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Matthias MS, Bolla AL, Bair SM, Adams J, Eliacin J, Burgess DJ, Hirsh AT. Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE): a Qualitative Analysis of a Tailored Coaching Program for Black Patients with Chronic Pain. J Gen Intern Med 2024; 39:222-228. [PMID: 37726645 PMCID: PMC10853119 DOI: 10.1007/s11606-023-08410-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/01/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Racial inequities in pain treatment are well-documented and persist despite national priorities focused on health equity. The COOPERATE (Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity) intervention was a patient-centered, tailored intervention aimed at improving health equity by targeting patient activation-the knowledge and confidence to manage one's health. COOPERATE led to significant and sustained increases in patient activation, significant short-term increases in communication self-efficacy (confidence to communicate with clinicians), and more intervention participants experienced clinically significant (≥ 30%) reductions in pain at 3 months than control group participants. OBJECTIVE To understand how participants experienced the intervention, including their perspectives on its effects on their health and healthcare experiences. DESIGN Semi-structured qualitative interviews. PARTICIPANTS Black veterans with chronic pain who participated in the COOPERATE intervention. KEY RESULTS Participants described acquiring new tools and cultivating skills to use in their clinic visits, including preparing for their visit (writing an agenda, listing questions); asking focused, effective questions; and expressing concerns and communicating goals, values, and preferences. Participants indicated that by putting these tools to use, they felt more confident and able to take ownership of their own pain care; for some, this led to better pain management and improved pain. Participants expressed mixed views of disparities in pain care, with some believing race and racism did not play a role in their care, while others valued being part of an intervention that helped equip them with tools to exercise autonomy over their healthcare. CONCLUSIONS Black patients with chronic pain described gaining greater confidence to self-manage and communicate with their clinicians after participating in the COOPERATE intervention. With its focus on empowering individuals, the COOPERATE intervention represents a promising approach to help advance equity in pain care.
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Affiliation(s)
- Marianne S Matthias
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, USA.
- Regenstrief Institute, Indianapolis, USA.
- Department of Medicine, Indiana University School of Medicine, Indianapolis, USA.
| | - Arya L Bolla
- Regenstrief Institute, Indianapolis, USA
- Indiana University School of Medicine, Indianapolis, USA
| | | | - Jasma Adams
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, USA
| | - Johanne Eliacin
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, USA
- Regenstrief Institute, Indianapolis, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, USA
- National Center for PTSD, VA Boston Healthcare System, Boston, USA
| | - Diana J Burgess
- Center for Care Delivery and Outcomes Research, Veterans Affairs Medical Center, Minneapolis, USA
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Adam T Hirsh
- Department of Psychology, Indiana University-Purdue University, Indianapolis, USA
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Matthias MS, Daggy JK, Perkins AJ, Adams J, Bair MJ, Burgess DJ, Eliacin J, Flores P, Myers LJ, Menen T, Procento P, Rand KL, Salyers MP, Shanahan ML, Hirsh AT. Communication and activation in pain to enhance relationships and treat pain with equity (COOPERATE): a randomized clinical trial. Pain 2024; 165:365-375. [PMID: 37733487 DOI: 10.1097/j.pain.0000000000003021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/23/2023] [Indexed: 09/23/2023]
Abstract
ABSTRACT Racialized disparities in chronic pain care are well-documented and persist despite national priorities focused on health equity. Similar disparities have been observed in patient activation (ie, having the knowledge, confidence, and skills to manage one's health). As such, interventions targeting patient activation represent a novel approach to addressing and reducing disparities in pain care. Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity is a randomized controlled trial of a 6-session telephone-delivered intervention to increase patient activation for Black patients with chronic pain. Two hundred fifty Black patients from a Midwestern Veterans Affairs medical center were randomized to the intervention or attention control. The primary outcome was patient activation; secondary outcomes included communication self-efficacy, pain, and psychological functioning. Outcomes were assessed at baseline and at 3 (primary endpoint), 6, and 9 months (sustained effects). Analyses used an intent-to-treat approach. Compared with baseline, patient activation increased 4.6 points at 3 months (versus +0.13 in control group, 95% CI: 0.48, 7.34; P = 0.03). These improvements in the intervention group were sustained, with +7 from baseline at 6 months and +5.77 at 9 months, and remained statistically significant from the control group. Communication self-efficacy increased significantly relative to the control group from baseline to 3 months. Pain intensity and interference improved at 3 months, but differences were not significant after adjusting for multiple comparisons. Most other secondary outcomes improved, but group differences were not statistically significant after controlling for multiple comparisons. Results suggest that increasing patient activation is a potentially fruitful path toward improving pain management and achieving health equity.
