Patient health information materials in waiting rooms of family physicians: do patients care?

Patient leaflets on respiratory tract infections did not improve shared decision making and antibiotic prescriptions in a low-prescriber setting

Patient information leaflets can reduce antibiotic prescription rates by improving knowledge and encouraging shared decision making (SDM) in patients with respiratory tract infections (RTI). The effect of these interventions in antibiotic low-prescriber settings is unknown. We conducted a pragmatic pre-/post interventional study between October 2022 and March 2023 in Swiss outpatient care. The intervention was the provision of patient leaflets informing about RTIs and antibiotics use. Main outcomes were the extent of SDM, antibiotic prescription rates, and patients' awareness/knowledge about antibiotic use in RTIs. 408 patients participated in the pre-intervention period, and 315 patients in the post- intervention period. There was no difference in the extent of SDM (mean score (range 0-100): 65.86 vs. 64.65, p = 0.565), nor in antibiotic prescription rates (no prescription: 89.8% vs. 87.2%, p = 0.465) between the periods. Overall awareness/knowledge among patients with RTI was high and leaflets showed only a small effect on overall awareness/knowledge. In conclusion, in an antibiotic low-prescriber setting, patient information leaflets may improve knowledge, but may not affect treatment decisions nor antibiotic prescription rates for RTIs.

Effectiveness of educational materials on levels of knowledge of thyroid associated orbitopathy in an endocrinology clinic

Objective

We aim to assess and quantify basic knowledge about TAO in patients presenting to an endocrinology clinic and the effect of different educational materials on patients' knowledge.

Methods

This study was conducted in a tertiary care center involving 255 patients presenting to an endocrinology clinic. The study was divided into three consecutive phases: 1. a control phase without any educational materials in the waiting room, 2. exposure to educational posters, and 3. exposure to educational pamphlets.

Results

In the control population, only 16.5% of patients reported having knowledge of TAO, with a low average TAO-K score of 29.8 (out of 100). After the poster and pamphlet interventions, the percentage of patients having any knowledge of TAO increased across the control, poster and pamphlet phases: 16.5%, 25.9%, 63.5% respectively (p < 0.001). Similarly, the mean TAO-K score increased: 29.8, 45.8, 63.2 respectively (p < 0.001).

Conclusion

This study confirms that patients with thyroid dysfunction have a low level of awareness and depth of knowledge of TAO.

Innovation

We suggest the dissemination of educational material to increase the knowledge of TAO in thyroid patients. This will help with early symptom detection and ensure proper management of this interdisciplinary condition.

Quebec Nurses’ Perceptions of the Integration of Sustainable Diet Promotion Into Clinical Appointments: A Qualitative Study

Introduction: A sustainable diet is a diet that is respectful of ecosystems, culturally acceptable, accessible and healthy. It is considered as a promising avenue for optimizing health and reducing the impacts of food on the environment. Several nursing associations have demonstrated a growing concern for nurses’ involvement in environmental and climate change issues, including in promoting sustainable diet. However, the literature reveals a lack of data on why and how nurses could address sustainable diet in their clinical practice. Objective: The aim of this study was to explore clinical nurses’ perceptions of their role in the promotion of sustainable diet. Methods: A descriptive qualitative study was conducted based on 6 focus groups involving 20 nurses from 7 regions of the province of Quebec, Canada. Computer-assisted thematic analysis was conducted on verbatim transcripts. Results: The discussions revealed 3 major themes. First, some dimensions of sustainable eating are already implicitly addressed and nurses were theoretically open to make further. However, it was difficult to see how nurses could translate this interest into concrete action due to a lack of time and their other clinical priorities. Lastly, in order to do this, nurses need support from health organizations as well as clear guidelines, training and tools. Discussion and conclusion: Despite experts’ recommendations, many barriers and inadequacies between experts’ recommendations and nurses’ reality prevent the implementation of concrete initiatives toward the promotion of sustainable diet among nurses. Nurses are invited to get involved and contribute to the promotion of sustainable diet with a “bottom-up” approach.

