Barriers to guideline adherence. Based on a presentation by Michael Cabana, MD.
Successful implementation of the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI) should improve quality of care by decreasing inappropriate variation and by disseminating new advances to everyday practice. A key component of this process is physician adherence to JNC-VI guidelines. However several reports in the literature show a discrepancy between hypertension guidelines and actual practice. The factors that influence physician behavior change and optimal use of practice guidelines are poorly understood. A combined model that uses the Awareness-to-Adherence Model and Social Cognitive Theory identifies five sequential steps that lead to adherence to a guideline--awareness, agreement, self-efficacy, outcome expectancy, and presence of a cueing mechanism. Barriers to implementation may occur at any of these steps and can be identified with this model. Programs can then be designed to overcome specific barriers. By conceptualizing the underlying issues in physician adherence, the combined model should be useful to guideline developers, practice directors, and health services researchers. (+info)
Comparison of stage-matched and unmatched interventions to promote exercise behaviour in the primary care setting.
This study examined the effectiveness of stages of change-based counselling for exercise delivered by nurses in four primary care centres. Two-hundred and ninety-four subjects enrolled, recruited from patients attending 30-min health checks. The average age of participants was 42.4 years (SD = 15.1) and 77% were female. Participants completed a questionnaire assessing stage of exercise adoption, self-efficacy and exercise levels. Each centre was assigned to either one of three experimental conditions or to a control condition. Participants were counselled accordingly, receiving either stage-oriented exercise materials with counselling (stage plus counselling), stage-oriented materials without counselling (stage no counselling), non-staged materials with counselling (counselling only) or the current level of advice (control). Sixty-one percent (n = 180) returned follow-up questionnaires. When baseline differences in self-efficacy, age and gender were controlled for, there was no significant group or interaction effect for stage. There was a significant time effect (F = 3.55, P = 0.031). Post hoc analyses showed that significant differences were between baseline and 2 (t = -3.02, P = 0.003) and 6 months (t = -2.67, P = 0.009). No changes in self-efficacy and exercise levels were observed. Stage-based interventions were not superior to the other interventions. All single-contact interventions, while having no impact on exercise behaviour and self-efficacy, did enhance motivation to change. (+info)
'Instilling the strength to fight the pain and get on with life': learning to become an arthritis self-manager through an adult education programme.
The aim of this study was to determine whether the Arthritis Self-Management Programme (ASMP) is effective in promoting perceived control and self-management ability when delivered in an adult education setting. The study was a pre-test-post-test design based on a sample of 89 people attending an ASMP. Data were collected by self-administered questionnaires prior to the intervention and after the intervention, 4 months from baseline. The sample comprised 80% women, with a mean age of 57 years and a mean disease duration of 13 years. Most participants had either osteoarthritis or rheumatoid arthritis. After 4 months, participants demonstrated significant increases in arthritis self-efficacy (P < 0.0005), cognitive symptom management (P < 0.0005), communication with doctors (P = 0.018), exercise (P = 0.003) and relaxation (P < 0.00005). In addition, significant decreases were found in terms of pain (P = 0.034) and visits to other health professionals (P = 0.004). The first evaluation of the ASMP, delivered within the context of adult education, suggests that this form of community health education programme can offer substantial benefits for participants, particularly in terms of perceived ability to control various aspects of arthritis and in greater utilization of cognitive-behavioral techniques. (+info)
Comparing smoking and smoking cessation process in the Republic of Karelia, Russia and North Karelia, Finland.
STUDY OBJECTIVE: The aims of this study were to assess and validate self reported smoking prevalence and to assess smoking cessation related process variables in the Republic of Karelia, Russia and in North Karelia, Finland. DESIGN: Comparative population surveys of random population samples from both areas in spring 1992. The study included a self administered questionnaire, physical measurements and laboratory tests. The validity of self reported smoking prevalence was assessed by serum cotinine analyses. SETTING: The district of Pitkaranta in the Republic of Karelia, Russia and province of North Karelia, Finland. PARTICIPANTS: The study population was a 25 to 64 year old population in both areas. A stratified random sample of 1000 people in Pitkaranta and 2000 people in North Karelia was drawn from the population registers. In Pitkaranta 380 men and 455 women, and in North Karelia 673 men and 803 women, participated in the survey. RESULTS: The self reported prevalence rates of daily smoking in Pitkaranta were 65% among men and 10% among women. In North Karelia the respective rates were 29% and 13%. Women in Pitkaranta greatly underreported their smoking status, which was assessed by comparing the self reported data to the serum cotinine measurements. The smoking prevalence among women in Pitkaranta would rise from 10% to 21% if all participants with high cotinine values would be regarded as smokers. Compared with smokers in North Karelia, a higher percentage of smokers in Pitkaranta expressed their wish to quit and believed that they would succeed. However, on average they had fewer previous smoking cessation attempts than smokers in North Karelia. In addition, the health personnel in North Karelia were more active in advising smokers to quit. CONCLUSIONS: High smoking prevalence among men in Pitkaranta obviously contributes much to the high premature death rate in the Republic of Karelia. There is considerable underreporting of smoking in Pitkaranta, especially among women, which is probably attributable to the cultural unacceptability of female smoking in Russia. The common wish to quit, few previous cessation attempts and much lower rates of ex smokers, together with less smoking cessation counselling from health personnel, need to be considered in tailoring antismoking interventions in the area. (+info)
A pragmatic intervention to promote condom use by female sex workers in Thailand.
