Physicians' attitudes in counseling patients about smoking

General Practitioner Interventions for Smoking Cessation: Past Results and Future Prospects

General practice is a critical setting for the identification, assessment, treatment, follow-up and onward referral of smokers. General practitioners (GPs) are in a unique position to play a part in reducing preventable morbidity and mortality attributable to tobacco use. During the past decade, numerous trials have been conducted in general practice and have shown that GP intervention with smokers has a variable degree of success depending on the intensity of contact. Although there are many positive reasons for GP involvement, there are also barriers to implementing smoking cessation strategies in general practice. In this paper we discuss some of these issues. The Stages of Change framework developed by Prochaska and DiClemente (1986) has been used to describe the stages a smoker goes through in the process of becoming a non-smoker. However, the incorporation of smoking cessation interventions in a GP's routine practice also involves a process of psychological change. In this paper, therefore, we apply the Stages of Change model to GPs' recognition, uptake and maintenance of smoking cessation interventions.

Development and evaluation of an instrument for assessing brief behavioral change interventions

OBJECTIVE

To develop an observational coding instrument for evaluating the fidelity and quality of brief behavioral change interventions based on the behavioral theories of the 5 A's, Stages of Change and Motivational Interviewing.

METHODS

Content and face validity were assessed prior to an intervention where psychometric properties were evaluated with a prospective cohort of 116 medical students. Properties assessed included the inter-rater reliability of the instrument, internal consistency of the full scale and sub-scales and descriptive statistics of the instrument. Construct validity was assessed based on student's scores.

RESULTS

Inter-rater reliability for the instrument was 0.82 (intraclass correlation). Internal consistency for the full scale was 0.70 (KR20). Internal consistencies for the sub-scales were as follows: MI intervention component (KR20=.7); stage-appropriate MI-based intervention (KR20=.55); MI spirit (KR20=.5); appropriate assessment (KR20=.45) and appropriate assisting (KR20=.56).

CONCLUSIONS

The instrument demonstrated good inter-rater reliability and moderate overall internal consistency when used to assess performing brief behavioral change interventions by medical students.

PRACTICE IMPLICATIONS

This practical instrument can be used with minimal training and demonstrates promising psychometric properties when evaluated with medical students counseling standardized patients. Further testing is required to evaluate its usefulness in clinical settings.

Knowledge of and practices related to smoking cessation among physicians in Nigeria

OBJECTIVE

To evaluate the knowledge and practices of smoking cessation among physicians in Nigeria.

METHODS

We conducted a cross-sectional survey in Lagos and three geopolitical zones of Nigeria. A self-administered structured questionnaire was used to obtain information on tobacco use and its health effects, as well as on the knowledge and practices of smoking cessation, from 436 physicians.

RESULTS

Of the 436 physicians, 292 (67.0%) were aware of smoking cessation, but only 132 (30.3%) showed good knowledge on this topic. The prevalence of smoking among the physicians was 17.7%. In addition, 308 physicians (70.6%) reported that tobacco education in the medical school curriculum was inadequate. Of the 436 physicians, 372 (86.2%) asked their patients whether they smoked, and 172 (39.4%) asked their patients the reasons for using tobacco. As a means of smoking cessation intervention, 268 (61.5%) used brief advice/counseling (2-5 min), 12 (3.7%) prescribed antidepressants, 16 (2.8%) prescribed nicotine replacement therapy (NRT), and 76 (17.4%) arranged follow-up visits. When the physicians were questioned regarding the obstacles to smoking cessation interventions, 289 (66.3%) cited poor knowledge of the issue, 55 (12.6%) cited a lack of time, and 20 (4.6%) cited unavailability of NRT.

CONCLUSIONS

The results of this study highlight the lack of knowledge among physicians in Nigeria in terms of smoking cessation, as well as their failure to apply appropriate practices. The results of this study can further the evaluation and formulation of guidelines on smoking cessation and smoking education programs for physicians. Our findings also underscore the need to offer smoking cessation programs in all treatment facilities.

Quality of life in hemodialysis patients: hepatitis C virus infection makes sense

PURPOSE

Hepatitis C virus (HCV) infection impairs quality of life (QOL) in patients who are not on dialysis therapy. In dialysis patients, how HCV infection affects QOL is unknown. In our study, we investigated the independent relationship between HCV infection and QOL.