The co-development of personalised 10-year breast cancer risk communications: a 'think-aloud' study

BACKGROUND

Risk stratified breast cancer screening is being considered as a means of improving the balance of benefits and harms of mammography. Stratified screening requires the communication of risk estimates. We aimed to co-develop personalised 10-year breast cancer risk communications for women attending routine mammography.

METHODS

We conducted think-aloud interviews on prototype breast cancer risk letters and accompanying information leaflets with women receiving breast screening through the UK National Breast Screening Programme. Risk information was redesigned following feedback from 55 women in three iterations. A deductive thematic analysis of participants' speech is presented.

RESULTS

Overall, participants appreciated receiving their breast cancer risk. Their comments focused on positive framing and presentation of the risk estimate, a desire for detail on the contribution of individual risk factors to overall risk and effective risk management strategies, and clearly signposted support pathways.

CONCLUSION

Provision of breast cancer risk information should strive to be personal, understandable and meaningful. Risk information should be continually refined to reflect developments in risk management. Receipt of risk via letter is welcomed but concerns remain around the acceptability of informing women at higher risk in this way, highlighting a need for co-development of risk dissemination and support pathways.

Improving Health Literacy Responsiveness: A Randomized Study on the Uptake of Brochures on Doctor-Patient Communication in Primary Health Care Waiting Rooms

Presenting attractive and useful health education materials in waiting rooms can help improve an organization’s health literacy responsiveness. However, it is unclear to what extent patients may be interested in health education materials, such as brochures. We conducted a three-week field study in waiting rooms of three primary care centers in Groningen. Three versions of a brochure on doctor-patient communication were randomly distributed, 2250 in total. One version contained six short photo stories, another version was non-narrative but contained comparable photos, and the third version was a traditional brochure. Each day we counted how many brochures were taken. We also asked patients (N = 471) to participate in a brief interview. Patients who consented (N = 390) were asked if they had noticed the brochure. If yes (N = 135), they were asked why they had or had not browsed the brochure, and why they had or had not taken it. Interview responses were categorized by two authors. Only 2.9% of the brochures were taken; no significant association with brochure version was found. Analysis of the interview data showed that the version with the photo narrative was noticed significantly more often than the non-narrative version or the traditional version. These results suggest that designing attractive and comprehensible health materials is not enough. Healthcare organizations should also create effective strategies to reach their target population.

A Qualitative Investigation of the Acceptability and Feasibility of a Urinary Tract Infection Patient Information Leaflet for Older Adults and Their Carers

Urinary tract infections (UTIs) can be life threatening in older adults. The aim of this study was to primarily understand the acceptability and feasibility of using a UTI leaflet for older adults in care homes and the community. Qualitative interviews and focus groups informed by the Theoretical Domains Framework were conducted in 2019 with 93 participants from two English areas where a UTI leaflet for older adults had been introduced to improve self-care advice. Discussions were conducted with care staff (carers and nurses), older adults, general practice staff (GPs, nurses and health care assistants), and other relevant stakeholders and covered experiences of using the leaflet; its implementation; and barriers and facilitators to use. Participants deemed the leaflet an acceptable tool. Clinicians and care staff believed that having information in writing would reinforce their messages to older adults. Care staff reported that some older adults may find the information overwhelming. Where implemented, care staff used the leaflet as an educational guide. Clinicians requested the leaflet in electronic and paper formats to suit preferences. Implementation barriers included lack of awareness of the leaflet, lack of staffing and resource, and weak working relationships between care homes and general practices. It is recommended that regional strategies must include plans for dissemination to care homes, training, promotion and easy access to the leaflet. Improvements to the leaflet consisted of inclusion of antibiotic course length, D-mannose, atrophic vaginitis and replacement of less alarmist terminology such as ‘life threatening’.

Acceptance and self-reported use of a dementia care toolbox by general practice personal: results from an intervention study in German practices

Background

Dementia is an age-related syndrome that is estimated to affect 46.8 million people worldwide (2015). In ageing populations, the prevalence of dementia is expected to increase. General practitioners (GPs) are often the first to be contacted when signs of dementia appear. This cluster-randomised trial (CRT) investigates the effects of a dementia care toolbox mailed to GP practices to facilitate dementia care. It contained patient brochures and posters for the waiting room in three languages, information cards for professionals and practical tools in three languages. The GPs’ and practice assistants’ (PrAs) use of and opinion about the toolbox is reported here.