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Affiliation(s)
- Marianne S Matthias
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
- Regenstrief Institute, Indianapolis, IN, United States
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Joanne K Daggy
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Anthony J Perkins
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Jasma Adams
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
| | - Matthew J Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
- Regenstrief Institute, Indianapolis, IN, United States
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Diana J Burgess
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Center for Care Delivery and Outcomes Research, Veterans Affairs Medical Center, Minneapolis, MN, United States
| | - Johanne Eliacin
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
- Regenstrief Institute, Indianapolis, IN, United States
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, United States
| | - Perla Flores
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
| | - Laura J Myers
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
- Regenstrief Institute, Indianapolis, IN, United States
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Tetla Menen
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
| | - Philip Procento
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States
| | - Kevin L Rand
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States
| | - Michelle P Salyers
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States
| | - Mackenzie L Shanahan
- VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
| | - Adam T Hirsh
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States
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Matthias MS, Burgess DJ, Eliacin J. Healthcare Access and Delivery During the COVID-19 Pandemic for Black Veterans with Chronic Pain: a Qualitative Study. J Gen Intern Med 2023; 38:1024-1029. [PMID: 36376625 PMCID: PMC9663172 DOI: 10.1007/s11606-022-07884-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The COVID-19 pandemic led to significant disruptions in healthcare and rapid increases in virtual healthcare delivery. The full effects of these shifts remain unknown. Understanding effects of these disruptions is particularly relevant for patients with chronic pain, which typically requires consistent engagement in treatment to maximize benefit, and for Black patients, given documented racial disparities in pain treatment and telehealth delivery. OBJECTIVE To understand how Black patients with chronic pain experienced pandemic-related changes in healthcare delivery. DESIGN In-depth, semi-structured qualitative interviews PARTICIPANTS: Black veterans with chronic pain. KEY RESULTS Participants described decreased ability to self-manage their chronic pain, obtain nonpharmacological services such as physical therapy, see their primary care providers, and schedule surgery. Most did not believe telehealth met their needs, describing feeling inadequately assessed for their pain and noting that beyond renewing prescriptions, telehealth visits were not that useful. Some believed their communication with their providers suffered from a lack of in-person contact. Others, however, were willing to accept this tradeoff to prevent possible exposure to COVID-19, and some appreciated the convenience of being able to access healthcare from home. CONCLUSIONS Black patients with chronic pain described mostly negative effects from the shift to telecare after the pandemic's onset. Given existing disparities and likely persistence of virtual care, research on the longer-term effects of virtual pain care for Black patients is needed.
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Affiliation(s)
- Marianne S Matthias
- VA HSR&D Center for Health Information and Communication, Indianapolis, IN, USA.
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
- Regenstrief Institute, Indianapolis, IN, USA.
| | - Diana J Burgess
- Center for Care Delivery and Outcomes Research, Veterans Affairs Medical Center, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Johanne Eliacin
- VA HSR&D Center for Health Information and Communication, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
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Matthias MS, Adams J, Burgess DJ, Daggy J, Eliacin J, Flores P, Hirsh AT, Myers LJ, Perkins AJ, Menen T, Procento P, Rand KL, Salyers MP, Shanahan ML, Bair MJ. Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE): Rationale, study design, methods, and sample characteristics. Contemp Clin Trials 2022; 118:106790. [PMID: 35568376 DOI: 10.1016/j.cct.2022.106790] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 05/06/2022] [Accepted: 05/06/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Chronic pain is associated with profound negative effects, and racial disparities are well-documented in chronic pain treatment. In addition, Black patients report poorer communication with providers and exhibit lower levels of patient activation (self-management self-efficacy) than White patients. Although the causes of healthcare disparities are complex and require intervention at multiple levels, empowering patients is one critical path to achieving health equity. The current study is a coaching intervention focused on increasing patient activation and building communication skills for Black patients with chronic pain. METHODS In this randomized controlled trial, 250 Black patients with chronic pain were randomized to either the coaching intervention or an attention control arm. Intervention patients attended 6 telephone-delivered individual coaching sessions over 12 weeks. Coaching focused on clarifying and prioritizing goals and on communication skills, such as agenda setting. The primary outcome is patient activation. Secondary outcomes include communication self-efficacy, pain intensity and interference, and psychological functioning. DISCUSSION Having the knowledge and confidence to participate in one's pain care, coupled with the skills needed to effectively communicate with providers, is essential to optimize chronic pain care. This is particularly important for Black patients who often experience lower quality pain care. Interventions such as COOPERATE hold promise for helping patients to acquire the requisite tools to take greater control of their chronic pain care. TRIAL REGISTRATION clinicaltrials.gov, # NCT03562793.
