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PubMedDate not supplied

Identifying the determinants of tuberculosis control in resource-poor countries: insights from a qualitative study in The Gambia.

Despite the availability of effective treatment, tuberculosis (TB) remains a major cause of death from an infectious disease in the world, particularly in resource-poor countries. Among the chief reasons for this are deficiencies in case tracing and in adherence to treatment. In order to investigate the contribution of non-biological factors to these deficiencies, we carried out a qualitative study in The Gambia, West Africa, from October 2000 to March 2001. The methods used were focus group discussions, interviews, participant and non-participant observation, and case histories. Four domains were distinctively investigated: the TB patients, the community, the health care providers (including programme staff), and the donors and policy makers. Analysis of the data from all these sources indicated the contribution of a wide range of socio-anthropological factors which influence the success or otherwise of the TB control programme in The Gambia, i.e. gender, urban/rural residence, recourse to traditional healers, adherence to national health policies, knowledge about TB, migration, and socio-economic factors. It is concluded that all these factors must be taken into account in formulating interventions to improve detection of TB cases and patient adherence to treatment within the framework of the national TB control programmes, and proposals have been made for targeted interventions.

Allied Health Personnel↗

PubMed2006

Effects of behavioral family systems therapy for diabetes on adolescents' family relationships, treatment adherence, and metabolic control.

BACKGROUND: Behavioral family systems therapy (BFST) for adolescents with diabetes has improved family relationships and communication, but effects on adherence and metabolic control were weak. We evaluated a revised intervention, BFST for diabetes (BFST-D). METHODS: One hundred and four families were randomized to standard care (SC) or to 12 sessions of either an educational support group (ES) or a BFST-D over 6 months. Family relationships, adherence, glycosylated hemoglobin (HbA1c), and health care utilization were measured at baseline and after treatment. RESULTS: BFST-D significantly improved family conflict and adherence compared to SC and ES, especially among those with baseline HbA1c > or = 9.0%. BFST-D and ES significantly improved HbA1c compared to SC among those with baseline HbA1c > or = 9.0%. CONCLUSIONS: The revised intervention (BFST-D) improved family conflict and treatment adherence significantly, while both ES and BFST-D reduced HbA1c significantly, particularly among adolescents with poor metabolic control. Clinical translation of BFST-D requires further study.

Adolescent↗

PubMedDate not supplied

Adherence to cardiovascular risk factor modification in patients with hypertension.

AIM: The effectiveness of the support of a healthcare practitioner and a family member in producing changes in cardiovascular risk factor modification was tested in a randomised, controlled trial in patients with hypertension. METHODS: The primary outcome measured after the 24-week intervention was blood pressure change. Secondary outcomes included patients' adherence to the programme, their knowledge about hypertension, exercise capacity, body weight, self-reported ability to control stress, adherence to medication and salt restriction, as well as symptoms. RESULTS: There were no marked improvements in blood pressure regulation in either group. The differences between the experimental and control groups were 3 mmHg (CI -6.18-12.18) for systolic blood pressure and 4 mmHg (CI -1.48-9.48) for diastolic blood pressure. The estimated blood pressure effects were small increases in both diastolic and systolic blood pressure, due to larger changes in the control group. These small changes were of no clinical significance. This intervention was not successful in reducing blood pressure of hypertensive patients who participated in a lifestyle programme. Secondary outcomes did show positive changes as a result of the given intervention. The absolute difference in improvement between the two groups was significantly greater for the experimental group than for the control group for the following variables: 24% better adherence to the programme (p = 0.007); 10% higher mean percentage score of hypertension knowledge and its management (p = 0.04); 20% more patients could control their stress levels (p = 0.05); 26% more patients could control their salt ingestion (p = 0.02); and 20% had better adherence to their given medication regimen (p = 0.05). The experimental group had a statistically significant weight reduction of 1 (+/- 4) kg relative to the control group (p = 0.03). Both groups increased their exercise capacity during the trial (p = 0.03). On the completion of the intervention, significantly fewer patients in the experimental group than in the control complained of tiredness (p = 0.05). Patients who had a 75% adherence or more to the programme were found to have maintained their knowledge and their exercise capacity, but not their weight loss after a maintenance phase of 12 weeks, during which time there was no intervention. CONCLUSION: Patients in a supported environment such as the one in this study were able to modify their cardiovascular risk factors, even though there were non-significant changes in blood pressure reported in this study.

