appear well for use in a clinic setting to facilitate client–provider communication.

Conceptualizing couples’ decision making in PGD: Emerging cognitive, emotional, and moral dimensions - Corrected Proof

Patricia E. Hershberger, Penny F. Pierce — 2010-01-11

Abstract: Objective: To illuminate and synthesize what is known about the underlying decision making processes surrounding couples’ preimplantation genetic diagnosis (PGD) use or disuse and to formulate an initial conceptual framework that can guide future research and practice.Methods: This systematic review targeted empirical studies published in English from 1990 to 2008 that examined the decision making process of couples or individual partners that had used, were eligible for, or had contemplated PGD. Sixteen studies met the eligibility requirements. To provide a more comprehensive review, empirical studies that examined healthcare professionals’ perceptions of couples’ decision making surrounding PGD use and key publications from a variety of disciplines supplemented the analysis.Results: The conceptual framework formulated from the review demonstrates that couples’ PGD decision making is composed of three iterative and dynamic dimensions: cognitive appraisals, emotional responses, and moral judgments.Conclusion: Couples think critically about uncertain and probabilistic information, grapple with conflicting emotions, and incorporate moral perspectives into their decision making about whether or not to use PGD.Practice implications: The quality of care and decisional support for couples who are contemplating PGD use can be improved by incorporating focused questions and discussion from each of the dimensions into counseling sessions.

Using the word ‘cancer’ in communication about an abnormal Pap test: Finding common ground with patient–provider communication - Corrected Proof

2010-01-08

Abstract: Objective: To investigate provider and patient views about communication regarding cervical cancer screening follow-up.Methods: Using qualitative analysis, we interviewed 20 providers and 10 patients from two urban clinics that serve low-income African American and Hispanic women. Semi-structured interviews and focus groups assessed familiarity with National Cancer Institute's Cancer Information Service (CIS) and reactions to a letter asking women with abnormal Pap test to telephone CIS. The letter suggested questions to ask prior to receiving follow-up.Results: No patient or provider was familiar with CIS. Providers but not patients expressed discomfort with use of the word ‘cancer’ in the letter and in CIS's name. Providers feared that reference to cancer would provoke fatalism and impede timely follow-up, whereas patients felt information about cancer risk was needed to prompt timely follow-up. Information providers found necessary to convey in order to accurately explain abnormal Pap tests surpassed patients’ literacy levels.Conclusion: Qualitative data suggest important gaps in perspective between providers and patients. There is a need to bridge the gap and overcome communication challenges to promote timely medical follow-up and have better health outcomes.Practice implications: Implications and strategies for improving patient–provider education and communication about abnormal Pap test are discussed.

The role of helplessness, outcome expectation for exercise and literacy in predicting disability and symptoms in older adults with arthritis - Corrected Proof

2010-01-08

Abstract: Objective: To examine the effect of outcome expectation for exercise (OEE), helplessness, and literacy on arthritis outcomes in 2 community-based lifestyle randomized controlled trials (RCTs) conducted in urban and rural communities with older adults with arthritis.Methods: Data from 391 participants in 2 RCTs were combined to examine associations of 2 psychosocial variables: helplessness and OEE, and literacy with arthritis outcomes. Arthritis outcomes namely, the Health Assessment Questionnaire-Disability Index (HAQ-DI) and arthritis symptoms pain, fatigue and stiffness Visual Analogue Scales (VAS), were measured at baseline and at the end of the interventions. Complete baseline and post-intervention data were analyzed using STATA version 9.Results: Disability after intervention was not predicted by helplessness, literacy, or OEE in the adjusted model. Arthritis symptoms after the intervention were all significantly predicted by helplessness at various magnitudes in adjusted models, but OEE and literacy were not significant predictors.Conclusion: When literacy, helplessness, and OEE were examined as predictors of arthritis outcomes in intervention trials, they did not predict disability. However, helplessness predicted symptoms of pain, fatigue, and stiffness, but literacy did not predict symptoms.Practice implications: Future sustainable interventions may include self-management components that address decreasing helplessness to improve arthritis outcomes.

Who's in charge? The role of responsibility attribution in self-management among people with chronic illness - Corrected Proof

Åsa Audulv, Kenneth Asplund, Karl-Gustaf Norbergh — 2010-01-08

Abstract: Objective: To explore how responsibility attribution influences self-management regimens among people with chronic illness.Methods: This qualitative content analysis included 26 interviews with people living with chronic illness.Results: The participants attributed responsibility to internal, external or a combination of these factors, meaning that they either assumed responsibility for self-management or considered other people or factors responsible. Internal responsibility was associated with a multifaceted self-management regimen, whereas external responsibility was related to “conventional” self-management such as taking medication, managing symptoms and lifestyle changes.Conclusion: How responsibility is attributed is vital for the way in which individuals perform self-management. In this study, those who attributed responsibility to external factors mainly performed recommended behaviours to control their illness. In contrast, to take charge of their illness and be an active participant in the care, individuals must take responsibility for themselves, i.e. internal responsibility.Practice implications: Health-care providers should acknowledge and support individuals’ wishes about various levels of responsibility as well as different kinds of patient–provider relationships.

Begin the BEGAN (The Brown Educational Guide to the Analysis of Narrative) – A framework for enhancing educational impact of faculty feedback to students’ reflective writing - Corrected Proof

Shmuel P. Reis, Hedy S. Wald, Alicia D. Monroe, Jeffrey M. Borkan — 2010-01-07

Abstract: Objective: The study aim was the development of a method to further enhance the educational benefit of medical students’ reflective writing. The setting is a Doctoring course at the Warren Alpert Medical School of Brown University, which includes reflective writing assignments, termed “field notes”, combining students’ reflective writing with ongoing individualized feedback from small group faculty.Methods: Three-year (2005–2008) iterative process with three stages of immersion, analysis, and revision that resulted in the analysis framework. An interdisciplinary team composed of the four authors with backgrounds in narrative medicine, qualitative research, psychology, and medical education analyzed 12 first and second year students’ selected field notes in iterative cycles. In each cycle, consultations with small group faculty and content experts were conducted to further validate the emergent framework.Results: This process culminated in the creation of the Brown Educational Guide to Analysis of Narrative (BEGAN) framework, a guide for crafting feedback to students’ reflective writing, and the integration of the BEGAN framework into the faculty and student manuals for the Doctoring Course in 2008–2009.Conclusions: We propose the BEGAN framework as a useful innovative tool that can be incorporated in reflective writing curricula in the field of health professions education. It is tailored to support the educational impact of the course through additional scaffolding of student writing, and the robust process it delineates for crafting of faculty feedback.Providing systematic feedback to enhance reflective writing may represent the path forward in fostering professional development through reflection in health professions education.Practice implications: The BEGAN can be incorporated in reflective writing curricula in the field of health professions education. It is a springboard for the necessary next steps of development and research into the acquisition of reflective and narrative competence in the emerging professional.

