Use of coaching and technology to improve blood pressure control in Black women with hypertension: Pilot randomized controlled trial study

Hypertension is the main cause of cardiovascular disease, especially in women. Black women (58%) are affected by higher rates of hypertension than other racial/ethnic groups contributing to increased cardio-metabolic disorders. To decrease blood pressure (BP) in this population, a pilot randomized controlled trial was conducted to examine the effects of Interactive Technology Enhanced Coaching (ITEC) versus Interactive Technology (IT) alone in achieving BP control, adherence to antihypertensive medication, and adherence to lifestyle modifications among Black women diagnosed with and receiving medication for their hypertension. Participants completed a 6-week Chronic Disease Self-Management Program (CDSMP), and 83 participants were randomly assigned to ITEC versus IT. Participants were trained to use three wireless tools and five apps that were synchronized to smartphones to monitor BP, weight, physical activity (steps), diet (caloric and sodium intake), and medication adherence. Fitbit Plus, a cloud-based collaborative care platform was used to collect, track, and store data. Using a mixed-effects repeated measures model, the main effect of group means indicated no significant difference between the treatment and referent groups on study variables. The main effect of time indicated significant differences between repeated measures for systolic BP (p < .0001), weight (p < .0001), and steps (p = .018). An interaction effect revealed differences over time and was significant for study measures except diastolic BP. An important goal of this preliminary analysis is to help Black women prioritize self-care management in their everyday environment. Future research is warranted in a geographically broader population of hypertensive Black women.

Working with communities: Meeting the health needs of those living in vulnerable communities when Primary Health Care and Universal Health Care are not available

RATIONALE, AIMS, AND OBJECTIVES

The health care delivery model in the United States does not work; it perpetuates unequal access to care, favours treatment over prevention, and contributes to persistent health disparities and lack of insurance. The vast majority of those who suffer from preventable diseases and health disparities, and who are at greatest risk of not having insurance, are low-income minorities (Native Americans, Hispanics, and African-Americans) who live in high risk and vulnerable communities. The historical lack of support in the United States for Universal Health Care (UHC) and Primary Health Care (PHC)-with their emphasis on health care for all, population health, and social determinants of health-requires community health scientists to develop innovative local solutions for addressing unmet community health needs.

METHODS

We developed a model community health science approach for improving health in fragile communities, by combining community-oriented primary care (COPC), community-based participatory research (CBPR), asset-based community development, and service learning principles. During the past two decades, our team has collaborated with community residents, local leaders, and many different types of organizations, to address the health needs of vulnerable patients. The approach defines health as a social outcome, resulting from a combination of clinical science, collective responsibility, and informed social action.

RESULTS

From 2000 to 2020, we established a federally funded research programme for testing interventions to improve health outcomes in vulnerable communities, by working in partnership with community organizations and other stakeholders. The partnership goals were reducing chronic disease risk and multimorbidity, by stimulating lifestyle changes, increasing healthy behaviours and health knowledge, improving care seeking and patient self-management, and addressing the social determinants of health and population health. Our programmes have also provided structured community health science training in high-risk communities for hundreds of doctors in training.

CONCLUSION

Our community health science approach demonstrates that the factors contributing to health can only be addressed by working directly with and in affected communities to co-develop health care solutions across the broad range of causal factors. As the United States begins to consider expanding health care options consistent with PHC and UHC principles, our community health science experience provides useful lessons in how to engage communities to address the deficits of the current system. Perhaps the greatest assets US health care systems have for better addressing population health and the social determinants of health are the important health-related initiatives already underway in most local communities. Building partnerships based on local resources and ongoing social determinants of health initiatives is the key for medicine to meaningfully engage communities for improving health outcomes and reducing health disparities. This has been the greatest lesson we have learned the past two decades, has provided the foundation for our community health science approach, and accounts for whatever success we have achieved.

Social Support and Religiosity as Contributing Factors to Resilience and Mental Wellbeing in Latino Immigrants: A Community-Based Participatory Research Study

Latino immigrants are at increased risk for mental disorders due to social/economic disadvantages and stressful conditions associated with migration. Resilience-the ability to recover from stress-may provide protection given its association with lower rates of anxiety and depression. This study examines the relationship between protective factors, resilience, and psychological distress in Latino immigrants. A community-based participatory research study conducted with a Latino agency using in-person surveys to obtain the following data: Brief Resilience Scale, Brief Symptom Inventory, Duke University Religion Index, Multi-group Ethnic Identity measure, and the Interpersonal Support Evaluation List. Linear regression, and mediation analysis was performed using SPSS. There are 128 participants. Resilience was positively related to social support (p = 0.001) and religiosity (p = 0.006); inversely related to psychological distress (p = 0.001); and mediated the relationship between the two (p = 0.006). Promoting social support and religion in Latino communities can improve wellbeing by increasing resilience and reducing distress.