METHODS

Sociodemographic and laboratory variables were recorded. Severity of depressive symptoms and QOL were assessed by Beck Depression Inventory (BDI) and Short Form-36 (SF-36), respectively.

RESULTS

Among 165 patients, 83 were anti-HCV antibody positive and 82 were anti-HCV antibody negative. Anti-HCV antibody positive patients had higher BDI scores than anti-HCV antibody negative patients (P = 0.011). Other than the social functioning subscale, all SF-36 subscales were lower in anti-HCV antibody positive patients when compared with anti-HCV negative patients. Anti-HCV antibody positive patients had lower physical (P = 0.003) and mental component summary scores (P = 0.018) than negative patients. Physical component summary score was independently associated with hemodialysis duration (P = 0.003), sleep disturbance (P = 0.046), BDI score (P = 0.027), albumin (P = 0.002), and serum hemoglobin (P < 0.0001). Physical component summary score was not associated with anti-HCV antibody positivity. Mental component summary score was independently associated with BDI score (P = 0.001), anti-HCV antibody positivity (P = 0.016), and serum hemoglobin (P < 0.0001).

CONCLUSION

HCV infection impairs QOL, especially in mental aspects, in hemodialysis patients.

Investigation of Hong Kong doctors' current knowledge, beliefs, attitudes, confidence and practices: implications for the treatment of tobacco dependency

BACKGROUND

Physicians play a crucial role in promoting smoking cessation. However, there are lack of data on Chinese doctors' knowledge, beliefs, attitudes, confidence and usual practices in relation to smoking cessation. Understanding of these indicators is important in the design of any effective intervention program targeting doctors.

METHODS

To assess Chinese doctors' knowledge, beliefs, attitudes, confidence and usual practices in relation to smoking cessation, a mailed questionnaire survey was conducted among 4,000 doctors registered with the Hong Kong Medical Association (HKMA) in 2002.

RESULTS

Of the 757 respondents (18.9% response rate), 78% were male, 94% were non-smokers and 50% had received no basic training on smoking cessation. More than half of the doctors did not hold adequate knowledge (53%) or favorable attitudes (55%) towards smoking cessation; 44% were less confident in their smoking cessation skills. About 77% of the doctors obtained information on their patients' smoking status and recorded it in their medical record, and 29% advised all smoking patients to quit. Doctors who gave smoking cessation advice were more likely to be aged above 50 years, with more than 30 years' practice experience, working in the private sector, non- or ex-smokers, with more positive beliefs towards smoking cessation, and with higher confidence in smoking cessation skills (p < 0.001). Different factors associated with establishing and recording smoking status, arranging follow-up sessions, acquiring more knowledge and developing a more favorable attitude and greater confidence on smoking cessation-related matters were also identified.

CONCLUSION

The survey has shown that existing smoking cessation service provision in Hong Kong for patients who smoke is inadequate, and has identified a lack of smoking cessation skills among doctors. Action should be taken to train doctors in smoking cessation skills and encourage them to routinely establish the smoking status of their patients and to advise all smokers to quit smoking.

The perceptions and practices of pediatricians: tobacco intervention

OBJECTIVES

To investigate pediatrician self-reported intervention practices related to tobacco use and cessation. We queried about practices with three groups 1) children/adolescents who do not smoke; 2) children/adolescents who smoke; and 3) parents, and the relationship of counseling practices with the personal and professional practice-related factors of pediatricians.

DESIGN

Mailed anonymous survey regarding their self-reported tobacco use prevention and cessation intervention practices.

POPULATION

Random sample of 350 pediatricians in one state.

RESULTS

A response rate of 75% was achieved. Pediatricians reported the greatest counseling practice in encouraging children/adolescents to not start smoking, followed by counseling adolescents who smoke. The lowest practice score was for intervening with parents who smoke. The age, gender, site of practice (eg, HMO, solo practice), and subspecialty status of the pediatricians were not related to practice. Pediatricians who reported at least some community involvement in local tobacco control efforts reported significantly higher levels of smoking cessation counseling with both children and adolescents and with parents who smoke. Pediatricians who reported previous training in counseling about tobacco issues also reported significantly higher levels of counseling of both adolescent smokers and parents who smoke but not of children and adolescents who do not smoke. Higher role perception, believing that smoking cessation counseling provided by pediatricians can be effective, and self-efficacy, were predictive of intervention with all three groups. The perceived barriers scale was not related to intervention with any group.