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Affiliation(s)
- Marianne S Matthias
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America; Regenstrief Institute, Indianapolis, IN, United States of America; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America.
| | - Jasma Adams
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America
| | - Diana J Burgess
- Center for Care Delivery and Outcomes Research, Veterans Affairs Medical Center, Minneapolis, MN, United States of America; Department of Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Joanne Daggy
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Johanne Eliacin
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America; Regenstrief Institute, Indianapolis, IN, United States of America; Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Perla Flores
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America
| | - Adam T Hirsh
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States of America
| | - Laura J Myers
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America; Regenstrief Institute, Indianapolis, IN, United States of America; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Anthony J Perkins
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Tetla Menen
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America
| | - Philip Procento
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States of America
| | - Kevin L Rand
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States of America
| | - Michelle P Salyers
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States of America
| | - Mackenzie L Shanahan
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States of America
| | - Matthew J Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America; Regenstrief Institute, Indianapolis, IN, United States of America; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
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Hamed S, Bradby H, Ahlberg BM, Thapar-Björkert S. Racism in healthcare: a scoping review. BMC Public Health 2022; 22:988. [PMID: 35578322 PMCID: PMC9112453 DOI: 10.1186/s12889-022-13122-y] [Citation(s) in RCA: 82] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Racism constitutes a barrier towards achieving equitable healthcare as documented in research showing unequal processes of delivering, accessing, and receiving healthcare across countries and healthcare indicators. This review summarizes studies examining how racism is discussed and produced in the process of delivering, accessing and receiving healthcare across various national contexts. METHOD The PRISMA guidelines for scoping reviews were followed and databases were searched for peer reviewed empirical articles in English across national contexts. No starting date limitation was applied for this review. The end date was December 1, 2020. The review scoped 213 articles. The results were summarized, coded and thematically categorized in regards to the aim. RESULTS The review yielded the following categories: healthcare users' experiences of racism in healthcare; healthcare staff's experiences of racism; healthcare staff's racial attitudes and beliefs; effects of racism in healthcare on various treatment choices; healthcare staff's reflections on racism in healthcare and; antiracist training in healthcare. Racialized minorities experience inadequate healthcare and being dismissed in healthcare interactions. Experiences of racism are associated with lack of trust and delay in seeking healthcare. Racialized minority healthcare staff experience racism in their workplace from healthcare users and colleagues and lack of organizational support in managing racism. Research on healthcare staff's racial attitudes and beliefs demonstrate a range of negative stereotypes regarding racialized minority healthcare users who are viewed as difficult. Research on implicit racial bias illustrates that healthcare staff exhibit racial bias in favor of majority group. Healthcare staff's racial bias may influence medical decisions negatively. Studies examining healthcare staff's reflections on racism and antiracist training show that healthcare staff tend to construct healthcare as impartial and that healthcare staff do not readily discuss racism in their workplace. CONCLUSIONS The USA dominates the research. It is imperative that research covers other geo-political contexts. Research on racism in healthcare is mainly descriptive, atheoretical, uses racial categories uncritically and tends to ignore racialization processes making it difficult to conceptualize racism. Sociological research on racism could inform research on racism as it theoretically explains racism's structural embeddedness, which could aid in tackling racism to provide good quality care.
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Affiliation(s)
- Sarah Hamed
- Department of Sociology, Uppsala University, Uppsala, Sweden.
| | - Hannah Bradby
- Department of Sociology, Uppsala University, Uppsala, Sweden
| | - Beth Maina Ahlberg
- Department of Sociology, Uppsala University, Uppsala, Sweden.,Skaraborg Institute for Research and Development, Skövde, Sweden
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Mentrup S, Harris E, Gomersall T, Köpke S, Astin F. Patients' Experiences of Cardiovascular Health Education and Risk Communication: A Qualitative Synthesis. QUALITATIVE HEALTH RESEARCH 2020; 30:88-104. [PMID: 31729937 DOI: 10.1177/1049732319887949] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Coronary heart disease (CHD) has no cure, and patients with myocardial infarction are at high risk for further cardiac events. Health education is a key driver for patients' understanding and motivation for lifestyle change, but little is known about patients' experience of such education. In this review, we aimed to explore how patients with CHD experience health education and in particular risk communication. A total of 2,221 articles were identified through a systematic search in five databases. 40 articles were included and synthesized using thematic analysis. Findings show that both "what" was communicated, and "the way" it was communicated, had the potential to influence patients' engagement with lifestyle changes. Communication about the potential of lifestyle change to reduce future risk was largely missing causing uncertainty, anxiety, and, for some, disengagement with lifestyle change. Recommendations for ways to improve health education and risk communication are discussed to inform international practice.