Everything you always wanted to know about HPV (but could not ask your doctor) - Corrected Proof

2010-01-07

Abstract: Objective To investigate specific information needs of people who search for information about the human papillomavirus (HPV) on the Internet.Methods We performed a qualitative analysis of the e-mail questions asked by the visitors of a website with evidence-based information about HPV. The website, hosted by Antwerp University, provided basic information on epidemiology and natural history of HPV in women and men, diagnostic and treatment options, screening, and vaccination. If visitors did not find an answer to their questions, they could mail their question to an e-mail address associated with the website.Results We received 713 questions posed by 527 e-mail correspondents. The following themes emerged as most important: transmission of HPV, the HPV vaccine, the natural history of the virus, the vicious circle (re-infection between partners), HPV detection in men and women, treatment of men and women, incubation time, pregnancy/fertility, genital warts (in)fidelity, and symptoms of HPV infection.Conclusion Both men and women are seeking health information on HPV on the Internet, often after being counseled by a health care provider.Practice implications Practitioners should be prepared for questions on the themes that concern people most. Practitioners may play a role in guidance towards reliable sources of information.

Can interactive skills-based seminars with standardized patients enhance clinicians’ prevention skills? Measuring the impact of a CME program - Corrected Proof

2010-01-06

Abstract: Objective: Communication skills are crucial for high-risk behavior screening and counseling. Practicing physicians have limited opportunities to improve these skills. This paper assesses the impact of a continuing medical education (CME) program for Student Health Center clinicians that targeted communication skills, screening practices and patient satisfaction.Methods: Program evaluation included pre- and post-objective structured clinical examinations (OSCE's), chart review, and provider and patient satisfaction surveys. Data were analyzed using paired t-tests and ranked sum tests.Results: OSCE scores (n=15) revealed significant improvements in communication skills overall (p=0.004) and within specific domains (data gathering: p=0.003; rapport building: p=0.01; patient education: p=0.02), but no change in case-specific knowledge (p=0.1). Participants (n=14) reported high satisfaction with program methods (mean=4.6/5) and content (mean=4.7/5), 70% planning to alter their clinical practice. Chart audits (pre=96, post=103) showed increased screening for smoking (RR 1.65, p=0.03), depressed mood (RR 1.40, p=0.04), anhedonia (RR 1.47, p=0.01), sexual activity (RR 1.73, p=0.002) and drinking (RR 1.77, p=0.04). Sampling of satisfaction among participants’ patients (pre n=689, post n=383) detected no increase in already high baseline satisfaction.Conclusion: This curriculum improved clinicians’ relevant skills and screening behavior.Practice implications: Skills-oriented CME can improve clinicians’ communication skills and screening and counseling practices.

The narrative-autobiographical approach in the group education of adolescents with diabetes: A qualitative research on its effects - Corrected Proof

2010-01-04

Abstract: Objective: To introduce a narrative-autobiographical approach in the care and education of adolescents with type-1 diabetes and observe the effects of this novel approach on adolescents’ self-awareness, concern for self-care, and well-being.Methods: Ninety-four adolescents with type-1 diabetes attending one 9-day summer camp in 2004, 2005, or 2006 participated in structured daily self-writing proposals on diabetes, integrated with daily interactive self-management education. After some months, we sent participants interview-like questionnaires, and two independent researchers performed a qualitative analysis of the 50 answers that were mailed back.Results: Writing about the discovery of diabetes was, for many, a stressful experience, but with a strong liberating effect. One relevant point was change, which occurred: (a) in the perception of self; (b) in the relationship with others; (c) in the relationship with the disease.Conclusions: The integration of autobiography in diabetes camps, by adding the value of sharing individual stories to the liberating power of self-writing, can allow the adolescents to overcome their feelings of diversity, and can initiate several changes reflecting increased self-efficacy, maturity, acceptance of the disease and responsibility in self-management.Practice implications: Self-writing is feasible and well accepted, and provides healthcare professionals a proper way to patient-centered care.

The role of HIV nursing consultants in the care of HIV-infected patients in Dutch hospital outpatient clinics - Corrected Proof

2010-01-04

Abstract: Objective: In the Netherlands HIV nursing consultants have participated in HIV-care since 1985; their profession has changed with developments in HIV-treatment over time. The study goal was to gather information about their role in HIV-care and to provide an useful example to other (HIV-)care settings over the world.Methods: Interviews were held with HIV nursing consultants from all AIDS treatment centres. Descriptive analyses and statistical tests to detect differences between centres categorized by care model (parallel/unstructured/alternating), were performed.Results: 58% centres perform substitution of care. HIV nursing consultants see almost all patients at least once a year and see all patients when treatment is started/altered. The frequency of consultations for HIV-patients in stable condition varies, 2–4 times a year. Substitution leads to a slight, non-significant decrease in number of consultations. Adherence support is provided at the start of and during treatment. Regular patient discussions are common. All respondents are acquainted with the guidelines. Detailed knowledge of the adherence issues is limited: 58.3% had read the adherence chapter.Conclusion: Substitution of care model is an appropriate and effective method for the management of HIV-infected patients.Practice implications: Further development of and research into this new role of HIV nurse consultants is appropriate.

The effect of conflicting medication information and physician support on medication adherence for chronically ill patients - Corrected Proof

2009-12-31

Abstract: Objective: This article explores the effect of conflicting information, defined as contradictory information about medication topics from different sources, on medication adherence in a sample of chronically ill patients. We specifically investigate whether conflicting information and physician support directly affect medication adherence or whether the effect is mediated by adherence self-efficacy and outcome expectations for medications.Methods: Vasculitis patients (n=228) completed two on-line questionnaires which contained measures of conflicting information, adherence self-efficacy, outcome expectations, physician support, and medication adherence. We conducted a mediation analysis using a bootstrapping approach to generate point estimates and 95% confidence intervals to test the significance of each mediated effect.Results: A majority of patients (51.3%) received conflicting medication information. Conflicting information had a direct negative effect on medication adherence, which was not mediated by self-efficacy or outcome expectations. Alternatively, self-efficacy mediated the positive effect of physician support on medication adherence.Conclusion: Patients who encounter conflicting medication information are less adherent to their medications. The presence of a supportive physician may counteract the negative effect of conflicting medication information.Practice implications: Physicians should initiate conversations about conflicting medication information with their patients. Consensus-based guidelines that address medication discrepancies may also reduce the availability of conflicting information.

