A systematic review of adaptations of evidence-based public health interventions globally

BACKGROUND

Adaptations of evidence-based interventions (EBIs) often occur. However, little is known about the reasons for adaptation, the adaptation process, and outcomes of adapted EBIs. To address this gap, we conducted a systematic review to answer the following questions: (1) What are the reasons for and common types of adaptations being made to EBIs in community settings as reported in the published literature? (2) What steps are described in making adaptations to EBIs? and (3) What outcomes are assessed in evaluations of adapted EBIs?

METHODS

We conducted a systematic review of English language publications that described adaptations of public health EBIs. We searched Ovid PubMed, PsycINFO, PsycNET, and CINAHL and citations of included studies for adapted public health EBIs. We abstracted characteristics of the original and adapted populations and settings, reasons for adaptation, types of modifications, use of an adaptation framework, adaptation steps, and evaluation outcomes.

RESULTS

Forty-two distinct EBIs were found focusing on HIV/AIDS, mental health, substance abuse, and chronic illnesses. More than half (62%) reported on adaptations in the USA. Frequent reasons for adaptation included the need for cultural appropriateness (64.3%), focusing on a new target population (59.5%), and implementing in a new setting (57.1%). Common adaptations were content (100%), context (95.2%), cultural modifications (73.8%), and delivery (61.9%). Most study authors conducted a community assessment, prepared new materials, implemented the adapted intervention, evaluated or planned to evaluate the intervention, determined needed changes, trained staff members, and consulted experts/stakeholders. Most studies that reported an evaluation (k = 36) included behavioral outcomes (71.4%), acceptability (66.7%), fidelity (52.4%), and feasibility (52.4%). Fewer measured adoption (47.6%) and changes in practice (21.4%).

CONCLUSIONS

These findings advance our understanding of the patterns and effects of modifications of EBIs that are reported in published studies and suggest areas of further research to understand and guide the adaptation process. Furthermore, findings can inform better reporting of adapted EBIs and inform capacity building efforts to assist health professionals in adapting EBIs.

Cessation and reduction in smoking behavior: impact of creating a smoke-free home on smokers

The aim of this study was to assess the effect of a creating a smoke-free home (SFH) on cessation and reduction of cigarette smoking on low-income smokers. This secondary data analysis uses data from study participants who were originally recruited through 2-1-1 information and referral call centers in Atlanta (Georgia, 2013), North Carolina (2014) and the Texas Gulf Coast (2015) across three randomized controlled trials testing an intervention aimed at creating SFHs, pooling data from 941 smokers. Participants who reported adopting a SFH were more likely to report quitting smoking than those who did not adopt a SFH. This was true at 3-month follow-up and even more pronounced at 6-month follow-up and persisted when considering only those who consistently reported no smoking at 3 and 6 months. Among those who did not stop smoking, the number of cigarettes per day declined significantly more and quit attempts were more frequent for those who created a SFH compared with those who did not. Findings suggest that creating a SFH facilitates cessation, reduces cigarette consumption and increases quit attempts. Future studies should assess the long-term impact of SFHs on sustaining cessation.

How local and state regulations affect the child care food environment: A qualitative study of child care center directors' perspectives

Almost one-third of preschoolers spend regular time in child care centers where they can consume the majority of their daily dietary intake. The child care setting influences children's dietary intake. Thus, it is important to examine factors, such as local and state regulations, that influence the food environment at the center. This qualitative study explored directors' perceptions of how regulations influence the foods available at child care centers. Ten directors of centers in Travis County, Texas completed semi-structured interviews. Directors reported that changes in local health department regulations (e.g., kitchen specifications) result in less-healthful foods being served (e.g., more prepackaged foods). Directors of centers that do not participate in the federal Child and Adult Care Food Program (CACFP) said the state licensing regulations clarify the portion size and nutritional requirements for preschoolers thereby improving the nutritional quality of the food served. Directors of centers participating in CACFP said they are not affected by state mandates, because the CACFP regulations are more stringent. These findings suggest that state regulations that specify and quantify nutritional standards may beneficially impact preschoolers' diets. However, local health department regulations enacted to improve food safety may negatively influence the nutritional value of food served in centers.

Development of an expert system knowledge base: a novel approach to promote guideline congruent asthma care

Existing guidelines for the clinical management of asthma provide a good framework for such tasks as diagnosing asthma, determining severity, and prescribing pharmacological treatment. Guidance is less explicit, however, about establishing a patient-provider partnership and overcoming barriers to asthma management by patients in a way that can be easily adopted in clinical practice. We report herein the first developmental phase of the "Stop Asthma" expert system. We describe the establishment of a knowledge base related to both the clinical management of asthma and the enhancement of patient and family self-management (including environmental management). The resultant knowledge base comprises 142 multilayered decision rules that describe clinical and behavioral management in three domains: 1) determination of asthma severity and control; 2) pharmacotherapy, including prescription of medicine for chronic maintenance, acute exacerbation, exercise pretreatment, and rhinitis relief; and 3) patient self-management, including the process of intervening to facilitate the patient's asthma medication management, environmental control, and well-visit scheduling. The knowledge base provides a systematic and accessible approach for intervening with family asthma-related behaviors.

Motor-vehicle occupant injury: strategies for increasing use of child safety seats, increasing use of safety belts, and reducing alcohol-impaired driving

The Task Force on Community Preventive Services has conducted systematic reviews of interventions designed to increase use of child safety seats, increase use of safety belts, and reduce alcohol-impaired driving. The Task Force strongly recommends the following interventions: laws requiring use of child safety seats, distribution and education programs for child safety seats, laws requiring use of safety belts, both primary and enhanced enforcement of safety belt use laws, laws that lower the legal blood alcohol concentration (BAC) limit for adult drivers to 0.08%, laws that maintain the minimum legal drinking age at 21 years, and use of sobriety checkpoints. The Task Force recommends communitywide information and enforcement campaigns for use of child safety seats, incentive and education programs for use of child safety seats, and a lower legal BAC for young drivers (in the United States, those under the minimum legal drinking age). This report provides additional information regarding these recommendations, briefly describes how the reviews were conducted, and provides information to help apply the interventions locally.