An overview is presented of a multifaceted intervention to promote consistent condom use by female commercial sex workers in Thailand, in the context of the government's 100% condom use policy for preventing spread of human immunodeficiency virus (HIV) infection. The project is described with reference to a succession of stages including pre-programme needs assessment, intervention design, implementation and evaluation. The key elements of the intervention were video scenarios and discussions coordinated by health personnel, and video-depicted open-ended narratives aimed at helping sex workers to explore their personal and work-related dilemmas and concerns. A core objective was to enhance sex workers' self-esteem and perceived future with a view to strengthening their motivation to take preventive action against HIV infection. The intervention was evaluated using a combination of qualitative (process evaluation) and quantitative (outcome) methods. The outcome evaluation was undertaken using a pretest, post-test intervention and control group quasi-experimental design. There were significant increases in consistent condom use among the intervention groups but not among the controls. Pragmatic stability is advocated for the Thai sex industry and recommendations are offered for good quality HIV prevention activities. (+info)
Hip protectors improve falls self-efficacy.
OBJECTIVES: To investigate the effect of use of external hip protectors on subjects' fear of falling and falls self-efficacy (belief in their own ability to avoid falling). DESIGN: Randomized controlled trial. SETTING: Aged-care health services in Sydney, Australia. PARTICIPANTS: 131 women aged 75 years or older, who had two or more falls or one fall requiring hospital admission in the previous year and who live at home. Sixty-one subjects were in the intervention group and 70 in the control group. INTERVENTION: Use of external hip protectors and encouragement to use the protectors by an adherence nurse. MEASUREMENTS: At the time of enrolment into a wider study examining the effect of hip protectors on hip fractures, participants recruited at home completed an assessment of fear of falling and falls efficacy as measured by the Falls Efficacy Scale and the Modified Falls Efficacy Scale. At 4-month follow-up, these scales were readministered by an observer who was not aware of the allocation of the participant to intervention or control groups. RESULTS: Fear of falling and falls self-efficacy, as measured by the Falls Efficacy and Modified Falls Efficacy Scales, were similar at baseline in both groups. Fear of falling was present at follow-up in 43% of subjects using hip protectors and 57% of the control group (chi2 = 2.58, P = 0.11). Hip protector users had greater improvement in falls self-efficacy at follow-up as measured by the Falls Efficacy Scale (t = 2.44, P = 0.016) and the Modified Falls Efficacy Scale (t = 2.08, P = 0.039). CONCLUSION: Hip protectors improve falls self-efficacy. As users of hip protectors feel more confident that they can complete tasks safely, they may become more physically active and require less assistance with activities of daily living. (+info)
Development and evaluation of the Kansas City Cardiomyopathy Questionnaire: a new health status measure for heart failure.
OBJECTIVES: To create a valid, sensitive, disease-specific health status measure for patients with congestive heart failure (CHF). BACKGROUND: Quantifying health status is becoming increasingly important for CHF. The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a new, self-administered, 23-item questionnaire that quantifies physical limitations, symptoms, self-efficacy, social interference and quality of life. METHODS: To establish the performance characteristics of the KCCQ, two distinct patient cohorts were recruited: 70 stable and 59 decompensated CHF patients with ejection fractions of <40. Upon entry into the study, patients were administered the KCCQ, the Minnesota Living with Heart Failure Questionnaire and the Short Form-36 (SF-36). Questionnaires were repeated three months later. RESULTS: Convergent validity of each KCCQ domain was documented by comparison with available criterion standards (r = 0.46 to 0.74; p < 0.001 for all). Among those with stable CHF who remained stable by predefined criteria (n = 39), minimal changes in KCCQ domains were detected over three months of observation (mean change = 0.8 to 4.0 points, p = NS for all). In contrast, large changes in score were observed among patients whose decompensated CHF improved three months later (n = 39; mean change = 15.4 to 40.4 points, p < 0.01 for all). The sensitivity of the KCCQwas substantially greater than that of the Minnesota Living with Heart Failure and the SF-36 questionnaires. CONCLUSIONS: The KCCQis a valid, reliable and responsive health status measure for patients with CHF and may serve as a clinically meaningful outcome in cardiovascular research, patient management and quality assessment. (+info)
Self-efficacy as a mediator between stressful life events and depressive symptoms. Differences based on history of prior depression.
BACKGROUND: Self-efficacy, a characteristic that is protective against depressive symptoms, may be undermined by stressful life events. AIMS: To estimate the effects of stressful life events on self-efficacy, and to examine self-efficacy as a mediator of the effect of stressful life events on symptoms of depression. METHOD: Using a sample of 2858 respondents from the longitudinal Americans' Changing Lives study, path analyses were used to evaluate interrelationships between self-efficacy, life events and symptoms of depression controlling for a variety of potentially confounding variables. Separate models were estimated for those with and without prior depression. RESULTS: For those with prior depression, dependent life events had a significant, negative impact on self-efficacy. For those without prior depression, life events had no effect on self-efficacy. CONCLUSIONS: For those with prior depression, self-efficacy mediates approximately 40% of the effect of dependent stressful life events on symptoms of depression. (+info)