CONCLUSIONS

Pediatricians are missing opportunities to help their patients to stop smoking and to prevent smoking initiation. Pediatricians are intervening least frequently with parents who smoke. Practices should be tailored to the specific target group.

Barriers to physical activity promotion by general practitioners and practice nurses

OBJECTIVE

To examine the promotion of physical activity by general practitioners (GPs) and practice nurses (PNs).

METHODS

A questionnaire that examined the types of barriers and the levels of their influence as well as stage of change for activity promotion and for personal behaviour was mailed to 846 subjects.

RESULTS

The return rate exceeded 70% in each group with a high proportion (69%) of GPs and PNs reporting that they regularly promote physical activity with their patients. GPs were less likely to regularly promote physical activity with their patients if they indicated lack of time as a barrier (odds ratio (OR) = 0.73, 95% confidence interval (CI) 0.58 to 0.93) or lack of incentives (OR = 0.74, 95% CI 0.59 to 0.94), and more likely to promote exercise if they themselves were regular exercisers (OR = 3.19, 95% CI 1.96 to 5.18). However, for PNs longer consultation times (by 1.5 to 2 minutes) had a higher likelihood of producing regular promotion of activity (OR = 1.61, 95% CI 1.02 to 1.62). For PNs personal physical activity stage was the strongest significant predictor of promotion level, but with a stronger effect (OR = 4.77, 95% CI 1.48 to 15.35) than in the GPs.

CONCLUSION

The main finding is that GPs in the action or maintenance stage of changing their own physical activity are three times more likely to regularly promote the same behaviour in their patients than those in the other stages; for PNs the same difference quadruples the likelihood of them promoting physical activity. Professional readiness to change is influenced by known system barriers in GPs, and not in PNs, but is more strongly predicted by personal physical activity behaviour in both groups.

Promotion of healthy lifestyle: knowledge and attitudes of primary care physicians

This study was conducted in Riyadh city to determine the knowledge and attitudes of primary health care physicians regarding promotion of certain healthy lifestyles. Using a stratification technique, 50% of the male physicians were selected at random. A validated self-administered questionnaire was distributed to (and recollected from) the participants. One physician refused to participate resulting in a response rate approaching 99%. Most of the physicians (77.5%) were shown to have satisfactory knowledge, while only 20% possessed reasonably positive attitudes. Physicians above 40 years of age were more knowledgeable than younger age group (P < 0.0001). There was a general pessimism about compliance of patients to lifestyle advice. The relatively acceptable knowledge possessed by physicians was not properly translated into positive attitudes towards promotion of healthy lifestyle. To improve the situation, a greater emphasis should be placed on health promotion during undergraduate and postgraduate training of physicians.

The multilevel compliance challenge: recommendations for a call to action. A statement for healthcare professionals

Despite the universally accepted importance of compliance, strategies known for more than two decades to be effective are not routinely incorporated into clinical practice. For the benefits of primary and secondary prevention to be realized in diverse population groups and settings, emphasis must be placed on implementing strategies at the patient, provider, and organization levels. Current knowledge of compliance strategies, if integrated into a multilevel approach, offers enormous promise for decreasing risk and improving patient outcomes.

A comparison of self-report and chart audit in studying resident physician assessment of cardiac risk factors

OBJECTIVE

To examine the relationship between resident physicians' perceptions of their preventive cardiology practices and a chart audit assessment of their documented services.

DESIGN

A criterion standard comparison of two methods used to assess resident physicians' practices: self-report and chart audit.

SETTING

Physician ambulatory care in a residency program.

PATIENTS AND OTHER PARTICIPANTS

Coronary artery disease (CAD) risk factor assessment was evaluated by self-report for 72 resident physicians and by chart audit of randomly selected records of 544 of their patients who did not have CAD or a debilitating chronic disease during a one-year period.

INTERVENTION

Measurements of the residents' perceived CAD risk factor assessment practice by self-report, and chart audit assessments of their recorded care.

MAIN OUTCOME

The relationship between self-reported and chart audit assessments of CAD risk factors.

RESULTS

Chart audit assessment of CAD risk factor management was highly significantly (p < 0.01) lower than self-reported behaviors for evaluation of cigarette smoking, diet, physical activity, stress, plasma cholesterol, blood pressure, and body weight/obesity.