Postpartum return to smoking: staging a "suspended" behavior

Two hundred fifty-six pregnant women who had quit smoking were classified into the precontemplation (PC), contemplation (C), preparation (PA), or action (A) stages of change for postpartum smoking cessation based on a 3-item algorithm assessing personal goals, self-efficacy, and smoking behavior. Logistic regression and event history analyses indicated group differences in return to smoking at 6 weeks and 3, 6, and 12 months postpartum. The percentage of women who returned to postpartum smoking was highest in the precontemplation stage and decreased with each subsequent stage, that is, at 6 weeks 83% of PCs, 64% of Cs, 35% of PAs, and 24% of As had returned to smoking. Results lend support for the stages of change for postpartum smoking abstinence. Stage-based interventions may be developed to assist women in maintaining abstinence postpartum.

Decision making, beliefs, and attitudes toward hysterectomy: a focus group study with medically underserved women in Texas

Variations in hysterectomy rates have been associated with assorted physician and patient characteristics, and the disproportionate rate of hysterectomies in African American women has been attributed to a higher prevalence of leiomyomas. The role of women's beliefs and attitudes toward hysterectomy and participation in decision making for medical treatment has not been explored as a source of variance. The purposes of this qualitative study were to explore these constructs in a triethnic sample of women to understand beliefs, attitudes, and decision-making preferences among underserved women; to facilitate development of a quantitative survey; and to inform development of interventions to assist women with such medical decisions. Twenty-three focus groups were conducted with 148 women from community sites and public health clinics. Thirteen self-identified lesbians participated in three groups. Analysis of audiotaped transcripts yielded four main themes: perceived outcomes of hysterectomy, perceived views of men/partners, opinions about healthcare providers, decision-making process. Across groups, the women expressed similar expectations from hysterectomy, differing only in the degree to which dimensions were emphasized. The women thought men perceived women with hysterectomy as less desirable for reasons unrelated to childbearing. Attitudes toward physicians were negative except among Hispanic women. All women expressed a strong desire to be involved in elective treatment decisions and would discuss their choice with important others. Implications for intervention development include enhancing women's skills and confidence to evaluate treatment options and to interact with physicians around treatment choices and creation of portable educational components for important others.

Developing an evidence-based Guide to Community Preventive Services--methods. The Task Force on Community Preventive Services

Systematic reviews and evidence-based recommendations are increasingly important for decision making in health and medicine. Over the past 20 years, information on the science of synthesizing research results has exploded. However, some approaches to systematic reviews of the effectiveness of clinical preventive services and medical care may be less appropriate for evaluating population-based interventions. Furthermore, methods for linking evidence to recommendations are less well developed than methods for synthesizing evidence. The Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide) will evaluate and make recommendations on population-based and public health interventions. This paper provides an overview of the Guide's process to systematically review evidence and translate that evidence into recommendations. The Guide reviews evidence on effectiveness, the applicability of effectiveness data, (i.e., the extent to which available effectiveness data is thought to apply to additional populations and settings), the intervention's other effects (i.e., important side effects), economic impact, and barriers to implementation of interventions. The steps for obtaining and evaluating evidence into recommendations involve: (1) forming multidisciplinary chapter development teams, (2) developing a conceptual approach to organizing, grouping, selecting and evaluating the interventions in each chapter; (3) selecting interventions to be evaluated; (4) searching for and retrieving evidence; (5) assessing the quality of and summarizing the body of evidence of effectiveness; (6) translating the body of evidence of effectiveness into recommendations; (7) considering information on evidence other than effectiveness; and (8) identifying and summarizing research gaps. Systematic reviews of and evidence-based recommendations for population-health interventions are challenging and methods will continue to evolve. However, using an evidence-based approach to identify and recommend effective interventions directed at specific public health goals may reduce errors in how information is collected and interpreted, identify important gaps in current knowledge thus guiding further research, and enhance the Guide users' ability to assess whether recommendations are valid and prudent from their own perspectives. Over time, all of these advantages could help to increase agreement regarding appropriate community health strategies and help to increase their implementation.

Maternal smoking during pregnancy and evidence-based intervention to promote cessation

Maternal smoking during pregnancy is hazardous to the developing fetus and mother. Smokers should be identified and offered personalized advice and assistance, including self-help materials tailored for pregnancy. Results of a meta-analysis of 16 randomized trials with validated outcomes indicate that such intervention increases cessation by 70% in diverse populations of pregnant women. At this time, intensive counseling on multiple occasions does not appear to increase cessation.

Nonconvulsive status epilepticus in the critically ill elderly

PURPOSE

To describe the electrographic and clinical features of nonconvulsive status epilepticus (NCSE) in the critically ill elderly and to identify potential predictors of outcome.

METHODS

We prospectively identified 25 episodes of altered mentation and NCSE in 24 critically ill elderly patients associated with generalized, focal, or bihemispheric epileptiform EEG patterns. Patients with anoxic encephalopathy were excluded.

RESULTS

Of 25 hospitalizations, 13 (52%) resulted in death, and 12 (48%) patients survived to discharge. Death was associated with the number of acute, life-threatening medical problems on presentation (survivors, 1.8; fatalities, 2.8; p = 0.013) and with generalized EEG pattern (p = 0.017). Higher doses or greater number of antiepileptic drugs (AEDs) did not improve outcome. Treatment with intravenous benzodiazepines was associated with increased risk of death (p = 0.033). Ten patients with advance directives were managed outside the intensive care unit (ICU). Mean hospitalization was 39 days in the ICU group and 22 for those with advance directives (p = 0.017).

CONCLUSIONS

Severity of illness correlates with mortality in critically ill elderly patients with NCSE. Treatment with intravenous benzodiazepines may increase their risk of death. Aggressive ICU management may prolong hospitalization at considerable cost, without improving outcome. It is unclear whether NCSE affects outcome in the critically ill elderly or is merely a marker for severity of disease in predisposed patients. The benefits of aggressive therapy are unclear. Carefully controlled, prospective trials will be necessary to determine the best therapies for NCSE in the critically ill elderly and the appropriate role of the ICU in their management.