Antihypertensive Agents↗

PubMed1995

Psychological counseling strategies for women at risk of breast cancer.

Women with family histories of breast cancer have a much higher risk of developing the disease than women in the general population. In the absence of primary prevention for breast cancer, secondary prevention in the form of early detection is our best bet against premature morbidity and mortality. This article describes the most salient psychological issues for high-risk women as well as ways for improving screening behaviors. Based on our work and other studies in the literature, we found that there were several key variables related to psychological distress and surveillance behaviors. Barriers to screening were a major reason why women did not engage in any breast cancer prevention behaviors. Cognitive deficits, in terms of lack of knowledge, and breast cancer misbeliefs contributed to poor adherence to screening. Most important, anxiety or emotional distress not only interfered with adherence to screening but also affected quality of life negatively in that many women needed psychological counseling. In developing psychological counseling strategies for high-risk women, we focused on the treatment outcomes of reducing emotional distress, decreasing perceived vulnerability, and improving adherence to screening behaviors. We conducted a preliminary study by piloting a group psychoeducational intervention for 6 consecutive weeks. This intervention was found to significantly reduce perception of risk (P < .02) and to increase adherence to screening behaviors (P < .01). If proven effective in a randomized controlled trial, this intervention can be proposed to other cancer centers and prevention programs for implementation and enhancement of the behaviors among high-risk women that will assure early detection and decrease breast cancer mortality.

Breast Neoplasms↗

PubMed1999

Motivating the well elderly to exercise.

Most older adults hope to remain independent until death, but their inactivity, poor nutrition, and disabling diseases contribute to the loss of functions that are necessary for independence. Although exercise has been shown to improve a person's functioning and decrease health care costs, two thirds of persons over age 65 do not exercise regularly. The purpose of this article is to describe intervention strategies and evaluate their usefulness in motivating adherence to an exercise program designed specifically for well-elderly community dwellers. Attendance records were reviewed and informal discussions were held to determine the usefulness of the selected intervention strategies. Fifty-seven percent of the group's members attended at least one half of the 52 sessions indicating that our strategies were effective. Information about the exercise strategies that we used can help community health providers to promote health by designing exercise programs that will entice the elderly to attend on a regular basis.

Activities of Daily Living↗

PubMedDate not supplied

Cancer screening practices among women in a community health center population.

BACKGROUND: Cancer takes a disproportionate toll on disadvantaged Americans. Poverty and low education are risk factors for underuse of cancer screening. METHODS: In this report, we discuss predictors of adherence to cancer screening (mammography, clinical breast exam [CBE], and Pap tests) among 926 women who receive care at a community health center that serves a predominantly low-income and minority population. We examine predictors for each of the tests and for a composite measure of overall cancer screening test compliance. In studying multiple screening behaviors we not only investigate factors associated with each individual behavior, but we also identify consistently effective factors across several behaviors. RESULTS: The analysis indicates consistent effects of age, education, and insurance status on cancer screening. In addition, decisional balance, a measure of a person's beliefs about the pros and cons of complying with the screening test, is associated strongly with adherence. We have extended earlier findings about the positive relationship between decisional balance and mammography to include decisional balance and Pap tests, as well. This finding suggests that behavioral interventions that target decisional balance can effectively promote adherence to cancer screening tests.

Adolescent↗

PubMed2006

[Effectiveness of a quality improvement intervention in blood pressure control in Primary Care].

