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Moving from undiagnosed to diagnosed diabetes: the patient's perspective.
BACKGROUND AND OBJECTIVES: One third of diabetes cases in the United States are undiagnosed. Knowledge of the patient's experience from symptom recognition to diabetes diagnosis will help clinicians and policy makers optimize their approach to diabetes detection. METHODS: We interviewed 15 patients diagnosed with type 2 diabetes within the past 6 months about how they came to be diagnosed and about any barriers that might have prevented their diagnosis. We used grounded theory qualitative methods to approach and analyze the semi-structured interviews. RESULTS: Most diagnoses of diabetes in these patients were either serendipitous, symptom driven, or patient initiated. None resulted from physician-initiated screening. Patients had only a superficial knowledge of the symptoms of diabetes prior to diagnosis, despite strong family histories of diabetes. Patients often incorrectly attributed symptoms of diabetes to other causes and sometimes physicians also did this. Barriers of cost, insurance, and trust were not deemed to be important by these patients. CONCLUSIONS: Many individuals with undiagnosed diabetes are likely unaware of the relevance of their symptoms. Clinicians must be vigilant in identifying people at risk for diabetes. Improved education of individuals at risk for diabetes may be a useful strategy to increase diabetes detection.
Focus groups in family practice research: an example study of family physicians' approach to wife abuse.
Focus groups have been extensively used in marketing research and recently adapted for studies in the behavioral sciences and primary care. The purpose of this paper is two-fold: 1) to describe the application of focus group methodology to research in family practice, and 2) to demonstrate the use of this qualitative method to examine a specific issue--family physicians' approach to wife abuse.
Universal hepatitis B immunization of infants: reactions of pediatricians and family physicians over time.
OBJECTIVE: In November 1991 the Advisory Committee on Immunization Practice (ACIP) recommended universal hepatitis B immunization of infants. In February 1992 the American Academy of Pediatrics (AAP) and in August 1992 the American Academy of Family Physicians (AAFP) issued similar recommendations. The purpose of this study was to assess over time the effectiveness and impact of the dissemination efforts of the ACIP, AAP, and AAFP regarding this new recommendation and to determine the factors affecting its adoption. DESIGN: Cohort survey over time. SETTING: North Carolina. PARTICIPANTS: All 778 pediatricians and a random sample of 300 family physicians in North Carolina were surveyed by mail 3 months after publication of the ACIP recommendation (January/February 1992), but before the AAP and AAFP recommendations. Response rate was 78%. Of these, 83% responded to a follow-up survey 8 months later (October 1992). MAIN OUTCOME MEASURES: Rates of agreement and adoption of the recommendation for universal infant immunization with hepatitis B vaccine; factors affecting agreement and adoption of the recommendation. RESULTS: In the first survey (3 months after the ACIP recommendation) more pediatricians than family physicians were aware of the new recommendation (82% vs 48%), yet only 37% of pediatricians and 23% of family physicians agreed that immunization of all newborns in their practice was warranted. Eight months later, after the AAP and AAFP recommendation, 66% of pediatricians and 32% of family physicians agreed universal immunization was warranted, but still only 53% of pediatricians and 23% of family physicians had adopted it into practice. Factors associated with these low rates of adoption include physician and practice characteristics, cost, perceived need for the vaccine, and aversion to multiple injections. CONCLUSIONS: Federal, AAP, and AAFP efforts have not been effective thus far in fostering widespread agreement and adoption of this recommendation. If this and future vaccine programs are to succeed, research is needed to determine influences on implementation of new recommendations and to address the economic and noneconomic concerns of physicians and parents.
Prostate cancer screening: what general practitioners and patients need to know.
Much controversy surrounds the appropriateness of screening for prostate cancer. The individual benefit from screening is unproven. Screening may result in many men being unnecessarily treated for prostate cancer with the associated risks of developing treatment related side effects, including impotence and incontinence. Men requesting screening need to be informed of these issues before they decide whether to proceed. This article reviews the current position in relation to screening, critically appraising current thinking in order to clarify the issues.
Herpes zoster--results from a questionnaire-based surveillance of patients and their general practitioners.
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Exploring the gap between knowledge and behavior: a qualitative study of clinician action following an educational intervention.
PURPOSE: Many medical education interventions improve clinicians' knowledge but fail to change behavior. The authors exposed this knowledge-behavior gap through standardized clinical interactions, thus allowing in-depth exploration of the contributing factors. METHOD: A typical evidence-based educational intervention in one clinical domain (early signs of autism) was administered to family medicine residents at the University of Toronto in 2001-02, and change in knowledge was assessed through a multiple-choice test. Six to eight weeks later, participants' relevant knowledge was documented, and their clinical behavior was observed during four interactions with standardized patients. Factors producing a knowledge-behavior discrepancy were then explored using semistructured interviews, which were audiotaped, transcribed, and analyzed using grounded theory methods. RESULTS: Half of participants demonstrated varying degrees of knowledge-behavior gap. Eight main rationalizations (relationships, patient agenda, knowledge deficit, clinical style, means to an end, ideals, autism stigma, and systems barriers) were used to justify choices of clinical behavior, and the same rationalizations were used to justify opposite choices of behavior. Two conditions that promote clinical action based on knowledge (level of certainty and sense of urgency) were identified. CONCLUSION: The knowledge-behavior gap was exposed and factors reported to influence clinicians' decisions about whether to implement new knowledge were elicited. That identical rationalizations were used to justify opposite behaviors implies these factors may not be behavioral determinants. Sense of urgency and level of certainty promote clinical action based on knowledge; focusing on these may increase the impact of education on practice.
