Pilot Study of an Encounter Decision Aid for Lung Cancer Screening

The Centers for Medicare and Medicaid Services has mandated in-person shared decision-making (SDM) counseling with the use of one or more decision aids (DAs) prior to lung cancer screening. We developed a single-page, paper-based, encounter DA (EDA) to be used within a clinician-patient encounter for lung cancer screening and conducted a pre-post pilot intervention study to evaluate its feasibility and effects on patient decisional conflict. Patients referred to a pulmonary practice-based lung cancer screening program were surveyed before and after an SDM visit with a pulmonologist, who used the EDA to counsel the patient. Patient knowledge of the mortality benefit from screening and the frequency of abnormal screening test results was evaluated after the visit, while decisional conflict was measured before and after the visit using the Decisional Conflict Scale (DCS). Twenty-three patients participated (mean age = 65.8 years; 43% female; mean smoking history = 57.8 pack-years; 48% currently smoking). Following the visit, 28% of participants correctly understood the mortality benefit of lung cancer screening, while 82% understood the frequency of abnormal screening tests. The mean total DCS score decreased from 35.0 to 0.2 after the visit (p < 0.001). These data suggest that a single-page, paper-based EDA is feasible and potentially effective in reducing decision conflict when used within a SDM visit, although more research is needed to establish the independent effects of the EDA, and future efforts to promote SDM may need to devote greater attention to improving patient understanding of the mortality benefit of screening.

Epistemic Beliefs: Relationship to Future Expectancies and Quality of Life in Cancer Patients

CONTEXT

Expectations about the future (future expectancies) are important determinants of psychological well-being among cancer patients, but the strategies patients use to maintain positive and cope with negative expectancies are incompletely understood.

OBJECTIVES

To obtain preliminary evidence on the potential role of one strategy for managing future expectancies: the adoption of "epistemic beliefs" in fundamental limits to medical knowledge.

METHODS

A sample of 1307 primarily advanced-stage cancer patients participating in a genomic tumor testing study in community oncology practices completed measures of epistemic beliefs, positive future expectancies, and mental and physical health-related quality of life (HRQOL). Descriptive and linear regression analyses were conducted to assess the relationships between these factors and test two hypotheses: 1) epistemic beliefs affirming fundamental limits to medical knowledge ("fallibilistic epistemic beliefs") are associated with positive future expectancies and mental HRQOL, and 2) positive future expectancies mediate this association.

RESULTS

Participants reported relatively high beliefs in limits to medical knowledge (M = 2.94, s.d.=.67) and positive future expectancies (M = 3.01, s.d.=.62) (range 0-4), and relatively low mental and physical HRQOL. Consistent with hypotheses, fallibilistic epistemic beliefs were associated with positive future expectancies (b = 0.11, SE=.03, P< 0.001) and greater mental HRQOL (b = 0.99, SE=.34, P = 0.004); positive expectancies also mediated the association between epistemic beliefs and mental HRQOL (Sobel Z=4.27, P<0.001).

CONCLUSIONS

Epistemic beliefs in limits to medical knowledge are associated with positive future expectancies and greater mental HRQOL; positive expectancies mediate the association between epistemic beliefs and HRQOL. More research is needed to confirm these relationships and elucidate their causal mechanisms.

How Physicians Manage Medical Uncertainty: A Qualitative Study and Conceptual Taxonomy

BACKGROUND

Medical uncertainty is a pervasive and important problem, but the strategies physicians use to manage it have not been systematically described.

OBJECTIVES

To explore the uncertainty management strategies employed by physicians practicing in acute-care hospital settings and to organize these strategies within a conceptual taxonomy that can guide further efforts to understand and improve physicians' tolerance of medical uncertainty.

DESIGN

Qualitative study using individual in-depth interviews.

PARTICIPANTS

Convenience sample of 22 physicians and trainees (11 attending physicians, 7 residents [postgraduate years 1-3), 4 fourth-year medical students), working within 3 medical specialties (emergency medicine, internal medicine, internal medicine-pediatrics), at a single large US teaching hospital.

MEASUREMENTS

Semistructured interviews explored participants' strategies for managing medical uncertainty and temporal changes in their uncertainty tolerance. Inductive qualitative analysis of audio-recorded interview transcripts was conducted to identify and categorize key themes and to develop a coherent conceptual taxonomy of uncertainty management strategies.