INTRODUCTION AND OBJECTIVES: To evaluate the effectiveness of a quality improvement intervention on professionals sanitary in blood pressure control in hypertensive patients. METHODS: Quality improvement trials with cuasi-experimental design. Two primary care health centres. One centre was assigned intervention group (7 family doctors and 419 patients) and the other was control group (7 family doctors and 419 patients). The quality improvement intervention consisted of a combined program comprising audit, feedback, training sessions about main hypertension clinical guidelines during 6 months. The main measurement were blood pressure, lipid levels, diabetes, smoking and body index mass, antihypertensive drugs and record treatment adherence and therapeutic plan in march 2002 the baseline measurement and march 2004 the post intervention. RESULTS: In study group blood pressure systolic and diastolic decreased 8.16/3.71 mmHg and control group increased 1.56/0.13 mmHg, respectively. The intervention effect was a drop of 9.72 mmHg (IC 95%: 7.50-11.94) and diastolic blood pressure in 3.84 mmHg (IC 95%: 2.40-5.28). The rate of hypertensive patients with blood pressure < 140/90 mmHg increased from 37.5% to 68.8% in study group, without changes in control group (p < 0.05). The drugs and combination drugs prescribed increased in both group, while the records of therapeutics plans and adherence increased only in intervention group (p < 0.05). CONCLUSIONS: The quality improvement intervention was associated to a systolic and diastolic blood pressure reduction and a increase of rate patients with blood pressure controlled.

Aged↗

PubMed2003

Lifestyle intervention according to general recommendations improves glucose tolerance.

OBJECTIVE: Changing dietary and physical activity habits has the potential to postpone or prevent the development of type 2 diabetes. However, it needs to be assessed whether moderate interventions, in agreement with current guidelines for the general population, are effective. We evaluated the impact of a 2-year combined diet and physical activity intervention program on glucose tolerance in Dutch subjects at increased risk for developing diabetes. RESEARCH METHODS AND PROCEDURES: Subjects with glucose intolerance were randomly assigned to either the lifestyle intervention group (INT) or control group (CON). The INT received regular dietary advice and was stimulated to increase their physical activity. The CON received a brief leaflet about healthy diet and increased physical activity. Primary outcome measure was the change in glucose tolerance. RESULTS: In total, 88 subjects completed 2 years of intervention (40 subjects in the INT, 48 subjects in the CON, mean BMI 29.4 kg/m2). Subjects in the INT reduced their body weight, waist circumference, and (saturated) fat intake and improved their aerobic capacity. Two-hour plasma glucose concentration declined from 8.7 to 8.0 mM in the INT and rose from 8.6 to 9.4 mM in the CON (p < 0.01). Subjects adherent to both the diet and exercise intervention showed the largest reduction in 2-hour glucose levels. DISCUSSION: Our results showed that a lifestyle intervention program according to general recommendations improves glucose tolerance, even in a less obese and more physical active population. Furthermore, our results underscore the importance of combining diet and physical activity to improve glucose tolerance and insulin resistance.

Behavior Therapy↗

PubMed2000

Stress management intervention for primary prevention of hypertension: detailed results from Phase I of Trials of Hypertension Prevention (TOHP-I).

PURPOSE: Stress Management Intervention (SMI) was one of seven nonpharmacologic approaches evaluated in Phase I Trials of Hypertension Prevention (TOHP-I) for efficacy in lowering diastolic blood pressure (BP) in healthy men and women aged 30 to 54 years with diastolic BP 80-89 mm Hg. METHODS: A total of 242 and 320 participants were randomized to SMI or an "assessment only" SMI Control, respectively, at four clinical centers. The SMI consisted of 37 contact hours in 21 group and two individual meetings over 18 months and included: training in four relaxation methods, techniques to reduce stress reactions, cognitive approaches, communication skills, time management, and anger management within a general problem-solving format. Standardized protocols detailed methods and timing for collecting BP, psychosocial measures, and urinary samples from both SMI and SMI Control participants. RESULTS: In intention-to-treat analyses, although significant baseline to termination BP reductions were observed in both groups, net differences between the SMI and SMI Control groups' BP changes (mean (95% CI)) were not significant: -0.82 (-1.86, 0.22) for diastolic BP, and -0.47 (-1.96, 1.01) for systolic BP. Extensive adherence sub-group analyses found one effect: a significant 1.36 mm Hg (p = 0.01) reduction in diastolic BP relative to SMI Controls at the end of the trial for SMI participants who completed 61% or more of intervention sessions. CONCLUSIONS: While the TOHP-I SMI was acceptable to participants as evident from high levels of session completion, the absence of demonstrated BP lowering efficacy in intention-to-treat analyses suggests that the TOHP-I SMI is an unlikely candidate for primary prevention of hypertension in a general population sample similar to study participants. The isolated finding of significant diastolic BP lowering in SMI participants with higher adherence provides very weak evidence of SMI BP lowering efficacy and may be a chance finding. Whether similar or other stress management interventions can produce significant BP lowering in populations selected for higher levels of BP, stress, or intervention adherence remains to be demonstrated.