The guideline contradiction: health visitors' use of formal guidelines for identifying and assessing families in need.
The aim of this paper is to examine health visitors' use of formal guidelines in identifying health needs and prioritizing families requiring extra health visiting support. With the increasing emphasis on targeted health visiting, a case study was used to explore the extent to which health visitors in three case sites use needs assessment guidelines in the assessment of family health need. The findings indicate how the presence of core visiting protocols hints at elements of control by managers, leading to conflicts in the relationship between professional judgements and official guidelines. Despite a management ethos of guideline formulation, several contradictions exist for which these guidelines are a focus. These include: little involvement of health visitors in guideline development, some staff not informed about the existence of formal guidelines, little evidence of guidelines contributing to improved client outcomes and their limited use by many health visitors in practice. Thus, even when guidelines exist, no accurate predictions can be made about health visitors' knowledge of or use of such guidelines in practice.
Exploring district nursing competencies in health promotion: the use of the Delphi technique.
AIMS AND OBJECTIVES: The research outlined in this paper aimed to establish a consensus view amongst primary healthcare professionals about the competencies that district nurses need in order to fulfil an effective role in health promotion. BACKGROUND: In recent years there has been a growing emphasis on health promotion in primary care in the United Kingdom and health promotion is becoming increasingly important to nurses who work in the community. However, consideration of the role of the district nurse in health promotion is rather restricted and consequently district nurses have limited access to empirical evidence, from which they can develop their work in health promotion. DESIGN AND METHODS: The Delphi technique was used for this study. Seventy-two primary healthcare professionals were mailed a series of three questionnaires, which achieved response rates of 86, 87.5 and 78.9%. RESULTS: There was a consensus amongst the panellists that district nurses require a range of competencies to engage effectively in health promotion. These were categorized to produce a definitive list of eight knowledge-, seven attitude- and eight skill-related competencies. CONCLUSIONS: For the first time, this study achieves a consensus on the competencies needed by district nurses to engage in health promotion. RELEVANCE TO CLINICAL PRACTICE: District nurses should feel encouraged to develop their health promotion role in light of the fact that many of the competencies that they require for this activity have been identified as essential for their day-to-day nursing practice. The research highlights the fact that new paradigm health promotion is a concept that has moved beyond the academic arena and is recognized as significant by practising health professionals.
Decision analysis for newly diagnosed hypertensive patients: a qualitative investigation.
This study adopted a qualitative approach to explore patients' views on the usefulness of a decision analytic decision aid (DA). Semi-structured interviews were conducted with 15 newly diagnosed hypertensive patients who had been recruited for a factorial randomised controlled trial of two decision aids. Issues investigated included respondents' attitudes to information, their views on the nature of their relationship with their general practitioner (GP) (paternalistic, shared or consumerist), the ease of use and potential wider application of the computerised decision aid and its influence upon their decision-making about whether or not to begin anti-hypertensive treatment. Views on the decision aid were favourable. For the majority, the decision aid appeared to confirm and/or clarify their stated preferences towards medicine-taking. Occasionally it could provoke a major shift in a respondent's attitude to medicine-taking, while in a few it had no discernible effect. While views on the decision aid were favourable, it was difficult to determine whether this was due to the individualised cardiovascular risk information it provided or the decision analytic process itself.
Making decisions about cancer screening when the guidelines are unclear or conflicting.
OBJECTIVE: Our purpose was to determine the factors involved in the cancer screening decisions of family physicians in situations where the clinical practice guidelines are unclear or conflicting as opposed to when they are clear and uncontroversial. STUDY DESIGN: We analyzed discussions with focus groups using a constant comparative approach. POPULATION: A total of 73 family physicians in active practice participated in 10 focus groups (1 urban group and 1 rural group in each of 5 Canadian provinces). OUTCOME MEASURES: Our main outcome measures were participants' perceptions regarding cancer screening when the guidelines were unclear or conflicting. RESULTS: We propose a model of the determinants of cancer screening decision making with regard to unclear and conflicting guidelines. This model is rooted in the physician-patient relationship, and is an interactive process influenced by patient factors (anxiety, expectations, and family history) and physician factors (perception of guidelines, clinical practice experience, influence of colleagues, distinction between the screening styles of specialists and family physicians, and the amount of time and financial costs involved in performing the maneuver). CONCLUSIONS: Our model is unique, because it is embedded in the physician-patient relationship. Ultimately, a modified model could be used to design interventions to assist with the implementation of preventive services guidelines.
Improving compliance with universal precautions: effectiveness of interventions.
