PREMIER--a trial of lifestyle interventions for blood pressure control: intervention design and rationale

Interventions encouraging adoption of healthy diets and increased physical activity are needed to achieve national goals for preventing and treating hypertension, cardiovascular disease, diabetes, and other chronic diseases. PREMIER was a multicenter clinical trial testing the effects of two lifestyle interventions on blood pressure control, compared with advice only. Both interventions implemented established national guidelines for blood pressure control (weight loss, reduced sodium and alcohol intake, and increased physical activity), and one intervention also included the Dietary Approaches to Stop Hypertension (DASH) diet. Both interventions focused on behavioral self-management, motivational enhancement, and personalized feedback. This article describes the design and evaluation approaches for these interventions. Evaluation of multicomponent lifestyle change interventions can help us understand the benefits and difficulties of making multiple lifestyle changes concurrently and the effects such changes can have on blood pressure, particularly in minorities at higher risk for hypertension.

Effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control: 18-month results of a randomized trial

BACKGROUND

The main 6-month results from the PREMIER trial showed that comprehensive behavioral intervention programs improve lifestyle behaviors and lower blood pressure.

OBJECTIVE

To compare the 18-month effects of 2 multicomponent behavioral interventions versus advice only on hypertension status, lifestyle changes, and blood pressure.

DESIGN

Multicenter, 3-arm, randomized trial conducted from January 2000 through November 2002.

SETTING

4 clinical centers and a coordinating center.

PATIENTS

810 adult volunteers with prehypertension or stage 1 hypertension (systolic blood pressure, 120 to 159 mm Hg; diastolic blood pressure, 80 to 95 mm Hg).

INTERVENTIONS

A multicomponent behavioral intervention that implemented long-established recommendations ("established"); a multicomponent behavioral intervention that implemented the established recommendations plus the Dietary Approaches to Stop Hypertension (DASH) diet ("established plus DASH"); and advice only.

MEASUREMENTS

Lifestyle variables and blood pressure status. Follow-up for blood pressure measurement at 18 months was 94%.

RESULTS

Compared with advice only, both behavioral interventions statistically significantly reduced weight, fat intake, and sodium intake. The established plus DASH intervention also statistically significantly increased fruit, vegetable, dairy, fiber, and mineral intakes. Relative to the advice only group, the odds ratios for hypertension at 18 months were 0.83 (95% CI, 0.67 to 1.04) for the established group and 0.77 (CI, 0.62 to 0.97) for the established plus DASH group. Although reductions in absolute blood pressure at 18 months were greater for participants in the established and the established plus DASH groups than for the advice only group, the differences were not statistically significant.

LIMITATIONS

The exclusion criteria and the volunteer nature of this cohort may limit generalizability. Although blood pressure is a well-accepted risk factor for cardiovascular disease, the authors were not able to assess intervention effects on clinical cardiovascular events in this limited time and with this sample size.

CONCLUSIONS

Over 18 months, persons with prehypertension and stage 1 hypertension can sustain multiple lifestyle modifications that improve control of blood pressure and could reduce the risk for chronic disease.

Minor life events as predictors of medical utilization in low income African American family practice patients

This study assessed the ability of minor life events to predict medical utilization among 141 low-income, predominantly African American family practice patients. Subjects completed one year of stress assessments including major and minor life events. Four years of prospective medical utilization was collected, including outpatient, inpatient, and emergency department visits. Hierarchical regressions were conducted to assess the predictive value of minor life events for utilization, after controlling for demographic variables and major life events. The impact of minor life events was a significant predictor of outpatient utilization, accounting for 3.6% of the variance. Minor life events were unrelated to emergency department and inpatient visits. The relationship between minor life events and some types of utilization suggests traditional stress management techniques may be beneficial in reducing utilization for some patients, although such conclusions are tempered by the modest relationship between stress and utilization.

Stage of change movement across three health behaviors: the role of self-efficacy

PURPOSE

In this study, we examined the influence of self-efficacy in predicting stage of change (SOC) movement, without intervention, over a 1-month period for smoking cessation, exercise adoption, and dietary fat reduction.

DESIGN

The design of this study was longitudinal. Patients' stage of change and self-efficacy were assessed at baseline, and stage of change was reassessed at a 1-month follow-up. Patients were categorized as (1) Regressors (moved backward at least one stage), (2) Stables (no change), or (3) Progressors (moved forward at least one stage). Chi-square analyses were used to determine the ability of self-efficacy to predict stage movement at 1-month follow-up.

SETTING

The data were collected at a large, inner city, academic hospital in the southeastern United States. Patients were attending primary care clinics.

SUBJECTS

Five hundred fifty-four low income, predominantly African-American, individuals attending primary care clinics were participants in the study.

MEASURES

Previously validated scales of stage of change and self-efficacy from Prochaska's laboratory were used in this study.

RESULTS

Results showed statistically significant differences between predicted and actual SOC movement for smoking cessation, exercise adoption, and dietary fat intake reduction. Baseline self-efficacy ratings were significantly related to stage progression, regression, and stability of stage of change for all three health behaviors. Thirty-seven percent of smokers who were predicted to progress on the basis of their self-efficacy scores progressed. For exercise adoption and dietary fat reduction, 50% and 44%, respectively, of individuals expected to progress at least one stage on the basis of self-efficacy scores progressed.

CONCLUSION

Self-efficacy influences SOC movement for smoking cessation, dietary fat reduction, and exercise adoption.

