Trusting technology: women aged 40-49 years participating in screening for breast cancer--an exploratory study

OBJECTIVE

This paper reports key findings from an exploratory study of factors associated with women's decision to participate in mass mammography screening in Tasmania. In particular, we explored factors that contribute to the choice to participate in screening by women who are outside the primary target group, and for whom the evidence of benefit remains contentious.

METHODS

Semi-structured interviews were conducted with a small sample of women aged between 40 and 49 years in rural Tasmania who had participated in mammography screening.

RESULTS

Key ideas that appeared to shape participation included the fear of breast cancer, trust in technology, and taking responsibility for health. Information provision is also an important factor in shaping participation patterns.

CONCLUSIONS AND IMPLICATIONS

In order to facilitate informed consent, information provision in this area should take account of the dominant ideas that shape the decision to participate in breast cancer screening.

Why are patients in clinical trials of heart failure not like those we see in everyday practice?

BACKGROUND/OBJECTIVES

Evidence-based research has been criticized for not being relevant to the real world of patient care in the community, mainly because participants in research studies are dissimilar to those typically seen in every day practice. This article examines recruitment difficulties, and identifies the main reasons why patients with heart failure declined to participate in a research trial.

METHODS

Postal survey of potential trial participants (n=667), at time of recruitment. Analysis of (1) clinical and sociodemographic characteristics of respondents and nonrespondents to survey, and decliners and consenters to participation in a randomized controlled trial.

RESULTS

No significant differences were found between respondents and nonrespondents in respect to sociodemographic or clinical variables. Males (OR=1.58, CI=1.04-2.41), younger patients (OR=1.05, CI=1.03-1.08), and those prescribed an angiotensin converting enzyme (ACE) inhibitor (OR=1.68, CI=1.10-2.57) were significantly more likely to consent to participate. Main reasons for nonparticipation were perceptions of being too old, too unwell, or too busy.

CONCLUSIONS

Explanations of the purpose of research need to counter against perceptions among participants and clarify the benefits and disadvantages of participating in an intervention study when unwell. Study design should recognize that many elderly patients have busy lives and caring responsibilities. Financial support for participation should be considered.

Patients' preferences for communicating a prostate cancer diagnosis and participating in medical decision-making

OBJECTIVES

To assess patients' preferences about how physicians' deliver news of a prostate cancer diagnosis, and patients' preferred participation in medical decision-making, with a secondary objective being to validate the Measure of Patients' Preferences (MPP) scale with these patients.

PATIENTS AND METHODS

Eighty-seven men (mean age 62.4 years) referred to an ultrasound/radiology department for their first transrectal ultrasonography (TRUS)-guided biopsy completed the MPP and Control Preferences measures. Patients were asked to identify how they would like to be told about a potential prostate cancer diagnosis by their physician, and what role they would like in making treatment-related decisions with their physicians.

RESULTS

Most patients wanted either an active (43%) or collaborative (47%) role in medical decision-making if the TRUS showed prostate cancer. Men rated content items (what and how much information is provided by their physician) as more important than supportive (emotional support during interaction) or facilitative (setting and context variables) items. Men who preferred a collaborative role in the patient-physician interaction wanted significantly (P = 0.04) more content (detailed information on available treatments and the effect of these treatments on their quality of life) than men who had a preference for either an active or passive role in medical decision-making. Demographic characteristics were not indicative of either preferred role in decision-making or communication preferences. The MPP was shown to be reliable.

CONCLUSIONS

Men have expectations about how physicians disclose a diagnosis of prostate cancer and how they wish to participate in making treatment decisions. These results underline the importance of identifying patient preferences before embarking on treatment discussions, as the way 'bad news' is disclosed has previously been identified as a predictor of the outcome of the patient-physician interview.

National Institutes of Health's Clinical Center Sets New Policy on Use of Herbal and Other Alternative Supplements by Patients Enrolled in Clinical Trials

The nationwide concern over the escalating use of herbal and other alternative dietary supplements is prompting a call for action in health care organizations. Not only is there mounting evidence to support a strong concern for patient safety, but the use of these products by people participating in biomedical research protocols has an added impact on the integrity of the research design and data gathering. These issues are of increasing concern to the National Institutes of Health's hospital for biomedical research, the Warren Grant Magnuson Clinical Center. Surveys completed in 2000 showed that 25-45% of Clinical Center patients reported taking herbal and other alternative dietary supplements. In 2001, the Clinical Center moved forward to develop and implement a policy to guide hospital staff in the management of patient use of herbal and alternative supplements. The policy established the requirement for all patients to be screened for supplement use upon admission or outpatient visit. Continued use of supplement products during hospitalization and/or outpatient enrollment on protocol require a physician's authorizing order. The implementation of this policy has increased awareness and provided an important step forward in protecting patient safety and preserving the scientific integrity of the research at the NIH's Clinical Center.

