Patient perceptions about illness self-management in ANCA-associated small vessel vasculitis

OBJECTIVES

To characterize patient perceptions, related to eight self-management behaviours relevant for adults with ANCA-associated small vessel vasculitis (ANCA-SVV), and to determine if these perceptions were associated with performance of each behaviour.

METHODS

Adults with ANCA-SVV (n = 202) completed a self-administered questionnaire that assessed eight self-management behaviours (adherence to recommendations for medication, health service use, diet, exercise, infection avoidance and symptom monitoring; prompt reporting of symptoms and side effects; and adjusting activities in response to symptoms), perceptions about these behaviours, socio-demographics, clinical factors and social desirability bias. Descriptive statistics were generated to characterize patients' perceptions about difficulty of, importance of, and specific barriers to performing each behaviour. Regression analyses explored whether these variables were associated with performing each behaviour, controlling for potential confounders.

RESULTS

With few exceptions, higher perceived importance and lower perceived difficulty of each behaviour were associated with more frequent performance of the behaviour. For each behaviour, several specific barriers were frequently endorsed by patients and a number of these were associated with lower levels of self-management.

CONCLUSION

This study reveals that patient perceptions about the illness and its treatment influence ANCA-SVV self-management. Perceived barriers to medication, health services, diet and exercise adherence were similar to those in other illnesses. This study also provides insight into barriers experienced by patients in performing behaviours (infection avoidance, symptom monitoring, reporting symptoms and side-effects and adjusting activities) not often previously studied. How the identification of these barriers can help inform future interventions for ANCA-SVV patients is to be discussed.

Validity and factor structure of the AUSCAN Osteoarthritis Hand Index in a community-based sample

OBJECTIVE

The AUStralian CANadian Osteoarthritis Hand Index (AUSCAN) is a self-report assessment of hand pain, stiffness, and function. Prior studies have examined its validity in small clinical samples and family-based samples. This study examined measurement properties of the AUSCAN in a large, community-based sample, extending knowledge about the scale's generalizability.

METHODS

Participants (N=1730, mean age=61 years, 65% female, 30% African American) were enrolled in the Johnston County Osteoarthritis Project. We examined the internal consistency, construct validity, and factor structure of the AUSCAN among the total sample, as well as in subgroups according to gender, race, presence of hand pain, and presence of radiographic hand osteoarthritis (OA).

RESULTS

Internal consistency was high for the total scale and subscales among the full study sample and all subgroups (Cronbach's alphas=0.89-0.96). Construct validity was also supported, as grip and pinch strength were more strongly correlated with the AUSCAN function subscale than with the pain and stiffness subscales. Factor analysis showed that for the full sample and most subgroups, all pain items loaded on one factor (standardized regression coefficients 0.59-0.81) and all function items loaded on another (standardized regression coefficients 0.61-0.78), supporting the intended subscale structure of the scale. However, for African Americans, a different factor pattern emerged, with three function items loading on a factor with the pain items.

CONCLUSIONS

Results support the validity of the AUSCAN in a general sample of adults, as well as across demographic and clinical subgroups, although the subscale structures differed slightly by race.

Food intake patterns and gallbladder disease in Mexican Americans

OBJECTIVE

Results of previous studies on diet and gallbladder disease (GBD), defined as having gallstones or having had surgery for gallstones, have been inconsistent. This research examined patterns of food intake in Mexican Americans and their associations with GBD.

DESIGN

Cross-sectional.

SUBJECTS

The study population included 4641 Mexican Americans aged 20-74 years who participated in the 1988-94 third National Health and Nutrition Examination Survey (NHANES III). GBD was diagnosed by ultrasound. Food intake patterns were identified by principal components analysis based on food frequency questionnaire responses. Component scores representing the level of intake of each pattern were categorized into quartiles, and prevalence odds ratios (POR) were estimated relative to the lowest quartile along with 95% confidence intervals (CI).