Evaluating the implementation of peer counseling in a church-based dietary intervention for African Americans - Corrected Proof

2009-12-31

Abstract: Objective: Body & Soul, an evidence-based nutrition program for African Americans churches, is currently being disseminated nationally and free of charge by the National Cancer Institute. For dissemination feasibility, the peer counseling training is done via DVD rather than by live trainers. We describe implementation and process evaluation of the peer counseling component under real world conditions.Methods: The study sample included 11 churches (6 early intervention, 5 delayed intervention) in 6 states. Data sources included training observations, post-training debriefing sessions, coordinator interviews, and church participant surveys. Survey data analysis examined associations between exposure to peer counseling and change in dietary intake. Qualitative data were analyzed using the constant comparative method.Results: Eight of 11 churches initiated the peer counseling program. Recall of talking with a peer counselor was associated with significantly (p<.02) greater fruit and vegetable intake. Data indicate sub-optimal program execution after peer counselor training.Conclusion: Inconsistent implementation of the peer counseling intervention is likely to dilute program effectiveness in changing nutrition behaviors.Practice implications: Disseminating evidence-based programs may require added resources, training, quality control, and technical assistance for improving program uptake. Similar to earlier research phases, systematic efforts at the dissemination phase are needed for program success.

Development and validation of a low-literacy Chronic Obstructive Pulmonary Disease knowledge Questionnaire (COPD-Q) - Corrected Proof

2009-12-31

Abstract: Objective: The objective of this study was to develop a content valid, understandable, readable, and reliable Chronic Obstructive Pulmonary Disease knowledge Questionnaire (COPD-Q).Methods: Twenty-one questions were generated as potential items to include in the COPD-Q. Twenty-two content experts provided both qualitative and quantitative assessments of two COPD-Q drafts. Ten patient volunteers completed a field test to assess clarity of individual COPD-Q items. An additional 24 patient volunteers completed a pilot test to determine internal consistency and test–retest reliability of the COPD-Q. The Flesch Reading Ease (FRE) was used to assess reading grade level of the COPD-Q.Results: Thirteen items were rated as “essential” (content validity ratio=p<0.05) by content experts and composed the final COPD-Q. Internal consistency, using Cronbach's alpha, was 0.72. Test–retest reliability, using intraclass correlation coefficient, was 0.90. The FRE score of the COPD-Q was 74.7 (equivalent to a 5th grade reading level).Conclusion: The COPD-Q is a valid, readable and reliable knowledge assessment instrument for assessing COPD knowledge in patients who may have low health literacy skills.Practice implications: Health care providers can use the COPD-Q to tailor counseling efforts according to individual patient needs, and to assess the effectiveness of their educational interventions.

Do people with diabetes understand their clinical marker of long-term glycemic control (HbA1c levels) and does this predict diabetes self-care behaviours and HbA1c? - Corrected Proof

Emma Beard, Marie Clark, Steve Hurel, Debbie Cooke — 2009-12-25

Abstract: Objective: Research demonstrates that patients have a poor understanding of glycosylated haemoglobin A1c (HbA1c) and that this impacts on effective diabetes self-management. This study attempted to replicate these findings in a UK outpatient sample of people with diabetes.Method: 83 participants were recruited and asked to fill in a questionnaire assessing their understanding of HbA1c, diabetes self-care behaviours and diabetes-specific self-efficacy in relation to carrying out these self-care behaviours.Results: Only 26.5% of the participants were classified as having a good understanding of HbA1c. Correlational and univariate analyses indicated that this level of understanding was related to demographic variables, HbA1c levels and certain aspects of self-care and self-efficacy. A series of multiple regressions found that understanding was a significant predictor of HbA1c levels.Conclusion: The majority of participants seemed to have a poor understanding of HbA1c and this was related to aspects of their diabetes management, self-efficacy and HbA1c levels.Practical implications: These findings provide support for the application of programmes and initiatives aimed at improving patients understanding of clinical disease markers.

The role of counseling for obstetric fistula patients: Lessons learned from Eritrea - Corrected Proof

2009-12-25

Abstract: Objective: The goal of this study was to evaluate the first formal counseling program for obstetric fistula patients in Eritrea.Methods: To evaluate the impact of the counseling program, clients were interviewed both before pre-operative counseling and again after post-operative counseling. A questionnaire was used in the interviews to assess women's knowledge about fistula, self-esteem, and their behavioral intentions for health maintenance and social reintegration following surgical repair. In addition, two focus groups were conducted with a total of 19 clients assessing their experiences with the surgical care and counseling.Results: Data from the questionnaires revealed significant improvements in women's knowledge about fistula, self-esteem, and behavioral intentions following counseling. Focus group data also supported increased knowledge and self-esteem.Conclusion: Evaluation of the short-term impact of an initial formal counseling program for fistula patients in sub-Saharan Africa affirmed the positive effects that such a program has for fistula patients, with increased knowledge about the causes of fistula, fistula prevention and enhanced self-esteem.Practical implications: Culturally appropriate counseling can be incorporated into services for surgical repair of obstetric fistula in low-resource settings and has the potential to improve the physical and mental well-being of women undergoing fistula repair.

Impact of a brief intervention on patient communication and barriers to pain management: Results from a randomized controlled trial - Corrected Proof

Meredith Y. Smith, Katherine N. DuHamel, Jennifer Egert, Gary Winkel — 2009-12-25

Abstract: Objective: This study examined the impact of a brief pain communication/education intervention on patient outcomes in breast cancer. We hypothesized that our intervention would improve patient communication and reduce misconceptions (“Barriers”) concerning pain management, and that patients with lower Barriers, or who perceived their physician as being more facilitative and receptive, would report better outcomes.Methods: Female breast cancer patients with persistent pain (n=89) were randomly assigned to either a 30-min in-person pain education/communication intervention or control condition and followed for 12 weeks.Results: Intervention group patients reported a significant decrease in pain Barriers but not in other outcomes. Overall, patients with lower barrier scores reported less distress and better emotional well-being. Patients who scored higher in active communication (e.g., asking questions, giving information) reported fewer Barriers and better pain relief. Individuals who perceived their physicians as being more receptive reported better pain management while those who perceived their physicians as being both more receptive and facilitative were more satisfied with their health care.Conclusion: A brief education/communication intervention reduced patients’ Barriers to pain management but did not impact other patient outcomes.Practical Implications: Pain outcomes may be improved by addressing patients’ pain misconceptions and emphasizing a receptive and responsive communication style.