Patient-led variable dosing with balsalazide as long-term therapy for maintenance in ulcerative colitis: a 3-year prospective observational study

BACKGROUND

The patient-centred approach is new to the management of ulcerative colitis. To date, it has only been shown to be successful in a short-term study.

AIM

To assess the feasibility, safety and efficacy of patient-led dosing using balsalazide in the long-term treatment of ulcerative colitis.

METHODS

This was a 3-year, two-cohort, multi-centre study: one cohort was in stable remission (52 patients) and the other was newly in remission (76 patients) from ulcerative colitis. Two 750-mg balsalazide capsules were given twice daily for maintenance, increased by 750-mg increments to a maximum of 6 g for up to 7 days depending on symptom severity. Clinical assessments were made every 12-14 weeks; laboratory assessments were made every 6 months.

RESULTS

The average median daily dose of balsalazide was 3 g (range, 1.5-6 g). In the cohort with stable remission, 23 patients (44%) had relapsed by 3 years [median time to relapse, > 1095 days (36 months)]. In the cohort newly in remission, these values were 45 patients (59%) and 656 days (22 months), respectively. In the cohort with stable remission, the time since last relapse was significantly associated with relapse during the first year of treatment (P < 0.033).

CONCLUSIONS

Long-term, patient-led, maintenance treatment with balsalazide is well tolerated with a good safety profile and is effective for patients with ulcerative colitis.

How rheumatologists and patients with rheumatoid arthritis discuss exercise and the influence of discussions on exercise prescriptions

OBJECTIVE

To describe how patients and their rheumatologists discuss exercise, and to identify predictors of exercise prescriptions.

METHODS

Twenty-five rheumatologists and 132 patients with rheumatoid arthritis completed questionnaires and were audiotaped during a subsequent clinic visit. Chi-square and t-tests assessed associations between variables. Principal components analysis identified patterns of talk about exercise. Multivariate logistic regression identified predictors of an exercise prescription.

RESULTS

Seventy of the 132 patients (53%) discussed exercise. Of these, 18 (26%) received an exercise prescription. Principal components analysis identified 3 patterns of talk about exercise. Aerobic exercise discussions contained more information about drawbacks, side effects, pain, and bargaining than did discussions about general exercises, and referral to physical therapy for exercise. Significant predictors of a prescription included rheumatologist-initiated discussion about exercise (odds ratio [OR] 4.6; P = 0.03); talk about exercise in improving function, exercise instructions, opinions about the usefulness of exercise (OR 3.1; P = 0.01); and discussions about non-exercise treatments (OR 1.6; P = 0.01).

CONCLUSION

Exercise and referral to physical therapy for exercise are discussed differently and are 4 times more likely to occur when the rheumatologist initiates the discussion. These discussions strongly impact on the likelihood a patient receives an exercise prescription.

Teaching received in caries prevention and perceived need for Best Practice Guidelines among recent graduates in Finland

The present study evaluated teaching that recent graduates in Finland had received in caries prevention and their perceived need for updated Best Practice Guidelines. A two-page questionnaire was mailed to all dentists in Finland who had graduated from 1995 to 1998 (n = 390). After one reminder, the response rate was 46%. The closed questions covered teaching in 14 caries-preventive methods and its suggestions as to when and on whom to apply such methods. Each dentist's own opinion on the three most important methods for caries prevention in patients with various types of dentition was sought in open questions. The respondents reported that at dental school, on average 12.5 (SD = 2.4) of 14 aspects of caries prevention were covered in theoretical teaching, 5.5 (SD = 3.8) in demonstrations and 8.5 (SD = 3.0) in clinical training. The top four methods teaching suggested for every patient were toothbrushing (100%), use of fluoridated toothpaste (99%), interdental cleaning (98%), and use of xylitol (97%); followed by fluoride varnish (77%) and fissure sealants (54%). The three caries-preventive methods the respondents felt to be most useful were the same for all types of dentitions, in order of importance: (i) toothbrushing and use of fluoridated toothpaste, (ii) supplementary use of fluorides at home and (iii) healthy dietary habits, in particular, avoidance of sucrose. As regards clinical work, such teaching had served the respondents' real-life needs in patients' caries prevention either extremely (44%) or moderately (54%) well; 91% said, however, that they would benefit from nationwide Best Practice Guidelines. In conclusion, the recent graduates' emphasis on patient-active methods in caries prevention may indicate a change in the current policy favouring patient-passive methods.