CONCLUSIONS

Three different interpretations of these findings are apparent. 1) Physician self-report is a poor tool for the measurement of clinical behavior, and therefore research of physician behavior should not rely solely on self-reported data; 2) physicians' chart recording of their clinical practice is insufficient to reflect actual care; or 3) neither is an accurate measure of actual practice.

Making "time" for preventive services

Although the implementation of clinical preventive services is a high priority on the national agenda and physicians acknowledge the importance of these services, implementation rates remain far below the target years after the recommendations have been released. Physicians repeatedly report that the reason for not providing preventive services is that they do not have "time." In this article, we identify attributes of the health-services system that create this phenomenon. We present evidence that formal delivery systems for preventive services must be developed if the "time" problem is to be solved, and we review why preventive-services systems need to be integrated into the current health-services system. Finally, we list the attributes that we believe a preventive-services system must have if it is to be successful. The success of clinical trials of such systems indicates that our goals of preventive services can be achieved if all persons who have an investment in clinical preventive services commit themselves to developing and supporting these systems.

Impact of a clinical preventive medicine curriculum for primary care faculty: results of a dissemination model

BACKGROUND

This study was designed to test a dissemination model for providing clinical preventive medicine (CPM) training to general internal medicine faculty across the United States.

METHODS

The model incorporated direct instruction of a few faculty as seminar facilitators who, in turn, taught a CPM curriculum to their faculty colleagues, who then could teach it to housestaff and students. The CPM curriculum consisted of six seminars that focused primarily on the risk factors for chronic diseases and on behavior change methods for modifying smoking, diet, and exercise.

RESULTS

Faculty who participated in the seminars had significant pre- to post-test increase in knowledge and reported self-efficacy to implement CPM strategies with patients, as well as changes in CPM clinical practices. These faculty, in turn, successfully disseminated CPM information to their housestaff, who also had increases in self-efficacy and changed clinical practices regarding CPM topics.

CONCLUSIONS

The successful implementation of the dissemination model attests to its viability as a mechanism for disseminating CPM curricula and increasing the emphasis on CMP issues in both clinical teaching and clinical encounters with patients.

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.

The clinician's role in promoting smoking cessation among clinic patients

Like other chronic conditions, nicotine dependence offers both challenges and rewards to clinicians. The treatment of this condition frequently requires experience in pharmacology, behavioral science, and social aspects of medicine. Physicians are uniquely qualified to assist patients in their efforts to overcome the multifaceted condition of tobacco addiction. In providing this treatment, the clinical challenges are far outweighed by the benefit to patients who stop smoking. For many patients, smoking cessation is, by far, the most important step they can take to improve their health and increase their life span. Physicians who help patients accomplish this difficult goal provide a life-saving service. There is sufficient scientific evidence to guide physicians in their approach to smoking patients. Brief, systematic interventions have been shown to increase patient smoking cessation rates. The intervention can be described in four steps: ask about smoking, advise smokers to stop, assist those who want to stop, and arrange adequate follow-up. These interventions are used consistently when a smoking cessation program is adopted by an entire office practice. The components of this office-based program include defining staff roles, maintaining a smoke-free office, stocking appropriate materials, making use of the medical record to identify smokers and to remind staff to intervene, and monitoring patient progress. The potential public health impact of physician intervention with smoking patients is enormous. Even with very modest expectations of cessation rates, 100,000 physicians using effective intervention can produce over 3 million new ex-smokers in the United States each year. In conjunction with other community-based tobacco control efforts, this physician-lead effort will result in a marked reduction in the morbidity and mortality caused by smoking and, thus, control of "the most important public health issue of our time."

Predictors of smoking behavior change 6 and 18 months after individual counseling during periodic health examinations

Predictors of smoking behavior change were examined in a randomized controlled trial of individualized smoking cessation counseling delivered by a smoking cessation counselor during periodic health examination. Self-reports of not smoking at 6 and 18 months and attempts to quit were greater, but not significantly so, in the intervention group compared with the usual care group. There was no difference between the intervention group and the usual care group in reported continuous abstinence. Multivariate analysis showed that longer periods of abstinence in the past and having smoking identified as the main problem were important predictors of subsequent quitting. Having fewer other smokers in the household, stronger intentions to stop smoking in the next month, and being in the intervention group were also significant predictors of abstinence at 6 months, but not at 18 months. Those who had tried to quit by 6 months and 18 months were more likely to be in the intervention group, to have greater motivation to stop smoking, and to have more problems of daily living. Supplementing physician's advice with individualized smoking cessation counseling during health maintenance examinations was associated with a greater short-term quit rate and more quit attempts over 18 months than physician advice alone, but did not influence continuous abstinence from cigarettes over this time.