Validation of the Beck Depression Inventory-II in a Low-Income African American Sample of Medical Outpatients

The psychometric properties of the Beck Depression Inventory-II (BDI-II) are well established with primarily Caucasian samples. However, little is known about its reliability and validity with minority groups. This study evaluated the psychometric properties of the BDI-II in a sample of low-income African American medical outpatients (N=220). Reliability was demonstrated with high internal consistency (.90) and good item-total intercorrelations. Criterion-related validity was demonstrated. A confirmatory factor analysis supported a hierarchical factor structure in which the BDI-II reflected 2 first-order factors (Cognitive and Somatic) that in turn reflected a second-order factor (Depression). These results are consistent with previous findings and thus support the use of the BDI-II in assessing depressive symptoms for African American patients in a medical setting.

Environmental and lifestyle influences on obesity

Obesity is an end result of the intricate interactions of biology, behavior, and environment. Recent hypotheses in the scientific community suggest the current obesity epidemic is being driven largely by environmental factors (e.g., high energy/high fat foods, fast food consumption, television watching, "super-sized" portions, etc.) rather than biological ones. Individuals are bombarded with images and offers of high fat, high calorie, highly palatable, convenient, and inexpensive foods. These foods are packaged in portion sizes that far exceed federal recommendations. Furthermore, the physical demands of our society have changed resulting in an imbalance in energy intake and expenditure. Today's stressful lifestyles compound the effects of environmental factors by impairing weight loss efforts and by promoting fat storage. Combating the obesity epidemic demands environmental and social policy changes, particularly in the areas of portion size, availability of healthful foods, and promotion of physical activity.

Attitudes toward HIV Health Care Providers scale: development and validation

Patient attitudes toward their health care providers can play an important role in determining health behavior change. The frequency of contact with health care professionals and disease stigma makes assessing patients' perception of this relationship of particular interest in an HIV medical population. While past general satisfaction and attitude tools have been used to assess this construct, there is a need for an assessment tool specific to patient attitudes in an HIV setting. This study was designed to validate the Attitudes toward HIV Health Care Provider scale (AHHCP) in an HIV medical population. Principal components analysis of the AHHCP yielded a two-factor structure accounting for 53.3% of the total variance in attitudes toward health care providers. The two factors represented items concerning Professionalism and Emotional Support. The AHHCP was found to have good internal consistency (0.92) and convergent validity with a measure of patient satisfaction (r = 0.59). The results of the present study suggest that the AHHCP is a reliable and valid instrument for use in assessing patient attitudes toward their health care providers.

Use of the Beck Depression Inventory-II with African American primary care patients

The Beck Depression Inventory-II (BDI-II) is one of the most common self-report instruments used for depression screening. However, there is a lack of research examining the effectiveness of this instrument in detecting depression in an African American primary care sample. The current study included 220 African American primary care patients who completed the BDI-II and were administered a diagnostic interview to establish depressive diagnoses. Results indicated that depressed patients demonstrated significantly greater BDI-II total scores compared to non-depressed patients. The recommended cutoff score of 14 for screening for depression appears to be appropriate for African American patients in the primary care setting. This cutoff yielded sensitivity of 87.7% and specificity of 83.9%. Positive predictive value of the BDI-II was .70, and negative predictive value was .94. Similar to findings with predominantly Caucasian samples, current results suggest the BDI-II is an appropriate and accurate instrument to use for depression screening among African American primary care patients.

Use of the weight efficacy lifestyle questionnaire with African American women: validation and extension of previous findings

While the Weight Efficacy Lifestyle Questionnaire (WEL) shows promise as a measure of self-efficacy for eating control, there is a lack of research examining the psychometric properties of this measure with ethnic minorities. The current study examined the WEL with a sample of 144 overweight and obese African American females. Analyses indicated similar self-efficacy levels compared to predominantly Caucasian samples. Supporting the validity of the WEL, participants undergoing obesity treatment demonstrated modest improvement in WEL scores, while standard care participants showed no changes in self-efficacy over time. Factor analysis indicated a four-factor structure rather than the five factors previously found. The four-factor structure accounted for 61.85% of the variance. Results indicate the WEL may be a valid measure of self-efficacy for overweight and obese African American women, although researchers should be mindful of the variation in scale properties when using the WEL with this population.

Ideal weight goals of African American women participating in a weight management program

This descriptive study examined the ideal weight goals of low-income African American women enrolled in a weight loss intervention. Prior to treatment, 107 overweight African American women were weighed, heights were measured, and participants completed a self-report measure of various weight-related variables (e.g., ideal goal weight, amount lost with previous attempts). The average baseline body mass index (BMI) was 38.8kg/m(2). The average ideal BMI was 27.2kg/m(2), which would require a 29.2% reduction in weight. Ideal weight loss was approximately 25kg greater than that achieved during past attempts. Results suggest this ethnic minority sample demonstrated satisfaction with achieving an ideal weight still classified as overweight. However, the percentage of weight loss required to reach such goals is much greater than that recommended by expert guidelines. Although future research is needed, weight loss interventionists may need to address African American women's acceptance of heavier weight when treating their obesity.

Factor Structure of the Center for Epidemiologic Studies Depression Scale in Low- Income Women Attending Primary Care Clinics

Given the high rates of major depressive disorder in primary care settings, routine use of screening measures to assist in identifying depressed individuals is warranted. The Center for Epidemiologic Studies Depression Scale (CES-D) ( Radloff, 1977 ) is a self-rated measure of distress commonly used to screen for depression in primary care settings. The present study was undertaken to confirm the original four-factor model in a sample of low-income women attending primary care clinics (N = 179). Although the original four-factor structure has been replicated in a variety of population groups, internal validity of the measure has not been previously examined in this population sample. A series of confirmatory factor analytic procedures failed to replicate the original four-factor structure or a second-order model. An exploratory analysis, using principal components and a VARIMAX rotation yielded three factors: Depressed Affect/Somatic Symptoms, Positive Affect, and Interpersonal Difficulties. Results of this study add support to previous research documenting an increased somatic presentation of depression in low-income samples. Implications for the use of the CES-D as a screening tool to identify depression in similar primary care samples are discussed.