Methods

Three months after receiving the toolbox, participating GPs and PrAs were sent a standardised, self-administered questionnaire asking about the use and helpfulness of the various toolbox items by mail.

Results

A total of 50 GPs and PrAs (14 GPs and 36 PrAs) from 15 practices completed the questionnaire. Of the participants, 82.0% reported using at least one of the tools, while 18.0% had used none. In descending order, the patient brochures (70.0%), the information card (58.0%) and the poster (40.0%) were used. In general, the brochures (52.1%), the information card (44.9%) as well as the poster (28.6%) were perceived as helpful.

Conclusion

Overall, the dementia toolbox was widely accepted by both professional groups. Future research should investigate long-term effects of information strategies for GP practice settings.

Trial registration

German Clinical Trials Register, DRKS00014632. Registered 02 August 2018. Clinical register of the study coordination office of the University hospital of Bonn. Registered 05 September 2017.

Effectiveness of diet and physical activity interventions amongst adults attending colorectal and breast cancer screening: a systematic review and meta-analysis

Purpose

To estimate the effectiveness of tailored physical activity and dietary interventions amongst adults attending colorectal and breast cancer screening.

Methods

Five literature databases were systematically searched to identify randomised controlled trials (RCTs) of tailored physical activity and/or dietary interventions with follow-up support initiated through colorectal and breast cancer screening programmes. Outcomes included markers of body fatness, physical activity, and dietary intake. Mean differences (MDs) or standardised mean differences (SMDs) with 95% confidence intervals (CIs) were pooled using random effects models.

Results

Five RCTs met the inclusion criteria encompassing a total of 722 participants. Diet and physical activity interventions led to statistically significant reductions in body mass (MD − 1.6 kg, 95% CI − 2.7 to − 0.39 kg; I² = 81%; low quality evidence), body mass index (MD − 0.78 kg/m², 95% CI − 1.1 to − 0.50 kg/m²; I² = 21%; moderate quality evidence), and waist circumference (MD − 2.9 cm, 95% CI − 3.8 to − 1.91; I² = 0%; moderate quality evidence), accompanied by an increase in physical activity (SMD 0.31, 95% CI 0.13 to 0.50; I² = 0%; low quality evidence) and fruit and vegetable intake (SMD 0.33, 95% CI 0.01 to 0.64; I² = 51%; low quality evidence).

Conclusion

There is low quality evidence that lifestyle interventions involving follow-up support lead to modest weight loss and increased physical activity and fruit and vegetable intake. Due to the modest intervention effects, low quality of evidence and small number of studies, further rigorously designed RCTs with long-term follow-up of modifiable risk factors and embedded cost–benefit analyses are warranted (PROSPERO ref: CRD42020179960).

Electronic supplementary material

The online version of this article (10.1007/s10552-020-01362-5) contains supplementary material, which is available to authorized users.

Health Literacy in Hospital Outpatient Waiting Areas: An Observational Study of What Is Available to and Accessed by Consumers

AIM

To investigate: (1) the types of health information, resources, and supports available to consumers in hospital outpatient waiting areas and (2) whether these are accessed by consumers.

BACKGROUND

Outpatient waiting areas commonly offer health information, resources, and supports to improve the health literacy of waiting consumers. It is not known what is available to or accessed by consumers in hospital outpatient rehabilitation waiting areas.

METHODS

A multicenter, prospective, observational, cross-sectional study was conducted in the waiting areas of two hospital outpatient rehabilitation services. Direct observations (in person and video recordings) of the waiting areas were used to describe what health information, resources, and supports were available and, if present, what was being accessed and for how long by consumers.

RESULTS

Fifteen hours of in-person and video-recorded observations were documented on purpose-designed instruments across the two sites during 18 observation sessions over 8 days. A total of 68 different health information and resources were identified. Approximately half were specifically for consumers (Site 1: 57%; Site 2: 53%). Only seven (10%) were accessed by consumers across both sites. Each resource (n = 7) was only accessed once. Health resources were used by consumers for 0.8% (3/360 min) of the observation time at each site. Health and social supports and use of other non health resources were also observed.