Adult↗

PubMed2003

Research on the quality of parent-provider communication in pediatric care: implications and recommendations.

This narrative review of the correlates of effective parent-provider communication and relevant interventions indicates that effective parent-provider communication is associated with parental satisfaction with care, adherence to treatment recommendations, and enhanced discussion of psychosocial concerns. Moreover, interventions designed to improve parent-provider communication resulted in more discussion of psychosocial concerns, better recall of information from the visit, and improved parent-provider communication. Recommendations for the development of more effective studies of parent-provider communication and relevant interventions in pediatric primary care include the need for theoretical models to help guide research, the development of reliable and valid self-report measures of communication, the assessment of clinically relevant correlates of parent-provider communication, and the study of children's roles in communication with their pediatricians.

Communication↗

PubMed1999

Improving adherence to dementia guidelines through education and opinion leaders. A randomized, controlled trial.

BACKGROUND: Educational methods that encourage physicians to adopt practice guidelines are needed. OBJECTIVE: To evaluate an educational strategy to increase neurologists' adherence to specialty society-endorsed practice recommendations. DESIGN: Randomized, controlled trial. SETTING: Six urban regions in New York State. PARTICIPANTS: 417 neurologists. INTERVENTION: The educational strategy promoted six recommendations for evaluation and management of dementia. It included a mailed American Academy of Neurology continuing medical education course, practice-based tools, an interactive evidence-based American Academy of Neurology-sponsored seminar led by local opinion leaders, and follow-up mailings. MEASUREMENTS: Neurologists' adherence to guidelines was measured by using detailed clinical scenarios mailed to a baseline group 3 months before the intervention and to intervention and control groups 6 months after the intervention. In one region, patients' medical records were reviewed to determine concordance between neurologists' scenario responses and their actual care. RESULTS: Compared with neurologists in the baseline and control groups, neurologists in the intervention group were more adherent to three of the six recommendations: neuroimaging for patients with dementia only when certain criteria are present (odds ratio, 4.1 [95% CI, 1.9 to 8.9]), referral of all patients with dementia and their families to the Alzheimer's Association (odds ratio, 2.8 [CI, 1.7 to 4.8]), and encouragement of all patients and their families to enroll in the Alzheimer's Association Safe Return Program (odds ratio, 10.8 [CI, 3.5 to 33.2]). For the other three recommendations, adherence did not differ between the intervention and the nonintervention groups. Agreement between scenario responses and actual care ranged from 27% to 99% for the six recommendations and was 95% or more for three of the recommendations. CONCLUSION: A multifaceted educational program can improve physician adoption of practice guidelines.

Dementia↗

PubMed1998

Social cognitive and physical health determinants of exercise adherence for HIV-1 seropositive, early symptomatic men and women.

This study examined social cognitive and physical health factors that might explain variations in exercise adherence in a 3-month supervised exercise intervention for a group of mildly symptomatic, HIV-1 seropositive men and women. The social cognitive predictor variables were outcome expectations and self-efficacy. The physical health predictor variables included CD4+ cell counts, self-report inventories of physical symptoms, and physicians' examinations. Self-report inventories of physical symptoms were associated with physicians' examinations and combined into a composite measure of physical health. Criterion variables included exercise adherence rates, VO2max change, and status as a 'remainder' versus 'drop-out.' The composite measure of physical health emerged as a significant predictor of adherence rate and gave perfect prediction of remainers and a moderate prediction of dropouts. No significant associations were observed between the social cognitive predictors and adherence. Results suggest that for this population physical health status is a better predictor of exercise adherence than either perceived self-efficacy or outcome expectancy.