Causal relationships of processes of change and decisional balance: stage-specific models for smoking

This study, a secondary analysis of prospective data of smokers, tested whether the causal relationships between the processes of change and decisional balance of the transtheoretical model of change (TTM) are stage-specific. It was expected that for smokers in the contemplation stage, higher levels of experiential processing cause the cons of smoking to become more important and the pros of smoking to become less important. In other words, the level of experiential process use was expected to causally influence decisional balance (pros minus cons) for people in the contemplation stage. For ex-smokers in the action stage, when the cons outweigh the pros (cons become more important while pros become less important), they should increase their behavioral process use: decisional balance was expected to causally influence use of behavioral processes. Cross-lagged panels were analyzed using structural equation modeling. Results indicate that experiential process use has causal predominance over decisional balance for smokers in the contemplation stage. For those in the action stage, however, neither decisional balance nor behavioral process had apparent causal predominance. Mean-level invariance indicates that the contemplation and action stages are different. Further analysis investigated smokers who progressed from contemplation to either preparation or action or from preparation to action. For these smokers who had progressed toward action, decisional balance did causally influence use of behavioral processes. This evidence provides support for the use of the TTM as the basis for planning interventions that target specific stage-dependent causal mechanisms.

Prenatal smoking cessation counseling by Texas obstetricians

BACKGROUND

Smoking during pregnancy causes 20 to 30 percent of low birthweight and 10 percent of infant mortality in the United States. Brief counseling can reduce rates of smoking. The study objectives were to describe Texas obstetricians' pregnancy smoking cessation counseling activity and to identify attributes associated with consistent, effective counseling.

METHODS

A survey was mailed to a random sample of Texas obstetricians.

RESULTS

A response rate of 44 percent (n = 204) was attained. A counseling coverage-effectiveness index was created based on the percentage of smokers counseled and use of specific techniques. Almost all respondents reported asking about smoking; fewer, however, reported counseling smokers. Physicians with low index scores, indicating inconsistent coverage, ineffective counseling, or both were dissatisfied with their current counseling, did not perceive counseling to decrease smoking, were not aware of the risks of smoking, and were unfamiliar with expert reports and recommendations for prenatal care.

CONCLUSIONS

Obstetricians who are not reached by expert reports and guidelines from groups outside their specialty or who do not perceive the seriousness of maternal smoking are less likely to counsel consistently and to use the most effective techniques. Continuing medical education at local, state, and national levels should be directed toward increasing knowledge and skills about smoking cessation counseling of pregnant women.

Prenatal weight gain patterns and infant birthweight associated with maternal smoking

BACKGROUND

Maternal smoking during pregnancy is recognized as an important and modifiable risk factor for low infant birthweight. The objective of this study was to compare the effects of maternal smoking status on prenatal weight gain and infant birthweight, and to determine if maternal weight gain mediates the effect of smoking cessation on infant birthweight.

METHODS

This prospective study of 341 white, non-Hispanic pregnant smokers, never smokers, and women who stopped smoking during pregnancy used multivariate analysis of variance to evaluate prenatal weight gain patterns. Multiple regression was used to investigate the effects of smoking status and maternal weight gain on infant birthweight.

RESULTS

Women who stopped smoking gained on average 39.68 lb during pregnancy. Smokers gained 32.75 lb, and never smokers gained 34.16 lb. Women who stopped gained significantly more weight than both smokers and never smokers (p = 0.01). Rates of weight gain differed significantly beginning in the second trimester, when women who stopped smoking gained more weight than never smokers (2.57 lb, 99% CI = 0.46, 8.07) and continued during the third trimester, with those who stopped smoking gaining more weight than both smokers (4.31 lb, 99% CI = 1.88, 12.00) and never smokers (1.25 lb, 99% CI = 0.56, 10.49). Infant birthweight differences were significant for women who stopped smoking versus continuing smokers (292 g, 99% CI = 145, 440) and for never smokers versus continuing smokers (253 g, 99% CI = 104, 401). Controlling for baseline maternal body mass index and infant gender, smoking status and weight gain each contributed significantly to infant birthweight (p < 0.001). No evidence of interaction between smoking status and weight gain on infant birthweight was found.

CONCLUSIONS

Maternal smoking status significantly affects prenatal weight gain and infant birthweight, but smoking cessation protects against lower birthweight through mechanisms other than increased maternal weight gain or different weight gain patterns.

A meta-analysis of trials evaluating patient education and counseling for three groups of preventive health behaviors

OBJECTIVES

To examine the overall effectiveness of patient education and counseling on preventive health behaviors and to examine the effects of various approaches for modifying specific types of behaviors.

DATA SOURCES

Computerized databases (Medline, Healthline, Dissertation Abstracts, and Psychological Abstracts), bibliographies 1971-1994. Search terms (patient education, patient compliance, and self care) with modifiers (evaluation and specific preventive behaviors).

STUDY SELECTION

Randomized and non-randomized controlled trials measuring behavior in clinical settings with patients without diagnosed disease. Abstracts and retrieved studies screened by multiple reviewers; 13% of retrieved studies met screening criteria.

DATA EXTRACTION

Replicated coding by multiple observers.

DATA SYNTHESIS

Behaviors were grouped based on whether the behavior is addictive and whether the desired change required subtraction of existing behaviors or adding new behaviors. The weighted average effect size from a random effects model for smoking/alcohol studies was 0.61 (CI = 0.45, 0.77), for nutrition/weight, 0.51 (CI = 0.20, 0.82) and for other behaviors, 0.56 (CI = 0.34, 0.77) indicating that the behavioral outcomes for these subgroups were significantly different from zero. Multiple regression models for the three groups indicated that using behavioral techniques, particularly self-monitoring, and using several communication channels, e.g., media plus personal communication, produces larger effects for the smoking/alcohol and nutrition/weight groups.

CONCLUSIONS

Patient education and counseling contribute to behavior change for primary prevention of disease. Some techniques are more effective than others in changing specific behaviors.

Postpartum return to smoking: who is at risk and when

PURPOSE

Despite high rates of spontaneous and assisted smoking cessation during pregnancy, postpartum maintenance is disappointingly low. Predictors of return to smoking remain unclear, thus limiting the development of interventions that could protect the health of women and their children. This study followed women who had participated in a prenatal smoking cessation intervention trial and successfully stopped smoking to address two aims: (1) describe the probability of relapse in confirmed quitters during the first 6 months after the birth, and (2) identify factors that increase relapse.

DESIGN

Prospective design during pregnancy and retrospective report at 6 months postpartum used survival analysis with return to smoking as the dependent variable and the Cox proportional hazards regression technique.