CONCLUSIONS

Available health information, resources, and supports were infrequently and briefly accessed by consumers. Further research is required to explore what consumers want and need to improve the health literacy responsiveness of hospital outpatient waiting areas.

Creation of consensus recommendations for collaborative practice in the Malaysian psychiatric system: a modified Delphi study

BACKGROUND

There is strong evidence that collaborative practice in mental healthcare improves outcomes for patients. The concept of collaborative practice can include collaboration between healthcare workers of different professional backgrounds and collaboration with patients, families and communities. Most models of collaborative practice were developed in Western and high-income countries and are not easily translatable to settings which are culturally diverse and lower in resources. This project aimed to develop a set of recommendations to improve collaborative practice in Malaysia.

METHODS

In the first phase, qualitative research was conducted to better understand collaboration in a psychiatric hospital (previously published). In the second phase a local hospital level committee from the same hospital was created to act on the qualitative research and create a set of recommendations to improve collaborative practice at the hospital for the hospital. Some of these recommendations were implemented, where feasible and the outcomes discussed. These recommendations were then sent to a nationwide Delphi panel. These committees consisted of healthcare staff of various professions, patients and carers.

RESULTS

The Delphi panel reached consensus after three rounds. The recommendations include ways to improve collaborative problem solving and decision making in the hospital, ways to improve the autonomy and relatedness of patients, carers and staff and ways to improve the levels of resources (e.g. skills training in staff, allowing people with lived experience of mental disorder to contribute).

CONCLUSIONS

This study showed that the Delphi method is a feasible method of developing recommendations and guidelines in Malaysia and allowed a wider range of stakeholders to contribute than traditional methods of developing guidelines and recommendations.Trial registration Registered in the National Medical Research Register, Malaysia, NMRR-13-308-14792.

Prevalence and Correlates of Unmet Supportive Needs of Nigerian Patients With Cancer

PURPOSE

Diagnosis and treatment of cancer are associated with significant psychological distress, and patients face a broad range of challenges that create a vacuum of unmet needs felt by patients, such as a loss of personal control and frustration. The aim of the current study was to determine the magnitude, distribution, and correlates of unmet needs in Nigerian patients with cancer.

PATIENTS AND METHODS

Using a descriptive cross-sectional approach, we assessed 205 patients with cancer who attended oncology outpatient clinics at the Lagos University Teaching Hospital. Eligible patients were administered the Supportive Care Needs Survey (SCNS) –Short Form 34 with a focus on five domains of need: psychological, health system and information, physical and daily living, patient care and support, and sexuality.

RESULTS

Mean age was 47.4 ± 12.3 years and patients were predominantly female (96.6%). The most common diagnosis was breast cancer (92.2%), and mean duration since diagnosis was 20.9 ± 21.9 months for all patients. Mean SCNS score was 83.9 ± 24.8 and at least 46% of participants indicated unmet needs in 15 items of the SCNS. The most frequent unattended needs were related to the health information (53.4%), physical and daily living (49.4%), psychological (48.5%), sexuality, and patient care and support domains. None of the factors considered—age, sex marital status, family type, educational attainment, employment status, economic status, the presence of financial support, social support, and cancer type—was significantly predictive of unmet needs in these patients (P > .05).

CONCLUSION

Nigerian patients with cancer experience considerable levels of unmet needs. These needs require urgent and long-term interventions to help patients achieve increased care satisfaction and a better quality of life.

Patient and clinician engagement with health information in the primary care waiting room: A mixed methods case study

Background. Primary care waiting rooms can be sites of health promotion and health literacy development through the provision of readily accessible health information. To date, few studies have considered patient engagement with televised health messages in the waiting room, nor have studies investigated whether patients ask their clinicians about this information. The aim of this study was therefore to examine patient (or accompanying person) and clinician engagement with waiting room health information, including televised health messages.

Design and methods. The mixed methods case study was undertaken in a regional general practice in Victoria, Australia, utilising patient questionnaires, waiting room observations, and clinician logbooks and interviews. The qualitative data were analysed by content analysis; the questionnaire data were analysed using descriptive statistics.