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Affiliation(s)
| | - Emma Harris
- University of Huddersfield, Huddersfield, United Kingdom
| | - Tim Gomersall
- University of Huddersfield, Huddersfield, United Kingdom
| | | | - Felicity Astin
- University of Huddersfield, Huddersfield, United Kingdom
- Huddersfield Royal Infirmary, Huddersfield, United Kingdom
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Peltzer S, Hellstern M, Genske A, Jünger S, Woopen C, Albus C. Health literacy in persons at risk of and patients with coronary heart disease: A systematic review. Soc Sci Med 2019; 245:112711. [PMID: 31855729 DOI: 10.1016/j.socscimed.2019.112711] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 11/08/2019] [Accepted: 11/30/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Health literacy (HL) plays a crucial role in the maintenance and improvement of individual health. Empirical findings highlight the relation between a person's HL-level and clinical outcomes. However, the role of HL in persons at risk for coronary heart disease (CHD) and patients with CHD has not been researched conclusively. OBJECTIVE The aim of this study was to review systematically the current evidence on HL, its dimensions (access to, understanding, appraisal and apply of health-related information), and its important influencing factors, with regard to CHD risk. METHOD We used a mixed-methods approach. Eligible articles needed to employ a validated tool for HL or mention the concept and at least one of its dimensions. After the screening process, 14 quantitative and 27 qualitative studies were included and referred to one or more dimensions of HL. Six observational studies measured HL with a validated tool. RESULTS Findings suggest that patients with lower HL feel less capable to perform lifestyle changes, exhibit fewer proactive coping behaviors, are more likely to deny CHD, are generally older, are less often employed, have lower educational levels and lower socioeconomic status, experience faster physical decline, and use the healthcare system less, compared to patients with higher HL. Barriers to HL include inadequate provision of information by health providers, lack of awareness of the risk factors for CHD, perceived impairment of quality of life due to lifestyle changes, and negative experiences with the healthcare system. Facilitators include a good patient-physician relationship based on good communicative competences of health providers. CONCLUSIONS The concept of HL yields a promising potential to understand the process from obtaining information to actual health behavior change, and the results clearly indicate the need for more systematic research on HL in CHD patients and persons at risk.
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Affiliation(s)
- Samia Peltzer
- University Hospital Cologne, Department of Psychosomatics and Psychotherapy, Weyertal 76, 50931, Cologne, Germany.
| | - Marc Hellstern
- University Hospital Cologne, Department of Psychosomatics and Psychotherapy, Weyertal 76, 50931, Cologne, Germany.
| | - Anna Genske
- University of Cologne, Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health (ceres), Albertus-Magnus-Platz, 50923, Cologne, Germany.
| | - Saskia Jünger
- University of Cologne, Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health (ceres), Albertus-Magnus-Platz, 50923, Cologne, Germany.
| | - Christiane Woopen
- University of Cologne, Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health (ceres), Albertus-Magnus-Platz, 50923, Cologne, Germany.
| | - Christian Albus
- University Hospital Cologne, Department of Psychosomatics and Psychotherapy, Weyertal 76, 50931, Cologne, Germany.
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Rosen MI, Afshartous DR, Nwosu S, Scott MC, Jackson JC, Marx BP, Murdoch M, Sinnott PL, Speroff T. Racial differences in veterans' satisfaction with examination of disability from posttraumatic stress disorder. Psychiatr Serv 2013; 64:354-9. [PMID: 23318842 PMCID: PMC3677046 DOI: 10.1176/appi.ps.201100526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The examination that determines if a veteran has service-connected posttraumatic stress disorder (PTSD) affects veterans' lives for years. This study examined factors potentially associated with veterans' perception of their examination's quality. METHODS Veterans (N=384) being evaluated for an initial PTSD service-connection claim were randomly assigned to receive either a semistructured interview or the examiner's usual interview. Immediately after the interview, veterans completed confidential ratings of the examinations' quality and of their examiners' interpersonal qualities and competence. Extensive data characterizing the veterans, the 33 participating examiners, and the examinations themselves were collected. RESULTS Forty-seven percent of Caucasian veterans and 34% of African-American veterans rated their examination quality as excellent. African Americans were less likely than Caucasians to assign a higher quality rating (odds ratio=.61, 95% confidence interval=.38-.99, p=.047). Compared with Caucasians, African Americans rated their examiners as having significantly worse interpersonal qualities but not lower competence. Ratings were not significantly related to the veterans' age, gender, marital status, eventual diagnosis of PTSD, Global Assessment of Functioning score, the examiner's perception of the prevalence of malingering, or the presence of a third party during the examination. CONCLUSIONS Ratings of disability examinations were generally high, although ratings were less favorable among African-American veterans than among Caucasian veterans.
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Affiliation(s)
- Marc I Rosen
- Department of Psychiatry, Veterans Affairs (VA) Connecticut Healthcare System, 116A, West Haven, CT 06516, USA.