The transtheoretical model: gender differences across 3 health behaviors

OBJECTIVE

To investigate gender differences in stage-of-change distribution, self-efficacy, and decisional balance, for 3 health behaviors.

METHODS

Five hundred fifty-four (males = 107; females = 447) low-income, predominantly African American, patients completed stage-of- change, self-efficacy, and decisional balance scales for smoking cessation, exercise adoption, and dietary fat reduction.

RESULTS

Males and females differ in stage of change for smoking and exercise, but not dietary fat intake.

CONCLUSIONS

Gender-specific interventions may be needed to promote certain health behaviors but not others, and self-efficacy and decisional balance may be related differently to stage of change in low-income populations.

Congruence of readiness to change, self-efficacy, and decisional balance for physical activity and dietary fat reduction

PURPOSE

The current study examines the relations between decisional balance and self-efficacy variables on stage of change between the behaviors of avoiding dietary fat and increasing exercise.

DESIGN

A cross-sectional design was used.

SETTING

The current study took place in public primary care clinics from four sites across Louisiana. Clinics were associated with teaching hospitals and located in urban and rural areas.

SUBJECTS

Subjects included 515 adult outpatients, 60% African-American, 81% women, and 43% married. The age ranged from 18 to 87 years old, and the mean age was 45 (SD = 14). Patients were predominantly low-income (mean household income of $490 per month) and uninsured (71%).

MEASURES

Standard questionnaires were given to asses stage of change, decisional balance, and self-efficacy for exercise and dietary fat reduction.

RESULTS

Although the chi 2 analysis revealed that dietary fat and exercise stage of change were significantly related, Pearson chi 2 (df = 16) = 74.30, p < .001, 35% of the sample was stage incongruent between behaviors (e.g., a significant percentage of exercise maintainers were precontemplators for reducing dietary fat). Only 27% of the sample was in the same stage for both behaviors. Correlations and multivariate analyses of variance (MANOVAs) indicated that relationships between behaviors were similar to those found previously within behaviors; however, the effect sizes were markedly attenuated.

CONCLUSIONS

These results have implications for healthcare providers working with weight management. Accurate assessment of readiness for change for both exercise and dietary fat consumption is critical. For many patients, readiness for change differs dramatically between the two behaviors, and interventions may need to be tailored more precisely. Providers may need to use more active, behaviorally focused interventions for the more advanced behavior while simultaneously implementing more cognitively focused interventions for the less advanced one.

Changing multiple health behaviors: smoking and exercise

BACKGROUND

Previous stage of change research examining health behaviors has tended to examine one behavior at a time. However, one recent study by King et al. (1996) examined the relationship between smoking and exercise across cognitive-behavioral mediators (i.e., decisional balance and self-efficacy) shown to be important in predicting readiness to change. In this study, we seek to replicate the study of King et al. (1996) in a low-income sample, the majority of whom are women, with at least one chronic illness who are attending primary care clinics.

METHODS

Data were obtained from 270 adult outpatients attending four public primary care clinics in Louisiana.

RESULTS

Smoking and exercise stage of change were not related. Significant relationships existed between the cognitive variables of smoking and exercise. No significant differences existed within exercise stage of change on the cognitive variables of smoking, and vice versa, no significant differences were noted within smoking stage of change on the cognitive variables of exercise.

CONCLUSIONS

Smoking and exercise appear to be specific health behaviors that are independent constructs in this particular sample. However, caution should be taken when interpreting the findings since 75% of the sample had at least one chronic illness.

Applying exercise stage of change to a low-income underserved population

OBJECTIVES

To validate the transtheoretical model for exercise behavior and the constructs of decisional balance and self-efficacy for exercise in a low-income, poorly educated primary care sample.

METHODS

Patients attending public primary-care clinics from 4 separate sites in Louisiana were interviewed regarding their health behaviors.

RESULTS

The data provide equivocal support for applying the transtheoretical model for exercise and integrating it with other models of behavior change within this population.

CONCLUSIONS

Further studies modifying the decisional balance measures are necessary before definitive statements regarding the applicability of these models to exercise within this specialized population can be made.

Primary care weight management counseling: physician and patient perspectives

This paper examines the use of the Guide to Clinical Preventive Services for behavioral counseling for overweight patients in the primary care setting.

METHODS

Study 1 assessed counseling practices of family physicians with a 13-item physician questionnaire based on the Guide to Clinical Preventive Services. Study 2 assessed the perception of weight loss recommendations made to obese primary care patients attending a family practice clinic.

RESULTS

46% of the family physicians responded. The most common referrals were made to dieticians and exercise programs. The patient survey indicated that 80.3% had received weight loss recommendations, and 68.9% had received counseling on diet change or exercise.

CONCLUSIONS

This study found adequate rates of compliance with the Guide to Clinical Preventive Services. However, these results have highlighted the need to expand the guidelines to counsel patients more specifically with regard to weight loss recommendations and to focus on improving patient compliance and motivation.

Examination of the temporal relationship between smoking and major depressive disorder among low-income women in public primary care clinics

PURPOSE

To determine the prevalence of major depressive disorder (MDD) by smoking status, and the temporal relationship between smoking and MDD, and explore other smoking-related variables that may be associated with MDD.