MEASURES

Questionnaires were used at the first prenatal visit and telephone interviews at the 26th week of pregnancy and 6 months postpartum. Nonsmoking after the 20th week was measured by urine cotinine tests (m = 3); nonsmoking postpartum was measured by retrospective self-report.

SETTING

The setting was an HMO-based group practice in Los Angeles.

SUBJECTS

Subjects were white, black, and Hispanic women (n = 127) available for follow-up.

RESULTS

The proportion of the sample classified as relapsers at 6 months postpartum was 62.9%. The final model identified the following risk factors for smoking: taking puffs in late pregnancy and having friends who smoke at the first prenatal visit, less confidence in mid-pregnancy that they could maintain nonsmoking postpartum, and a partner who smokes postpartum.

CONCLUSIONS

Intervention should begin in late pregnancy, and smoking networks, including partner smoking, should be addressed.

Telephone-guided placement and removal of nicotine monitors for the assessment of passive exposure to environmental tobacco smoke

The aim of this study was to determine the feasibility of telephone-guided placement of nicotine air sampling monitors in homes of women with infants. A monitor was mailed to homes in which the mother, her partner, or both were smokers, and a research assistant telephoned the woman and guided her through proper placement of the monitor according to a standard protocol. To assess the success of the guided placement, research assistants visited the homes of 50 women at the end of the two-week air-sampling period. The placement was determined to be correct if the monitor was positioned at least 1 ft from windows, more than 1 ft from the nearest corner of the room, and more than 2 ft from ashtrays. We had a 94% success rate for monitor placement in our study population, and our cost assessment showed that guided placement and removal cost approximately one-tenth the amount of methods requiring research assistants to conduct placements onsite. These results suggest that telephone-guided placement of monitors is an acceptable, inexpensive alternative to onsite placement by research assistants.

Effectiveness of health education and health promotion: meta-analyses of effect studies and determinants of effectiveness

Interventions to promote health that have been developed over the last 20 years in the relatively new scientific health education tradition, have often been evaluated for their effectiveness. Meta-analyses of effect studies on various subfields, show that these interventions generally have quite substantial effects (mean effect sizes, ES, of 0.46 for primary prevention and 0.49 for secondary prevention and patient education). A planned and systematic application of social science theory in intervention development is a strong determinant of effectiveness. However, learning principles such as rewards and feedback, that have been shown to increase effectiveness, are often not or not adequately applied. Also, too few interventions focus on possibilities to facilitate the desired behavior (such as reminders, financial stimuli, and skills improvement). The potential effectiveness of interventions in practice may be increased by systematic development of adoption and implementation strategies, including the creation of 'linkage systems' between intervention developers and representatives of the target and user systems.

Pregnancy smoking cessation: a case of mistaken identity

This study examined the process of change in pregnancy smoking cessation, using the stages and processes of change from the Transtheoretical Model, to compare women who stopped smoking during pregnancy with women who were in the process of smoking cessation, but were not pregnant. Differences in smoking cessation process activity and abstinence self-efficacy were hypothesized between the pregnant and nonpregnant groups of women. Study participants were 89 pregnant women who quit smoking, 28 nonpregnant women in the action stage of smoking cessation, and 92 nonpregnant women in the preparation stage. The Smoking Cessation Processes of Change Scale and the Smoking Abstinence Self-Efficacy Scale served as dependent measures. One-way MANOVA and follow-up Newman-Keuls comparisons indicated significant differences between pregnant and nonpregnant women in their levels of process activity and self-efficacy. Pregnancy smoking cessation differed dramatically from the process of nonpregnancy smoking cessation. Pregnant quitters were not engaging in experiential and behavioral processes at levels associated with the action stage of change. Low levels of process use and high efficacy indicated an externally (for the baby) motivated stopping rather than an internal, intentional process of change, which may account for high relapse rates postpartum.

Inadequacies of surgical patient education

Education of surgical patients by hospital staff members is often hampered by temporal, spatial and personnel barriers. It is desirable that regular staff members themselves provide patients with information. To improve surgical patient education by staff members, an examination was performed in two hospitals of events related to surgical patients' treatment, care and education during the course of their admission in hospital. The method consisted of interviews with patients and health care providers and observations of critical events. Patients were found to experience emotional problems, such as fear of surgery and anesthesia and lack of information about medical details, the roles of various health care providers and about discharge from the hospital. These problems appeared to be caused by organizational barriers and by inadequacies of the method of information provision. The results of the examination provide a sound basis to develop, in collaboration with hospital staff members, programs to improve surgical patient education.

Initiation of prenatal care by low-income Hispanic women in Houston

OBJECTIVE

To understand why many Hispanic women begin prenatal care in the later stages of pregnancy.

METHODS

The authors compared the demographic profile, insurance status, and health beliefs--including the perceived benefits of and barriers to initiating prenatal care--of low-income Hispanic women who initiated prenatal care at different times during pregnancy or received no prenatal care.

RESULTS

A perception of many barriers to care was associated with later initiation of care and non-use of care. Perceiving more benefits of care for the baby was associated with earlier initiation of care, as was having an eligibility card for hospital district services. Several barriers to care were mentioned by women on open-ended questioning, including long waiting times, embarrassment the physical examination, and lack of transportation.

CONCLUSIONS

Recommendations for practice included decreasing the number of visits for women at low risk for poor pregnancy outcomes while increasing the time spent with the provider at each visit, decreasing the number of vaginal examinations for low risk women, increasing the use of midwives, training lay workers to do risk assessment, emphasizing specific messages about benefits to the baby, and increasing general health motivation to seek preventive care through community interventions.

Health promotion outreach for rural family physicians: a feasibility study

This project examined the feasibility of using an educational representative, modeled in part on a drug detailing representative, to increase health promotion counseling by rural family physicians in east Texas. The physicians were offered, at no charge, materials for patients and training for themselves and their office staff on patient education regarding smoking, weight problems, sedentary living, and stress. Visits from the representative were accepted by 76 percent of the physicians, about half of whom requested training for themselves and/or their office staffs. A high degree of satisfaction with the training was expressed by trainees in follow-up interviews. Pretest data indicated that the physicians were using at least one counseling technique before the introduction of the intervention. Posttest data suggested that use of more effective counseling techniques and materials increased. Use of an educational representative when travel time and costs are minimized appears to merit further exploration.