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Fix GM, Bokhour BG. Understanding the context of patient experiences in order to explore adherence to secondary prevention guidelines after heart surgery. Chronic Illn 2012; 8:265-77. [PMID: 22387691 DOI: 10.1177/1742395312441037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
After coronary artery bypass surgery, many patients do not incorporate healthy behaviors into their postoperative lifestyle or enroll in cardiac rehabilitation, key aspects of secondary prevention. This qualitative study examined patients' post-coronary artery bypass surgery experiences to explore barriers in adhering to dietary and activity guidelines. We conducted semi-structured, in-depth interviews with 30 male patients from a military veteran's hospital, using emergent, thematic analysis to identify experiences that led to poor adherence. RESULTS were grouped according to barriers to diet, activities, and enrolling in cardiac rehabilitation. Overall, understandings of postoperative health, priorities that diverged from guidelines, and the context of household members and other health conditions impacted postoperative health behaviors. Many participants were familiar with secondary prevention guidelines. However, postoperative perceptions of health as well as the context of recovery influenced self-management. Providers must consider a patient's context when discussing secondary prevention. Venues such as cardiac rehabilitation may provide an opportunity to improve adherence to secondary prevention guidelines by expanding available class times, engaging patients' household members, or tailoring recommendations to also address other health conditions.
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Affiliation(s)
- Gemmae M Fix
- Center for Health Quality, Outcomes and Economic Research, Department of Veterans Affairs, ENMR Veterans Hospital, USA.
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A community and culture-centered approach to developing effective cardiovascular health messages. J Gen Intern Med 2012; 27:1308-16. [PMID: 22584728 PMCID: PMC3445691 DOI: 10.1007/s11606-012-2102-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 04/10/2012] [Accepted: 04/23/2012] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Little is known about how best to target cardiovascular health promotion messages to minorities. This study describes key lessons that emerged from a community and culture-centered approach to developing a multimedia, coronary heart disease (CHD) patient education program (PEP) for medically underserved South Asian immigrants. METHODS The prototype PEP integrated the surface structures (e.g. language) and deeper structures (e.g. explanatory models (EMs), values) of South Asians' socio-cultural context. Seven focus groups and 13 individual interviews were used to investigate South Asians' reactions and obtain qualitative feedback after viewing the culturally targeted PEP. Qualitative data were organized into emergent thematic constructs. RESULTS Participants (n=56) mean age was 51 years and 48 % were Hindi speakers. Community members had a strong, negative reaction to some of the targeted messages, "This statement is a bold attack. You are pin-pointing one community." Other important themes emerged from focus groups and interviews about the PEP: 1) it did not capture the community's heterogeneity; 2) did not sufficiently incorporate South Asians' EMs of CHD; and 3) did not address economic barriers to CHD prevention. Feedback was used to revise the PEP. CONCLUSION A community and culture-centered approach to developing cardiovascular health promotion messages revealed tensions between the researcher's vantage point of "cultural targeting" and the community's perceptions and reactions to these messages. Engaging communities in every phase of message design, incorporating their EMs, recognizing community heterogeneity, and addressing economic and structural barriers, are critical steps to ensuring that health promotion messages reach their intended audience and achieve true cultural appropriateness.
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Individual influences on lifestyle change to reduce vascular risk: a qualitative literature review. Br J Gen Pract 2012; 62:e403-10. [PMID: 22687232 DOI: 10.3399/bjgp12x649089] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Management of cardiovascular risk includes adoption of healthy lifestyles. Uptake and completion rates for lifestyle programmes are low and many barriers and facilitators to lifestyle behaviour change have been reported in the literature. Clarity on which barriers and facilitators to target during consultations in primary care may support a more systematic approach to lifestyle behaviour change in those at high risk of cardiovascular events. AIM To identify the main barriers and facilitators to lifestyle behaviour change in individuals at high risk of cardiovascular events. DESIGN A content synthesis of the qualitative literature reporting patient-level influences on lifestyle change. METHOD Qualitative studies involving patients at high risk of cardiovascular events were identified through electronic searching and screening against predefined selection criteria. Factors (reported influences) were extracted and, using a clustering technique, organised into categories that were then linked to key themes through relationship mapping. RESULTS A total of 348 factors were extracted from 33 studies. Factors were organised into 20 categories and from these categories five key themes were identified: emotions, beliefs, information and communication, friends and family support, and cost/transport. CONCLUSION It is possible to organise the large number of self-reported individual influences on lifestyle behaviours into a small number of themes. Further research is needed to clarify which of these patient-level barriers and facilitators are the best predictors of uptake and participation in programmes aimed at helping people to change lifestyle.