RESULTS

Participants identified various uncertainty management strategies that differed in their primary focus: 1) ignorance-focused, 2) uncertainty-focused, 3) response-focused, and 4) relationship-focused. Ignorance- and uncertainty-focused strategies were primarily curative (aimed at reducing uncertainty), while response- and relationship-focused strategies were primarily palliative (aimed at ameliorating aversive effects of uncertainty). Several participants described a temporal evolution in their tolerance of uncertainty, which coincided with the development of greater epistemic maturity, humility, flexibility, and openness.

CONCLUSIONS

Physicians and physician-trainees employ a variety of uncertainty management strategies focused on different goals, and their tolerance of uncertainty evolves with the development of several key capacities. More work is needed to understand and improve the management of medical uncertainty by physicians, and a conceptual taxonomy can provide a useful organizing framework for this work.

How Physicians Manage Medical Uncertainty: A Qualitative Study and Conceptual Taxonomy

BACKGROUND

Medical uncertainty is a pervasive and important problem, but the strategies physicians use to manage it have not been systematically described.

OBJECTIVES

To explore the uncertainty management strategies employed by physicians practicing in acute-care hospital settings and to organize these strategies within a conceptual taxonomy that can guide further efforts to understand and improve physicians' tolerance of medical uncertainty.

DESIGN

Qualitative study using individual in-depth interviews.

PARTICIPANTS

Convenience sample of 22 physicians and trainees (11 attending physicians, 7 residents [postgraduate years 1-3), 4 fourth-year medical students), working within 3 medical specialties (emergency medicine, internal medicine, internal medicine-pediatrics), at a single large US teaching hospital.

MEASUREMENTS

Semistructured interviews explored participants' strategies for managing medical uncertainty and temporal changes in their uncertainty tolerance. Inductive qualitative analysis of audio-recorded interview transcripts was conducted to identify and categorize key themes and to develop a coherent conceptual taxonomy of uncertainty management strategies.

RESULTS

Participants identified various uncertainty management strategies that differed in their primary focus: 1) ignorance-focused, 2) uncertainty-focused, 3) response-focused, and 4) relationship-focused. Ignorance- and uncertainty-focused strategies were primarily curative (aimed at reducing uncertainty), while response- and relationship-focused strategies were primarily palliative (aimed at ameliorating aversive effects of uncertainty). Several participants described a temporal evolution in their tolerance of uncertainty, which coincided with the development of greater epistemic maturity, humility, flexibility, and openness.

CONCLUSIONS

Physicians and physician-trainees employ a variety of uncertainty management strategies focused on different goals, and their tolerance of uncertainty evolves with the development of several key capacities. More work is needed to understand and improve the management of medical uncertainty by physicians, and a conceptual taxonomy can provide a useful organizing framework for this work.

Cause or Effect? The Role of Prognostic Uncertainty in the Fear of Cancer Recurrence

Background

Fear of cancer recurrence (FCR) is an important cause of suffering for cancer survivors, and both empirical evidence and theoretical models suggest that prognostic uncertainty plays a causal role in its development. However, the relationship between prognostic uncertainty and FCR is incompletely understood.

Objective

To explore the relationship between prognostic uncertainty and FCR among patients with ovarian cancer (OC).

Design

A qualitative study was conducted utilizing individual in-depth interviews with a convenience sample of patients with epithelial ovarian cancer who had completed first-line treatment with surgery and/or chemotherapy. Semi-structured interviews explored participants’ (1) understanding of their prognosis; (2) experiences, preferences, and attitudes regarding prognostic information; and (3) strategies for coping with prognostic uncertainty. Inductive qualitative analysis and line-by-line software-assisted coding of interview transcripts was conducted to identify key themes and generate theoretical insights on the relationship between prognostic uncertainty and FCR.

Results

The study sample consisted of 21 participants, nearly all of whom reported experiencing significant FCR, which they traced to an awareness of the possibility of a bad outcome. Some participants valued and pursued prognostic information as a means of coping with this awareness, suggesting that prognostic uncertainty causes FCR. However, most participants acknowledged fundamental limits to both the certainty and value of prognostic information, and engaged in various strategies aimed not at reducing but constructing and maintaining prognostic uncertainty as a means of sustaining hope in the possibility of a good outcome. Participants’ comments suggested that prognostic uncertainty, fear, and hope are connected by complex, bi-directional causal pathways mediated by processes that allow patients to cope with, construct, and maintain their uncertainty. A provisional dual-process theoretical model was developed to capture these pathways.