Results. Patients engaged with a range of health information in the waiting room and reportedly received health messages from this information. 44% of the questionnaire respondents (33 of 74) reported watching the television health program, and half of these reported receiving a take home health message from this source. Only one of the clinicians (N=9) recalled a patient asking about the televised health program.

Conclusions. The general practice waiting room remains a site where people engage with the available health information, with a televised health ‘infotainment’ program receiving most attention from patients. Our study showed that consumption of health information was primarily passive and tended not to activate patient discussions with clinicians. Future studies could investigate any link between the health infotainment program and behaviour change.

A printed information leaflet about MRI and radiologists improves neuroradiology patient health literacy

PURPOSE

To determine the health literacy benefit of a printed informational leaflet for patients scheduled to undergo brain magnetic resonance imaging (MRI) scans.

METHODS AND MATERIALS

A two-page leaflet that provided an overview of MRI and the role of radiologists was prepared and given to outpatients scheduled to undergo brain MRI examinations while in the waiting room. A survey composed mainly of yes/no and Likert scale questions pertaining to the leaflet, as well as patient demographics, was administered to the patients.

RESULTS

A total of 147 patients completed the survey, of which 110 (75%) had undergone a prior MRI scan, 120 (82%) stated that their ordering provider explained the reason for the MRI scan, and less than 1% reported having referenced online resources related to MRI. The average score for how well patients understood the MRI scan procedure and how it is reviewed was 4.16/5 (standard deviation 1.18) before versus 4.39/5 (standard deviation 1.08) after reading the leaflet, which was a statistically significant improvement based on the Wilcoxon signed-rank test ( P < 0.01). The score for how helpful the reading material was for explaining what is MRI was 4.06/5 (standard deviation 1.02) and the score for how helpful the reading material was for explaining what is a radiologist was 4.18/5 (standard deviation 0.98).

CONCLUSION

A printed leaflet about MRI and radiologists can serve as an opportunity to educate patients about certain aspects of their scans during their stay in the waiting room.

Effectiveness of health education materials in general practice waiting rooms: a cross-sectional study

BACKGROUND

Health education materials (HEMs) are widely used in general practice. However, there is little information on the variety of HEMs currently available to patients in the UK, or their preferences for accessing educational materials.

AIM

To assess patients' perceptions of HEMs, and the variety and accessibility of these materials.

DESIGN AND SETTING

Cross-sectional study conducted in general practices in Brighton and Hove.

METHOD

An anonymous questionnaire was distributed to patients in the waiting room (WR). Additionally, an audit was conducted to measure the variety of the HEMs. Results were analysed using binary multiple logistic regression.

RESULTS

In all, 556 participants (response rate 83.1%) from 19 practices took part. The mean age of participants was 49.3 years (SD ±18.9) and 63% were female. Perceived usefulness of HEMs was associated with reading in the WR using written HEMs, and not having a university degree; noticeability was associated with reading in the WR, and being female; attractiveness was associated with not having a university degree and shorter waiting time. On average, WRs contained 72 posters covering 23 topics, and 53 leaflets covering 24 topics, with many outdated and poorly presented materials of limited accessibility.

CONCLUSION

This study found substantial variation in the amount, topicality, and quality of material available in WRs. As most patients notice HEMs and find them useful, available technology could be better utilised to widen access to HEMs. The introduction of wireless free internet (Wi-Fi) to waiting rooms should provide an opportunity to update this area.

Dual diagnosis competencies: A systematic review of staff training literature

Objective

To conduct a systematic review of the literature regarding approaches to staff training in dual diagnosis competencies.

Methods

A search was conducted using eight databases: Informit, Taylor & Francis, Springer, Proquest, Expand, Sage, Psych info, Elsevier and Cinahl. The year range was 2005 to April 2015. An additional manual search of reference lists was conducted to ensure relevant articles were not overlooked.

Results

Of 129 potential results, there were only 11 articles regarding staff training in dual diagnosis. The limited studies included problems: small sample sizes, selection biases, and questions as to validity of some capability instruments, and low inclusion of service user perspectives. Organisational challenges to greater uptake of staff training including agency size, agency willingness to change, and a need to change policies.