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Onukwugha E, Saunders E, Mullins CD, Pradel FG, Zuckerman M, Loh FE, Weir MR. A qualitative study to identify reasons for discharges against medical advice in the cardiovascular setting. BMJ Open 2012; 2:e000902. [PMID: 22850166 PMCID: PMC4400638 DOI: 10.1136/bmjopen-2012-000902] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2012] [Accepted: 06/25/2012] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is responsible for the largest number of discharges against medical advice (AMA). However, there is limited information regarding the reasons for discharges AMA in the CVD setting. OBJECTIVE To identify reasons for discharges AMA among patients with CVD. DESIGN Qualitative study using focus group interviews (FGIs). PARTICIPANTS A convenience sample of patients with a CVD-related discharge diagnosis who left AMA and providers (physicians, nurses and social workers) whose patients have left AMA. PRIMARY AND SECONDARY OUTCOMES To identify patients' reasons for discharges AMA as identified by patients and providers. To identify strategies to reduce discharges AMA. APPROACH FGIs were grouped according to patients, physicians and nurses/social workers. A content analysis was performed independently by three coauthors to identify the nature and range of the participants' viewpoints on the reasons for discharges AMA. The content analysis involved specific categories of reasons as motivated by the Health Belief Model as well as reasons (ie, themes) that emerged from the interview data. RESULTS 9 patients, 10 physicians and 23 nurses/social workers were recruited for the FGIs. Patients and providers reported the same three reasons for discharges AMA: (1) patient's preference for their own doctor, (2) long wait time and (3) factors outside the hospital. Patients identified an unmet expectation to be involved in setting the treatment plan as a reason to leave AMA. Participants identified improved communication as a solution for reducing discharges AMA. CONCLUSIONS Patients wanted more involvement in their care, exhibited a strong preference for their own primary physician, felt that they spent a long time waiting in the hospital and were motivated to leave AMA by factors outside the hospital. Providers identified similar reasons except the patients' desire for involvement. Additional research is needed to determine the applicability of results in broader patient and provider populations.
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Affiliation(s)
- Eberechukwu Onukwugha
- Department of Pharmaceutical Health Services Research, School of
Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Elijah Saunders
- Division of Cardiology, Department of Medicine, School of Medicine,
University of Maryland, Baltimore, Maryland, USA
| | - C Daniel Mullins
- Department of Pharmaceutical Health Services Research, School of
Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Françoise G Pradel
- Department of Pharmaceutical Health Services Research, School of
Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Marni Zuckerman
- Department of Pharmaceutical Health Services Research, School of
Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - F Ellen Loh
- Department of Pharmaceutical Health Services Research, School of
Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, School of Medicine,
University of Maryland, Baltimore, Maryland, USA
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Munter JSLD, Agyemang C, Stronks K, Valkengoed IGMV. Association of physical activity, smoking, and alcohol intake with CVD-related hospital discharge in people of European, South Asian, or African descent. Eur J Prev Cardiol 2012; 20:80-8. [DOI: 10.1177/2047487311434232] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Charles Agyemang
- Academic Medical Center, University of Amsterdam, The Netherlands
| | - Karien Stronks
- Academic Medical Center, University of Amsterdam, The Netherlands
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Tirodkar MA, Baker DW, Khurana N, Makoul G, Paracha MW, Kandula NR. Explanatory models of coronary heart disease among South Asian immigrants. PATIENT EDUCATION AND COUNSELING 2011; 85:230-6. [PMID: 21093195 PMCID: PMC3380445 DOI: 10.1016/j.pec.2010.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 09/30/2010] [Accepted: 10/04/2010] [Indexed: 05/08/2023]
Abstract
OBJECTIVE This study investigated South Asians' explanatory models (EM) of CHD and compared them to the biomedical model as part of an effort to inform the development of culturally targeted CHD prevention messages. METHODS We conducted in-depth, semi-structured interviews in English, Hindi and Urdu with 75 respondents from a federally qualified health center and at a community center for South Asian immigrants in Chicago, Illinois. RESULTS While EMs of CHD included risk factors from the biomedical model, they also included psychosocial and spiritual risk factors. Respondents emphasized that stress causes CHD and suggested that CHD was caused by sudden or inexplicable factors. Few respondents discussed cholesterol, blood pressure, or diabetes as part of CHD prevention. Women and those with lower education had low perceptions of being at-risk for CHD. CONCLUSION South Asians' EMs of CHD encompassed the biomedical model; however, EMs also included psychosocial and spiritual factors. PRACTICE IMPLICATIONS Clinicians and health educators should be aware that South Asian individual's EM of CHD may include psychosocial and spiritual factors which can affect CHD prevention behaviors.