Conclusion

Among patients with OC, prognostic uncertainty is both a cause and an effect of FCR—a fear-inducing stimulus and a hope-sustaining response constructed and maintained through various strategies. More work is needed to elucidate the relationships between prognostic uncertainty, fear, and hope, to validate and refine our theoretical model, and to develop interventions to help patients with OC and other serious illnesses to achieve an optimal balance between these states.

What is Quality End-of-Life Care for Patients With Heart Failure? A Qualitative Study With Physicians

Background

Advanced heart failure (AHF) carries a morbidity and mortality that are similar or worse than many advanced cancers. Despite this, there are no accepted quality metrics for end‐of‐life (EOL) care for patients with AHF.

Methods and Results

As a first step toward identifying quality measures, we performed a qualitative study with 23 physicians who care for patients with AHF. Individual, in‐depth, semistructured interviews explored physicians' perceptions of characteristics of high‐quality EOL care and the barriers encountered. Interviews were analyzed using software‐assisted line‐by‐line coding in order to identify emergent themes. Although some elements and barriers of high‐quality EOL care for AHF were similar to those described for other diseases, we identified several unique features. We found a competing desire to avoid overly aggressive care at EOL alongside a need to ensure that life‐prolonging interventions were exhausted. We also identified several barriers related to identifying EOL including greater prognostic uncertainty, inadequate recognition of AHF as a terminal disease and dependence of symptom control on disease‐modifying therapies.

Conclusions

Our findings support quality metrics that prioritize receipt of goal‐concordant care over utilization measures as well as a need for more inclusive payment models that appropriately reflect the dual nature of many AHF therapies.

Effects of Personalized Risk Information on Patients Referred for Lung Cancer Screening with Low-Dose CT

Background. Low-dose computed tomography (LDCT) screening for lung cancer is a preference-sensitive intervention that should ideally be individualized according to patients' likelihood of benefit and personal values. Personalized cancer risk information (PCRI) may facilitate this goal, but its effects are unknown. Objective. To evaluate the effects of providing PCRI to patients referred for LDCT screening. Design. Mixed-methods, pre-post study using surveys administered to patients before and after provision of PCRI-calculated by the PLCOm2012 risk prediction model-in shared decision-making consultations, and postvisit qualitative interviews. Setting. Centralized specialty-based LDCT screening program at a tertiary care hospital. Participants. Convenience sample of eligible patients referred for LDCT screening. Measurements. Pre- and postvisit surveys assessed patients' 1) perceived lung cancer risk, 2) uncertainty about their risk, 3) minimum risk threshold for wanting screening, 4) interest in LDCT screening, and 5) interest in smoking cessation. Qualitative interviews explored patients' perceptions of the value of PCRI. Screening uptake was assessed by chart review. Results. Sixty of 70 (86%) patients received PCRI and completed pre-post surveys, and 17 patients (28%) completed qualitative interviews. Perceived lung cancer risk decreased from 52% previsit to 31% postvisit (P < 0.0001). However, patients' minimum risk thresholds for screening decreased, their screening interest increased, and all patients completed screening. Qualitative interviews corroborated these effects, suggesting that patients discount and interpret PCRI according to preexisting beliefs and attitudes. Limitations. The study population was a relatively small, single-institution sample of patients referred for screening. Conclusions. Personalized cancer risk information decreases cancer risk perceptions of patients referred for LDCT screening, but has complex effects on screening-related judgments and decisions. The value of PCRI for patients considering LDCT screening requires further investigation.

Quantitative Analysis of Surgical Residency Reform: Using Case-Logs to Evaluate Resident Experience

BACKGROUND

Curricular changes at a mid-sized surgical training program were developed to rebalance clinical rotations, optimize education over service, decrease the size of service teams, and integrate apprenticeship-type experiences. This study quantifies the operative experience before and after implementation as part of a mixed-methods program evaluation.

STUDY DESIGN

Retrospective review of case-log data and data from the Accreditation Council for Graduate Medical Education (ACGME) and the American College of Surgeons National Surgical Quality Improvement Program: quality in-training initiative to evaluate case volume pre- and postintervention.

