Principles of changing health behavior

Perceptions of Facilitators and Barriers to Smoking Cessation Among Patients and Providers in a Cancer Center: A Single Institution Qualitative Exploratory Study

PURPOSE

Cancer patients who remain tobacco users have poorer outcomes, including increased mortality and decreased treatment tolerance; however, cessation post-diagnosis is challenging. Our formative research explored cessation-related perspectives among patients and staff at one National Cancer Institute-designated cancer center, to inform improving cessation services within oncology care.

METHODS

Using a descriptive phenomenological approach, a purposive sample of current cancer patients (n = 13) and cancer center physicians and cessation program staff (n = 9) were recruited to complete one-on-one audio-recorded in-depth qualitative interviews, to explore experiences providing or receiving cessation support, and perspectives on patients' readiness and needs regarding cessation. Thematic coding utilized Green's predisposing, enabling, and reinforcing framework to identify factors having positive, negative, or mixed impact on delivery of best-practices cessation services (ie, 5As) and patient cessation success.

RESULTS

Patients identified cancer diagnosis as a wake-up call, existing health problems, persistent healthcare providers, cost of cigarettes, and societal disapproval of smoking as factors facilitating quitting. Futility of quitting after a cancer diagnosis, cost and logistics of program participation, clinician time constraints, and lifetime addiction made quitting harder. Family, friends, stigma and motivation, and pharmacotherapies played mixed roles. Patients felt survivor-focused cessation programs, including stress management, could better enable quitting. Provider-anticipated problems with implementing cessation counseling included so-called "therapeutic nihilism" (ie, pessimism regarding cessation post-diagnosis), lack of training and standardized approaches, and time and documentation burden. Clinicians saw both policies and peer clinician "champions" as potentially increasing prioritization of cessation within oncology.

CONCLUSIONS

Findings highlight unmet needs for patients and providers regarding provision of effective cessation care. Despite survival benefit, cessation is still not standard within cancer care. Our results show that many patients would benefit from standardized programs where they are routinely asked about cessation. Providers would benefit from both structural enhancements and professional education to ensure that evidence-based cessation services tailored to cancer patients, are offered throughout treatment and survivorship.

Health promotion practices as perceived by primary healthcare professionals at the Ministry of National Guard Health Affairs, Saudi Arabia

INTRODUCTION

In recent years, several research studies have investigated health promotion practices in Saudi healthcare organizations, yet no published literature exists on health promotion practices of primary healthcare professionals working for the Ministry of National Guard Health Affairs (MNG-HA).

METHODS

A cross-sectional study was conducted in a convenience sample of 206 primary healthcare professionals at the MNG-HA. A self-reporting questionnaire was used to investigate the attitudes, awareness, satisfaction, and methods regarding health promotion practices of primary healthcare professionals.

RESULTS

Of the 206 primary healthcare professionals surveyed, 58.1% reported awareness of health promotion programs conducted in the hospitals and 64.6% reported that the health promotion system in the hospitals needs to be improved. Language barriers and cultural beliefs were viewed as obstacles to carrying out effective health promotion by 65% and 64.6% of primary healthcare professionals, respectively. The majority (79.9%) of the primary healthcare professionals perceived themselves as having the necessary skills to promote health and 80.6% believed that printed educational materials are the most prevalent method of health promotion/education, whereas 55.8% reported that counseling was the most preferred method of health promotion.

CONCLUSION

The awareness level of health promotion policies, strategies, and programs conducted in the hospitals was not found to be satisfactory. Therefore, widespread training programs are recommended to improve the health promotion system in the hospitals. These programs include facilitating behavioral change, introducing health promotion policies and strategies in hospitals, mandatory workshops, and systematic reminders.

Colorectal cancer screening disparities in Asian Americans and Pacific Islanders: which groups are most vulnerable?

BACKGROUND

Colorectal cancer (CRC) is a significant cause of mortality among Asian Americans and Pacific Islanders (AAPIs), yet studies have consistently reported lower CRC screening rates among AAPIs than among non-Latino Whites and African Americans. Moreover, existing research tends to aggregate AAPIs as one group when reporting CRC screening, masking the disproportionate burden in cancer screening that exists across AAPI groups.

METHODS

This study examines differences in CRC screening rates in both aggregated and disaggregated AAPI groups as compared with non-Latino Whites in order to identify the most vulnerable AAPI subgroups in terms of obtaining CRC screening. This study utilizes merged data from the 2001, 2003, and 2005 California Health Interview Survey (CHIS), specifically the data pertaining to adults aged 50 and older (n = 52,491) from seven AAPI groups (Chinese, Japanese, Korean, Filipino, South Asian, Vietnamese, and Pacific Islander) and non-Latino Whites. Andersen's Behavioral Model of Health Services Use was utilized to select potential confounders to racial/ethnic differences in CRC screening.