An interactive technology enhanced coaching intervention for Black women with hypertension: Randomized controlled trial study protocol

In the United States, hypertension (HTN) is the leading risk factor for cardiovascular disease, and a more significant health problem for Blacks compared with other racial/ethnic groups. The prevalence of HTN in Black women is among the highest in the world, underscoring the need for effective prevention and management approaches for blood pressure (BP) control. We developed a two-arm randomized controlled trial repeated measures design study for improving HTN self-management among Black women. The study tests whether the Chronic Disease Self-Management Program (CDSMP) combined with interactive technology-enhanced coaching, can improve BP control and adherence to treatment (e.g., medication-taking, physical activity, calorie intake, and weight management) compared with the CDSMP alone. Repeated measurements were conducted at 3, 6, and 9 months. A sample of 90 community-dwelling Black women with uncontrolled Stage 1 HTN (BP ≥ 130/80) were enrolled, completed CDSMP training, and randomized. This study will contribute to our understanding of novel methods to empower Black women to increase their active involvement in self-care management of HTN.

Designing health care: A community health science solution for reducing health disparities by integrating social determinants and the effects of place

BACKGROUND

In the United States chronic illnesses have become a way of life for multiple generations - they are the number one cause of death and disability (accounting for more than 70% of deaths), 60% of American adults have at least one chronic disease, and 40% have multiple chronic conditions. Although multiple factors contribute to the growth in chronic disease prevalence, a major factor has been overreliance on health care systems for promoting health and preventing disease. Large health care systems are ill equipped for this role since they are designed to detect, treat, and manage disease, not to promote health or address the underlying causes of disease.

METHODS

Improving health outcomes in the U.S. will require implementing broad-based prevention strategies combining biological, behavioral, and societal variables that move beyond clinical care. According to community medicine, clinical care alone cannot create, support, or maintain health. Rather, health can only ensue from combining clinical care with epidemiology and community organization, because health is a social outcome resulting from a combination of clinical science, collective responsibility, and informed social action.

RESULTS

During the past 20 years, our team has developed an operational community medicine approach known as community health science. Our model provides a simple framework for integrating clinical care, population health, and community organization, using community-based participatory research (CBPR) practices for developing place-based initiatives. In the present paper, we present a brief overview of the model and describe its evolution, applications, and outcomes in two major urban environments.

CONCLUSION

The paper demonstrates means for integrating the social determinants of health into collaborative place-based approaches, for aligning community assets and reducing health disparities. It concludes by discussing how asset-based community development can promote social connectivity and improve health, and how our approach reflects the emerging national consensus on the importance of place-based population system change.

Prevalence of Diabetes and Health-Related Quality of Life Among Rural-to-Urban Nong Zhuan Fei Migrants in an Urban Area of Northern China, 2013

OBJECTIVE

In China's Nong Zhuan Fei (NZF) communities, farmers living in rural villages are uprooted and moved into newly constructed urban apartments when the government purchases their land for residential and commercial development. With their relocation from a traditional rural setting to a modern urban setting, residents of NZF communities face lifestyle-based risk factors for diabetes and other chronic diseases. We reported estimates of diabetes prevalence, risk factors, and health-related quality of life among adult Chinese NZF rural-to-urban migrants.

METHODS

We conducted a descriptive cross-sectional study through a U.S.-China partnership with an NZF community of 3,184 residents. Health and disease history, risk factors, and sociodemographic information were collected by questionnaire. Participants completed a 24-hour diet recall, three-day physical activity recall, a health-related quality of life Short-Form 36 (SF-36) health survey, the Beck Depression Inventory, and fasting blood glucose tests.

RESULTS

We gathered complete data from 1,150 of 1,772 eligible participants. The prevalence of diabetes was 11.6% (95% confidence interval 9.8, 13.6). Diabetes risk increased significantly with age, income, obesity, and hypertension. Based on SF-36 scores, residents aged ≥60 years with diabetes reported significantly greater physical (47.7 v. 70.2, p=0.001) and emotional (76.9 vs. 89.7, p=0.006) limitations, more bodily pain (79.7 vs. 84.9, p=0.021), and worse overall physical health (67.6 vs. 76.0, p=0.015) than those without diabetes.