RESULTS

There were four distinct patterns in women (vegetable, high calorie, traditional, fruit) and three in men (vegetable, high calorie, traditional). After age adjustment, none were associated with GBD in women. However, men in the third (POR = 0.42, 95%CI 0.21-0.85) and fourth (POR = 0.53, 95%CI 0.28-1.01) quartiles of the traditional intake pattern were half as likely to have GBD as those in the lowest quartile.

CONCLUSIONS

These findings add to a growing literature suggesting dietary intake patterns can provide potentially useful and relevant information on diet-disease associations. Nevertheless, methods to do so require further development and validation.

Development of a health status measure for older African-American women with type 2 diabetes

OBJECTIVE

To develop a health status measure in older African-American women with type 2 diabetes.

RESEARCH DESIGN AND METHODS

African-American women, age > or =40 years with type 2 diabetes, were recruited from central North Carolina to participate in three sequential phases: 1) Seven focus groups were convened and transcripts evaluated to generate questions and identify plausible domains; 2) Ten one-on-one cognitive response interviews were performed to ensure clarity and cultural appropriateness of the questions; and 3) 217 women participated in psychometric evaluation to establish the internal consistency and validity of the instrument.

RESULTS

Three broad categories--mental, physical, and social well-being--captured important issues generated during the focus groups. "My diabetes" was added during the cognitive response interviews as a way of separating the impact of diabetes from coexisting issues that affect health status. The response option was changed from a six- to a four-point Likert scale to accommodate subject preference. Using principal components and subsequent promax rotation, we identified two hierarchical domains (mental and social well-being) and a physical symptom index. The internal consistency (Cronbach's alpha) of the mental and social well-being subscales are 0.83 and 0.93, respectively. A priori hypothesized correlations between subscales along with each subscale and glycated hemoglobin, diabetes duration, physical activity, and a perceived health competence scale helped establish the construct validity of the instrument.

CONCLUSIONS

A culturally appropriate disease-specific health status measure for older African-American women with type 2 diabetes has been developed. We have established the internal consistency, construct validity, and factor analytic properties of the measure. This measure should prove useful for investigators who seek a health status instrument that addresses issues germane to African-American women with type 2 diabetes.

Interactive computer technology for skin cancer prevention targeting children

BACKGROUND

Computer technology has become an integral part of health care, yet there have been few studies exploring the use of multimedia technology in the prevention of cancer, especially targeting children.

OBJECTIVE

The aims of this study were to develop and evaluate a new multimedia computer program for the primary prevention of skin cancer among a childhood population.

DESIGN AND PARTICIPANTS

An interactive CD-ROM program was developed, then pilot tested in a public elementary school in rural North Carolina. This intervention trial involved 8 third- and fourth-grade classes (N = 209 students), randomized into 3 groups: computer intervention, standard teacher-led intervention, and controls.

MAIN OUTCOME MEASURES

Students were tested using pre- and postintervention surveys that measured knowledge, attitudes, and self-reported behaviors. A 7-month follow-up survey was performed.

RESULTS

There was a significant increase in postintervention knowledge for the computer group when compared to either the teacher-led or control groups (mean scores out of 100: 75.2, 59.5, 55.0, respectively; p < 0.001). Attitudes about suntanning demonstrated a significant difference between the 3 groups (mean scores out of 100: 64.0, 53.0, 48.6, respectively; p = 0.002). There were slight improvements in the behavioral scores, especially among the computer group, but the overall differences were not significant. Similar overall results were found for the long-term follow-up survey, except that attitudes about suntanning no longer demonstrated a significant difference.

CONCLUSION

These results indicate that this new educational tool is an effective way to introduce health education programs for young children in typical classroom settings. This prototype may serve as a model for the development of future preventive school-based programs, including applications to other conditions associated with high-risk behaviors among children.

Effects of educational materials concerning osteoporosis on women's knowledge, beliefs, and behavior

PURPOSE

This study examined the effects of brief written educational materials on osteoporosis-related knowledge, beliefs, and behaviors. The study also examined whether observed effects varied as a function of one's stage in the precaution adoption process.