RESULTS

11,365 cases, excluding "first-assistant" and "endoscopic" cases, were logged for an average of 291 and 263 cases/resident pre- and postintervention, respectively. Average case volume increased significantly for postgraduate year (PGY) 3 residents and decreased significantly for PGY 4 residents between the two time periods. Variability was observed among residents at the same PGY level both pre- and postintervention, with coefficients of variation of 6.0% to 34.1% in 2014 to 2015 and 11.2% to 66.8% in 2015 to 2016. Inter-resident variability persisted when comparing a specific procedure between ACGME case-log and quality in-training initiative data sets.

CONCLUSION

The data suggest that inter-resident variability in case load is not an artifact of case logging behavior alone, but may reflect personal preferences and choices in case selection that are not impacted by curriculum change. Logging behavior and accuracy of case-logs may contribute to variability. The shift in case load from PGY 4 to PGY 3 after curriculum implementation requires validation by ongoing analysis of ACGME case-log data.

Tolerance of uncertainty: A systematic review of health and healthcare-related outcomes

BACKGROUND

Uncertainty tolerance (UT) is thought to be a characteristic of individuals that influences various outcomes related to health, healthcare, and healthcare education. We undertook a systematic literature review to evaluate the state of the evidence on UT and its relationship to these outcomes.

METHODS

We conducted electronic and bibliographic searches to identify relevant studies examining associations between UT and health, healthcare, or healthcare education outcomes. We used standardized tools to assess methodological quality and analyzed the major findings of existing studies, which we organized and classified by theme.

RESULTS

Searches yielded 542 potentially relevant articles, of which 67 met inclusion criteria. Existing studies were heterogeneous in focus, setting, and measurement approach, were largely cross-sectional in design, and overall methodological quality was low. UT was associated with various trainee-centered, provider-centered, and patient-centered outcomes which were cognitive, emotional, and behavioral in nature. UT was most consistently associated with emotional well-being.

CONCLUSIONS

Uncertainty tolerance is associated with several important trainee-, provider-, and patient-centered outcomes in healthcare and healthcare education. However, low methodological quality, study design limitations, and heterogeneity in the measurement of UT limit strong inferences about its effects, and addressing these problems is a critical need for future research.

PROACT: Iterative Design of a Patient-Centered Visualization for Effective Prostate Cancer Health Risk Communication

Prostate cancer is the most common cancer among men in the US, and yet most cases represent localized cancer for which the optimal treatment is unclear. Accumulating evidence suggests that the available treatment options, including surgery and conservative treatment, result in a similar prognosis for most men with localized prostate cancer. However, approximately 90% of patients choose surgery over conservative treatment, despite the risk of severe side effects like erectile dysfunction and incontinence. Recent medical research suggests that a key reason is the lack of patient-centered tools that can effectively communicate personalized risk information and enable them to make better health decisions. In this paper, we report the iterative design process and results of developing the PROgnosis Assessment for Conservative Treatment (PROACT) tool, a personalized health risk communication tool for localized prostate cancer patients. PROACT utilizes two published clinical prediction models to communicate the patients' personalized risk estimates and compare treatment options. In collaboration with the Maine Medical Center, we conducted two rounds of evaluations with prostate cancer survivors and urologists to identify the design elements and narrative structure that effectively facilitate patient comprehension under emotional distress. Our results indicate that visualization can be an effective means to communicate complex risk information to patients with low numeracy and visual literacy. However, the visualizations need to be carefully chosen to balance readability with ease of comprehension. In addition, due to patients' charged emotional state, an intuitive narrative structure that considers the patients' information need is critical to aid the patients' comprehension of their risk information.

Development and evaluation of the "BRISK Scale," a brief observational measure of risk communication competence

OBJECTIVE

To develop and evaluate a brief observational measure of clinical risk communication competence.

METHODS

A 4-item checklist-type measure, the BRISK (Brief Risk Information Skill) Scale, was developed by selecting and refining items from a more comprehensive measure of clinical risk communication competence. Six volunteer raters received brief training on the measure and then used the BRISK Scale to evaluate 52 video-recorded encounters between 2nd-year medical students and standardized patients conducted as part of an Observed Structured Clinical Examination (OSCE) involving a risk communication task. Internal consistency reliability, inter-rater reliability, and criterion validity were assessed.