CONCLUSION

The Chinese government hopes to integrate an additional 250 million people into city living by 2025. As the NZF population increases, so may the prevalence of diabetes associated with the change from a rural to an urban lifestyle. Action is needed now by public health professionals to prevent a possible diabetes crisis in NZF communities in the future.

Churches as targets for cardiovascular disease prevention: comparison of genes, nutrition, exercise, wellness and spiritual growth (GoodNEWS) and Dallas County populations

BACKGROUND

We compared cardiovascular (CV) risk factors (CVRFs) of community-based participatory research (CBPR) participants with the community population to better understand how CBPR participants relate to the population as a whole.

METHODS

GoodNEWS participants in 20 African-American churches in Dallas, Texas were compared with age/sex-matched African-Americans in the Dallas Heart Study (DHS), a probability-based sample of Dallas County residents. DHS characteristics were sample-weight adjusted to represent the Dallas County population.

RESULTS

Despite having more education (college education: 75 versus 51%, P< 0.0001), GoodNEWS participants were more obese (mean body mass index: 34 versus 31 kg/m(2), P< 0.001) and had more diabetes (23 versus 12%, P< 0.001) and hyperlipidemia (53 versus 14%, P< 0.001) compared with African-Americans in Dallas County. GoodNEWS participants had higher rates of treatment and control of most CVRFs (treated hyperlipidemia: 95 versus 64%, P< 0.001; controlled diabetes: 95 versus 21%, P< 0.001; controlled hypertension: 70 versus 52%, P= 0.003), were more physically active (233 versus 177 metabolic equivalent units-min/week, P< 0.0001) and less likely to smoke (10 versus 30%, P< 0.001).

CONCLUSIONS

Compared with African-Americans in Dallas County, CBPR participants in church congregations were more educated, physically active and had more treatment and control of most CVRFs. Surprisingly, this motivated population had a greater obesity burden, identifying them as a prime target for CBPR-focused obesity treatment.

The GoodNEWS (Genes, Nutrition, Exercise, Wellness, and Spiritual Growth) Trial: a community-based participatory research (CBPR) trial with African-American church congregations for reducing cardiovascular disease risk factors--recruitment, measurement, and randomization

INTRODUCTION

Although cardiovascular diseases (CVD) are the leading cause of death among Americans, significant disparities persist in CVD prevalence, morbidity, and mortality based on race and ethnicity. However, few studies have examined risk factor reduction among the poor and ethnic minorities.

METHODS

Community-based participatory research (CBPR) study using a cluster randomized design--African-American church congregations are the units of randomization and individuals within the congregations are the units of analysis. Outcome variables include dietary change (Diet History Questionnaire), level of physical activity (7-Day Physical Activity Recall), lipoprotein levels, blood pressure, fasting glucose, and hemoglobin A1c.

RESULTS

Eighteen (18) church congregations were randomized to either a health maintenance intervention or a control condition. Complete data were obtained on 392 African-American individuals, 18 to 70 years of age, predominantly employed women with more than a high school diploma. Treatment and intervention groups were similar at baseline on saturated fat intake, metabolic equivalent of tasks (METS) per day, and other risk factors for CVD.

CONCLUSIONS

The GoodNEWS trial successfully recruited and evaluated CVD-related risk among African-American participants using a CBPR approach. Several logistical challenges resulted in extending the recruitment, preliminary training, and measurement periods. The challenges were overcome with the assistance of a local community consultant and a professional event planner. Our experience supports the need for incorporating non-traditional community-based staff into the design and operational plan of CBPR trials.

Anthropometric measures, presence of metabolic syndrome, and adherence to physical activity guidelines among African American church members, Dallas, Texas, 2008

INTRODUCTION

The low prevalence of physical activity among African Americans and high risk of cardiovascular disease lends urgency to assessing the association between metabolic syndrome, abdominal obesity, and adherence to current physical activity guidelines. Few studies have examined this association among African American adults.