Training physicians about smoking cessation: a controlled trial in private practice

STUDY OBJECTIVE

To test the hypotheses that physicians in private practice who receive a continuing education program (entitled "Quit for Life") about how to counsel smokers to quit would counsel smokers more effectively and have higher rates of long-term smoking cessation among their patients.

DESIGN

Randomized trial with blinded assessment of principal outcomes.

SETTING

Private practices of internal medicine and family practice.

SUBJECTS

Forty-four physicians randomly assigned to receive training (24) or serve as controls (20) and consecutive samples of smokers visiting each physician (19.6 patients per experimental and 22.3 per control physician).

INTERVENTIONS

Physicians received three hours of training about how to help smokers quit. Physicians and their office staffs were also given self-help booklets to distribute to smokers and were urged to use a system of stickers on charts as reminders to counsel smokers about quitting.

MEASUREMENTS AND MAIN RESULTS

Based on telephone interviews with patients, physicians in the experimental group were more likely to discuss smoking with patients who smoked (64% vs. 44%), spent more time counseling smokers about quitting (7.5 vs. 5.2 minutes), helped more smokers set dates to quit smoking (29% vs. 5% of smokers), gave out more self-help booklets (37% vs. 9%), and were more likely to make a follow-up appointment about quitting smoking (19% vs. 11% of those counseled) than physicians in the control group. One year later, the rates of biochemically confirmed, long-term (greater than or equal to 9 months) abstinence from smoking were similar among patients in the experimental (3.2%) and control (2.5%) groups (95% confidence interval for the 0.7% difference: -1.7 to +3.1%).

CONCLUSIONS

The authors conclude that this continuing education program substantially changed the way physicians counseled smokers, but had little or no impact on rates of long-term smoking cessation among their patients. There is a need for more effective strategies to help physicians help their patients to quit smoking.

A strategy to define the role of the primary care physician in occupational and environmental medicine

Although occupational medicine has its own unique knowledge, skills, and organizational base, it exists in a cultural, social, and organizational environment that is common to other institutions in our culture. It is therefore possible that the task of introducing the practice of occupational medicine into primary care can be made easier by examining the experience of those who have already attempted to introduce preventive Cardiology Academic Award provides a potential paradigm for enlisting a cadre of 10 to 25 innovative primary care physicians who would begin to develop actual practice models and disseminate their findings about the implementation of occupational medicine in primary care. Introducing preventive cardiology into primary care has required that multiple barriers be overcome; it is not unreasonable to expect that occupational medicine will face many of the same barriers. However, if these barriers can be successfully overcome at the experimental sites, the result will be a group of primary care practices that can be used as models for the expansion of occupational medicine to primary care in general.

Principles of changing health behavior

Successful implementation of clinical preventive care programs is a shared responsibility of patients and health care professionals. The physician often laments patient failure to follow directions while the same patient complains that instructions were never given. Health care professionals should strive to "practice as they preach." They need to assure that their patients have clearly understood the recommendations and that patient concerns are assessed and addressed. Similarly, patients need to participate more actively in their own health care and to assume greater initiative in getting their questions answered and their concerns addressed. To increase the likelihood of these actions and their intended health behavior changes, a set of principles derived from theory and research can be followed. These principles represent a way to understand and influence the health behavior of physicians and patients. The principles are interactive and complementary and are based on the elements that appear to be associated with successful educational programs. Consideration of these principles in the conduct of educational diagnoses, interventions, and health education programs increases the incidence and durability of behavior change.

Physician-delivered interventions for smoking cessation: strategies for increasing effectiveness