RESULTS

Raters reported no difficulties using the BRISK Scale; scores across all raters and subjects ranged from 0 to 16 with a mean score of 6.49 (SD=3.17). The BRISK Scale showed good internal consistency reliability (α=0.64), and inter-rater reliability at the scale level (Intraclass Correlation Coefficient (ICC)=0.79 for consistency, and 0.75 for absolute agreement) and individual-item level (ICC range: 0.62-.91). Novice raters' BRISK Scale scores were highly correlated (r=0.84, p<0.01) with expert raters' scores on the Risk Communication Content measure, a more comprehensive measure of risk communication competence.

CONCLUSIONS

The BRISK Scale is a promising new brief observational measure of clinical risk communication competence.

Factors Affecting Physicians' Intentions to Communicate Personalized Prognostic Information to Cancer Patients at the End of Life: An Experimental Vignette Study

PURPOSE

To explore the effects of personalized prognostic information on physicians' intentions to communicate prognosis to cancer patients at the end of life, and to identify factors that moderate these effects.

METHODS

A factorial experiment was conducted in which 93 family medicine physicians were presented with a hypothetical vignette depicting an end-stage gastric cancer patient seeking prognostic information. Physicians' intentions to communicate prognosis were assessed before and after provision of personalized prognostic information, while emotional distress of the patient and ambiguity (imprecision) of the prognostic estimate were varied between subjects. General linear models were used to test the effects of personalized prognostic information, patient distress, and ambiguity on prognostic communication intentions, and potential moderating effects of 1) perceived patient distress, 2) perceived credibility of prognostic models, 3) physician numeracy (objective and subjective), and 4) physician aversion to risk and ambiguity.

RESULTS

Provision of personalized prognostic information increased prognostic communication intentions (P < 0.001, η(2) = 0.38), although experimentally manipulated patient distress and prognostic ambiguity had no effects. Greater change in communication intentions was positively associated with higher perceived credibility of prognostic models (P = 0.007, η(2) = 0.10), higher objective numeracy (P = 0.01, η(2) = 0.09), female sex (P = 0.01, η(2) = 0.08), and lower perceived patient distress (P = 0.02, η(2) = 0.07). Intentions to communicate available personalized prognostic information were positively associated with higher perceived credibility of prognostic models (P = 0.02, η(2) = 0.09), higher subjective numeracy (P = 0.02, η(2) = 0.08), and lower ambiguity aversion (P = 0.06, η(2) = 0.04).

CONCLUSIONS

Provision of personalized prognostic information increases physicians' prognostic communication intentions to a hypothetical end-stage cancer patient, and situational and physician characteristics moderate this effect. More research is needed to confirm these findings and elucidate the determinants of prognostic communication at the end of life.

Unknown Risks

Objective. This qualitative study of a select sample of vaccine-hesitant parents (VHPs) explores perceived and constructed personal judgments about the risks and uncertainties associated with vaccines and vaccine-preventable diseases (VPDs) and how these subjective risk judgments influence parents’ decisions about childhood vaccination. Methods. The study employed semistructured focus group interviews with 42 VHPs to elicit parents’ perceptions and thought processes regarding the risks associated with vaccination and nonvaccination, the sources of these perceptions, and their approach to decision making about vaccination for their children. Results. VHPs engage in various reasoning processes and tend to perceive risks of vaccination as greater than the risks of VPDs. At the same time, VHPs engage in other reasoning processes that lead them to perceive ambiguity in information about the harms of vaccination—citing concerns about the missing, conflicting, changing, or otherwise unreliable nature of information. Conclusions. VHPs’ refusal of vaccination may reflect their aversion to both the risk and ambiguity they perceive to be associated with vaccination. Mitigating this vaccine hesitancy likely requires reconstructing the risks and ambiguities associated with vaccination—a challenging task that requires providing parents with meaningful evidence-based information on the known risks of vaccination versus VPDs and explicitly acknowledging the risks that remain truly unknown.

Individual differences in aversion to ambiguity regarding medical tests and treatments: association with cancer screening cognitions

BACKGROUND

Aversion to "ambiguity"-uncertainty about the reliability, credibility, or adequacy of information-about medical tests and treatments is an important psychological response that varies among individuals, but little is known about its nature and extent. The purpose of this study was to examine how individual-level ambiguity aversion relates to important health cognitions related to different cancer screening tests.