METHODS

We examined the association between demographic characteristics, anthropometric measures, and metabolic syndrome and adherence to the 2008 Department of Health and Human Services guidelines for moderate and vigorous physical activity. Participants were 392 African American church members from congregations in Dallas, Texas. Physical activity levels were assessed via a validated questionnaire (7-Day Physical Activity Recall), and metabolic syndrome was determined on the basis of the American Heart Association/National Heart, Lung, and Blood Institute diagnostic criteria. We used bivariate and multinomial logistic regression to examine the associations.

RESULTS

Meeting guidelines for vigorous physical activity was significantly and independently associated with the absence of metabolic syndrome among women (odds ratio, 4.71; 95% confidence interval, 1.63-13.14; P = .003), after adjusting for covariates. No association was found between meeting moderate or vigorous physical activity guidelines and metabolic syndrome among men. Meeting physical activity guidelines was not associated with body mass index or waist circumference among this sample of predominantly overweight and obese African American church members.

CONCLUSION

Results indicate that meeting the 2008 guidelines for vigorous physical activity is associated with the absence of metabolic syndrome among African American women. This finding might suggest the need to integrate vigorous physical activity into interventions for African American women as a preventive therapy for cardiovascular risk. 

Patient perceptions of a community-based care coordination system

Community health workers (CHWs) work with health professionals to improve health outcomes by facilitating community-based health education and increase access and continuity to health services within a community. Uninsured, low-income participants of a community-based program, Project Access Dallas, participated in focus group sessions for determining participants' perceptions of CHW effectiveness and participants' abilities to independently manage their health needs. Of the 95 adults invited, 24 (25.3%) attended. Participants reported that CHWs are an invaluable asset in learning how to navigate the health care system, obtaining appointments and being better able to care for themselves with CHW emotional/psychological support. Results suggest that CHWs in a case management model improved patient comprehension of health issues, patient navigation through a health care system, and patients' abilities to independently manage health issues. Implementation of CHWs within a case management model appears to be an effective mechanism for providing health services to underserved populations.

Insights from practice-based researchers to develop family medicine faculty as scholars

BACKGROUND AND OBJECTIVES

National mandates call for accelerating scholarly development of family medicine faculty. One strategy to address these mandates is training more faculty to participate in practice-based research (PBR). We need to determine competencies that enable faculty to conduct PBR, methods for training faculty in PBR, and strategies to streamline PBR operations in clinics.

METHODS

Through a qualitative literature review process, we identified faculty knowledge, attitudes, and skills thought to promote PBR. We then conducted structured interviews with a sample of PBR experts to explore their experience with and opinions about PBR: What knowledge, attitudes, and skills support PBR? What types of training will prepare family physicians to participate in and conduct PBR? What factors in the ambulatory clinical setting facilitate the success of PBR? What are the most important barriers to conducting PBR?

RESULTS

Recommendations for PBR teaching and learning fell within the topic areas of scope of training, teaching methods, essential knowledge, and organizational environment. The most frequent expert recommendation was that all clinical practice and teaching settings should offer participatory research training for faculty, learners, and staff on an ongoing basis. Lack of funding and scarcity of time are the greatest impediments to conducting PBR. Additional barriers include lack of interest, lack of motivation, and lack of PBR knowledge and skills. Success in PBR often begins with an enthusiastic PBR champion whose characteristics include passion, initiative, and reflectiveness. Through organizational development, PBR champions can foster enthusiasm and commitment on the part of colleagues, administrators, and staff. It is important to continue to enhance PBR skill development opportunities at national meetings and to foster dissemination of PBR findings through presentations and publications.

CONCLUSIONS

To foster growth and success of practice-based researchers, we should implement and sustain comprehensive multi-level training in PBR and nurture a culture of ongoing inquiry in family medicine. A culture conducive to PBR offers opportunities for continual development of enthusiastic, informed, and skilled faculty whose interdisciplinary teams conduct PBR and develop physicians in training as future practice-based researchers.

Research funding and mentoring in family medicine residencies

BACKGROUND AND OBJECTIVES

This study's purpose was to measure the current status of research funding and mentoring in family medicine residencies and to ascertain what resources are needed to increase residencies' research output.

METHODS

This was a cross-sectional survey of family medicine residency program directors in the United States. We measured grant funding sources, availability of mentors, the likelihood programs could qualify for National Institutes of Health (NIH) K awards, barriers to research, and how these factors varied by program type.