Randomised controlled trial of a pedometer-based telephone intervention to increase physical activity among cardiac patients not attending cardiac rehabilitation - Corrected Proof

Susan Furber, Lyra Butler, Philayrath Phongsavan, Andrew Mark, Adrian Bauman — 2009-12-18

Abstract: Objective: To determine the effectiveness of a pedometer-based telephone intervention on the physical activity levels of cardiac patients who did not attend a CRP.Methods: A randomised controlled trial was conducted with 215 patients referred to a CRP but who could not or chose not to attend. The 6-week intervention included self-monitoring of physical activity using a pedometer and step calendar; and behavioural counselling and goal setting sessions. Data were collected at baseline, 6 weeks and 6 months.Results: Study groups did not differ significantly at baseline. After 6 weeks, improvements in total physical activity time (p=0.027), total physical activity sessions (p=0.003), walking time (p=0.013) and walking sessions (p=0.002) in the intervention group were significantly greater than the control group after adjusting for baseline differences, and remained significant at 6 months.Conclusion: The findings that the pedometer-based telephone intervention was successful in increasing physical activity levels in cardiac patients who did not attend a CRP could result in major health benefits for this group of people.Practical implications: The pedometer-based telephone intervention could be offered as an effective and accessible option for patients not attending a CRP to increase and maintain their physical activity levels after hospitalisation.

Patients’ experiences with navigation for cancer care - Corrected Proof

2009-12-14

Abstract: Objective: We examined how navigation, defined as the assessment and alleviation of barriers to adequate health care, influences patients’ perspectives on the quality of their cancer care.Methods: We conducted post-study patient interviews from a randomized controlled trial (usual care vs. patient navigation services) from cancer diagnosis through treatment completion. Patients were recruited from 11 primary care, hospital and community oncology practices in New York. We interviewed patients about their expectations and experience of patient navigation or, for non-navigated patients, other sources of assistance.Results: Thirty-five patients newly diagnosed with breast or colorectal cancer. Valued aspects of navigation included emotional support, assistance with information needs and problem-solving, and logistical coordination of cancer care. Unmet cancer care needs expressed by patients randomized to usual care consisted of lack of assistance or support with childcare, household responsibilities, coordination of care, and emotional support.Conclusion: Cancer patients value navigation. Instrumental benefits were the most important expectations for navigation from navigated and non-navigated patients. Navigated patients received emotional support and assistance with information needs, problem-solving, and logistical aspects of cancer care coordination.Practice implications: Navigation services may help improve cancer care outcomes important to patients by addressing fragmented, confusing, uncoordinated, or inefficient care.

Themes affecting health-care consumers’ choice of a hospital for elective surgery when receiving web-based comparative consumer information - Corrected Proof

Albine Moser, Irene Korstjens, Trudy van der Weijden, Huibert Tange — 2009-12-14

Abstract: Objective: To get insights into the decision-making strategy of health-care consumers when confronted with comparative consumer information.Methods: Qualitative descriptive study among 18 consumers who had a hip or knee replacement no longer than five years ago. To study their decision-making strategies a paper draft for a website was used providing comparative consumer information. Data were collected by cognitive interviews and focus-group meetings and subjected to thematic analysis.Results: Consumers were able to understand the presented information, but had problems to use it as a decision aid. They primarily relied on previous experiences. Four themes were revealed: decision making, perceived benefits, unmet information needs, and trustworthiness. Consumers used different decision strategies and showed unpredictable behavior when choosing a hospital.Conclusion: Individual decision strategies, unsatisfied information needs, limited tenability and too coarse aggregation levels of quality scores are barriers for a proper use of comparative consumer information. Personal experience remains a valuable information source for hospital selection. We suggest that a website presenting comparative consumer information should be flexible in various ways and should include functionality to share personal experience.

What constitutes evidence-based patient information? Overview of discussed criteria - Corrected Proof

Martina Bunge, Ingrid Mühlhauser, Anke Steckelberg — 2009-12-14

Abstract: Objective: To survey quality criteria for evidence-based patient information (EBPI) and to compile the evidence for the identified criteria.Methods: Databases PubMed, Cochrane Library, PsycINFO, PSYNDEX and Education Research Information Center (ERIC) were searched to update the pool of criteria for EBPI. A subsequent search aimed to identify evidence for each criterion. Only studies on health issues with cognitive outcome measures were included. Evidence for each criterion is presented using descriptive methods.Results: 3 systematic reviews, 24 randomized-controlled studies and 1 non-systematic review were included. Presentation of numerical data, verbal presentation of risks and diagrams, graphics and charts are based on good evidence. Content of information and meta-information, loss- and gain-framing and patient-oriented outcome measures are based on ethical guidelines. There is a lack of studies on quality of evidence, pictures and drawings, patient narratives, cultural aspects, layout, language and development process.Conclusion: The results of this review allow specification of EBPI and may help to advance the discourse among related disciplines. Research gaps are highlighted.Practice implications: Findings outline the type and extent of content of EBPI, guide the presentation of information and describe the development process.

Obese young people's accounts of intervention impact - Corrected Proof

Jennifer R. Hester, Jim McKenna, Paul J. Gately — 2009-12-14

Abstract: Objective: To uncover in-depth qualitative accounts of intervention impact from obese young people during a period of lifestyle change after attending a residential weight-loss camp.Methods: An innovative, progressively focused process of (1) single end-of-stay interviews, (2) interviews repeated in the home environment at 3 months and (3) 9 months. Comprehensive data were collected from five information-rich cases who contributed at each stage. Verbatim transcripts were analysed to identify issues associated with camp impact.Results: Reporting positive in-camp experiences, there were also anxieties about returning home and successfully translating knowledge and behaviors into longer term strategies. Inductive analysis suggested cognitive ambiguity in relation to positive camp impact. This developed and intensified over the 9 months of post-camp experience, despite the help of supportive others.Conclusion: Young people described a positive post-camp impact that continued into the home environment. Unexpectedly, though it was also an ambiguous experience. Cognitive ambiguity created behavioral conflict which undermined motivation for sustained healthy living.Practice implications: These unique accounts enable service providers to better understand post-camp experiences and use them to work with young people towards more positive outcomes. Even after intensive and successful intervention young people may still require ongoing support for continued lifestyle change.