METHODS

A survey of 1,074 adults, ages 40 to 70 years, was conducted in four integrated U.S. healthcare systems. The Ambiguity Aversion in Medicine (AA-Med) scale, a measure of individual differences in aversion to ambiguity (AA) about medical tests and treatments, was administered along with measures of several cancer screening-related cognitions: perceived benefits and harms of colonoscopy, mammography, and PSA screening, and ambivalence and future intentions regarding these tests. Multivariable analyses were conducted to assess the associations between AA-Med scores and cancer screening cognitions.

RESULTS

Individual-level AA as assessed by the AA-Med scale was significantly associated (P < 0.05) with lower perceived benefits, greater perceived harms, and greater ambivalence about all three screening tests, and lower intentions for colonoscopy but not mammography or PSA screening.

CONCLUSION

Individual-level AA is broadly and simultaneously associated with various pessimistic cognitive appraisals of multiple cancer screening tests. The breadth of these associations suggests that the influence of individual-level AA is insensitive to the degree and nonspecific with respect to the causes of ambiguity.

IMPACT

Individual-level AA constitutes a measurable, wide-ranging cognitive bias against medical intervention, and more research is needed to elucidate its mechanisms and effects.

The value of personalised risk information: a qualitative study of the perceptions of patients with prostate cancer

OBJECTIVE

To explore the experiences of patients with prostate cancer with risk information and their perceptions of the value of personalised risk information in treatment decisions.

DESIGN

A qualitative study was conducted using focus groups. Semistructured interviews explored participants' experiences with using risk information, and their perceptions of the potential value of personalised risk information produced by clinical prediction models.

PARTICIPANTS

English-speaking patients, ages 54-82, diagnosed with prostate cancer within the past 3 years, residing in rural and non-rural geographic locations in Maine (USA), and attending prostate cancer patient support groups.

SETTING

6 focus groups were conducted with 27 patients; separate groups were held for patients with low-risk, medium-risk and high-risk disease defined by National Comprehensive Cancer Network guidelines.

RESULTS

Several participants reported receiving risk information that was imprecise rather than precise, qualitative rather than quantitative, indirect rather than direct and focused on biomarker values rather than clinical outcomes. Some participants felt that personalised risk information could be useful in helping them make better informed decisions, but expressed scepticism about its value. Many participants favoured decision-making strategies that were heuristic-based and intuitive rather than risk-based and deliberative, and perceived other forms of evidence-emotions, recommendations of trusted physicians, personal narratives-as more reliable and valuable in treatment decisions.

CONCLUSIONS

Patients with prostate cancer appear to have little experience using personalised risk information, may favour heuristic-based over risk-based decision-making strategies and may perceive personalised risk information as less valuable than other types of evidence. These decision-making approaches and perceptions represent potential barriers to the clinical use of personalised risk information. Overcoming these barriers will require providing patients with greater exposure to risk information, education about the nature and value of personalised risk information and training in deliberative decision-making strategies. More research is needed to confirm these findings and address these needs.

Social influences, social context, and health behaviors among working-class, multi-ethnic adults

Little research has explored the relationship between social influences (e.g., social networks, social support, social norms) and health as related to modifying factors that may contribute to health disparities. This is a cross-sectional analysis of fruit and vegetable intake and physical activity, using baseline data from two cancer prevention studies with working-class, multi-ethnic adults. Several social influence and social contextual variables were associated with fruit and vegetable intake and physical activity in both samples. Fruit and vegetable consumption was associated with social norms and social networks, although different contextual variables also were related to intake across the two samples. Physical activity was associated with social networks, social norms, and competing demands. By examining how key social influence and contextual mediating variables relate to health behaviors, we can learn more about the types of interventions that might be needed to promote sustained health behavior change in this population.

Cancer prevention among working class, multiethnic adults: results of the healthy directions-health centers study

OBJECTIVES

We analyzed outcomes from a study that examined social-contextual factors in cancer prevention interventions for working class, multiethnic populations.

METHODS

Ten community health centers were randomized to intervention or to control. Patients who resided in low-income, multiethnic neighborhoods were eligible; the intervention targeted fruit and vegetable consumption, red meat consumption, multivitamin intake, and physical activity. Outcomes were measured at 8 months.