DESIGN

Cross-sectional study.

SETTING

Public primary care clinics.

SUBJECTS

Researchers studied 338 women (76% African-Americans) who were randomly selected while attending appointments in two public primary care clinics.

MEASURES

Data pertaining to smoking-related variables and MDD diagnosis were obtained using the Diagnostic Interview Schedule for the Diagnostic Statistical Manual of Mental Disorder IV (DSM-IV).

RESULTS

The prevalence of a lifetime history of MDD was significantly higher for current smokers (56.6%) than among former smokers (37.5%) or never-smokers (30.3%; p < .001). Most ever-smokers (81.3%) began smoking and were nicotine-dependent (63.6%) prior to their first episode of MDD. Using logistic regression, after controlling for demographic and smoking-related variables, age of smoking onset was the strongest variable associated with MDD among ever-smokers. Specifically, the odds of having an MDD decreased by 8.2% for each year delay in smoking initiation.

CONCLUSION

These results suggest that smoking initiation precedes MDD and that smoking is associated with a high prevalence of MDD among low-income women attending primary care clinics. Further, the younger women start smoking the more likely they are to have MDD.

Utilization of medical services and quality of life among low-income patients with generalized anxiety disorder attending primary care clinics

OBJECTIVE

Anxiety disorders appear to influence morbidity and medical utilization. However, little is known about the relationship between Generalized Anxiety Disorder, quality of life, and medical utilization, especially among low-income patients. The goals of this investigation were to 1) determine if low-income patients with GAD utilize medical services more than patients with other Axis I diagnoses, or no psychopathology, and 2) compare the health-related quality of life of these three groups.

METHOD

Participants were randomly recruited from public primary care clinics and administered intake assessments of demographics, stress, and health-related self-report questionnaires. At the end of the first year a structured psychiatric interview was administered (N = 431). Over the second year, patients (n = 360) were administered a health-related quality of life measure every three months for four assessments. Medical charts were abstracted to collect information about chronic illnesses and visits to outpatient clinics and the emergency department during the two years.

RESULTS

Patients were predominantly middle-aged, low-income, uninsured African-American females. In this low-income sample, patients with GAD utilized the emergency department more and reported poorer quality of life than patients with other Axis I disorders and patients without any psychopathology.

CONCLUSION

Low-income patients with GAD utilize the emergency department more and report poorer quality of life than patients with other Axis I disorders and patients without any psychopathology. Programs to identify and treat patients with GAD may yield improvements in quality of life, as well as reduce emergency department utilization.

The utility of the CES-D as a depression screening measure among low-income women attending primary care clinics. The Center for Epidemiologic Studies-Depression

OBJECTIVE

Depressive disorders are among the most common medical disorders seen in primary care practice. The Center for Epidemiologic Studies-Depression (CES-D) scale is one of the measures commonly suggested for detecting depression in these clinics. However, to our knowledge, there have been no previous studies examining the validity of the CES-D among low-income women attending primary care clinics.

METHOD

Low-income women attending public primary care clinics (n = 179, ages 20-77) completed the CES-D and the Diagnostic Interview Schedule for the DSM-IV (DIS-IV).

RESULTS

The results supported the validity of the CES-D. The standard cut-score of 16 and above yielded a sensitivity of .95 and specificity of .70 in predicting Major Depressive Disorder (MDD). However, over two-thirds of those who screened positive did not meet criteria for MDD (positive predictive value = .28). The standard cut-score appears valid, but inefficient for depression screening in this population. An elevated cut-score of 34 yielded a higher specificity (.95) and over 50 percent of the patients who screened positive had a MDD (positive predictive value = .53), but at great cost to sensitivity (.45).

CONCLUSION

Results indicated that the CES-D appears to be as valid for low-income, minority women as for any other demographic group examined in the literature. Despite similar validity, the CES-D appears to be inadequate for routine screening in this population. The positive predictive value remains very low no matter which cut-scores are used. The costs of the false positive rates could be prohibitive, especially in similar public primary care settings.

Behavioral treatment of chronic psychogenic polydipsia with hyponatremia: a unique case of polydipsia in a primary care patient with intractable hiccups

Psychogenic polydipsia is recognized as a dangerous and potentially life threatening disorder. Few studies have focused on the treatment of polydipsia presenting in the outpatient setting. A review of the behavioral treatment literature pertaining to psychogenic polydipsia is presented. This review is followed by a case illustration of an outpatient behavioral approach to the treatment of psychogenic polydipsia in a non-psychiatric, primary car, adult, male patient suffering from intractable hiccup. An ABA single-case design was used, with sodium concentration as the dependent variable. This behavioral method appears promising in settings where restriction of fluid intake is not practical.

A prospective study of the impact of stress on quality of life: an investigation of low-income individuals with hypertension

The role that major and minor life events play in the quality of life in low-income hypertensives was examined. Participants were randomly recruited from 2 primary care clinics at a public medical center. The study utilized a prospective design. Participants were determined to have hypertension and were being treated with antihypertensive medication prior to and throughout the duration of the study. Participants were administered the Life Experiences Survey and the Weekly Stress Inventory repeatedly during Year 1 to assess major and minor stress, respectively. Participants were repeatedly administered the RAND 36-Item Health Survey during Year 2 to assess quality of life. Usable data were obtained from 183 patients. Analyses revealed that major and minor stress were significant predictors of all measured domains of quality of life, even after age and number of chronic illnesses were statistically controlled. Minor stress contributed uniquely to the prediction of each dimension of quality of life even when age, number of chronic illnesses, and major life events were accounted for. Findings suggest that stress has a significant, persistent impact on the quality of life of low-income patients with established hypertension. These findings extend prior research that has examined the impact of medications on quality of life and suggest that stress needs to be accounted for as well.