Conclusions

There is a pressing need for more research, and quality research, in this important area of knowledge translation, dissemination and implementation of evidence-based practices. In particular there is limited literature regarding the efficacy of dual diagnosis competency resources, and a gap as to use of the mentoring in dual diagnosis capacity building.

•

A systematic review of 8 databases across 10 years found only 11 articles.

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No research into capacity building efficacy of evidence-based dual diagnosis tools

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Training and mentoring is needed for staff to use evidence well in practice.

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Organisational barriers include agency size, willingness, and need to change policies.

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Limitations included small samples, selection bias; lack of service user responses.

Waiting Room Education in a Community Health System: Provider Perceptions and Suggestions

The increasing burden of chronic diseases in the United States presents a major challenge to the nation's primary care systems, so improving the efficacy and efficiency of patient education is an important goal. Understanding the current perspectives, practices, and needs of primary care providers should guide innovation towards this end. As a part of the authors' ongoing quality improvement work, a short internet survey was an effective method of enhancing this understanding in one health care system. With a response rate of 24.6 %, the survey revealed that primary care waiting rooms in the health system studied are not conceived of or used by providers as spaces to engage patients in health education. To change this, providers suggested using both printed and technological methods for delivering health information, primarily related to medications, diabetes, and healthy lifestyle practices. Common barriers to improvement cited by providers included diverse language and literacy backgrounds in the patient population, as well as difficulty sustaining change due to infrastructural and administrative barriers. These results suggest steps for development, implementation, and investigation of new educational interventions for patients in the local primary care context.

Placing wireless tablets in clinical settings for patient education

OBJECTIVE

The authors explored the feasibility and possible benefit of tablet-based educational materials for patients in clinic waiting areas.

METHODS

We distributed eight tablets preloaded with diagnosis-relevant information in two clinic waiting areas. Patients were surveyed about satisfaction, usability, and effects on learning. Technical issues were resolved.

RESULTS

Thirty-seven of forty patients completed the survey. On average, the patients were satisfied in all categories.

CONCLUSIONS

Placing tablet-based educational materials in clinic waiting areas is relatively easy to implement. Patients using tablets reported satisfaction across three domains: usability, education, and satisfaction.

Patient information materials in general practices and promotion of health literacy: an observational study of their effectiveness

BACKGROUND

Government policy in the UK emphasises providing patients with good health information to encourage participation in their health care. Patient information leaflets (PILs) form part of this policy and have been shown to affect patient health outcomes; however, many are poorly written.

AIM

To describe the PILs in general practice surgeries in Stoke-on-Trent in terms of readability and variety of content.

DESIGN AND SETTING

An observational study of randomly selected GP practices (n = 17) across Stoke-on-Trent.

METHOD

PILs were assessed for readability (Flesch Reading Ease and Flesch-Kincaid Grade Level) and compared with national skills level data and with the recommended level for medical information. The PILs were also categorised for content using the Rudd (2007) health material classification framework.

RESULTS

A total of 345 PILs were collected and assessed. Only 24.3% meet recommended reading-level criteria. Compared with national skills levels, over 75% of the PILs collected were too complex for at least 15% of the English population. Of the PILs, 47.8% were classified as 'systems navigation' (information regarding services); 22.9% were disease prevention (screening and immunisations); 14.2% personal and public safety; and less than 10% were for managing illness or health promotion.

CONCLUSION

Current PILs in general practices do not all promote health literacy. Information only accessible to a proportion of higher skilled patients may increase inequalities in health. Less than 10% of PILs promote managing illness or healthy lifestyles. Processes must be put in place to improve the readability and variety of content of PILs in GP practices.

Television-based health promotion in general practice waiting rooms in London: a cross-sectional study evaluating patients' knowledge and intentions to access dental services

BACKGROUND

This study aimed to evaluate whether television-based dental health promotion initiatives in General Practice waiting rooms would increase patients' knowledge of and intentions to seek dental services.

METHODS

This cross-sectional survey of 2,345 patients attending 49 General Practices in Brent, northwest London, evaluated the 'Life Channel' - a series of six brief health promotion advertisements, including one dental health promotion advertisement, displayed over ten minutes on television in General Practice waiting rooms. Primary outcome measures were a self-reported gain in the knowledge to contact a National Health Service (NHS) and emergency dentist, and an intention to seek dental services, attributed to viewing the Life Channel.