RESULTS

The response rate was 66% (298/453). Medical school-based programs were much more likely to report that their family medicine faculty wrote funded research grants than were community-based medical school affiliated programs (76% versus 32%). The majority of both program types reported that research mentors were available (85% versus 60%). Very few programs of either type were likely to meet the minimum requirements for NIH K01, K08, or K23 awards (29% for medical school programs versus 3% for community programs). The most commonly reported specific resources needed to increase research output were time, money, and more faculty (range 86% to 92% between program types).

CONCLUSIONS

The majority of family medicine residencies did not receive grant funding for research, reported that time and money were the most significant barriers to research, but were ineligible to receive support from NIH K awards. More realistic funding mechanisms are needed to support residency-based research faculty.

Health programs in faith-based organizations: are they effective?

OBJECTIVES

We examined the published literature on health programs in faith-based organizations to determine the effectiveness of these programs.

METHODS

We conducted a systematic literature review of articles describing faith-based health activities. Articles (n = 386) were screened for eligibility (n = 105), whether a faith-based health program was described (n = 53), and whether program effects were reported (28).

RESULTS

Most programs focused on primary prevention (50.9%), general health maintenance (25.5%), cardiovascular health (20.7%), or cancer (18.9%). Significant effects reported included reductions in cholesterol and blood pressure levels, weight, and disease symptoms and increases in the use of mammography and breast self-examination.

CONCLUSIONS

Faith-based programs can improve health outcomes. Means are needed for increasing the frequency with which such programs are evaluated and the results of these evaluations are disseminated.

Revisiting the Navajo way: lessons for contemporary healing

Given the paradox of the success of modern medical technology and the growing patient dissatisfaction with present-day medicine, critics have called for a reevaluation of contemporary medical practice. This paper offers a phenomenological analysis of traditional Navajo healers and their ceremonies to highlight key aspects of healing. A phenomenological view of medical practice takes into account three key features: the lifeworld, the lived body, and understanding. Because of their closeness to a phenomenological view, traditional Navajo mythology and healing practices offer insight into the healing process. Contemporary physicians can appreciate the phenomenological elements of Navajo healing ceremonies, including the Mountain Chant. Navajo healers help patients make sense of their illnesses and direct their lives accordingly, an outcome available to contemporary practitioners, who are also gifted with the benefits of new technologies. By examining scientific medicine, Navajo healing practices, and phenomenology as complementary disciplines, the authors provide the groundwork for reestablishing a more therapeutic view of health.

Survey methodology for the uninitiated

Mailed, self-administered questionnaires are a common data collection method used in family practice research. However, little guidance exists in the medical literature about survey methodology specifically designed for family practitioners. As a result, primary care physicians sometimes struggle with questionnaire design and interpretation. Our goal was to synthesize general survey methodology guidelines (from other disciplines as well as our own) in a manner that would be meaningful to novice family practice researchers.

Short stays in hospice. A review & update

Despite the proven benefits and popularity of hospice, the average hospice patient receives only one month of services before death. Advanced progression of a patient's disease at admission contributes to short lengths of stay, and precludes patients from receiving the full benefit of hospice services. This article uses the results of the literature review to articulate reasons for delayed enrollment and to advance suggestions for ameliorating the problem of short stay in hospice.

Creating a research culture: what we can learn from residencies that are successful in research

BACKGROUND AND OBJECTIVES

Despite a growing need for family practice to contribute to the national primary care research agenda, the specialty is ill-equipped to assume a more active role. Information about residency programs that are successful in research is a valuable resource for increasing family medicine's research capacity.

METHODS

A three-stage investigation was completed in May 1996, consisting of 1) a telephone survey of family practice residency program directors, 2) a mail survey of recent graduates from relatively successful programs identified in stage 1, and 3) in-depth interviews with the program directors or research directors identified by combining data from the first two stages.

RESULTS

Most residents in the programs included in stage 2 completed a research project (68.7%) and currently have an interest in practice-based research (57.2%). Residents from programs selected for the study's final stage were more likely to have published a research article (32% versus 20.3%) and to have completed a project while a resident (81% versus 60.1%) than those from the programs not selected. Virtually unanimous characteristics of successful programs include program director support of research, time for research, faculty involvement, a research curriculum, professional support, and opportunities for presenting research.

CONCLUSIONS

Individual family practice residencies can be considered to be at one of three levels with respect to their level of research activity: 1) relatively undeveloped, 2) developing, or 3) relatively developed. Programs can expect successful results if they make research a priority, and means are needed for communicating successful strategies between programs.