The realisation of patient-centred care during a 3-year proactive telephone counselling self-care intervention for diabetes - Corrected Proof

Tina Gambling, Andrew F. Long — 2009-12-14

Abstract: Objective: To explore the way that patient-centred care is realised within a tele-carer behavioural change intervention.Method: In-depth, semi-structured interviews undertaken at years 1 and 3 with a purposively selected sample from the intervention group within a 3-year randomised controlled trial (RCT) of a telephone-based education and support for persons with type 2 diabetes, and interviews with the non-medically trained tele-carers and supervising diabetes specialist nurse.Results: A four-phased flow of the patient-centred interactions was identified, which evolved over the process of the intervention. Initially, attention centred on building a picture for and of the patient and assessing their knowledge base. Later, focus moved towards understanding diabetes from the patient's perspective and advice-giving became more individualised. Throughout, the interaction dynamics varied for patients.Conclusion: This study provides insight into the development of patient-centred behaviours over time and the influence of patients on tele-carer communication styles.Practice implication: When adopting a patient-centred approach, tele-carers need to be flexible and recognise that patients vary in their knowledge, skills and psychological adaption to diabetes. Continuity of care and consistent contact is pivotal to patients being able to move through the various phases of their illness trajectory and make the transition towards improved self-care management.

Medical nutrition therapy for overweight youth in their medical home: The KIDPOWER experience - Corrected Proof

2009-12-14

Abstract: Objective: To determine the feasibility and impact of implementing a standardized medical nutrition therapy (MNT) protocol to treat overweight children in their medical home. Primary outcomes evaluated were changes in eating behaviors, television habits, and weight status.Methods: A MNT protocol with handouts (known as KIDPOWER) was delivered by a registered dietitian (RD) to overweight children (2–20 years) in 9 primary care practices in a rural community. A medical record review yielded height, weight and selected patient/parent reported eating and TV behaviors from each MNT visit. Mean values were compared by paired samples t-tests. Changes in behaviors and BMI z score were compared using repeated measures ANOVA.Results: For patients with at least three MNT visits (n=109) significant improvements in eating and TV viewing habits were seen by the third visit. Weight status, as determined by a significant decline in mean BMI z score, was improved.Conclusion: The KIDPOWER protocol delivered by a RD in the pediatric medical home aided overweight youth in making behavior changes that positively impacted their weight status.Practice implications: Reimbursement to RDs for treating childhood obesity is improving and KIDPOWER provides a model and tools for community practice.

Emotional and informational patient cues: The impact of nurses’ responses on recall - Corrected Proof

2009-12-11

Abstract: Objective: To investigate older cancer patients’ informational and emotional cues, how nurses respond to these cues and the effect of cues and responses on patients’ information recall.Methods: 105 cancer patients (aged ≥65 years) completed a recall questionnaire after an educational session preceding chemotherapy treatment. Recall was checked against the actual communication in videorecordings of the consultations. Patients’ emotional and informational cues and subsequent responses by the nurse were rated using an adaptation of the Medical Interview Aural Rating Scale (MIARS).Results: Patients gave more informational than emotional cues. The most frequent response to emotional cues was distancing followed by acknowledgement. Nurses gave appropriate information in response to the majority of informational cues. Patients’ expression of emotional or informational cues did not influence recall; neither did nurses’ responses to informational cues. Responses to emotional cues did affect recall. The more nurses responded by giving ‘minimal’ encouragements (e.g. ‘Hmmm’), the more patients recalled, while distancing responses (e.g. switching focus) were associated with lower recall scores.Conclusion: Responding to patients’ emotions is likely to impact information recall.Practice implications: These results highlight the importance of addressing patients’ expressions of emotions in the context of patient education, as it enhances information recall.

Testing whether decision aids introduce cognitive biases: Results of a randomized trial - Corrected Proof

2009-12-10

Abstract: Objective: Women at high risk of breast cancer face a difficult decision whether to take medications like tamoxifen to prevent a first breast cancer diagnosis. Decision aids (DAs) offer a promising method of helping them make this decision. But concern lingers that DAs might introduce cognitive biases.Methods: We recruited 663 women at high risk of breast cancer and presented them with a DA designed to experimentally test potential methods of identifying and reducing cognitive biases that could influence this decision, by varying specific aspects of the DA across participants in a factorial design.Results: Participants were susceptible to a cognitive bias – an order effect – such that those who learned first about the risks of tamoxifen thought more favorably of the drug than women who learned first about the benefits. This order effect was eliminated among women who received additional information about competing health risks.Conclusion: We discovered that the order of risk/benefit information influenced women's perceptions of tamoxifen. This bias was eliminated by providing contextual information about competing health risks.Practice implications: We have demonstrated the feasibility of using factorial experimental designs to test whether DAs introduce cognitive biases, and whether specific elements of DAs can reduce such biases.

Improving physician–patient communication about cancer pain with a tailored education-coaching intervention - Corrected Proof

2009-12-07

Abstract: Objective: This study examined the effect of a theoretically grounded, tailored education-coaching intervention to help patients more effectively discuss their pain-related questions, concerns, and preferences with physicians.Methods: Grounded in social-cognitive and communication theory, a tailored education-coaching (TEC) intervention was developed to help patients learn pain management and communication skills. In a RCT, 148 cancer patients agreed to have their consultations audio-recorded and were assigned to the intervention or a control group. The recordings were used to code for patients’ questions, acts of assertiveness, and expressed concerns and to rate the quality of physicians’ communication.Results: Patients in the TEC group discussed their pain concerns more than did patients in the control group. More active patients also had more baseline pain and interacted with physicians using participatory decision-making. Ratings of physicians’ information about pain were higher when patients talked more about their pain concerns.Conclusions: The study demonstrates the efficacy of a theoretically grounded, coaching intervention to help cancer patients talk about pain control.Practice implications: Coaching interventions can be effective resources for helping cancer patients communicate about their pain concerns if they are theoretically grounded, can be integrated within clinical routines, and lead to improve health outcomes.

Linking urban families to community resources in the context of pediatric primary care - Corrected Proof

Arvin Garg, Sonia Sarkar, Mark Marino, Rebecca Onie, Barry S. Solomon — 2009-12-07

Abstract: Introduction: Pediatric guidelines emphasize the importance for healthcare providers to view children in the context of family and community, and promote community resources at visits. In 2006, a Family Help Desk (FHD) was established in an urban academic-based clinic in Baltimore, MD to assist healthcare providers in educating families about available community-based resources.Methods: A longitudinal cohort pilot study was conducted during a 6-week period in 2007 to evaluate the impact of the FHD in connecting at-risk families to community resources.Results: Overall, 6% of parents (n=59) who brought their child for a scheduled clinic visit accessed the FHD. Parents had a mean of 1.7 social needs, including after-school programs and childcare (29%), employment (13%), housing (12%), and food (11%). Most parents who utilized the FHD (64%) contacted a community resource or service within 6 months of their clinic visit. Nineteen parents (32%) who utilized the FHD enrolled in community programs.Conclusion: A clinic-based multi-disciplinary model can empower families to connect with community-based resources for basic social needs.Practice implications: The Family Help Desk model has great potential for addressing family psychosocial needs, and educating families about community resources within the context of pediatric primary care.