DESIGN

The study used an experimental research design.

SETTING

Participants were identified from North Carolina driver's license records.

SUBJECTS

Of the 1476 women in the initial sample, 536 (36.3%) enrolled in the study and 307 completed all follow-up assessments.

INTERVENTION

Participants were randomly assigned to one of four groups. One group received an information packet containing general information about osteoporosis. One group received an action plan packet containing instructions on how to increase one's level of exercise and calcium intake. One group received both packets. The final group received neither packet.

MEASURES

Primary study variables were beliefs related to osteoporosis, calcium, and exercise; osteoporosis knowledge; calcium and exercise stage; calcium intake; and exercise level.

RESULTS

Overall, receipt of the information packet was associated with changes in knowledge and beliefs (F[18,283] = 2.11, p < .01) irrespective of participants' stage of change. No effects on behavior were observed.

CONCLUSIONS

These findings suggest that brief written educational materials can facilitate knowledge and belief change but that they do not promote behavior change. The generalizability of these findings is limited by the low study response rate.

Locus of control for general health and STD acquisition among adolescent girls

PURPOSE

To examine adolescent girls' perception of control over general health and sexually transmitted disease (STD) acquisition.

METHODS

Adolescents participating in a longitudinal study were asked questions regarding their perception of their locus of control. These questions, adopted from a previous measure, focused on six loci: internal control, control by parents, partners, peers, and health care providers, and chance.

RESULTS

There were 128 girls (mean age, 17 years; range, 14.5 to 18.8); 82% were black and 18% white. Statistically significant associations were found between control of general health and STD acquisition for each locus of control subscale, with the exception of partner control. However, the girls reported significantly less control over STD acquisition than over general health for health care providers, parents, and by chance, and significantly more partner and internal control over STD acquisition than general health. The correlations between parental control over general health and over STD acquisition were inversely correlated with age. Partner control was positively related to current condom use, but internal control was not.

CONCLUSIONS

The degree of the locus of control was specific for STD acquisition. Girls who believe they should be able to control STD acquisition may not be using condoms. The view of partners as having control over STD acquisition may represent joint communication or coercion. However, in general these findings support the development of female-controlled methods for STD prevention, such as topical microbicides.

Innovative newsletter interventions improve fruit and vegetable consumption in healthy adults

OBJECTIVE

To evaluate the effectiveness of computer-tailored newsletter interventions in improving the number and variety of fruits and vegetables eaten by adults.

DESIGN

The 4-group randomized trial with pre- and postintervention measures consisted of a control group and 3 intervention groups receiving nontailored newsletters, computer-tailored newsletters, or tailored newsletters with tailored goal-setting information. Intervention groups received 1 newsletter each month for 4 months.

SUBJECTS

Baseline surveys were completed by 710 health maintenance organization clients. Postintervention surveys administered 6 months after baseline were completed by 573 participants (80.8%).

INTERVENTION

All newsletters contained strategies for improving fruit and vegetable consumption. Tailored newsletters used computer algorithms to match a person's baseline survey information with the most relevant newsletter messages for promoting dietary change.

MAIN OUTCOME MEASURES

Daily intake and weekly variety of fruits and vegetables were measured using a food frequency questionnaire.

STATISTICAL ANALYSES PERFORMED

Analysis of covariance and Tukey's honestly significant difference test were used to assess differences in the number and variety of fruits and vegetables consumed among intervention groups.

RESULTS

For persons completing postintervention surveys (n = 573), all 3 newsletter groups had significantly higher daily intake and variety scores compared with the control group. Although there was a trend of improved intake and variety with each added newsletter element, there were no significant differences at follow-up among the newsletter groups.

CONCLUSIONS

Newsletters can be effective in improving the fruit and vegetable consumption of adults. In this study, a computer-tailoring system did not significantly enhance the effect of the nutrition newsletters on fruit and vegetable intake.

Using a short food frequency questionnaire to estimate dietary calcium consumption: a tool for patient education

OBJECTIVE

To develop a short food frequency questionnaire (FFQ) assessing calcium intake and a prediction equation for estimating total calcium intake from the short FFQ.