RESULTS

When AAPI groups were considered as an aggregate, their CRC screening rate (46.8%) was lower than that of non-Latino Whites (57.7%). When AAPI groups were disaggregated, further disparity was noted: Koreans (32.7%) showed the lowest CRC screening rate, whereas Japanese (59.8%) had the highest. When the influence of potential predisposing, enabling, and need confounders was adjusted, Koreans, Filipinos, and South Asians were found to have a lower likelihood than non-Latino Whites to undergo CRC screening. Comparisons among AAPI subgroups further revealed that Filipinos, Koreans, Pacific Islanders, and South Asians were less likely than Chinese, Japanese, and Vietnamese to receive CRC screening.

CONCLUSION

These results highlight the importance of identifying differences in CRC screening behavior among disaggregated AAPI subgroups in order to help health professionals and policy-makers prioritize which AAPI subgroups need the most urgent interventions in terms of CRC screening promotion.

Health Behaviors of Employed and Insured Adults in the United States, 2004-2005

Purpose.

To examine the prevalence of health behaviors, including clinical preventive services and lifestyle risk behaviors, among insured workers and to determine whether disparities in health behaviors based on demographic factors exist among this group.

Design.

Cross-sectional analysis of 2004–2005 Behavioral Risk Factor Surveillance System data.

Setting.

United States.

Subjects.

A representative sample of noninstitutionalized employed and insured adults aged 18 to 64 years (139,738 in 2004 and 159,755 in 2005).

Measures.

Self-reported clinical preventive services utilization and lifestyle-related behaviors, as well as multiple logistic regression analyses assessing the independent effects of demographic and access variables on health behaviors.

Results.

Among insured workers, rates of not using recommended clinical preventive services ranged from 8.5% (cervical cancer screening) to 73.9% (influenza vaccination). Rates for engaging in lifestyle-related risks ranged from 5.5% (heavy drinking) to 77.1% (inadequate fruit-vegetable consumption). In multivariate analyses, lower income, lower education, cost as a barrier to health care, and no health care provider were associated with significantly decreased clinical preventive services utilization (p < .01). Lower education and no health care provider were associated with lifestyle-related risks (p < .01).

Conclusions.

Working insured adults are not meeting recommendations for health behaviors. Significant disparities in health behaviors related to socioeconomic status exist among this group. Employers and insurers should consider these poor health behaviors and disparities when designing insurance benefits addressing clinical preventive services utilization and workplace health promotion programs addressing lifestyle-related behaviors.

A health promotion intervention for families in a Medicaid managed care plan

OBJECTIVE

To determine whether implementation of an intervention based on a model of health promotion will encourage patients to seek care from their primary care provider (PCP) and reduce visits to the pediatric ED (PED) for minor illness.

METHODS

Prospective, randomized, controlled study in the PED of an urban children's hospital (CH). Children <13 months old, enrolled in a Medicaid managed care plan, who identified the CH as their site for primary care and presented to the PED for evaluation of minor illness were enrolled after being seen by the triage nurse, before being seen by a physician. Subjects were randomly assigned to the intervention (I) group or control (C) group. Parents of all enrollees completed a survey about health care utilization habits. Each family in the I group received health promotion teaching from a single investigator. The intervention consisted of a review of the child's medical record with the parents, an explanation of what to expect at future well-child visits, and a discussion of the role of the PCP. A follow-up appointment was also provided prior to discharge from the PED. The C group received usual care. Use of health care by all subjects was tracked for one year by medical record review and phone interviews at six and 12 months.

RESULTS

102 subjects in the I group and 93 in the C group (mean +/- SD ages 6.4 months +/- 3.8 and 7.2 months +/- 3.9, respectively, p = 0.15) were enrolled from March 1996 to November 1996. The two groups were similar with respect to demographics and overall health status at enrollment. At study entry: 94 of 102 (92%) subjects in I and 87 of 93 (94%) in C had made at least one visit to the PED in the previous 12 months (p = 0.11); 95 of 102 (93%) in I and 75 of 93 (81%) in C had seen their PCP at least once for well-child care (p = 0.24). Twelve-month follow-up by medical record review was completed for all subjects; phone interviews were completed in 90 of 102 (88%) in I and 80 of 93 (86%) in C. At 12-month follow-up: 84 of 102 (82%) in I and 73 of 93 (78%) in C had made at least one visit to the PED (p = 0.59); 81 of 102 (79%) in I and 77 of 93 (83%) in C had made at least one visit to their CH PCP (p = 0.54).

CONCLUSIONS

There was no difference in health care utilization between the intervention and control groups at 12-month follow-up. The health promotion intervention did not alter utilization habits.

Health counseling in adolescent preventive visits: effectiveness, current practices, and quality measurement

Most morbidity and mortality among adolescents results from their participation in health-compromising behaviors. Recent guidelines for clinical adolescent preventive services recommend that primary care clinicians routinely screen for and counsel adolescents about these behaviors, identify and address related social, psychological, and biologic factors. Office-based counseling can influence adult health behaviors, but little is known about the effectiveness of office-based counseling for adolescents. In this review we: (a) evaluate available information about the effectiveness of office-based health counseling to improve outcomes; (b) report what is known about the health counseling adolescents receive from primary care clinicians; and (c) critically review different approaches that have been, or might be, used to measure the content and quality of health counseling provided during adolescent medical visits. With the emphasis on accountability in the current health care environment, evidence supporting the effectiveness of counseling is needed to justify investment in this aspect of clinical adolescent preventive services. Challenges to studying the effectiveness of health counseling include the lack of well-defined theory-based models for adolescent office-based counseling, the complexity of measuring counseling quality, and the many factors that influence adolescent outcomes. Reliable and valid measures of counseling quality are needed both to study and to ensure the quality of counseling received by adolescents. No single measure can be expected to fully capture counseling quality, although patient self-report deserves further development.