If physicians and other health-care providers were able to facilitate long-term cessation in 1 of every 10 smokers--a safe estimate based on the outcomes of randomized physician-delivered intervention studies--almost 4 million smokers would become former smokers. Evidence from randomized trials and observational studies demonstrates that physicians who intervene with smokers have an impact on their cigarette-smoking behavior. Greater smoking cessation occurs as physician interventions become more intensive and contacts more frequent. Adding modalities such as counseling, self-help booklets, and nicotine-containing chewing gum appears to augment the effectiveness of advice alone. The consistent demonstration of the need for follow-up and the possible use of several modalities is not unlike the demonstrated components of effective overall management approaches to such medical problems as hypertension. Surveys have indicated that physicians often do not intervene because they experience a low success rate with smokers. Educational programs have demonstrated substantial success in training physicians to counsel smokers; therefore, new goals for medical education, house-staff training, and continuing medical education need to include the development of skills and office management practices that can be used by providers to facilitate health-promoting behaviors among their patients. This article reviews the impact of physician-delivered smoking interventions on smokers, physician attitudes toward intervention, and physicians' reported intervention practices. It identifies those strategies that have been demonstrated to be effective in an out-patient office setting and emphasizes the need for every smoker to be considered a candidate for intervention.

The relationship of patient characteristics to physician delivery of advice to stop smoking

To investigate the frequency of physician delivery of advice to stop smoking and patient characteristics affecting whether physicians deliver such advice, the authors surveyed 97 current cigarette smokers seen in two specialty and one general medicine clinic at a university medical center. Approximately two thirds of the smokers reported ever having been advised to stop smoking by their current physicians. In univariate and multivariate analyses, the presence of a smoking-related illness, the number of prior attempts to quit, and the duration of cigarette smoking were significantly related to delivery of smoking cessation advice by physicians. Knowledge of factors that affect the provision of advice to stop smoking can be used to enhance the physician's role in smoking intervention.

A comparison of health promotion practices of general practitioners and residency trained family physicians

Physicians who specialize in family medicine and general practice have the potential to assume a major role in helping patients change their health promotion practices. Little is known about the proportion of routine consultation time devoted to primary prevention counseling or the factors that influence the provision of this kind of patient education. A survey of General and Family Practitioners was conducted to determine the extent to which these physicians perform health promotion counseling as well as their perceptions regarding constraints affecting their efforts, confidence in their ability to change patient's behaviors, and the training required to enhance their efforts. Differences, with respect to their health promotion practices, between General and Family Practitioners, were also examined. One hundred and ninety-five physicians completed the survey for a response rate of 68%. When year of graduation from medical school was controlled there was little difference in the health promotion practices of General and Family Practitioners. This study suggests residency training in the specialty of family medicine does not provide residents with the knowledge, confidence and skills to perform health prevention counseling at a level different than that practiced by General Practitioners.

The physician and patient education: a review

Education is an essential part of medical care and must be conducted properly for the patient to receive optimal benefit. Since physicians are responsible for a major portion of the health care delivered, there is a need to understand how patient education is used by these practitioners. Our current understanding of physician-patient education practices is reviewed in this paper. The frequency of patient education by physicians, the educational content and processes employed, and physician attitudes toward patient education are examined. This analysis shows that patient education is a salient issue among physicians. They report a high frequency of use of patient education with as many as 20% of visits containing a major educational intervention. The content of these interventions is weighed heavily toward instructions and information, with little assessment, monitoring or reinforcement noted. Physician attitudes toward patient education reflect an awareness of its importance and insecurity with actual educational interventions. A number of substantive issues remain to be addressed, including interventions to improve physician educational practice.

A model for predicting the counseling practices of physicians

The authors present a conceptual model of the determinants of the counseling practices of physicians and an empirical test of the model. Seventy-six per cent of a 50% random sample of physicians in a western county medical society completed a questionnaire (n = 151). This instrument measures the aggressiveness, the indications and techniques used by physicians in counseling patients about smoking, exercise, weight control and alcohol use. The independent variables assessed by this instrument are motivations, perceived skills and barriers, medical specialty, and personal health habits. Significant associations were found between the counseling practices reported and physicians' personal health habits, attitudes and specialties. Non-surgeons counseled more patients, counseled more intensively, and used a greater variety of techniques than surgeons and obstetrician-gynecologists. In general, physicians who had poor health habits did not fully counsel patients about those habits; however, physicians attempting to improve poor habits counseled patients significantly more often than physicians who were not trying to change their own behavior. Health maintenance efforts among physicians may have a multiplier effect.

Health education by professionals during pregnancy: assessing needs and effectiveness

Pregnancy care is undergoing an evolution. The trend toward professional control and technological intervention begun decades ago is under challenge by some women's groups and health professionals, who seek to make the pregnant woman herself the locus of control. In the same period, a developing literature concerning the relation of health to psychological and social factors has demonstrated their importance (3) and raised the issue of the place of social support and social action in health care (24).