The Attitudes Toward Women with HIV/AIDS Scale (ATWAS): development and validation

Over the past 20 years, many scales have been created to measure general attitudes toward People with HIV/AIDS (PWA). A high correlation between negative attitudes toward PWA and rejecting attitudes toward homosexuality has been demonstrated in many studies, which may suggest that although the scales posit to examine "attitudes toward PWA," they may actually tap into attitudes toward homosexuals with HIV/AIDS. These scales may be inappropriate to use for examining attitudes toward other groups of people with HIV/AIDS (e.g., heterosexual women). The present researchers developed and validated the Attitudes Toward Women with HIV/AIDS Scale (ATWAS). Principal components analysis of the ATWAS yielded a four-factor structure accounting for 48.6% of the total variance of attitudes toward women with HIV/AIDS. The four factors were Child Care, Myths/Negative Stereotypes, Reproduction/Contraception issues, and Sympathy/Transmission Route. The ATWAS was found to have good internal consistency (r = .82) and construct validity.

Knowledge and attitudes of family physicians about clinical practice guidelines and the care of patients with type 2 diabetes mellitus

This study examined the attitudes of Louisiana family physicians toward clinical practice guidelines in general and specifically how attitudes and familiarity with the American Diabetes Association Clinical Recommendations (ADACR) correlated with knowledge and evidence-based "best practice" in the care of type 2 diabetes. Surveys were mailed to a random sample of 278 eligible physicians from which a 32% response rate was obtained (n = 90). Family physicians' general attitudes towards guidelines were neutral. Attitude correlated significantly with knowledge of the ADACR (P = .03) but not with "best practice". Despite low scores for knowledge, all but one of the ADACR were adhered to by more than 85% of respondents. Physician attitudes do not appear to be barriers to guideline implementation. Results may be used to focus studies of processes and outcomes in guideline implementation.

Maximizing medication adherence in low-income hypertensives: a pilot study

A pilot study was conducted to examine the association between free medication and comprehensive care on blood pressure control for 60 adults with uncontrolled essential hypertension (mean blood pressure = 157/96 mm Hg) referred from a variety of primary care clinics at a public teaching hospital. Subjects received comprehensive care, free antihypertensive medication dispensed in the clinic, and patient education regarding hypertension and medication compliance. Matched-pair t-tests revealed average drops in blood pressure of 22 mm Hg systolic and 13 mm Hg diastolic for the entire sample from baseline to 6 months post-enrollment (both P's < .001). The comprehensive hypertension management program with education and free medication was significantly related to reduced blood pressure across the 6 months of the study period.

Aerobic fitness and leisure physical activity as moderators of the stress-illness relation

Exercise as a moderator of the stress-illness relation was examined by exploring leisure physical activity and aerobic fitness as potential "buffers" of the association between minor stress on physical and psychological symptoms in a sample of 135 college students. The goal was to gather information regarding the mechanisms by which exercise exhibits its buffering effects. Researchers have examined both physical activity and physical fitness in an attempt to demonstrate this effect; however, whether both of these components are necessary to achieve the protective effects against stress is unknown. This study examined engaging in leisure physical activity and having high aerobic fitness to determine if both were necessary for the stress-buffering effects or if one factor was more important than the other. Findings suggested a buffering effect for leisure physical activity against physical symptoms and anxiety associated with minor stress. This effect was not found with depression. Additionally, there was no moderating effect for aerobic fitness on physical or psychological symptoms. Collectively, the data suggested that participation in leisure physical activity as opposed to level of aerobic fitness is important to the stress-buffering effect of exercise. Implications for exercise prescription are discussed.

Chronic minor stressors and major life events experienced by low-income patients attending primary care clinics: a longitudinal examination

Chronic minor stressors and major life events were assessed from 129 randomly selected low-income patients attending primary care medical clinics. Participants reported experiencing an average of 15 chronic minor stressors in a 12-month period. The most common chronic minor stressors were reported in the areas of finances and domestic activities. Participants also reported these stressors as the most intense. The t tests revealed that female participants reported significantly (p = .05) more chronic events than males. The most common major life events were reported in the areas of vegetative symptoms (i.e., major change in sleeping and eating habits), financial status, illness, and interpersonal relationships. The most stressful life events were changes in vegetative symptoms, family illness, and interpersonal relationships. The t tests revealed that employed participants reported significantly (p < .05) more positive life events than did unemployed participants. Implications of the findings are discussed.

Minor stressors and generalized anxiety disorder among low-income patients attending primary care clinics

The total number of minor life events and subjective ratings of distress associated with these events were assessed for individuals with generalized anxiety disorder (GAD) and for nonanxious controls. Participants consisted of 256 randomly selected, low-income patients from primary care medical clinics. Diagnoses were obtained using the Diagnostic Interview Schedule for the DSM-IV (DIS-IV). An analysis of variance revealed that GAD individuals reported significantly more minor life events than did nonanxious controls (F = 50.97, p < .001). An analysis of covariance indicated that persons with GAD perceived their minor stressors as significantly more stressful than did nonanxious controls, even after the total number of events was controlled (F = 42.07, p < .001). These findings are consistent with cognitive theories of GAD and current revisions to the definition of the disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Implications for theory and research on GAD are discussed.