Counseling overweight in primary care: An analysis of patient–physician encounters - Corrected Proof

2009-12-07

Abstract: Objective: The aim of this study was to assess general practitioners’ (GPs’) and patients’ practices and attitudes regarding overweight encountered during preventive counseling talks.Methods: Twelve GPs audiotaped their preventive counseling talks with overweight patients, including the assessment of individual risk profiles and further medical recommendations. Fifty-two dialogues were transcribed and submitted to qualitative content analysis.Results: Dietary advice and increased physical activity are mostly discussed during talks. Recommendations appear to be more individual if patients are given the chance to reflect on causes of their overweight during counseling talks.Conclusions: A dialogue approach affects the strength and quality of weight loss counseling in primary care. However, physicians and overweight patients rarely agreed on weight loss goals during the physician–patient talks.Practical implications: Patient centeredness, particularly the integration of patients’ perceptions towards weight management, might be an important step towards improving weight counseling in primary care.

Using group support to complement a task-based weight management programme in multi-ethnic localities of high deprivation - Corrected Proof

Peter Hajek, Kirsty Humphrey, Hayden McRobbie — 2009-12-07

Abstract: Objective: Two pilot studies were undertaken to assess the efficacy and potential reach of a weight management programme in two inner-city areas of East London.Methods: The programme provides a 6 weekly group sessions combining a task-based cognitive-behavioural intervention with interactive group support to increase client engagement and retention. Treatment outcome was assessed at end of treatment and at 2 and 3 months by objective markers including pedometer readings, improvements in knowledge of healthy eating, and weight change.Results: A total of 162 people (mean BMI 35kg/m2) participated. Forty-one started the first pilot and 21 (51%) completed it, losing on average 3.0kg. In the second pilot 121 participants started the course and 75 (62%) completed it, losing on average 2.6kg. A total of 62 and 39 participants completed 2- and 3-month follow-up, with average weight loss of 3.8 and 4.5kg. There were significant increases in mean daily pedometer readings and improvements in objectively assessed knowledge of caloric intake.Conclusions: A task-based lifestyle-modification programme complemented by social support proved attractive to inner-city residents and generated significant short-term effects comparable to those achieved by intensive interventions with more traditional target groups.

Assessing the impact of a modified informed consent process in a South African HIV/AIDS research trial - Corrected Proof

Claire Penn, Melanie Evans — 2009-12-07

Abstract: Objective: The process of informed consent may be jeopardized in cross-linguistic research trials but little is known about the factors which contribute to this. The present study was designed to assess the impact on the understanding of trial participants of the essential components of a trial, as well as on the perceptions of the participants, through enrollment via a standard versus a modified informed consent protocol.Methods: Counselors from two HIV trial sites in South Africa were trained to enroll patients for a trial, using a modified informed consent protocol. The standard and modified protocols were compared.Results: Marked differences were noted in effectiveness of the process after training using the modified protocol, resulting in improved patient understanding. An item analysis suggested those areas of the trial which were most difficult for counselors to communicate effectively and highlighted potential barriers and facilitators to the process.Conclusions: Cultural and linguistic modifications to the informed consent process can enhance the understanding of components of a research trial and are viewed as largely positive by the participants.Practice implications: Some implications for future enrollments, for developing policy and for the role of a language specialist on research ethics committees and in trial design are highlighted.

“I need to lead my own life in any case”—A study of patients in dialysis with or without a partner - Corrected Proof

Marie-Louise Ekelund, Sven Ingmar Andersson — 2009-12-07

Abstract: Objective: To elicit psychological and psychosocial problems existing in patients in dialysis and their partners, its being felt that the diversity involved has important implications for how service in dialysis units is delivered to patients and their partners.Methods: The results of a series of interviews of 39 patients in dialysis and 21 partners of theirs, each interview individual, concerning their ways of thinking and their feelings and the behaviour, were analyzed in qualitative and content-oriented terms.Results: Five basic themes could be identified: importance of treatment being individualized, dependency on an apparatus, consequences of the disease and its treatment, hopes for the future, and thoughts concerning life and death. Diversities relating to age, civil status, cultural and gender matters were disclosed.Conclusion: The interview approach illustrated the importance of extended professional and individualized support in handling psychological and psychosocial disparities and needs in order to make treatment regimes more acceptable to the persons involved.Practice implications: Suggestions are made concerning efforts to improve the care of patients receiving dialysis, and the importance of working with the patients and those closest to them in multidisciplinary teams.

How was patient empowerment portrayed in information leaflets describing the community pharmacy Medicines Use Review service in the UK? - Corrected Proof

Melandi van den Berg, Parastou Donyai — 2009-12-07

Abstract: Objective: The Medicines Use Review (MUR) community pharmacy service was introduced in 2005 to enhance patient empowerment but the service has not been taken up as widely as expected. We investigated the depiction of the patient–pharmacist power relationship within MUR patient information leaflets.Methods: We identified 11 MUR leaflets including the official Department of Health MUR booklet and through discourse analysis examined the way language and imagery had been used to symbolise and give meaning to the MUR service, especially the portrayal of the patient–pharmacist interactions and the implied power relations.Results: A variety of terminology was used to describe the MUR, a service that aimed ultimately to produce more informed patients through the information imparted by knowledgeable, skilled pharmacists.Conclusion: The educational role of the MUR overshadowed the intended patient empowerment that would take place with a true concordance-centred approach. Although patient empowerment was implied, this was within the boundaries of the biomedical model with the pharmacist as the expert provider of medicines information.Practice implications: If patient empowerment is to be conveyed this needs to be communicated to patients through consistent use of language and imagery that portrays the inclusivity intended.