1. Compliance with universal barrier precautions is associated with the type of patient contact, such as emergent or nonemergent. Compliance may also vary by the type of barrier and health care worker group. 2. Stronger research designs are needed to determine the effect of interventions on improving health care workers' use of barrier precautions. 3. Occupational health nurses have the opportunity to take a leadership role to resolve issues that include accessibility to proper fitting gloves and safe work practice procedures.
Nurses' perceived knowledge, beliefs, skills, and needs regarding evidence-based practice: implications for accelerating the paradigm shift.
BACKGROUND: The paradigm shift to evidence-based nursing practice in the United States has been slow. Although multiple barriers to evidence-based practice (EBP) have been identified through prior studies, there is a gap in the literature specifically identifying key variables (e.g., belief that EBP produces quality outcomes) that are correlated with the extent to which nurses engage in EBP. AIM: The primary aims of this study were to (1) describe nurses' knowledge, beliefs, skills, and needs regarding EBP; (2) determine whether relationships exist among these variables; and (3) describe major barriers and facilitators to EBP. METHODS: A descriptive survey was conducted with a convenience sample of 160 nurses who were attending EBP conferences or workshops in four states located within the Eastern Region of the United States. RESULTS: Although participant beliefs about the benefit of EBP were high, knowledge of EBP was relatively low. Significant relationships were found between the extent to which the nurses' practice is evidence-based and (1) nurses' knowledge of EBP, (2) nurses' beliefs about the benefits of EBP, (3) having an EBP mentor, and (4) using the Cochrane Database of Systematic Reviews and the National Guideline Clearinghouse. CONCLUSION AND IMPLICATIONS: Health care systems need to implement interventions that not only increase nurses' EBP knowledge and skills, but also strengthen their beliefs about the benefit of evidence-based care. EBP mentors may be key in accelerating a more rapid shift toward evidence-based nursing practice. Theoretically driven randomized controlled trials are urgently needed to test the effectiveness of interventions on advancing evidence-based care.
Delivery of HIV prevention counseling by physicians at HIV medical care settings in 4 US cities.
OBJECTIVES: We investigated physicians' delivery of HIV prevention counseling to newly diagnosed and established HIV-positive patients. METHODS: A questionnaire was developed and mailed to 417 HIV physicians in 4 US cities. RESULTS: Overall, rates of counseling on the part of physicians were low. Physicians reported counseling newly diagnosed patients more than established patients. Factors associated with increased counseling included having sufficient time with patients and familiarity with treatment guidelines. Physicians who perceived their patients to have mental health and substance abuse problems, who served more male patients, and who were infectious disease specialists were less likely to counsel patients. CONCLUSIONS: Intervention strategies with physicians should be developed to overcome barriers to providing counseling to HIV-positive patients.
Family care in the United States. A national profile.
OBJECTIVES: The authors describe the epidemiology of family care in the United States. METHODS: A cross-sectional analysis of data from the household component of the 1987 National Medical Expenditure Survey was performed. A representative sample of the civilian, noninstitutionalized US population was analyzed. Participants in the study were all households with at least a mother between the ages of 18 and 55 years and at least one child younger than age 18 (n = 2,975). For this analysis, family care was defined as all families in which there was provider congruence between at least one parent and one child, compared with individual care, defined as families with separate providers. RESULTS: Family care occurred in 35% of families studied. As opposed to individual care, family care was more prevalent in families that resided in non-standard metropolitan statistical area regions and outside of the Northeast, as well as in families whose female heads of household were less educated, older, and had higher unhealthy behavior scores. Except for unhealthy behavior scores, these results remained significant after multivariate adjustment for race, marital status, family income, insurance status, and health care attitudes. Family or general practitioners were more likely than other physicians to provide family care. CONCLUSIONS: Family care occurs in a significant proportion of US families, and location and education are significant determinants of this kind of care. This descriptive epidemiologic analysis of a nationally representative sample provides a foundation for studies examining the cost and quality implications of family care.
The role and theoretical evolution of knowledge translation and exchange in public health.
BACKGROUND: There is an increased emphasis in public health research on effective models and strategies to support knowledge translation (KT), the exchange, synthesis and ethically sound application of research findings within a complex set of interactions among researchers and knowledge users. In other words, KT can be seen as an acceleration of the knowledge cycle-an acceleration of the natural transformation of knowledge into use (Canadian Institutes of Health Services Research. Knowledge Translation Strategy, 2004). The most recent conceptualizations consider the complexities of public health decision-making. The role of practitioners and communities is increasingly considered. METHODS: We identify, describe and discuss the theoretical underpinnings of KT and recommend a way forward to build the evidence for more effective practice. RESULTS: Theoretical perspectives increasingly influence research on KT in public health. A range of innovative work is being conducted to explore methods for KT using practical tools, often with the support of government. CONCLUSIONS: KT describes a crucial and to date under-developed element of the research process. There is an important gap in theoretically informed empirical studies of effectiveness of proposed approaches in public health, health promotion and preventive medicine, and thus much of the debate remains abstract. There is clearly an urgent policy need to establish the effectiveness of KT models in a range of contexts. This must include both the consideration of development and the utilization of knowledge.
What are nurses' attitudes, knowledge and practice of the universal precautions policy?
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