Journal Article↗

PubMedDate not supplied

The nurse as exercise leader.

Adherence rates to our nurse-led exercise interventions were considerably higher (88%) than those reported in the literature for overweight women of this age. Bonding between the women and the nurse leaders, as well as socialization opportunities and program design, may have contributed to this high rate. Future studies would be strengthened by comparing adherence rates of women between nurse-led and non-nurse-led exercise groups. Women tested at 3 and 6 months after the intervention stated they tried many fitness clubs and spas in the area, but could find no exercise programs that were tailored to their age and fitness level or that took into consideration their individual health needs. Nurses interested and knowledgeable about changes of aging are in an ideal position to develop and lead exercise programs for older individuals, particularly those with chronic nondisabling physical problems. Nurses in this study have expanded their health-promotion role by gaining knowledge and skills in exercise science. Resources available for any nurse to gain knowledge and experience about exercise are found in the resource list.

Aged↗

PubMed1994

Value of symphysiotomy in obstructed labour management and follow-up of 31 cases.

Experience of 32 cases of symphysiotomy carried out in Mozambique and in Botswana is reviewed. Of all cases only 1 was lost to follow-up. The observation period varied from 7 days to 6 months. Among 31 cases examined at discharge or on return from check-up few complications occurred. Vaginal laceration occurred in 3 cases, haematuria in 1 case and wound infection in 1 case. In 2 cases there was significant postoperative pain causing gait problems, but in no case were there significant problems with pain at discharge or at follow-up. It is concluded that the intervention is seldom complicated by severe sequelae, provided strict adherence to given indications is respected. In rural areas in the third world symphysiotomy is a life-saving and simple surgical intervention, which should be regarded as an adjunct measure in some cases with a moderately contracted pelvic outlet incompatible with normal vaginal delivery.

Botswana↗

PubMed2003

Impact of a critical pathway on inpatient management of diabetic ketoacidosis.

To assess the management of diabetic ketoacidosis (DKA) and evaluate if introduction of a critical pathway improves management, we studied adults admitted with DKA to the Medicine and Critical Care Services in a US teaching hospital. Patients admitted with DKA in 1997 before implementation of the critical pathway were the control group (n=72). In 1998, housestaff and nurses in the emergency department (ED) and on the General Medicine and Critical Care Services were instructed in the use of the critical pathway. Patients admitted with DKA during 1998 (n=77) were the intervention group. Length of stay (LOS), hospital cost, adherence to guidelines, and medical outcomes to be avoided were compared, and regression analyses were performed to correlate processes and outcomes of care. Mean LOS and variability in LOS decreased during the intervention period, especially in patients treated without endocrinology consultation (EC) (5.2 +/- 10.6 vs. 2.4 +/- 2.1 days, P=0.01), and hospital cost and variability in cost tended to decrease ($6441 +/- 15,204 vs. $3625 +/- 3478, P=0.24). More intervention subjects received the recommended intravenous fluid volume (88 vs. 71%, P=0.013), education in sick-day management (77 vs. 54%, P=0.006), and EC (38 vs. 21%, P=0.03). Insulin management was not changed. We conclude that implementation of a DKA critical pathway reduced practice variation and was associated with shorter LOS and a trend toward decreased cost. Some processes of care were improved but many require additional interventions.

APACHE↗

PubMed2003

Maintenance of exercise participation in individuals with spinal cord injury: effects on quality of life, stress and pain.