Settings as an important dimension in health education/promotion policy, programs, and research

Settings--community, worksite, schools, and healthcare sites--constitute an important dimension of health education/health promotion policy and programs and for research about program needs, feasibility, efficacy, and effectiveness. These settings vary in the extent of coverage of and relationships with their respective constituencies, valued outcomes, and quantity and quality of evidence about the effectiveness of setting-specific and cross-setting programs. Main sources of evidence for program efficacy and effectiveness are summarized, leading to the conclusion that strides have been made toward building a strong evidentiary base for health education/health promotion in these settings. Gaps in research exist, especially for diffusion of effective programs, new technologies, the influence of policy, relations between settings, and approaches to marginal and special subgroups. Recommendations are offered for cross-setting and within-setting research related to intervention.

Relapse prevention among women who stop smoking early in pregnancy: a randomized clinical trial of a self-help intervention

Studies have demonstrated the effectiveness of smoking cessation interventions targeted at women who are smoking during pregnancy. In contrast, there is limited information about the experience of smokers who have stopped before entering prenatal care--"spontaneous quitters." These women constitute the majority of women who stop smoking sometime during pregnancy, although evidence suggests that as many as one third relapse prior to delivery. We report the results of a population-based randomized clinical trial that tested the effectiveness of a relapse prevention program for spontaneous quitters. The intervention consisted predominantly of printed materials received through the mail. The population (n = 171) of spontaneous quitters was an ethnically diverse group of women enrolled in a large health maintenance organization. Biochemical confirmation of continuous abstinence through delivery revealed that 16% of the women in the experimental self-help program relapsed compared with 20% of usual care controls (NS). Analysis confirmed that the program was equally ineffective among all subgroups including women at highest risk for relapse. Given the negative outcomes associated with self-help materials and clinic-based counseling reported in this and other trials, alternative intervention strategies need to be developed and tested for this significant group of prepregnancy smokers.

A survey of physician beliefs and self-reported practices concerning screening for early detection of cancer

Cancer is the second leading cause of death in the United States. Early detection of cancer greatly improves 5-year survival for many sites, and in 1980 the American Cancer Society (ACS) published recommendations for performing cancer screening with the goal of promoting early cancer detection in asymptomatic persons. This cross-sectional survey examined beliefs and practices related to six cancer screening tests and procedures in a group of 68 primary care physicians in a multi-specialty group practice in Houston, Texas. Constructs from the Health Belief Model and Social Cognitive Theory were used to identify factors that might influence performance of cancer screening. Physicians in this study reported greater compliance with ACS recommendations for performance than has been found in other studies, and there is an indication that some screening tests may be performed even when not indicated based on age-specific criteria. Respondents reported performing digital rectal examination, stool occult blood testing, and sigmoidoscopy more frequently in men than in women. No belief factor emerged as being associated with performance of all screening procedures, and associations that were noted for some procedures were not consistent across patient age and gender groups. Some possible directions for further research and development of programs to promote the appropriate and cost effective use of cancer screening are physician education to include information about age and gender appropriate guidelines for screening and opportunities for skills training and practice workshops for some procedures.

The information-seeking behavior of cancer outpatients: a description of the situation

The information-seeking behavior of cancer outpatients has been studied with the purpose of collecting data for the development of an educational intervention: stimulating communication between cancer outpatients and their specialists. The intention to seek information, the realization of the intention and the reasons for not realizing it are measured with several qualitative and quantitative methods: written questionnaires (n = 60, n = 18), audio records (n = 40) and focus group interviews (n = 19). Not every patient (58%) intends to discuss topics of illness and treatment with the specialist. Possible incentives to plan a discussion with the specialist are experienced uncertainty, fear and dissatisfaction with information received. In 22% of cases cancer outpatients do not realize their intention, and in 25% of cases the realization of the intention is due to the initiative of the specialist or the patient's companion. The information-seeking behavior of cancer outpatients appears to be influenced by several factors, including patients' needs, values and beliefs; unexpected situations; patients' skills; and specialists' and companions' behavior.

A meta-analysis of studies of the Health Belief Model with adults

The Health Belief Model (HBM) relates a socio-psychologic theory of decision making to individual health-related behaviors. We conducted a meta-analysis of the relationships between four HBM dimensions (Susceptibility, Severity, Benefits and Costs) and health behavior on 16 studies that measured all four of the dimensions, measured a behavioral dependent variable and included some measures of reliability, minimal criteria for establishing the validity of the dimensions. Mean effect sizes were computed for all the studies, subgroupings representing studies of screening, risk reduction and adherence to medical regimen, and prospective and retrospective study designs. Of 24 mean effect sizes, 22 were found to be positive and statistically significant. The actual variance accounted for ranged from 0.001 to 0.09. Homogeneity was rejected for 15 of the 22, however, suggesting that the same underlying construct was not measured. Retrospective studies were found to have significantly large effect sizes for benefits and costs and smaller effect sizes for severity when compared to prospective studies. The weak effect sizes and lack of homogeneity indicate that it is premature to draw conclusions about the predictive validity of the HBM as operationalized in these studies. Our finding of only 16 studies meeting minimal criteria for valid representation of the HBM dimensions indicates that future studies should focus more on such issues.

Definition and yield of inclusion criteria for a meta-analysis of patient education studies in clinical preventive services

Because selection of studies for a literature review influences conclusions, inclusion criteria are of utmost importance. For a meta-analysis of studies testing effects of patient education on preventive behaviors, we present the framework and concepts used for setting inclusion criteria for primary studies. We also present the yield in terms of number and distribution of studies that resulted from the inclusion criteria. Because we were interested in a diverse range of behaviors and a broad definition of patient education, we present a method for grouping behaviors by type of behavior change and describe parameters for subgrouping interventions by orientation and communication channel. Of 5,451 citations located and abstracts screened, 561 citations reporting potentially relevant studies were reviewed. Based on our inclusion criteria, 171 citations contained relevant studies, of which 64 studies (found in 62 citations) also met our acceptability criteria. We examine the effects of alternate inclusion criteria on the yield of primary studies and their distributions across the subgroupings.