Predictors of outpatient medical appointment attendance among persons with HIV

Non-adherence to medical regimens is a critical threat to the health of HIV-infected individuals. Patients who do not adhere to routine medical care cannot fully benefit from the increasingly efficacious treatments available to them. Consistent attendance at medical appointments plays a central role in both prolonging life and enhancing quality of life for persons living with HIV/AIDS. By identifying why many patients do not reliably attend medical services, interventions can be undertaken to improve appointment-keeping. The primary purpose of the present study was to identify factors predictive of HIV-related medical appointment attendance. One-hundred-and-forty-four outpatients in a public hospital ambulatory care HIV clinic were followed for seven months. Demographic, medical care and psychosocial factors were measured in order to prospectively predict the percentage of missed clinic appointments by persons with HIV disease. Greater outpatient appointment non-attendance was associated with younger age, minority status, less severe illness and lower perceived social support. Treatment duration, provider consistency, hopelessness and religious coping did not emerge as significant predictors of outpatient appointment-keeping in this sample. Practical and theoretical implications of these findings are discussed in light of recent medical advances in HIV/AIDS care.

Attentional reactions to an MI: the impact of mood state, worry, and coping style

This study investigated the possible development of an attentional bias to cardiac-related words in subjects who recently experienced a myocardial infarction (MI). It was hypothesized that cardiac-related stimuli would have attention-capturing characteristics for post-MI subjects, and this bias would be moderated by level of anxiety, degree of cardiac-related worry, and the subject's coping style. Post-MI subjects (n = 33) and matched controls (n = 31) participated in an attentional search task. The post-MI subjects failed to show the predicted group increases in attention allocated to cardiac stimuli, but a difference between groups still occurred as the control group exhibited directed inattention to cardiac stimuli. Subsequent analysis indicated those post-MI subjects who did evince an attentional bias toward cardiac stimuli had higher monitoring scores on a self-report measure of coping style. Level of emotional distress and cardiac-related worry failed to predict attentional bias for the post-MI subjects.

Prevalence of high-risk behaviors and obesity among low-income patients attending primary care clinics in Louisiana

This study examined the prevalence of the most prominent high-risk behaviors that contribute to mortality in the United States (i.e., sedentary lifestyle, cigarette smoking, and high dietary fat intake) and obesity among low-income patients attending primary care clinics in Louisiana. The sample consisted of 1,132 patients attending primary care clinics that were randomly selected and administered a demographic questionnaire, the 1994 Behavioral Risk Factor Surveillance System, and the Eating Patterns Questionnaire. Participants consisted predominantly of African-American (67.7%), uninsured (73.3%), low-income, middle-aged females. Prevalence of high-risk behaviors included sedentary lifestyle (47.1%), cigarette smoking (26.2%), and high dietary fat intake (61.3%). Prevalence of obesity was 63.5%. In conclusion, low-income patients attending primary care clinics in Louisiana display a high frequency of important high-risk behaviors that contribute to mortality in this country. Obesity is also extremely prevalent in this population. Clinical implications and directions for future studies are discussed.

Emergency medical technician schedule modification: impact and implications during short- and long-term follow-up

OBJECTIVE

To determine whether modifying work schedules from 24- to 12-hour shifts results in favorable improvements across a range of psychological and social variables among emergency medical technicians (EMTs).

METHOD

Sequential (before and after) surveys were completed voluntarily by EMTs at 1 month prior to, 2 months after, and 1 year after a workshift modification (change from 24- to 12-hour shifts). The surveys assessed job satisfaction, occupational burnout, and attitudes toward work schedules. The questionnaires were completed at emergency medical service stations.

RESULTS

Of 70 EMTs in the system, 51 (73%) completed the first 2 stages of this study; 35 (50%) completed all 3 stages. Paired-sample t-tests revealed significant differences between baseline and 2-month posttest scores on the following variables: the Maslach Burnout Inventory: Emotional Exhaustion Scale (less perceived exhaustion at 2 months); the Schedule Attitudes Survey: General Affect (perceived more positive view toward schedule at 2 months); Social/Family Impact (perceived less disruption of social/family life at 2 months); and Composite (less overall disruption in quality of life at 2 months). Statistically significant differences between baseline and 1-year posttest scores were found on the following: Schedule Attitudes Survey: General Affect (more positive view toward schedule at 1 year); Social/Family Impact (less disruption in social/family life at 1 year); and Composite (less overall disruption in quality of life at 1 year).

CONCLUSION

Modifying EMTs' work schedules from 24- to 12-hour shifts was associated with improvements in EMTs' general attitudes toward their schedules, less disruption of social and family life, and decreased levels of emotional exhaustion at 2 months after the change. While the improvements in EMTs' attitudes toward their schedules persisted at the 1-year follow-up, the measure of emotional exhaustion returned to baseline.

Alcoholism among indigent inpatients: identification and intervention by internal medicine residents

BACKGROUND

This study examined alcoholism identification and interventions by internal medicine residents, determined the prevalence of alcoholism among indigent inpatients, and examined some variables related to alcoholism in this population.

METHODS

The alcohol abuse and dependence section of the Diagnostic Interview Schedule was administered to 197 inpatients, and chart audits were done.

RESULTS

The obtained prevalence of alcoholism was 17%. Residents identified current alcohol abuse among 71% of current alcoholics, 17% of past alcoholics, and 3% of nonalcoholics. Sixty-two percent of alcoholics identified by the residents did not receive advice or referral, 13% received advice, 17% were referred to Alcoholics Anonymous, and 8% were referred to an inpatient facility.

CONCLUSIONS

Our results suggest that although residents' identification of alcoholism is satisfactory, it is necessary to improve their rates of intervention. The profile of the alcoholic inpatients in this study includes demographics, presence of chronic illnesses, and utilization of medical services as compared with nonalcoholics.