METHODS

Data were collected from 536 women via mailed questionnaires at 3 time points. Stepwise regression analyses were used to identify those foods and beverages included in the Black Health Habits and History Questionnaire (HHHQ) that explained the most variance in participants' dietary calcium intake. A prediction equation was developed to estimate total calcium intake based only on information from the foods/beverages identified.

RESULTS

Calcium obtained from 15 foods/beverages explained 97.2% of the variance in total calcium intake. The mean absolute difference between total calcium intake estimated from the 15 foods/beverages and the full HHHQ was less than 50 mg at each time point.

CONCLUSION

Findings suggest that a short FFQ can provide estimates of total dietary calcium consumption comparable to the full Block HHHQ.

Health salience: reclaiming a concept from the lost and found

This paper describes development of a new measure to assess one dimension of health motivation, the salience of health concerns. The new, five-item, measure was administered to 578 women as part of a larger investigation examining the determinants of exercise and calcium consumption. The study used a cross-sectional survey research design. Data were analyzed separately for premenopausal and menopausal women, allowing us to cross-validate our findings in two independent samples. Our findings suggest that the new measure has many desirable psychometric properties. It is internally consistent (Cronbach's alpha = 0.85 and 0.86 for premenopausal and menopausal women, respectively). For both samples, factor analysis revealed that over 60% of the total item variance was explained by a single underlying factor. All factor loadings exceeded 0.74. The measure also correlated in predictable ways with measures of other health beliefs, differentiated among women in different stages of change with respect to exercise and calcium consumption, and discriminated between women on the basis of their information-seeking behavior. We discuss the potential applications of this new measure in future research. Hopefully, the measure will facilitate research on the role that health salience plays in the behavior change process.

Correlates of changes in mood following a mood induction in osteoarthritis patients

OBJECTIVE

To determine the relationship of mood management skills, and affective and cognitive states to changes in moods following mood induction among people with osteoarthritis.

METHODS

After completing questionnaires, participants underwent a negative mood induction. Momentary moods were assessed prior to, immediately following, and several minutes after the mood induction.

RESULTS

A specific mood management skill, mood clarity, consistently predicted changes in positive mood following the mood induction: people who scored high on mood clarity experienced less diminution in positive affect. In contrast, changes in negative affect were unrelated to mood management skills. However, people who scored higher on measures of depressive symptoms and pessimism rebounded from the negative induced mood less strongly than others.

CONCLUSION

Positive and negative emotional states operate largely independently and are differentially influenced by mood clarity, depressive symptoms, and pessimism. High levels of mood clarity may be adaptive in illnesses such as osteoarthritis because negative affective experiences that may be unavoidable need not preclude positive affective states.

The health insurance puzzle: a new approach to assessing patient coverage preferences

Previous studies of preferences for health insurance benefits have required individuals to make a series of complex and repetitive decisions, and have assumed that all insured benefits are desirable. This study reports the development and testing of a simple, innovative instrument to measure preferences for health insurance benefits. The newly developed instrument (Puzzle) is designed to allow subjects to select health benefits in a way that underscores the trade-offs dictated by budgets and costs. A "puzzle-like" frame representing budget constraints and "puzzle piece" benefit cards proportionately sized to represent the premium price of a single year's coverage comprise the instrument. In a comparison procedure (Money Game), participants "purchase" individual benefits by exchanging "play" money for benefit tokens. The Puzzle's utility was assessed by examining the convergence of results from both instruments and the subject's ratings of and preference for the instruments. One hundred five elderly Medicare enrollees seen in the general Internal Medicine outpatient clinic of a major southeastern teaching hospital were interviewed. Subjects answered interviewer-administered questionnaires and completed both the Puzzle and the Money Game. Both McNemar's test and Kendall's tau-b indicated a high degree of concordance between benefit choices made using the two instruments. Descriptive statistics demonstrated that the Puzzle was clear, easy to use, understandable, and preferred to the Money Game. The results suggest that the Puzzle is a promising tool for assessing health insurance coverage preferences under circumstances of limited expenditures, which can be modified for use with various populations who face limited insurance benefits.