Identifying pregnant women who drink alcoholic beverages

This randomized 2 x 2 study compared disclosure rates of alcohol use with two response formats (multiple choice and dichotomous) and two communication channels (oral and written) in an adult prenatal population (N = 1078). The multiple choice question improved disclosure, regardless of channel, by 40% across white, African-American, and Hispanic subgroups.

Improving disclosure of smoking by pregnant women

Smoking is a major modifiable risk factor in pregnancy, and low-cost interventions have been developed and tested in diverse populations of pregnant smokers. Successful intervention depends on identification, however, and nondisclosure can be a problem. This randomized study compared rates of disclosure with two response formats--multiple choice, in which the patient is able to describe herself as having "cut down," and the usual history question, "Do you smoke?," in which she is forced to answer simply "yes" or "no". Each format was tested in both oral and written channels with a multiethnic adult prenatal population (n = 1078) entering care in a multispecialty group. Study results indicate that the multiple choice question improved disclosure, regardless of channel (oral versus written), by 40%. This effect was observed across racial and ethnic groups. Biochemical tests of urine samples from reported nonsmokers indicated smoking in only 3%. Eleven percent of the "nonsmokers" in the experimental groups refused consent for the urine test, however, and many of these were probably smokers.

Assessing the congruence between physician behavior and expert opinion in smoking cessation counseling

This study examines the degree of transfer of smoking cessation innovation from research to health care settings by comparing frequency-of-practice ratings by a national sample of family practice physicians (n = 903, response rate = 70%) and importance ratings by smoking cessation and prevention experts (n = 58, response rate = 84%) for 14 counseling techniques. The physician survey elicited a profile that combines traditional and behavioral techniques--discussing smoking with patients, encouraging goal setting, suggesting specific steps for quitting, and presenting pamphlets. They refer to others infrequently and rarely report planning for follow-up about smoking. The experts rated these selected techniques as moderately to highly important. They favored a behavioral approach coupled with active follow-up. The major differences between physician and expert rankings were that the experts placed higher priority on planned follow-up and a lower priority on pamphlets. The uneven quality of counseling reported by physicians suggests that weighting their responses according to expert opinion would provide a more sensitive profile. Scaled weighting produced scores that may help researchers define a composite quality-quantity measure of activity.

Women who stop smoking spontaneously prior to prenatal care and predictors of relapse before delivery

This study explores the experience of pregnant women who quit smoking prior to initiating prenatal care. These "spontaneous quitters" comprised 41% of a socioeconomically and ethnically diverse population of prepregnancy smokers enrolled in a health maintenance organization. Compared to women who were smoking at the start of prenatal care, spontaneous quitters had been lighter smokers, were less likely to have another smoker in their household, indicated a stronger belief in the harmful effect of maternal smoking, had a history of fewer miscarriages, and entered prenatal care earlier. Biochemical validation of smoking status over the course of pregnancy found that 21% of the spontaneous quitters relapsed prior to delivery. Characteristics reported at the first prenatal visit that were associated with maintenance included having achieved cessation for a longer period of time without smoking even a puff, higher self-efficacy for maintenance, stronger belief in the harmful effect of maternal smoking, primigravida, and greater frequency of nausea. The identification of spontaneous quitters and selected intervention for those at greatest risk of relapse is recommended for inclusion in routine prenatal care.

Maintenance of nonsmoking postpartum by women who stopped smoking during pregnancy

This paper describes self-reported maintenance of nonsmoking at six months postpartum by women whose abstinence was verified beginning before the 20th week of pregnancy and continuing through delivery (n = 134). The overall maintenance rate of 37 percent was not related to sociodemographic characteristics, smoking and obstetric history, the time when quitting occurred, or a prenatal smoking cessation program. Although this rate is encouraging, more attention should be directed to sustaining prenatal abstinence from smoking beyond delivery.

Identifying families at high risk of cardiovascular disease: alternative work site approaches

By examining coverage, concordance, and costs, this project evaluated four methods of cardiovascular disease (CVD) risk screening at a work site with 1821 central office employees of an energy company in Houston, Tex. Screening methods included a health risk appraisal mail questionnaire (HRA), an HRA plus brief physical assessment, an analysis of medical claims data, and an analysis of absenteeism data. Coverage ranged from 99% of employees for the absenteeism method to about 30% for the HRA method. Combining the first three screening methods, 18% of families had at least one member with a CVD or related diagnosis or one of four major CVD risk factors. The absenteeism method yielded 12.1% of the central office employees with 9 or more days absent. Although the absenteeism method identified high-cost families, only 9% had a heart disease or related diagnosis. This lack of concordance also occurs with other methods. For example, only 9.4% of families identified with the claims data were also identified by the HRA. Therefore, the methods identify different groups of high-risk families. Findings are discussed in relation to costs and other factors important to firms' selection of screening methods.

Selected predictors of health promotion counseling by three groups of allied health professionals

Three groups of allied health professionals, including dental hygienists, dietitians, and certified nurse-midwives, were surveyed to determine current practice, beliefs, and attitudes regarding health promotion and disease prevention. The study aimed to explore the power of selected variables drawn from social learning theory in predicting self-reported level of counseling. We conducted separate analyses for 10 areas of health promotion and disease prevention: high blood pressure, smoking, lack of exercise, overweight, high-fat diet, alcohol abuse, illicit drug use, stress, isolation and loneliness, and nonuse of safety belts. The predictor variables were respondents' professional group membership, confidence that they possess appropriate skills and knowledge to counsel patients (self-efficacy), belief that patients will follow through on recommendations (adherence expectation), and belief that reduction of risk will improve patients' health status (expectation of health impact). The level of counseling activity varied markedly across the risk areas, with blood pressure and weight receiving the most emphasis on average and isolation and loneliness and nonuse of safety belts receiving markedly less attention. There also was variation across the professional groups. Certified nurse-midwives had higher mean counseling scores in all topics except those related to diet, where the dietitians' mean scores were approximately the same. Of all the areas about which counseling might be increased, use of safety belts stands out as having the lowest reported prevalence, the least complexity in terms of implementation, and the most relevance to at least two of the professional groups. These findings suggest the importance of skills training, including the provision of actual or simulated counseling experience and modeling by others in the same professional group.(ABSTRACT TRUNCATED AT 250 WORDS)

Pregnancy and medical cost outcomes of a self-help prenatal smoking cessation program in a HMO

The results of a randomized clinical trial of a prenatal self-help smoking cessation program are reported in terms of the pregnancy and cost outcomes. The study population were the socioeconomically and ethnically diverse members of a large health maintenance organization (HMO) who reported that they were smoking at the time of their first prenatal visit. The intervention consisted predominantly of printed materials received through the mail. Compared with the usual care control group, women assigned to the self-help program were more likely to achieve cessation for the majority of their pregnancy (22.2 percent versus 8.6 percent), gave birth to infants weighing on average 57 grams more, and were 45 percent less likely to deliver a low birth weight infant. An economic evaluation of the self-help program was conducted from the perspective of the sponsoring HMO. Based upon the expenditures associated with the neonates' initial hospital episode, the intervention had a benefit-cost ratio of 2.8:1. These findings provide strong evidence to support widespread incorporation of smoking cessation interventions as a standard component of prenatal care.