Predicting smoking stage of change among a sample of low socioeconomic status, primary care outpatients: replication and extension using decisional balance and self-efficacy theories

An expanding body of research using the transtheoretical model with both self-change and treatment programs suggests that differences in readiness for smoking cessation are important predictors of successful abstinence. Understanding the cognitive processes underlying these differences may hold tremendous potential for improving the efficacy and efficiency of intervention strategies. Decisional balance theory and self-efficacy theory have been used to help explore how and why people move through the stages of change, but they have been validated almost exclusively with middle-class, educated White samples This study sought to investigate whether these theories relate in each other in the same manner among low socioeconomic status (SES) primary care outpatients. Results indicated that variables from decisional balance theory (pros, cons) and self-efficacy theory successfully differentiated stage membership and yielded results consistent with the extant literature. Self-efficacy demonstrated the most powerful association with stage membership, whereas pros, cons, and temptations exhibited varying degrees of association. Clinical implications and special considerations when conducting research and implementing interventions with low-SES smokers are discussed.

Stress, job satisfaction, coping, and psychological distress among emergency medical technicians

INTRODUCTION

Although several studies link job-related stressors with adverse reactions among emergency medical technicians (EMTs), more standardized research is needed, since much remains unknown about stress responses, coping styles and their consequences for EMTs. This paper presents the results of two studies. Study I investigated the relation between job-related stressors, job satisfaction, and psychological distress, while Study II investigated how coping is related to occupational burnout, job-related stress, and physiological arousal.

HYPOTHESIS

Study I: Those EMTs experiencing greater job-related stressors are less satisfied with their jobs and more psychologically distressed. OBJECTIVE, STUDY II: To obtain preliminary information about which coping strategies are associated with greater feelings of stress and burnout and more intense autonomic nervous system reactivity.

METHODS

For both studies, EMTs from a large, urban, public EMS organization in the southern United States were asked to participate. Study I: Subjects completed an informed consent document, a demographics questionnaire, a measure of job stress (the Stress Diagnosis Inventory), a measure of job satisfaction (Job-in-General), and a measure of psychological symptomatology (Symptom Checklist-90, Revised). Pearson product-moment correlations were computed between the measures. Study II: Subjects completed an informed consent document, a demographics/information sheet, the Maslach Burnout Inventory (MBI), and the Ways of Coping Scale (WOCS). They then completed 30 days of monitoring using the Daily Stress Inventory (DSI) and the Daily Autonomic Nervous System Response Inventory (DANSRI). Pearson product-moment correlations were computed between the measures.

RESULTS

Study I: Those EMTs who experienced greater job-related stress also were significantly more dissatisfied with their jobs, more depressed, anxious, hostile, and endorsed greater global psychological distress. Study II: The Depersonalization subscale on the MBI correlated significantly with the following WOCS subscales: Accepting Responsibility, Confrontive Coping, Distancing, and Escape/Avoidance. Emotional Exhaustion on the MBI correlated significantly with Confrontive Coping, Escape/Avoidance, and Social Support, while data obtained on the 40 subjects who completed the daily monitoring revealed that DSI-Impact, DANSRI-Number, and DANSRI-Impact scores each correlated significantly with Accepting Responsibility, Confrontive Coping, and Escape/Avoidance.

CONCLUSION

A significant portion of an EMT's job satisfaction and psychological well-being is associated with the degree to which they are experiencing job-related stress, and, furthermore, this distress level appears to be clinically elevated. This implies that in-service programs and psychological support services designed to help EMTs manage their job-related stress may improve job satisfaction and decrease psychological distress. The coping styles most consistently associated with maladaptive outcomes were: Accepting Responsibility, Confrontive Coping, and Escape/Avoidance. Thus, subjects who were more likely to handle stress with self-blame, aggression, hostility, and risk taking or with wishful thinking, escape tendencies, and avoidance were more likely to endorse more negative outcomes.

The Multidisciplinary Hemodialysis Patient Satisfaction Scale: Reliability, Validity, and scale development

Patient satisfaction is frequently used to evaluate service quality. Although this is a common construct, satisfaction scale development has often overlooked the importance of psychometric properties and the uniqueness of patient experiences. Although there is a substantial body of literature investigating satisfaction with general patient services and physicians, development in the areas of multidisciplinary team assessment, specific patient populations, and minority groups is needed. To date, only one hemodialysis patient satisfaction scale with attention to psychometric properties appears to be available. However, this instrument does not assess satisfaction with the roles of the full hemodialysis treatment team. The present study reports the development and preliminary reliability and validity studies of the Multidisciplinary Hemodialysis Patient Satisfaction Scale (MHPSS). This 110-item Likert scale assesses the degree of satisfaction with the health care services of a multidisciplinary hemodialysis team. Methods used to construct the subscales, measuring different dimensions of service, include item analyses and principal components factor analysis. Matched-pair items were included and partialled out of a correlation matrix to control for inconsistent responding or for possible response biases. Results indicate that the MHPSS is psychometrically sound and may be a useful tool for assessment of patient satisfaction and continuous quality assessment of hemodialysis services.

Patient care and daily stress among emergency medical technicians

INTRODUCTION

There is conflicting research regarding the extent to which patient care is a source of stress for emergency medical technicians (EMTs). Some research indicates that it is important, whereas other studies suggest that it takes a "back seat" to administrative and organizational problems. This study sought to explore this issue further by investigating the relationship between caring for patients, daily workday stress, and daily non-workday stress among EMTs.