RESULTS

The intervention led to significant increases in fruit and vegetable consumption and multivitamin intake and reductions in red meat consumption; no change was found in physical activity levels. The intervention effect was not changed when contextual variables that may function as confounders or effect modifiers (e.g., gender, education, race/ethnicity, respondent and parents' country of birth, and poverty status) were included in the analyses.

CONCLUSIONS

The intervention led to significant improvements in health behaviors among a working class, multiethnic population, regardless of race/ ethnicity and socioeconomic status. Interventions that respond to the social context of working class individuals across racial/ethnic categories hold promise for improving cancer-related risk behaviors.

Cancer prevention for working class, multiethnic populations through small businesses: the healthy directions study

OBJECTIVE

We report demographic and social contextual characteristics of multiethnic, blue-collar workers from the baseline survey of a study conducted in 24 small businesses. We discuss ways in which we incorporated these characteristics into the design of the intervention.

METHODS

We used a randomized controled design, with 12 small businesses assigned to a social contextual intervention and 12 to a minimum intervention control condition. The response rates to the survey were 84% at baseline (n = 1717). Primary outcomes included reduction in red meat consumption and increase in physical activity and daily multivitamin intake. Secondary outcomes targeted reduction in smoking and occupational exposures.

RESULTS

The majority of the respondents were male (67.6%). This was an ethnically diverse sample with 24.7% representing racial/ethnic groups other than white and 43.6% of participants or their parents born outside of the US. To meet study recommendations, workers needed improvement in all behaviors measured. Participants reported a smoking rate of 25.8, 86.2% ate fewer than 5 servings of fruits and vegetables a day 69.5% ate more than three servings of red meat a week, 46.8% engaged in less than 2.5 h a week and 72.4% reported that they did not consume a daily multivitamin.

CONCLUSIONS

Interventions that address the contextual environment in which health behaviors occur, may provide a method that researchers and practitioners can use to reduce health disparities.

Cancer prevention for working class, multi-ethnic populations through health centers: the healthy directions study

BACKGROUND

This paper presents the study design and baseline data from Healthy Directions-Health Centers (HCs), a study designed to address social contextual factors in cancer prevention interventions for working class, multi-ethnic populations. This study is part of the Harvard Cancer Prevention Program Project.

METHODS

Ten community HCs were paired and randomly assigned to intervention or control. Patients who resided in low income, multi-ethnic neighborhoods were identified and approached for participation. This study targeted fruit and vegetable consumption, red meat consumption, multi-vitamin intake, and physical activity. The intervention components consisted of: (1) a brief in-person study endorsement from the participant's clinician at a scheduled routine care visit; (2) an initial in-person counseling session with a health advisor; (3) four follow-up telephone counseling sessions; (4) multiple mailings of tailored materials; and (5) linkages to relevant activities in the local community.

RESULTS

Fifteen percent of the sample smoked, 86% reported eating fewer than five servings of fruits and vegetables per day, 50% reported eating more than the recommended amounts of red meat, 40% did not meet recommended physical activity levels, and 63% did not take a multi-vitamin on a daily basis. Although overall social support was high, participants reported low levels of social norms for the target prevention behaviors. Other social contextual mediators and modifying factors are reported.

CONCLUSIONS

By examining the relationships between social contextual factors and health behaviors, it may be possible to enhance the effectiveness of interventions aimed at reducing social inequalities in risk behaviors.

The effects of clozapine on severely aggressive psychiatric inpatients in a state hospital

BACKGROUND

After noting a dramatic reduction in aggression and agitation in five psychotic inpatients residing on a specialized unit for the severely aggressive, the authors conducted a retrospective chart review to assess the possible role of clozapine treatment in this change.

METHOD

The authors culled 12 months of nursing data, including progress notes, orders for seclusion, and mechanical and chemical restraint, to tabulate the frequency of aggression before and after the initiation of clozapine treatment, and looked at ratings on the Brief Psychiatric Rating Scale and periodic review reports to assess overall clinical change.

RESULTS

The results of the review indicate that although psychotic symptoms were not greatly affected by the drug, the overall frequency of assaults, self-abuse, and the use of seclusion, mechanical restraint, and chemical restraint was reduced in the subjects.

CONCLUSION

The authors conclude that because the reduction of aggression and agitation coincided with clozapine treatment, it is likely that clozapine was responsible for the change. The authors propose possible reasons for this effect and suggest that controlled studies are needed to substantiate these preliminary results.