Should patients and their families contribute to the DSM-V process?

The authors consider arguments for and against the formal inclusion of mentally ill patients and their families in the deliberative processes leading to DSM-V. These discussions involve six key issues: the scientific status of psychiatric classifications; public policy and political considerations; the practical implications of widening the review process; the capacities of lay members of the workgroups; freedom of expression and the openness of the review process; and the uniqueness of consumer perspectives. The authors conclude that involving patients and families in the DSM review process is supportable on both scientific and public policy grounds.

Overweight and obesity: helping clients to take action

This article presents the results of a qualitative research project to explore factors that encourage or discourage overweight people from low income groups to access weight loss services. Semi-structured interviews were conducted with 16 people attending a commercial slimming organization in South Yorkshire. The study revealed weight loss decisions to be complex and fragile. The experiences reported mirror the 'stages of change' model described by Prochaska and DiClemente (1992). Triggers to action occurred cumulatively and decisions were reached gradually. The triggers included embarrassment and humiliation, health, fear, critical events and image. Disincentives to action were denial, previous bad experiences, previous failure and money. Decisions were linked to low self-esteem and confidence, making people vulnerable at the point they take action. The implications of this for nursing practice and services in primary care are considered.

Pedagogy, power and service user involvement

This paper explores mental health nurse educators' perceptions of the involvement of service users in preregistration nurse education. The idea for the study was developed from a local group of people including service users, lecturers and students committed to finding ways to develop service user involvement in education. This qualitative study uses semi-structured interviews to explore participants' perceptions in depth. Five lecturers who teach on the diploma programme based at a large teaching hospital were interviewed. The results suggest that the current situation of involving service users at the research site was ineffective. The concepts of 'role' and power relationships were used to explore the reasons for this. The development of service user involvement in education is complex and requires further research.

Potential research participants' views regarding researcher and institutional financial conflicts of interest

BACKGROUND

Financial conflict of interest in clinical research is an area of active debate. While data exist on the perspectives and roles of academic institutions, investigators, industry sponsors, and scientific journals, little is known about the perspectives of potential research participants.

METHODS

The authors surveyed potential research participants over the internet, using the Harris Interactive Chronic Illness Database. A potential research participant was defined by: (1) self report of diagnosis by a health care professional and (2) willingness to participate in clinical trials. Email invitations were sent to 20 205 persons with coronary artery disease, breast cancer, or depression; a total of 6363 persons were screened; of these, 86% or 5478 met inclusion criteria and completed the survey. The outcome measures were respondents' ratings on: importance of knowing conflict of interest information, whether its disclosure ought to be required, and its effect on willingness to participate-across seven widely discussed scenarios of financial conflicts of interest (ranging from commercial funding to equity ownership).

RESULTS

Majority responded that knowing conflict of interest information was "extremely" or "very" important; a larger majority felt financial conflicts of interest should be disclosed as part of informed consent (64% to 87%). In all seven scenarios, a majority was still willing to participate but in some scenarios a sizable minority would be wary of participation. Respondents were more wary of individual than institutional conflicts of interest. Illness group and sociodemographic factors had modest effects and did not affect the main trends.

CONCLUSIONS

The prevailing practice of non-disclosure of financial conflicts of interest in clinical research appears contrary to the values of potential research participants.