METHODS

All EMTs employed by East Baton Rouge Parish Emergency Medical Services were eligible for participation. After the study was described, subjects completed a demographic information sheet and informed consent was obtained. Participants then completed 30 days of monitoring with a standardized measure of daily stress (the Daily Stress Inventory) and a measure of patient care stress designed for use in this study (Emergency Call Questionnaire).

RESULTS

A very large portion of the variance in the EMTs' overall daily workday stress was associated with patient care (r = 0.677, p < 0.001). Additionally, patient care stress on workdays significantly predicted overall daily stress on the following nonworkday (i.e., postworkday) (r = 0.633, p < 0.001). Finally, EMTs who had stressful pre-workdays rated their patient care as more stressful on the following workday (r = 0.512, p < 0.01).

CONCLUSIONS

Results suggest that patient care is a critical factor in daily stress among EMTs, both on workdays and post-workdays, providing preliminary evidence for a carryover effect. Evidence also suggests that stress on the day before work may influence EMTs' perceptions of their patients on workdays.

Factors associated with depression in a heterogeneous HIV-infected sample

The present study examined factors contributing to depressive symptomatology in a low SES, heterogeneous HIV seropositive sample. The sample was comprised of 120 HIV-infected patients who completed psychosocial measures upon their initial visit to an outpatient HIV clinic. Length of time since HIV seropositive notification and HIV-related symptomatology were also assessed. Social support, major life stress, and HIV-related symptomatology were significantly associated with depression. Perceived availability of social support accounted for the greatest variance in depression scores. Length of time since seropositive notification was not significantly associated with depression. These findings extend previous research with middle-class, homosexual, white males to the rapidly growing minority, heterosexual, and low SES populations and point to the need for the inclusion of social support interventions in the provision of services of these individuals.

Ozone level effect on respiratory illness: an investigation of emergency department visits

This project examined the relationship of daily ozone (O3) levels to the number of respiratory-related emergency department (ED) visits. The confounding effects of temperature, humidity, mold, and pollen counts were examined, as were the effects of day of the week on numbers of ED visits. The design is a time-series relating concurrently measured variables that are repeatedly measured over time. Respiratory-related ED visits at three hospitals in a southern city were examined. Visits were analyzed separately for pediatric, adult, and geriatric patients. A significant association was found between elevated O3 levels and respiratory-related visits for adults. The same association was not found for pediatric or geriatric ED visits. Days with higher ozone were accompanied by higher numbers of adults going to the emergency department because of respiratory complaints. However, the effect was not large and does not appear to hold for pediatric or geriatric ED visits.

The relation of stress and depression to interdialytic weight gain in hemodialysis patients

Nonadherence to fluid restrictions is a common problem with serious health consequences for patients with end-stage renal disease (ESRD). For the present study, the authors evaluated psychological variables of stress, as measured by major and minor life events, and depression. They sought to determine the role of these events in patients' failure to adhere to fluid restrictions as measured by increased interdialytic weight gain. Forty-two hemodialysis patients completed inventories assessing major life events, daily stressful events, and depression on three consecutive dialysis sessions. Fluid adherence was measured by interdialytic weight gain. A path analysis model found daily minor stress to have a direct effect on nonadherence, whereas there was a direct inverse effect of depression on nonadherence. Possible mechanisms and implications for future studies are discussed.

Stress, depression, and anxiety predict average symptom severity and daily symptom fluctuation in systemic lupus erythematosus

Forty-one subjects diagnosed with systemic lupus erythematosus (SLE) were recruited from across the United States. Regressions were conducted to evaluate the relation among stress, depression, anxiety, anger, and SLE symptom complaints. Negative weighting of major life events predicted symptom history. Significant hierarchical regressions using negative weighting of major life events, impact of daily stress, depression, anxiety, and anger were found for severity of joint pain, abdominal distress, and rash. Analyses using 1-day-lagged predictors yielded similar results. Within-subject analyses suggested that there was much individual variability in the strength of the stress-illness relation. Thus, some individuals appeared to be stress responders, while others did not. Findings for impact of minor life events and depression were consistent across the different levels of analyses. It was concluded that stress, depression, anxiety, and anger are associated with, and may exacerbate, self-reported symptomatology of SLE patients.

Subsyndromal ("mixed") anxiety--depression in primary care

OBJECTIVE

To determine in primary care settings the prevalence, clinical characteristics, and functional status of patients who have anxious and depressive symptoms who did not meet diagnostic criteria for major mood and anxiety diagnoses.

DESIGN

Patients were screened with the General Health Questionnaire and interviewed if they exceeded the cutoff score of 5. Also, one patient whose score was below the cutoff was interviewed for every two patients whose scores were above the cutoff.

SETTING

Five primary care sites in the United States, France, and Australia.

PATIENT

Two hundred sixty-seven patients presenting to their primary care physicians for general medical care and follow-up.

METHODS

Structured diagnostic interviews were conducted and ratings of anxiety, depression, and functional impairment were obtained by trained interviewers.

RESULTS

After adjustments for sampling, 5% of the patients had symptoms of anxiety, depression, and functional impairment, without meeting formal criteria for a major DSM-III-R mood or anxiety disorder. This was comparable to the prevalence of diagnosable DSM-III-R mood disorders but only one-fourth the prevalence of diagnosable anxiety disorders. These patients who had subsyndromal symptoms had rates of lifetime psychiatric disorders and prior psychiatric treatment comparable to those of patients meeting criteria for major mood and anxiety disorders.

CONCLUSION

The comparable rates of symptomatic distress, functional impairment, and prior psychiatric illness and treatment suggest that patients with subsyndromal anxiety and depressive symptoms warrant clinical recognition and possibly specific treatment.