Cardiovascular mortality trends in Harris County, Texas: 1980 to 1986

Cardiovascular diseases are the leading causes of death in Texas and in the United States. This study determines the trend in mortality rates attributed to cardiovascular diseases in Harris County from 1980 to 1986. The region of the county that does not include the City of Houston was specifically studied. Mortality of cardiovascular diseases in these two areas follow patterns similar to that of the United States in the same time period. Both the entire county and Harris County excluding Houston show declines in cardiovascular mortality rates in the 7-year period. The populations were divided into four ethnic categories (white, black, Hispanic and "other"), and each ethnic group reported significant declines in overall cardiovascular mortality except in the "other" population, which showed an increase in the male group. Significant downward trends were noticed in the white and Hispanic population in the two major subcategories of cardiovascular diseases: diseases of the heart and cerebrovascular diseases. The black population in each geographic area studied was consistently higher in cardiovascular mortality than the other three ethnic groups observed (white, Hispanic and "other"). Knowledge of cardiovascular disease mortality rates by ethnicity, sex, and age as well as temporal changes in mortality rates within Harris County are important for health planners in continuing and implementing programs aimed at awareness, prevention, and treatment of cardiovascular diseases.

Patterns of counseling techniques used by family practice physicians for smoking, weight, exercise, and stress

Members of the American Academy of Family Physicians (nonfederal, continental U.S.) were surveyed regarding their involvement in health-habit modification (response rate = 70.4%, n = 903). Frequency and indications for use of specific counseling techniques were assessed in each of four health-habit areas: smoking, exercise, weight control, and stress management. Factor analysis of responses produced clusters of techniques labeled "traditional teaching," "behavioral," "interpersonal with follow-up," and "referral." The dominant style varied by health-habit area. The factors were less clear for stress than for the other three areas. Results indicated no relationships or weak relationships between counseling approaches and physician gender, year of graduation, board status, region, community size, practice type, average visit length, and selected patient characteristics. Study findings suggest that family physician counseling varies with the health habit and that background and practice variables are not associated with counseling approach.

Assessing the quality of health promotion and patient education programs

Quality assessment for health promotion and patient education programs helps ensure that these services are efficient and effective, and represent professional standards of practice. It also helps ensure that they are beneficial, accessible, and acceptable to members. Three program characteristics should be considered in defining the objectives of an assessment--the degree of existing knowledge regarding the effectiveness of the program, the degree of risk posed by the program, and the cost of the program. A menu of objective is presented, including assessment of the structure of the program; comparison of the program with state-of-the-art models; assessment of program implementation and coverage; measurement of member/patient response; evaluation of program outcome; and evaluation of cost-effectiveness, opportunity costs, and broad benefits to the organization. Major methods for assessment and evaluation are discussed briefly in relationship to the objectives they address--review of professional staff performance; comparison with models, standards, and other criteria; documentation and management information systems; focus groups and other small-scale qualitative methods; participation in plan monitoring and quality assurance activities; and controlled evaluation studies.

A randomized trial of a serialized self-help smoking cessation program for pregnant women in an HMO

We report the results of a population-based randomized clinical trial that tested the effectiveness of a prenatal self-help smoking cessation program. The intervention consisted predominantly of printed materials received through the mail. The population (n = 242) consisted of a socioeconomically and ethnically diverse group of pregnant women enrolled in a large health maintenance organization (HMO) who reported they were smoking at the time of their first prenatal visit. Biochemical confirmation of continuous abstinence achieved prior to the 20th completed week of pregnancy and lasting through delivery revealed 22.2 per cent of the women in the eight-week serialized program quit versus 8.6 per cent of controls with usual care. The adjusted odds ratio was 2.80 (95 per cent CI = 1.17, 6.69). We conclude that a low-cost prenatal self-help intervention can significantly affect the public health problem of smoking during pregnancy and its associated risks for maternal and child health.

Health beliefs and behaviors of physician assistants in Texas: implications for practice and education

Concern has been expressed over how the volume and effectiveness of physicians' practices relative to prevention can be increased. While a review of the health care services provided by physician assistants in medical practices indicated an emphasis on health education and patient counseling, there has existed an absence of data regarding their beliefs and practices in the area of health promotion. Based upon an analysis of self-reported data from 256 respondents (89%) of a random sample (n = 289) of the 870 physician assistants in Texas, it appears that physician assistants perceive themselves as having a role in health promotion, are generally satisfied with their preventive health care role, view health promotion activities as being more important in the future, and disagree with the idea that health promotion would not be well received by patients. They routinely gather information on health behaviors and discuss or recommend ways to reduce at-risk behavior. Furthermore, while expressing certainty about their knowledge and skills to educate and influence individuals to change certain risk behaviors, physician assistants indicate less certainty about patient follow-through when it relates to such activities as smoking, drinking, and the use of illicit drugs. Considering the perceived challenge and the view that health promotion will become an even larger component of the physician assistant's future role, these findings suggest a need for additional skills training to better assist patients to modify their more complex health risk behaviors.