Effect of satisfaction with one's abilities on positive and negative affect among individuals with recently diagnosed rheumatoid arthritis

OBJECTIVE

The purpose of this study was to examine the effect that self-evaluation processes have on psychologic well-being among individuals with rheumatoid arthritis (RA).

METHODS

The study used a longitudinal research design with 4 data collection points. Participants were 227 adults with recently diagnosed RA. Data were collected via mailed questionnaire and telephone interview. Two dimensions of psychologic well-being were assessed--positive affect and negative affect.

RESULTS

We found that, among participants who viewed the abilities being evaluated as very important, greater satisfaction at time 1 was associated with less negative affect at time 2 and time 4. Satisfaction was not associated with positive affect at any of the time points, however.

CONCLUSION

Study findings indicate that dissatisfaction with illness-related abilities can exacerbate psychologic distress. The findings also highlight the need for research examining the role that positive affect plays in adaptation to RA.

Reproductive decisions of women at risk for acquiring HIV infection

Approximately 1 to 1.5 million people in the United States are infected with HIV. The incidence of HIV is increasing among women and children. Little information exists regarding the determinants of reproductive decisions of women at risk of HIV infection. This study investigated the correlates of reproductive decisions using data from the National AIDS Demonstration and Research Projects funded by the National Institutes on Drug Abuse. Subjects for this study were 1,921 women. HIV serostatus, AIDS knowledge, and perceived risk for getting AIDS were not associated with the reproductive decisions. Major correlates of reproductive decisions were age, ethnicity, and the number of children living with the women. Pregnancy, 6 months after the baseline interview, was associated with intention to become pregnant at baseline. In addition age and education level were significant predictors of self-reported pregnancy at follow-up.

Older Medicare enrolees' choices for insured services

OBJECTIVES

The Medicare Trust Fund is expected to be bankrupt in the next decade, thus threatening the viability of the Medicare Program. We have ascertained what Medicare enrollees' priorities for insured services would be, and why, if it were fiscally necessary to limit Medicare benefits to maintain the viability of the Program.

DESIGN

A cross-sectional survey using anonymous, inperson interviews and an innovative instrument to elicit choices.

SETTING

General Internal Medicine outpatient clinic at a university teaching hospital.

PARTICIPANTS

One hundred five adults, 65 years of age and older, who had primary care physician visits between July and September 1995.

MEASUREMENTS

Desire to personally select insurance benefits, insurance benefit choices, and the reasons for selection or rejection of benefits.

RESULTS

Subjects of various educational and economic backgrounds were able to carry out the selection process with relative case, and four-fifths of respondents preferred to make their own choices about insured services. The most frequently selected services were hospitalization, outpatient care, prescription drugs, eye care, and home care, in descending order. Subjects selected 52 different combinations of services. Only 2% of respondents picked the current Medicare service package. The reasons given for selection varied by service; cost and current or anticipated need for a service were the most frequently cited forces driving the choices made.

CONCLUSION

These data suggest that Medicare enrollees prefer some element of choice about their health insurance coverage. Their choices vary widely and differ from the current Medicare package.

Do people with rheumatoid arthritis develop illness-related schemas?

OBJECTIVE

To assess, using both qualitative/inductive and quantitative data, whether people with rheumatoid arthritis (RA) have schemas related to arthritis.

METHODS

Themes identified from interview and focus group transcripts were used to develop 1) questionnaire items, and 2) statements participants were asked to recall during home interviews. Two hundred one people with RA completed questionnaires and recall tasks of the type used in cognitive research, followed 10 days later by another recall assessment by telephone.

RESULTS

Qualitative methods, item-level questionnaire data, and category-level recall data yielded convergent results supporting 4 final categories: mastery, support, loss of independence, and depression. Regression analyses indicated that category of earlier recollections predicted subsequent recollections assessed via phone.