African-American males and prostate cancer: assessing knowledge levels in the community

Although the available evidence indicates that African-American males are at risk for developing prostate cancer, little is known about the level of awareness among African Americans about prostate cancer or how receptive they are to screening. This study examined the level of knowledge African-American males have about prostate cancer and the factors affecting knowledge levels. Face-to-face interviews were conducted among a sample of African-American males older than 25 years. All respondents were asked if they knew what prostate cancer was (N = 897), and those older than age 40 (N = 556) answered a series of seven questions related to prostate cancer. An index was created that reflected respondents level of knowledge about prostate cancer. Slightly more than 19% of the sample scored relatively high on the index related to prostate cancer knowledge, but 30% answered three or fewer questions correctly. Income, marital status, education, and type of insurance were significantly related to a respondent's level of knowledge. Having a regular physician and discussing prostate screening with a physician were both positively related to a respondent's level of understanding. This study indicates that African-American men do not have adequate knowledge about prostate cancer. Although many African Americans may be getting the prostate cancer message, educational efforts need to be strengthened to reach the less affluent and the less educated. These findings also raise questions about why more African-American men are not being screened and why more primary care physicians are not discussing prostate cancer with their African-American patients.

Family practice residency program directors' views on research

BACKGROUND AND OBJECTIVES

The culture of family practice training programs does little to convince residents that research is a worthwhile and important activity. The traditional dichotomy between research and clinical medicine persists today, despite an identified clinical mission for research.

METHODS

As part of an effort to build the research capacity of family practice training programs, a telephone survey was administered in August 1995 to the program directors of all residency programs listed in the American Academy of Family Physicians 1995 Directory of Family Practice Residency Programs. The directors were asked about their program's research environment, features designed to promote research activity, and the level of resident research productivity.

RESULTS

More than half (53.6%) of the program directors felt that their training program actively promotes research. Three out of four indicated that involving residents in research is a goal of their program. However, only four of 10 (40.8%) programs provide specific time for research, and family practice residents appear to be relatively inactive by conventional measures of research productivity.

CONCLUSIONS

Research appears to be developing a limited role in family practice training programs. Resident research productivity remains relatively low and may be a result of residency programs not providing specific time for participating in research. However, the program directors' supportive attitudes may contribute to research and scholarly activity becoming an integral part of a family physician's training.

Does grandma need condoms? Condom use among women in a family practice setting

OBJECTIVE

To examine the relationship between age and condom use among women who are typically seen in the primary care setting.

DESIGN

Survey of a population using a self-administered questionnaire.

SETTING

Four community-based family practice clinics located in a low-income, racially mixed geographical area.

PATIENTS

All consenting patients (N = 995) during their visits for routine Papanicolaou tests. The mean age of patients was 35 years, with a range of 75 years (12 to 87 years). Respondents were predominantly black (63.2%), 39.2% were single, and over 65% had incomes no greater than $15,000/y.

MAIN OUTCOME MEASURE

The outcome measure of condom use is reported. Data analysis of patients' sexual behavior revealed that older women might be at risk for sexually transmitted diseases (STDs). The hypothesis that condom use is related to age emerged during data collection.

RESULTS

Condom use is related to being younger (< 31 years), having had an STD, having a sexual partner in whom an STD was diagnosed, having a lower income, or being single or black. In multivariate models, marital status (single), age (< 31 years), and having a partner with an STD remain significant. Among unmarried women, the effects of age, race, and a partner with STD remain, and being a nonsmoker is also significant. In the multivariate analysis for unmarried women, only age (< 31 years) is significantly related to condom use. An independent random sample of charts revealed that almost 45% of the patients aged 45 years or younger received condom counseling, whereas condoms were discussed with none of those older than 45 years.

CONCLUSIONS

Because older patients (those beyond child-bearing years) are less likely to use condoms and evidently receive little education about condom use, older patients must be educated about the need for condoms.

Developing a research program in a community-based department of family medicine: one department's experience

BACKGROUND

There is a growing consensus that an improved research environment is needed for family medicine to continue to evolve. At the same time, there is relatively little discussion about practical ways to implement such an environment. Many believe that our efforts in this area lag far behind our accomplishments in education, training, and the practice of family medicine.

PROGRAM DESCRIPTION

This manuscript discusses one community-based academic department's experience in formulating and implementing a research program. By slowly involving faculty in research and by instructing and encouraging residents, a research environment can be incorporated into a residency program's routine. The approach described in this manuscript is evolutionary and relies on committing resources to research while slowly involving faculty and residents in the process.