Health promotion and patient education benefits for employees

One step that employers can take to assure that employees receive such education services is pursuing coverage of education as a separate service. For some time now, insurers have shown interest in patient education services (15-17, 61), but patient education "integral to care" is typically covered only as a part of the "per diem" in the case of hospitals or as part of the visit fee in the case of outpatient visits. Education for patients with diabetes is being covered experimentally as a separate service in at least 17 states. Physicians whose practice is composed largely of "cognitive services" rather than "procedures" are also interested in education as a reimbursable service. The same arguments as described in relation to coverage of risk reduction services generally apply to this case. Education programs for employees who are under medical care can improve their adherence to the recommended regimen and hence can improve the effectiveness of care. Education and counseling prior to surgical and other stressful procedures decrease stress and the need for pain medications, and they can shorten the length of hospital stays. Education is an important component of programs to substitute home care for hospital care or expensive outpatient care. Currently, however, a patient cannot rely on usual providers of medical care to offer adequate education. Reimbursement for patient education on a selected, experimental basis is probably warranted for chronic conditions requiring complex adjustments and regimens. Cases of asthma where there is a history of hospitalization or emergency room visits is an excellent possibility. The experience of covering diabetes education should be monitored to help resolve the debate.

Selected allied health professionals' self-confidence in health promotion counseling skills and interest in continuing education programs

Mail surveys of samples of dental hygienists (n = 90, 36% response), registered dietitians (n = 262, 52% response), and physician assistants (n = 289, 89% response) in Texas and certified nurse midwives (n = 143, 57% response) in the US provided data regarding their confidence that they possess skills and knowledge to counsel patients about selected areas of health promotion (self-efficacy). Also, the surveys gathered information regarding respondents' beliefs that patients will follow through on their recommendations (adherence expectation), and their interest in continuing education programs. Overall, respondents displayed highest self-efficacy with regard to counseling patients about blood pressure and smoking. Confidence was lowest in illicit drug abuse and mental health areas. Certified nurse midwives and physician assistants indicated confidence in many more areas than the other two groups. Respondents consistently expressed less certainty about patient adherence than about their own skills and knowledge. They generally indicated a high degree of interest in continuing education across the several health promotion topics. Modest relationships were observed between self-efficacy and interest in continuing education programs for physician assistants and registered dietitians, indicating that those with greater self-efficacy had a greater interest in building their skills. A similar pattern was observed among physician assistant respondents with respect to adherence expectations.

Predictors of safety belt initiative by primary care physicians. A social learning theory perspective

Even with the passage of state safety belt laws, primary care physicians can contribute to their patients' safety by brief interventions. The present study explores the prevalence of such action with adult patients and tests the power of constructs taken from social learning theory to explain physicians' behavior. These constructs included self-efficacy, personal behavior (self-modeling) and three outcome expectations--expectation of patient follow-through, health impact, and impact of health promotion on the practice. Data were taken from a survey of Texas family physicians prior to enactment of the state law (n = 209). History-taking and advising were combined to form a single scale, "safety belt action." Prevalence of safety belt action was low. Overall, only 5% said they ask routinely about safety belts; 58.1% do not advise or discuss the risk even when they are aware of nonuse. Social learning theory variables accounted for 34% of the variance in safety-belt action after controlling for year of graduation in a hierarchical regression analysis. Self-efficacy was entered first, and it predicted 25% of the variance. The other social learning variables were entered together, and they predicted the additional 9% of the variance after controlling for year of graduation and self-efficacy. Of these other variables, only health impact was significant, however. These findings suggest several avenues for improving safety belt action and add evidence for the importance of outcome expectations over and above self-efficacy.

Stress management in primary care: physicians' beliefs and patterns of practice

We examined attitudes and practices related to stress management in a random sample of Texas primary care physicians. Two fifths of the physicians indicated that avoiding undue stress was very important, and more than one third reported that they gathered information about stress on a routine basis. Over two thirds of the physicians said that they had counseled their patients regarding stress and 13 percent had referred patients with high stress to outside programs. The physicians' confidence that they had the skills to help patients with high stress, their belief in the benefits of avoiding undue stress, and their estimate of patient follow-through on recommendations were positively associated with history-taking and counseling regarding stress. Recommendations for medical education include incorporating information about stress and health into medical school curriculums, building skills in stress management, and increasing feedback from patients who have coped successfully with high stress.

Efficacy of psychoeducational interventions on pain, depression, and disability in people with arthritis: a meta-analysis

Meta-analysis is a technique which combines data from several properly and similarly designed controlled studies so as to increase the power of the relevant statistical analysis. Fifteen studies on the effects of psychoeducational interventions on disability, pain and depression in individuals with chronic rheumatoid arthritis or osteoarthritis were analyzed by this method. The results indicate that patient education can indeed contribute to improving the health status of such patients.

The cost effectiveness of an education outreach representative to OB practitioners to promote smoking cessation counseling

Growing concern about mothers, smoking during pregnancy calls for effective patient education by health care professionals. Because most women receive prenatal care and people with high perceived self-risk do have high cessation rates when advised by physicians, prenatal care in private practice offers a unique opportunity to decrease the number of pregnant women who smoke. The pilot test described here is a one-group pretest and posttest community trial which tested the feasibility of using an education outreach representative to market smoking- and pregnancy-education materials to private practice physicians. The costs of the pilot test are compared to the costs of three other strategies for disseminating education materials. The pilot test proved more cost-effective than two direct-mail strategies and one commercial enterprise. These results suggest that this strategy is feasible and merits further study for distributing education materials and teaching effective education strategies to physicians.

Health promotion and disease prevention beliefs and behaviors of dietetic practitioners

Fifty-three percent of a random sample of 500 members of the Texas Dietetic Association responded to a survey designed to determine their personal health behavior, beliefs, and patient counseling practices related to health promotion and disease prevention. This article reports the responses of the 180 practitioners involved in direct patient care in order to depict the health promotion/disease prevention beliefs and behaviors of that particular group. Health habits (e.g., smoking, physical activity, and dietary patterns) of dietetic practitioners were better than those of the general female population. Personal health habits related to not smoking and to getting regular exercise were significantly associated with belief in the importance of that behavior for others. Although most of the dietetic practitioners indicated that the identified health behaviors were important to the health of the average person, only a few practitioners gave them routine attention in their practice. Respondents generally expressed a lack of confidence in their ability to educate clients about specified health behaviors, with the exception of weight control, high-fat diets, elevated blood pressure, and exercise patterns. The practitioners' confidence in their counseling skills was significantly correlated with intensity of counseling (p less than or equal to .001) and the likelihood of client compliance, except in the area of weight control. The majority of the dietitians strongly agreed that health promotion will be more important in the future.