CONCLUSIONS

Results from widely different methods offer at least partial support for arthritis schemas and suggest that the concepts identified are meaningful to patients as well as to researchers.

Physician attitudes regarding telephone medicine

OBJECTIVE

To measure physicians' attitudes regarding telephone medicine and identify determinants of these attitudes.

DESIGN

Cross-sectional survey.

SETTING

Ten internal medicine residency programs in the United States.

PARTICIPANTS

Graduates from 1988 through 1992. The response rate was 62% (n = 356).

MEASUREMENTS AND MAIN RESULTS

Survey items were assigned to one of four types of variables: demographic, attitude, training, or system variables. We used factor analysis to consolidate information from the individual questions about attitudes. Six scales describing attitudes toward telephone medicine were identified. Cronbach's alpha was greater than 0.70 for all scales. One scale measured physicians' satisfaction and confidence with the management of patient calls. Other attitude scales measured the helpfulness of personal experience or informal education and the importance of formal training in telephone medicine. Three of the scales measured how comfortable the physician felt prescribing over the telephone. We used regression analysis to predict physician attitudes towards telephone medicine using the demographic, training, and system variables. Availability of the patient's chart, feeling prepared for telephone medicine by one's residency training, and being comfortable prescribing narcotics by telephone predicted satisfaction and confidence with the management of patient calls (R2 = .25).

CONCLUSIONS

Several physician attitudes regarding telephone medicine can be measured reliably. Our findings suggest that improving systems for managing patient calls and improving telephone training for physicians will improve physician satisfaction and confidence with the practice of telephone medicine.

The reliability of high-risk adolescent girls' report of their sexual history

The purposes of this study were to determine the consistency in sexually active adolescent girls' self-report of sexual history and to examine their perceptions of providing sexual history information in an interview. Twenty-two adolescent girls (86% black and 14% white) were recruited from an outpatient dysplasia clinic to be interviewed 2 weeks apart. The interview consisted of questions regarding sexual history and whether they viewed their age at first intercourse as too young, too old, or appropriate. After the second interview they were asked whether there were any questions for which they thought other teenagers would be tempted not to tell the truth and any questions that were too embarrassing. Significant correlations between visits were seen for each sexual history variable. Girls described number of sexual partners and sexually transmitted disease history as questions to which adolescents might not be truthful. As part of sexual history taking, health care providers should explore with adolescent girls their perceptions of their history and address any concerns the girls have that might lead to inaccuracies or prevent the girls from obtaining appropriate anticipatory guidance.

Osteoporosis prevention in premenopausal women: using a stage model approach to examine the predictors of behavior

The precaution adoption process model was used to examine the predictors of 2 behaviors recommended to reduce the risk of developing osteoporosis: calcium consumption and weight-bearing exercise. A total of 452 premenopausal women completed a mailed questionnaire assessing stage in the precaution adoption process and 12 knowledge and attitudinal variables. Participants were also given an opportunity to request information about osteoporosis. In all, 11 of the 12 knowledge and attitudinal variables were associated with calcium stage; 8 were associated with exercise stage. Information requests were associated with both calcium and exercise stage. Findings provide substantial support for the precaution adoption process model and suggest that the model can be usefully applied in this area to increase understanding of why many women do not practice behaviors that could reduce their risk of developing osteoporosis.

Osteoporosis prevention in premenopausal women: using a stage model approach to examine the predictors of behavior

The precaution adoption process model was used to examine the predictors of 2 behaviors recommended to reduce the risk of developing osteoporosis: calcium consumption and weight-bearing exercise. A total of 452 premenopausal women completed a mailed questionnaire assessing stage in the precaution adoption process and 12 knowledge and attitudinal variables. Participants were also given an opportunity to request information about osteoporosis. In all, 11 of the 12 knowledge and attitudinal variables were associated with calcium stage; 8 were associated with exercise stage. Information requests were associated with both calcium and exercise stage. Findings provide substantial support for the precaution adoption process model and suggest that the model can be usefully applied in this area to increase understanding of why many women do not practice behaviors that could reduce their risk of developing osteoporosis.