From compliance to concordance: barriers to accomplishing a re-framed model of health care interactions

As a framework for organising health care interactions, compliance and adherence have come in for increasing criticism in recent years. It has been suggested that interactions with patients should not be viewed simply as opportunities to reinforce instructions around treatment: rather, they should be seen as a space where the expertise of patients and health professionals can be pooled to arrive at mutually agreed goals. This concept-known as concordance-is attracting increasing interest in health services research within the UK. In this paper, we seek to empirically explore the relevance of a re-framed consultation through qualitative interviews with a small group of English speaking patients of Pakistani origin with a diagnosis of type 2 diabetes. We suggest that the focus of many respondents in this study on material and structural factors limiting diabetic regimen integration and the emphasis on a 'doctor-centred' model of health care interactions represent distinct problems for the accomplishment of the concordance project. However, given that some patients sought greater understanding and appreciation by health professionals of the subjective aspects of living with diabetes, if it is evaluated at the level of health care relationships, rather than health outcomes (such as improved compliance) concordance may well be a significant development for those who suggest that respect for the patients agenda is a fundamental aspect of health care.

A Unique Set of Interactions: The MSU Sustained Partnership Model of Nurse Practitioner Primary Care

PURPOSE

To present a unified conceptual model that identifies the integral processes of nurse practitioner (NP) care delivery and that integrates major structural influences and potential outcomes. The model is further characterized to delineate the unique and "value-added" nature of NP primary care and to describe how this nature may be correlated with specific clinical outcomes.

DATA SOURCES

Extensive review of the literature, relevant conceptual models, clinical experiences of th authors, and two sets of qualitative dat exploring differences between NP practice an other practices.

CONCLUSIONS

The basis of NP primary care is the unique provider-client relationship that develops within the primary care setting. This relationship is oriented toward (a) helping client become empowered to more appropriately manage their own care in a way that will best meet their needs, (b) encouraging mutual deci sion making, (c) ensuring clients' continuity o care, and (d) providing a holistic approach to primary care. The major structural influences are NP role components, interdisciplinary practice relationships, budget resources and payer mix, and environmental characteristics. The potential outcomes are increased health promoting behaviors, improved utilization of care, higher client satisfaction levels, and improved health status.

IMPLICATIONS FOR PRACTICE

NPs can use this model to articulate the unique contribution of NP practice and its interrelationships within the broader primary care setting. Practicing NPs can use this framework to better understand the complexities of their current and future primary care practices. Faculty can utilize the concepts to help guide students' understanding of their prospective roles as advanced practice nurses. Finally, this conceptual framework can inform research about specific NP processes and related outcomes. A clearly delineated model that accurately depicts structures, processes, and outcomes relevant to NP primary care can strengthen NP education, distinguish NP practice, and advance evidenced-based research linking NP practice and outcomes.

Use of anti-emetic herbs in pregnancy: women's choices, and the question of safety and efficacy

The majority of North American pregnant women experience some degree of nausea and vomiting, usually in the first few months of pregnancy. Women utilize many coping strategies, including self-treatment with herbal medicine and other alternative therapies. In a qualitative study of self-care in pregnancy, birth and lactation within a non-random sample of 27 women in British Columbia, Canada, 20 women (74%) experienced pregnancy-induced nausea. Ten of these women used anti-emetic herbal remedies, which included ginger, peppermint, and Cannabis. The safety and efficacy of each of these herbal remedies is discussed here. Only ginger has been subjected to clinical trials among pregnant women, though all three herbs were clinically effective against nausea and vomiting in other contexts, such as chemotherapy-induced nausea and post-operative nausea. While safety concerns exist in the literature for all three herbs with regards to their use by pregnant women, clinical evidence of harm is lacking.

The Patient Perspective Survey (PPS): a new tool to improve consultation outcome and patient involvement in general practice patients with complex health problems. Psychometric testing and development of a final version

The Patient Perspective Survey (PPS) is designed to enhance consultation outcome and patient participation among general practice patients with complex health problems. This article presents the final version of the survey. This version is more condensed, tested for psychometric and clinical properties, and with increased emphasis on coping. The development and testing was performed in two phases with two groups of GPs and patients. Indications for use and criteria for rejection of items were defined, based on comprehensive data analysis and clinical judgement. The number of items was reduced to 38 items. The majority of diagnoses were related to psychosocial or musculoskeletal disorders. For the survey's main dimensions (psychological and somatic items, everyday life situation and coping) sound psychometric properties were identified. Seven open-ended questions were found useful for obtaining important new information and stimulating processes, often related to coping aspects. The revised 38-item PPS represents a condensed and final version, with increased focus on coping, and sound psychometric properties.