Intervention booster: adding a decision-making module to risk reduction and other health care programs for adolescents

A generic adolescent intervention booster of the decision-making module, "Choices for Tomorrow: Decision Making as a Life Tool," is described for patient education. The intent of the intervention booster is refinement of adolescent decision-making skills by teaching a life tool for making lifestyle decisions (such as smoking and alcohol use) and other health-related decisions. An overview of the module is presented. The module includes a curriculum, a 17-minute life-action videocassette, a participant's workbook, and two instruments to measure outcomes. The theoretical framework is based on the health/choice model, the Janis and Mann conflict model of decision making, and the Piagetian cognitive framework related to adolescent development. The decision-making module can be used alone or as a "booster" to supplement the content of new or existing intervention programs that are aimed at health promotion and maintenance during adolescence. Because the module was originally developed for adolescents who have survived cancer, a population that often experiences cognitive impairment from treatment, it includes cognitive remediation strategies (such as memory aids). The decision-making module can also be used in other learning situations with healthy or chronically ill adolescents and/or their parents.

Integrating learning into integrated delivery systems

Integrated delivery systems that promote learning and flexibility will be better prepared to face the challenges imposed by a complex and competitive environment. The integration of learning into these systems requires a shared vision, facilitative leadership, and highly functioning communication channels within an organic structure. Strategies that promote positive attitudes toward change are necessary for learning as is the provision of resources, training, incentives, and rewards that support learning, and feedback on how new administrative and clinical practices advance the mission and goals of the system.

Moving diabetes management from clinic to community: development of a prototype based on automated voice messaging

The purpose of this study is twofold. First, it provides a review of the literature supporting the development of a new service to help patients with diabetes and their providers manage their care. This service, automated voice messaging (AVM) with nurse follow-up, allows for systematic and intensive patient monitoring and diabetes education as well as a means of focusing clinical resources where they are most needed. Second, it provides a description of a prototype AVM-based diabetes management service that has been developed as part of two ongoing, randomized, controlled trials to test the efficacy of AVM care for patients with Type 2 diabetes. Preliminary findings from implementing this service in two large public healthcare systems suggest that AVM-supported care is feasible, desirable by clinicians and patients with diabetes, and may identify serious health problems that otherwise would go unnoted through standard means of clinic-based patient care.

Clinical health promotion and family physicians: a Canadian perspective

Many attempts have been made recently in North America to increase the activities of physicians in clinical prevention and health promotion. This article reviews: (1) the development of guidelines by both the Canadian Task Force on the Periodic Health Examination and the U.S. Preventive Services Task Force; (2) attempts at dissemination and implementation; (3) definitions of health promotion concepts, including clinical health promotion; (4) factors facilitating and limiting the incorporation of clinical prevention and health promotion into family practice; and (5) principles of learning and behavior change which can assist family physicians to practise clinical health promotion. Family physicians are best advised to focus on facilitating behavior change with their own patients, utilizing a triage strategy to determine which patients to target.

Participation in worksite health promotion: a critique of the literature and recommendations for future practice

One of the major rationales for conducting health promotion/disease prevention activities at the worksite is the potential to reach a high percentage of employees, including many who would otherwise be unlikely to engage in preventive health behaviors. Most studies of worksite health promotion do not report participation data, but among those that do, definitions of participation and participation rates vary dramatically. In general, men and blue-collar employees appear less likely to participate, but little is known about other employee variables related to participation. There have been few studies of worksite characteristics associated with participation and even fewer experimental evaluations of interventions to increase participation. In this paper we review what is known about participation in worksite health promotion programs and recommend procedures for defining participation for different types of programs, for reporting determinants of participation, and for increasing participation. We conclude that participation is both an important process measure and an outcome that should be reported routinely. Participation data have important implications for generalizability of results, feasibility of interventions, and health outcomes.

A systems model of clinical preventive care: an analysis of factors influencing patient and physician

An ideal model for clinical preventive care must consider the physician, the patient and the many factors which influence each of them. In this paper, we review existing models, examining their strengths and weaknesses. We then propose a new model, the Systems Model of Clinical Preventive Care. This model is unique in its focus on the patient-physician interaction and details the factors impinging on each that promote or inhibit the completion of preventive care activities. These factors include patient and physician predisposing factors, such as health beliefs and attitudes; enabling factors, such as skills and resources; and reinforcing factors, such as social support. Additional factors include health care system organizational factors, such as access or availability; characteristics of the preventive activity, such as cost; and cues to action, such as symptoms or reminders. The proposed model contains components of behavioral, communication, health education and psychosocial theories. We then apply our model to mammography as an example of a screening activity. Finally, we describe the strengths and weaknesses of the proposed model, and identify areas for future research.