New psycho-pedagogic approach to obesity treatment: A 5-year follow-up - Corrected Proof

Sévrine Buclin-Thiébaud, Zoltan Pataky, Vanessa Bruchez, Alain Golay — 2009-12-04

Abstract: Objective: The aim of the present study was to evaluate the body weight evolution in obese patients admitted for a 2-week residential program and followed-up on ambulatory basis, as well as to evaluate factors having impact on weight evolution after 5 years.Methods: Thirty-nine obese patients participated in a 2-week structured interdisciplinary weight loss program, involving individual and group therapies, and including physical activity, nutritional education and standard cognitive-behavioral techniques. Patients were then followed-up regularly by their general practitioners for 5 years.Results: After 5 years, 33 subjects completed the study. Seventy percent of the patients lost weight or maintained their weight loss. Total score for dietary structure, eating behavior disorders, dietary surveillance and weight management strategies, as evaluated by a validated questionnaire, was significantly lower in the weight loss group (22.4±4.3) as compared to maintenance group (24.4±6.1, p<0.05) and regain group (29.7±4.0, p<0.01). Patients who lost weight presented a more important follow-up on long-term weight management (p<0.05), a better dietary results (p<0.01) as well as more physical activity (p<0.05) that the regain group.Conclusion: The present study demonstrated that an initial multidimensional and multidisciplinary in-hospital program with a consecutive long-term ambulatory follow-up may lead to a significant weight loss (55%) and/or weight maintenance (15%).Practice implications: A multidisciplinary and well-designed initial treatment and long-term follow-up program is mandatory for obesity management.

The Statin Choice decision aid in primary care: A randomized trial - Corrected Proof

2009-12-03

Abstract: Objective: To assess the impact of a decision aid on perceived risk of heart attacks and medication adherence among urban primary care patients with diabetes.Methods: We randomly allocated 150 patients with diabetes to participate in a usual primary care visit either with or without the Statin Choice tool. Participants completed a questionnaire at baseline and telephone follow-up at 3 and 6 months.Results: Intervention patients were more likely to accurately perceive their underlying risk for a heart attack without taking a statin (OR: 1.9, CI: 1.0–3.8) and with taking a statin (OR: 1.4, CI: 0.7–2.8); a decline in risk overestimation among patients receiving the decision aid accounts for this finding. There was no difference in statin adherence at 3 or 6 months.Conclusion: A decision aid about using statins to reduce coronary risk among patients with diabetes improved risk communication, beliefs, and decisional conflict, but did not improve adherence to statins.Practice implications: Decision aid enhanced communication about the risks and benefits of statins improved patient risk perceptions but did not alter adherence among patients with diabetes.

Behavioural research in patients with end-stage renal disease: A review and research agenda - Corrected Proof

2009-12-02

Abstract: Objective: To suggest a behavioural research agenda for patients with end-stage renal disease (ESRD) based on a concise review of seven stages of psychosocial research, a literature review, and current behavioural research in other chronic somatic diseases.Methods: Historical behavioural ESRD research was classified. The specialized register of the Cochrane Behavioral Medicine Field was also checked, and additional papers were selected by screening reference lists and related behavioural science journals, to identify promising areas for future research.Results: The top-five topics identified via the literature search pertain to (1) psychological aspects and interventions, (2) adaptation, coping, and depression, (3) exercise, (4) counseling and education, and (5) compliance. ‘Illness and treatment beliefs’, ‘sexuality’, ‘suicide’, ‘family support’, and ‘self-management interventions’, were identified on the basis of research in other chronic illnesses as topics for future research. Regarding theory, the Common-Sense Model (CSM) was judged to offer useful theoretical perspectives; regarding methods, qualitative methods can be a valuable addition to quantitative research methods.Conclusion: Illness beliefs, treatment beliefs, and self-management behaviours are promising concepts in the assessment and clinical care of ESRD-patients. Cognitive–behavioural treatments appear to have potential and should be specified and elaborated for specific categories and problems of ESRD-patients.Practice Implications: This research agenda is in line with moves towards patient-centred disease-management to improve the quality of medical care for ESRD-patients.

Implementation and success of nurse telephone counseling in linguistically isolated Korean American patients with high blood pressure - Corrected Proof

2009-11-30

Abstract: Objective: Nurse telephone counseling can improve the management of chronic conditions, but the effectiveness of this approach in underserved populations is unclear. This study evaluated the use of bilingual nurse-delivered telephone counseling in Korean Americans (KAs) participating in a community-based intervention trial to improve management of hypertension.Methods: KAs were randomized to receive 12 months of hypertension-related telephone counseling that was more intensive (bi-weekly) or less intensive (monthly). Counseling logs were kept for 360 KAs who completed the pre- and post-intervention evaluations.Results: The overall success rate for the intervention was 80.3%. The level of success was significantly influenced by the dose of counseling, employment status, and years of US residence. Over the 12-month counseling period, both groups showed improvement with regard to medication-taking, alcohol consumption, and exercise but not smoking, with no significant group differences.Conclusion: Bilingual telephone counseling could reach monolingual KAs and improve their hypertension management behavior.Practice implications: Bilingual nurse telephone counseling may have wide applicability, serving as an effective means of disseminating evidence-based chronic disease management guidelines to a linguistically isolated community with limited health resources and information.

Shared decision-making in cardiology: Do patients want it and do doctors provide it? - Corrected Proof

D.A.M. Burton, N. Blundell, M. Jones, A.G. Fraser, G. Elwyn — 2009-11-30

Abstract: Objective: Doctors should involve their patients in making decisions about their care. We studied patients with heart disease to assess if shared decision-making occurs and to study factors that predict patients’ choices or influence cardiologists’ behaviour.Methods: 85 patients attending for arteriography were assessed to elicit preferred involvement in decision-making, perception of involvement, and confidence in the decision.Results: 40% of patients wished to be involved in decisions. Preferences were unrelated to demographic factors. Cardiologists involved patients more in decisions concerning severe disease (p=0.056). Involvement varied between cardiologists (p=0.001). The mean duration of consultations was 5.5min. Patients’ confidence in decisions correlated with duration (p=0.001), explicit reference to a decision that needed to be made (p=0.0026), and perceived, but not observed, involvement in decision-making (p=0.05).Conclusion: This study highlighted the complexity of doctor–patient communication. Irrespective of preferences for involvement, patients were more confident in decisions in which they perceived more involvement or which were the products of longer consultations.Practice implications: Patients’ confidence in clinical decisions can be increased by increasing consultation length and increasing their perception of involvement. Patients perceive more involvement in decisions when doctors specifically identify the need for treatment decisions early in the consultation.