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Yeboah-Korang A, Kleppinger A, Fortinsky RH. Racial and ethnic group variations in service use in a national sample of Medicare home health care patients with type 2 diabetes mellitus. J Am Geriatr Soc 2011; 59:1123-9. [PMID: 21649625 DOI: 10.1111/j.1532-5415.2011.03424.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Type 2 diabetes mellitus is known to affect adults in racial and ethnic minority groups disproportionately. When diabetes mellitus-related symptoms lead to the need for skilled care in the community-dwelling Medicare population, physicians can order the Medicare home health care (HHC) benefit, and Medicare-certified home health agencies can deliver it. Little is known about the extent to which racial and ethnic disparities exist in types and patterns of HHC services delivered to Medicare beneficiaries with diabetes mellitus when they are approved for the Medicare HHC benefit. This was examined by comparing racial and ethnic groups in terms of measures of HHC service use in a nationally representative sample of Medicare HHC beneficiaries with a primary diagnosis of type 2 diabetes mellitus. Uniform clinical data from the Outcome and Assessment Information Set were linked with Medicare HHC claims for beneficiaries who received a complete episode of HHC in 2002. In the study sample (n=9,838), 62% of participants self-identified as white, 22% African American, 12% Hispanic, and 3% Asian. Nearly all (99%) participants in all racial and ethnic groups received skilled nursing services. Controlling for numerous sociodemographic and health-related covariates and geographic region of the country, African-American participants received fewer nurse visits per week and fewer visits per week from all clinical disciplines combined than whites (both P<.001), and Hispanic participants were less likely than whites to receive physical therapy (adjusted odds ratio (AOR)=0.640, 95% confidence interval (CI)=0.543-0.754, P<.001) or home health aide (AOR=0.716, 95% CI=0.582-0.880, P=.002) services. Lower use of skilled nursing and rehabilitation services by African Americans and of rehabilitation services by Hispanics warrant further clinical and research attention.
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Affiliation(s)
- Amoah Yeboah-Korang
- School of Medicine, University of Connecticut, Farmington, Connecticut 06030, USA
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Raphael JL, Beal AC. A review of the evidence for disparities in child vs adult health care: a disparity in disparities. J Natl Med Assoc 2010; 102:684-91. [PMID: 20806679 DOI: 10.1016/s0027-9684(15)30653-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Racial and ethnic health disparities in primary care have been well documented in the US healthcare system. However, very little attention has been directed toward inequities in child health. The aim of this review is to provide context for the scope of the challenges associated with addressing pediatric health disparities in primary care by comparing the weight of evidence regarding racial/ethnic health disparities for children vs adults. A multisystem health disparities conceptual model will frame the search strategy and analysis of the review. This paper will: (1) identify knowledge deficits in the understanding of existing disparities in pediatric primary care relative to adult primary care; (2) assess root causes of disparities for children vs adults; and (3) propose recommendations for a research agenda and policy implementation to eliminate disparities in pediatric primary care.
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Affiliation(s)
- Jean L Raphael
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.
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Cohen SM. Concept analysis of adherence in the context of cardiovascular risk reduction. Nurs Forum 2009; 44:25-36. [PMID: 19187051 DOI: 10.1111/j.1744-6198.2009.00124.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
TOPIC Cardiovascular disease is the number one cause of death in the United States. Examination of the concept of adherence is essential to provide informed patient-centered care to prevent the development and progression of this largely preventable disease. OBJECTIVE The purpose of this concept analysis is to explore and clarify the concept of adherence. This analysis will provide a framework for those seeking a better understanding of patient decision-making, reduction of relapse to unhealthy behaviors, and increased long-term adherence to cardiovascular health recommendations. Reviews of major theories related to health behavior are reviewed in the second part of the article and are linked to the concept of adherence. METHOD Following a review of the literature, Morse's guidelines were utilized to present a concept analysis of adherence and the related terms concordance and compliance from the disciplines of nursing, health psychology, ethics, pharmacy, and medicine. RESULTS Adherence is dependent on the collaborative relationship between patient and healthcare provider. Adherence is influenced by the meaning of health, heart disease, and sense of personal risk as well as socioeconomic status, decision support, motivation, and desire for change, self-efficacy, and sources of credible health information. Attributes of successful adherence include alignment of patient behavior and health recommendations, mastery of new health knowledge and behavior, continued collaborative relationships between the patient and healthcare provider, and ability to meet outcome targets. CONCLUSION Adherence is defined as persistence in the practice and maintenance of desired health behaviors and is the result of active participation and agreement. Adherence is dependent on the development of a concordant relationship and its measurement should be specific utilizing the correct tools. Special attention should be paid to shared decision-making between patient and healthcare provider.
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Patient race and physicians' decisions to prescribe opioids for chronic low back pain. Soc Sci Med 2008; 67:1852-60. [DOI: 10.1016/j.socscimed.2008.09.009] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Indexed: 11/24/2022]
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Experiences with hospital care: perspectives of black and Hispanic patients. J Gen Intern Med 2008; 23:1234-40. [PMID: 18414953 PMCID: PMC2517954 DOI: 10.1007/s11606-008-0619-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2007] [Revised: 10/04/2007] [Accepted: 03/26/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND Significant racial and ethnic differences along several dimensions of patients'experiences with hospital care have been previously documented. However, the relationship between these differences and possible differences in processes of care has not been well described. METHODS We conducted focus groups with 37 black and Hispanic men and women who had recently been discharged from either medical or obstetrical services at an urban academic medical center to assess which dimensions of these patients' experiences with care were most important in determining overall levels of satisfaction. RESULTS Differences were found between Hispanics and blacks in the factors that influence their overall positive and negative experiences. Participants identified two themes that influence experiences with hospital care that are not commonly examined in many patient satisfaction instruments: availability and quality of translators, and attitudes of social workers and nursing staff. CONCLUSIONS Our findings suggest that hospitals should pursue hiring a culturally diverse work force and should collect racial and ethnically specific data about satisfaction with care including satisfaction with availability of social workers and interpreters.