STUDY DESIGN: Follow-up study of seven individuals with spinal cord injury (SCI) who completed a 9-month randomized control trial (RCT) of exercise training. OBJECTIVE: In a 9-month RCT conducted in our lab, individuals with SCI who participated in a twice-weekly supervised exercise training reported greater perceived quality of life (PQOL), and less stress and pain than a nonexercising control cohort. The present follow-up study examined the voluntary continuation of exercise training after the study ended and the persistence of the accrued psychosocial benefits. SETTING: Centre for Health Promotion and Rehabilitation, McMaster University, Hamilton, Ontario, Canada. METHODS: Five men and two women (age 42.3+/-3.6 years) with SCI (C5-T12; ASIA A-D 12.7+/-8.2 years postinjury) were invited to continue supervised exercise training twice weekly at the completion of the 9-month RCT. Exercise adherence, PQOL, stress and bodily pain were measured at a 3-month follow-up and were compared to values obtained at baseline, and at 3, 6 and 9 months during the intervention. RESULTS: There was a significant decrease in adherence at the 3-month follow-up compared to the overall 9-month adherence rate (42.7 versus 80.6%, respectively; P<0.01). There was also a significant decrease in PQOL (P<0.05) and a trend for increased pain (P=0.07) and stress (P=0.12), at follow-up compared to the end of the 9-month trial. Finally, there was a significant negative correlation between pain at the conclusion of the RCT and exercise adherence over the 3-month follow-up period (r=-0.91; P<0.01). CONCLUSIONS: These findings emphasize the importance of continued exercise adherence to the maintenance of exercise-related increases in psychological well-being among individuals with SCI.

Adult↗

PubMedDate not supplied

Initial knowledge and attitudes as predictors of intervention effects: the individual management plan.

This paper addresses questions concerning the effects of patient education strategies to increase adherence to antihypertensive medical regimens. It endeavors to fill gaps in our knowledge about intervention effects that may link research findings with health care applications. Data from a community intervention study of 432 hypertensives are used to address two broad questions relating research on patient education to health care practice: Do interventions have different effects on individuals who differ with respect to initial attitudes or knowledge, and to what extent do interventions produce changes in the factors thought to mediate their effects on behavior? This investigation tests a client-oriented approach to the delivery of interventions, the Individual Management Plan (IMP). The IMP approach is based on the hypothesis that interventions will be differentially effective for individuals with varying levels of initial attitudes and knowledge thought to mediate the effects of the interventions on behavior. Analysis of variance, correlational analyses, and analysis of covariance models are used to test various aspects of this hypothesis. Analyses are performed for adherence to medication regimens, dietary sodium restrictions, and weight-loss recommendations. The results of analyses offer only minimal support for the IMP hypothesis. The state of the art and constraining factors in the study are examined to guide future applications of the IMP approach.

Humans↗

PubMed1993

Proactive screening mammography counseling within the Cancer Information Service: results from a randomized trial.

In 1987, the Division of Cancer Prevention and Control, National Cancer Institute (NCI), funded a randomized trial of a proactive counseling protocol to promote screening mammography among age-eligible female callers to the Cancer Information Service (CIS). This protocol included interactive counseling by CIS counselors to help callers overcome barriers to screening mammography; this counseling was an extension of usual service and was combined with a 2-week follow-up mailout to reinforce the brief (6-minute) proactive telephone-counseling protocol. The screening-mammography counseling intervention was tested in two regional CIS offices using a randomized two-group design. Callers were randomly assigned to the intervention or control group based on the week of their call to the CIS (n = 1831 eligible female callers). Self-reported adherence to NCI screening-mammography guidelines was assessed from telephone interviews conducted at 12 months' follow-up (87% response rate). Among all CIS callers enrolled in this study, self-reported adherence to screening-mammography guidelines at 12 months' follow-up was 63.5%. The most frequently cited barriers to screening mammography reported by CIS callers were inconvenience/being too busy (52%), cost (36%), lack of physician referral (34%), no symptoms (34%), and fear of radiation (29%). A significant intervention effect on adherence behavior was found but only in one of the two test sites and only among CIS callers reporting total family income of $30,000 or more (odds ratio = 1.38, P = .04). The vast majority (90%) of CIS callers (both intervention and control subjects) endorsed the concept of proactive counseling by the CIS. The implications of these findings for the CIS and future research are discussed.

Adult↗