Effects of mode of presentation on ratings of empathic communication in medical interviews - Corrected Proof

Jennifer Nicolai, Ralf Demmel, Karin Farsch — 2009-11-30

Abstract: Objective: To test the impact of nonverbal behaviour on the assessment of a clinician's level of empathic communication.Methods: One hundred volunteers were asked to assess a clinician's level of empathic communication using the Rating Scales for the Assessment of Empathic Communication in Medical Interviews (REM). Participants were randomly assigned to three groups differing with regard to the level of nonverbal information made available to them. Participants either watched a simulated medical interview, listened to an audio-only version of this interview, or read a transcribed version of the interview.Results: Compared to watching a video and listening to an audiotape, respectively, reading a transcribed version of the interview produced lower empathy ratings and interrater reliabilities.Conclusions: The findings suggest that assessments of a clinician's level of empathic communication may differ according to the level of nonverbal information made available to the raters.Practice implications: Focusing on the verbal level of communication alone ignores the fact that empathy can be expressed through nonverbal means. Hence, nonverbal channels need to be taken into account in addition to the verbal channel when conducting research on empathic communication in health care.

Shared decision making models to inform an interprofessional perspective on decision making: A theory analysis - Corrected Proof

Dawn Stacey, France Légaré, Sophie Pouliot, Jennifer Kryworuchko, Sandy Dunn — 2009-11-30

Abstract: Objective: To conduct a theory analysis of shared decision making (SDM) conceptual models and determine the extent to which the models are relevant to interprofessional collaboration in clinical practice.Methods: Theory analysis of SDM models identified from three systematic reviews and personal files. Eligible publications: model of SDM; described concepts with relational statements. Two independently appraised models.Results: Of 54 publications, 15 unique models included 18 core concepts. Of two models that included more than one health professional collaborating with the patient, one included 3 of 10 elements of interprofessional collaboration and the other included 1 element. Fourteen were rated as having no logical fallacies, 10 as parsimonious, 7 had been empirically tested, 4 provided testable hypotheses, and 3 described the development process.Conclusion: Most SDM models failed to encompass an interprofessional approach. Those that included at least two professionals met few of the elements of interprofessional collaboration and had limited description of SDM processes. Although models were rated as logically adequate and parsimonious, only half were tested and few were developed using an explicit process.Practice implications: Appraisal of SDM models highlights the need for a model that is more inclusive of an interprofessional approach.

The physician's professional role in end-of-life decision-making: Voices of racially and ethnically diverse physicians - Corrected Proof

Ursula K. Braun, Marvella E. Ford, Rebecca J. Beyth, Laurence B. McCullough — 2009-11-30

Abstract: Objective: Previous studies have shown racial/ethnic differences in preferences for end-of-life (EOL) care. We aimed to describe values and beliefs guiding physicians’ EOL decision-making and explore the relationship between physicians’ race/ethnicity and their decision-making.Methods: Seven focus groups (3 Caucasian, 2 African American, 2 Hispanic) with internists and subspecialists (n=26) were conducted. Investigators independently analyzed transcripts, assigned codes, compared findings, reconciled differences, and developed themes.Results: Four themes appeared to transcend physicians’ race/ethnicity: (1) strong support for the physician's role; (2) responding to “unreasonable” requests; (3) organizational factors; and (4) physician training and comfort with discussing EOL care. Five themes physicians seemed to manage differently based on race/ethnicity: (1) preventing and reducing the burden of surrogate decision-making; (2) responding to requests for “doing everything;” (3) influence of physician–patient racial/ethnic concordance/discordance; (4) cultural differences concerning truth-telling; and (5) spirituality and religious beliefs.Conclusions: Physicians in our multi-racial/ethnic sample emphasized their commitment to their professional role in EOL decision-making. Implicitly invoking the professional virtue of self-effacement, they were able to identify racially/ethnically common and diverse ethical challenges of EOL decision-making.Practice implications: Physicians should use professional virtues to tailor the EOL decision-making process in response to patients’ race/ethnicity, based on patients’ preferences.

“Norwegians fear fatness more than anything else”—A qualitative study of normative newspaper messages on obesity and health - Corrected Proof

Kirsti Malterud, Kjersti Ulriksen — 2009-11-30

Abstract: Objective: To explore normative aspects of the Norwegian discourse on obesity.Methods: We conducted a qualitative study with data from five Norwegian newspapers, focusing normative entries about body weight. Discourse analysis provided a focus on the cultural attitudes when systematic text condensation was conducted. Data comprised 26 normative messages (prescriptions or comments on how obese people are or should be, messages mediating or discussing values prescribing a ‘good’ body).Results: Two main normative domains within the obesity discourse were identified. One group of entries warned about obesity from an aesthetic point of view, notifying the reader that beauty would suffer when weight increases, due to reduced attractiveness. These texts appealed to bodily conformity, linking leanness with attractiveness and delight, suggesting that fat people are ugly and unhappy. The other group referred to lack of control in the obese person, linking greediness to lack of responsibility and bad health. Fat people were displayed as undisciplined and greedy individuals who should be ashamed.Conclusions: Cultural messages of blame and shame are associated with obesity, but also spreading from body weight to the very scene of life. People with obesity cannot escape this cultural context, only find a way of coping with it.Practice implications: Quality care for people with obesity implies that public health and clinical medicine acknowledge the burden of cultural stigma. Developing awareness for cultural prejudices on body weight, doctors could counteract stigmatization and contribute to empowerment and health.

Health perceptions of African HIV-infected patients and their physicians - Corrected Proof

M. Dominicé Dao, J.F.E. Ferreira, N. Vallier, D. Roulin, B. Hirschel, A. Calmy — 2009-11-30

Abstract: Objective: We explored how patients from Sub Saharan Africa (SSA) infected with HIV and living in Switzerland, and their treating physicians perceived their health, whether these perceptions correlated with biological markers, and what organisational changes participants considered likely to improve quality of care.Methods: A prospective standardized questionnaire was submitted to HIV-infected patients from SSA and their physicians. Results were correlated with biological data.Results: While physicians deduced improved health status from laboratory results, these did not provide an adequate surrogate marker of good health for patients. Patients experienced important social and economical difficulties with adverse consequences on their mental health. They requested social assistance, whereas physicians sought improved cultural competency.Conclusion: Patients and physicians did not agree in their evaluation of patients’ health status. Patients did not perceive their health through biological markers, but linked their mental health with their socioeconomic context. Physicians underestimated patients’ biological health and their evaluation of global health.Practice implications: Exploring difficulties perceived by physicians with specific patients lead to identification of structural weaknesses, resulting in suggestions to improve physicians’ medical training and patients’ care. This illustrates the importance of accessing patients’ perspective and not relying solely on physicians’ perception of the problem.