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Saha S, Freeman M, Toure J, Tippens KM, Weeks C, Ibrahim S. Racial and ethnic disparities in the VA health care system: a systematic review. J Gen Intern Med 2008; 23:654-71. [PMID: 18301951 PMCID: PMC2324157 DOI: 10.1007/s11606-008-0521-4] [Citation(s) in RCA: 204] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Revised: 11/29/2007] [Accepted: 01/04/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To better understand the causes of racial disparities in health care, we reviewed and synthesized existing evidence related to disparities in the "equal access" Veterans Affairs (VA) health care system. METHODS We systematically reviewed and synthesized evidence from studies comparing health care utilization and quality by race within the VA. RESULTS Racial disparities in the VA exist across a wide range of clinical areas and service types. Disparities appear most prevalent for medication adherence and surgery and other invasive procedures, processes that are likely to be affected by the quantity and quality of patient-provider communication, shared decision making, and patient participation. Studies indicate a variety of likely root causes of disparities including: racial differences in patients' medical knowledge and information sources, trust and skepticism, levels of participation in health care interactions and decisions, and social support and resources; clinician judgment/bias; the racial/cultural milieu of health care settings; and differences in the quality of care at facilities attended by different racial groups. CONCLUSIONS Existing evidence from the VA indicates several promising targets for interventions to reduce racial disparities in the quality of health care.
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Kahan D, Al-Tamimi A. Strategies for recruiting Middle Eastern-American young adults for physical activity research: a case of snowballs and Salaam. J Immigr Minor Health 2008; 11:380-90. [PMID: 18214678 DOI: 10.1007/s10903-008-9117-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2007] [Accepted: 01/07/2008] [Indexed: 01/18/2023]
Abstract
Recruitment of minorities into health studies is a process that has been the subject of recent research effort. The prevalence of hypokinetic disease in the fast growing Middle Eastern-American community is higher than whites and some minority groups and descriptive research is needed to further quantify morbidity status and antecedent behavior. To date, we know of no study that reports recruitment methods of Middle Eastern-American young adults, a demographic group that is transitioning into an at-risk stratum for ethnically associated morbidity. We report and analyze a multi-method approach used in recruiting 240 young adults of this ethnic group into a 1-week study of physical activity utilizing activity logs and pedometers. Participants were primarily recruited through snowball sampling (48.3%), flyers (15.8%), presentations to university campus organizations (15.4%), and graduate research assistants (10.8%). Access was facilitated by assistants who were community insiders; active recruitment was more successful than passive recruitment; and different techniques appealed to different group segments based on gender and religion.
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Affiliation(s)
- David Kahan
- School of Exercise and Nutritional Sciences, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182-7251, USA.
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Sullivan KA, White KM, Young RM, Scott C, Mulgrew K. Developing a stroke intervention program: what do people at risk of stroke want? PATIENT EDUCATION AND COUNSELING 2008; 70:126-134. [PMID: 17997262 DOI: 10.1016/j.pec.2007.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2007] [Revised: 08/24/2007] [Accepted: 09/16/2007] [Indexed: 05/25/2023]
Abstract
OBJECTIVE There is currently little research examining what individuals who are at risk of a stroke want from an invention program. In order to increase the usefulness of such programs, qualitative research methods were used explore invention design issues such as factors affecting accessibility of programs and preferred health information sources. METHODS Thirty people, each with at least one stroke risk factor, participated in one of eight focus groups. RESULTS Broad support was indicated for our proposed intervention. Participants perceived the value and likely success of such a program enhanced if it: (a) was integrated with, and supported by, other respected health services; (b) included social components (particularly important to women); (c) produced long-term benefits; and (d) included information that was personally relevant and practical in terms of implementing change. Three reasons emerged for continuing stroke education campaigns as a component of intervention programs; these were: (a) a lack of awareness among some participants of gaps in their stroke knowledge; (b) participants' explicit requests for specific rather than general information; and (c) the apparent failure of some participants to self-identify as at risk. CONCLUSION This study yielded a number of important design considerations that should be taken into account when developing stroke intervention programs. PRACTICE IMPLICATIONS We discuss ways of maximising the personal relevance of stroke prevention information along theoretically important dimensions, and consumers' recommendations for the design and delivery of stroke intervention programs.
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Affiliation(s)
- Karen A Sullivan
- School of Psychology and Counselling & Institute of Health and Biomedical Innovation, Queensland University of Technology, Australia.
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