PROGRAM EVALUATION

Measures of research output (funding, publishing in refereed journals, and presenting at professional conferences) suggest that the program has achieved some momentum in the area of research. Although relatively modest by the standards of some university-based programs, the program's achievements demonstrate that a community-based, university-affiliated program can initiate a viable research effort.

CONCLUSIONS

Our experience has taught us that implementing a research program is a relatively lengthy process comprised of multiple components. First, individual projects typically consist of a process of funding, presenting, and publishing. Sharing research results with colleagues locally and at professional meetings is an especially important socialization component of research and scholarship. Second, it is important to use refereed and nonrefereed journals as outlets for scholarship, since the process of writing is itself important, especially for family physicians who lack formal research training. Finally, funding proposals and publications almost always require revision and resubmission, a process which contributes to creating and further refining the skills needed by successful researchers.

Effects of the Patient Self-Determination Act on patient knowledge and behavior

BACKGROUND

In effect since 1991, the Patient Self-Determination Act (PSDA) requires that institutions receiving government insurance payments document that they have informed patients of their right to decide on life-preserving measures. Implementing the PSDA should make discussion of advance directives a routine part of acute care hospital admissions. Yet the proportion of those actually completing advance directives such as living wills remains relatively small.

METHODS

A telephone survey questionnaire was administered to patients who were hospitalized before and after the implementation of the PSDA. Survey questions probed patient knowledge about living wills and behavior toward obtaining living wills.

RESULTS

Patient knowledge about advance medical directives correlated positively with race (white), income (> or = $10K), and level of education (high school or more). Moreover, a significantly greater number of patients hospitalized after implementation of the PSDA knew about living wills than the number of those hospitalized before the Act's implementation. However, actually obtaining a living will correlated positively with age (> 36 years) alone, and implementation of the PSDA was not related to the number of patients who obtained a living will.

CONCLUSIONS

Although the study results show that the measures the hospital in the study used to meet PSDA requirements increased patient awareness of living wills, they failed to increase the number of patients who act on this awareness. This finding indicates that simply informing patients about their right of self-determination is insufficient to meet the intended goals of the legislation.

Predicting atypical Pap smear progression: a case-control study

OBJECTIVE

This case-control study proposed to define risk factors for progression of cervical disease beyond an atypical level, and to explore the possibility of a clinical tool that would aid the clinician in deciding on the need for colposcopy.

METHODS

Twenty-three hundred (2,300) abnormal Papanicolaou smears were reviewed to identify documented cases of class II Papanicolaou smears that had progressed. Controls were randomly chosen for each case from the remaining pool of available class II Papanicolaou smears that did not progress. Data analyses were conducted to determine the predictive value of information that would be in a patient's chart with respect to progression from class II Papanicolaou smear to a higher level of disease.

RESULTS

A univariate analysis revealed several significant variables, including age, education, attendance at a public clinic, marital status, notification of Papanicolaou results, and a history of sexually transmitted disease. Next, a multivariate analysis demonstrated that a group of significant variables could not be defined, and only notification of an atypical Papanicolaou smear was significant.

CONCLUSIONS

The study's findings suggest that the data available in a patient's medical record are not sufficient to develop a risk assessment scale and provide evidence of the need for continued study in this area.

Hypercholesterolemia: case finding in family practice

The recommendations of the expert panel of the National Cholesterol Education Program (NCEP) have been endorsed by national medical organizations as standards for the detection and treatment of hypercholesterolemia, yet information on how these recommendations are being followed in primary care settings is limited. This study was done to determine how family physicians in four primary care clinics associated with a teaching hospital in a large southern city follow the NCEP guidelines. Of the total patient sample (N = 817), about 60% had at least one total serum cholesterol measurement. Patients in the younger age groups were less likely to have a cholesterol determination than older patients. Of those in the "self-pay" category only 33% had a cholesterol determination. Variability by clinic and provider type was also noted, with physician assistants showing the highest compliance with screening guidelines (75%), whereas only 43% of patients seen by family practice residents had a cholesterol measurement. Of patients who should have had a lipoprotein analysis, based on total serum cholesterol and risk factors, only 23% actually had a lipid profile. Our study and other similar ones point out that case finding varies considerably and that efforts to improve case finding need to continue.