RESULTS

Among the 1,088 patients who did not know how to contact an NHS dentist prior to the survey, and the 1,247 patients who did not know how to contact an emergency dentist prior to the survey, 48.0 % (95 % CI 45.0-51.0 %) and 35.1 % (95 % CI 32.4-37.8 %) attributed the Life Channel to educating them how to do so, respectively. Among the 1,605 patients who did not have any intention to contact a dentist prior to the survey, 15.2 % (95 % CI 13.4-17.0 %) attributed the Life Channel to creating such an intention. We report adjusted odds ratios on sociodemographic disparities in this evaluation.

CONCLUSIONS

Television-based dental health promotion may significantly increase knowledge of and intention to seek dental services in this sample in London. Television-based dental health promotion may appeal more to certain population groups. More research is needed to identify longer term outcomes of television-based health promotion.

The Challenge of Cardiovascular Diseases and Diabetes to Public Health: A Study Based on Qualitative Systemic Approach

The most common modeling approaches to understanding incidence, prevalence and control of chronic diseases in populations, such as statistical regression models, are limited when it comes to dealing with the complexity of those problems. Those complex adaptive systems have characteristics such as emerging properties, self-organization and feedbacks, which structure the system stability and resistance to changes. Recently, system science approaches have been proposed to deal with the range, complexity, and multifactor nature of those public health problems. In this paper we applied a multilevel systemic approach to create an integrated, coherent, and increasingly precise conceptual framework, capable of aggregating different partial or specialized studies, based on the challenges of the Longitudinal Study of Adult Health - ELSA-Brasil. The failure to control blood pressure found in several of the study's subjects was discussed, based on the proposed model, analyzing different loops, time lags, and feedback that influence this outcome in a population with high educational level, with reasonably good health services access. We were able to identify the internal circularities and cycles that generate the system's resistance to change. We believe that this study can contribute to propose some new possibilities of the research agenda and to the discussion of integrated actions in the field of public health.

Patient information leaflets to reduce antibiotic use and reconsultation rates in general practice: a systematic review

OBJECTIVE

Patients' knowledge and expectations may influence prescription of antibiotics. Therefore, providing evidence-based information on cause of symptoms, self-management and treatment is essential. However, providing information during consultations is challenging. Patient information leaflets could facilitate consultations by increasing patients' knowledge, decrease unnecessary prescribing of antibiotics and decrease reconsultations for similar illnesses. Our objective was to systematically review effectiveness of information leaflets used for informing patients about common infections during consultations in general practice.

DESIGN, SETTING AND PARTICIPANTS

We systematically searched PubMed/MEDLINE and EMBASE for studies evaluating information leaflets on common infections in general practice. Two reviewers extracted data and assessed article quality.

PRIMARY AND SECONDARY OUTCOME MEASURES

Antibiotic use and reconsultation rates.

RESULTS

Of 2512 unique records, eight studies were eligible (7 randomised, controlled trials, 1 non-randomised study) accounting for 3407 patients. Study quality varied from reasonable to good. Five studies investigated effects of leaflets during consultations for respiratory tract infections; one concerned conjunctivitis, one urinary tract infections and one gastroenteritis and tonsillitis. Three of four studies presented data on antibiotic use and showed significant reductions of prescriptions in leaflet groups with a relative risk (RR) varying from 0.53 (0.40 to 0.69) to 0.96 (0.83 to 1.11). Effects on reconsultation varied widely. One large study showed lower reconsultation rates (RR 0.70 (0.53 to 0.91), two studies showed no effect, and one study showed increased reconsultation rates (RR 1.53 (1.03 to 2.27)). Studies were too heterogenic to perform a meta-analysis.

CONCLUSIONS

Patient information leaflets during general practitioners consultations for common infections are promising tools to reduce antibiotic prescriptions. Results on reconsultation rates for similar symptoms vary, with a tendency toward fewer reconsultations when patients are provided with a leaflet. Use of information leaflets in cases of common infections should be encouraged. Their contributing role in multifaceted interventions targeting management of common infections in primary care needs to further exploration.