Arthritis and perceptions of quality of life: an examination of positive and negative affect in rheumatoid arthritis patients

The utility of measuring both positive and negative affective states for assessing rheumatoid arthritis (RA) patients was examined in 3 independent samples of male and female RA patients (Sample A: 179 women, 48 men; Sample B: 177 women, 24 men; Sample C: 134 women, 38 men). Confirmatory factor analyses of each sample indicated that positive and negative affect constituted separate, negatively correlated factors. The relations among disease variables, coping, and affects were consistent with a model in which coping mediates the relationship between disease variables and positive and negative affect. Patients with higher pain and limitation from RA had higher levels of maladaptive coping, and maladaptive coping was associated with lower positive affect and higher negative affect. Those RAs with higher activity limitation also reported less adaptive coping, which was associated with less positive affect.

Arthritis and perceptions of quality of life: an examination of positive and negative affect in rheumatoid arthritis patients

The utility of measuring both positive and negative affective states for assessing rheumatoid arthritis (RA) patients was examined in 3 independent samples of male and female RA patients (Sample A: 179 women, 48 men; Sample B: 177 women, 24 men; Sample C: 134 women, 38 men). Confirmatory factor analyses of each sample indicated that positive and negative affect constituted separate, negatively correlated factors. The relations among disease variables, coping, and affects were consistent with a model in which coping mediates the relationship between disease variables and positive and negative affect. Patients with higher pain and limitation from RA had higher levels of maladaptive coping, and maladaptive coping was associated with lower positive affect and higher negative affect. Those RAs with higher activity limitation also reported less adaptive coping, which was associated with less positive affect.

Psychological distress among survivors of burn injury: the role of outcome expectations and perceptions of importance

This study examined factors associated with psychologic distress among survivors of burn injury. The study tested hypotheses derived from Scheier and Carver's model of behavioral self-regulation and focused on two primary predictor variables: expectations concerning rehabilitative outcomes and the importance attached to those outcomes. The study used a cross-sectional research design. Two hundred sixteen people who had sustained major or moderate thermal burn injuries within 2 years of study entry served as subjects. Data were collected via mailed questionnaire and chart review. Consistent with study hypotheses, we found that participants who had low expectations for further improvement but who attached high importance to the need for improvement exhibited the most psychologic distress. Study findings lend support to Scheier and Carver's model and suggest that application of this model within the context of burn rehabilitation may increase our understanding of the rehabilitation process. Directions for future theory-based research are discussed.

Improving dietary behavior: the effectiveness of tailored messages in primary care settings

OBJECTIVES

To achieve the Healthy People 2000 objectives, public health professionals must develop effective dietary interventions that address psychosocial and behavioral components of change. This study tested the effect of individually computer-tailored messages designed to decrease fat intake and increase fruit and vegetable intake.

METHODS

Adult patients from four North Carolina family practices were surveyed at baseline and then randomly assigned to one of two interventions or to a control group. The first intervention consisted of individually computer-tailored nutrition messages; the second consisted of nontailored nutrition information based on the 1990 Dietary Guidelines for Americans. Patients were resurveyed 4 months postintervention.

RESULTS

The tailored intervention produced significant decreases in total fat and saturated fat scores compared with those of the control group (P < .05). Total fat was decreased in the tailored group by 23%, in the nontailored group by 9%, and in the control group by 3%. Fruit and vegetable consumption did not increase in any study group. Seventy-three percent of the tailored intervention group recalled receiving a message, compared with 33% of the nontailored intervention group.

CONCLUSIONS

Tailored nutrition messages are effective in promoting dietary fat reduction for disease prevention.

Measuring health status among survivors of burn injury: revisions of the Burn Specific Health Scale

This study examined the reliability of a revised version of the Burn Specific Health Scale (BSHS). Two hundred fifty-four former patients recruited from eight burn centers in the southeastern United States participated in the study. Data were collected via chart review and mailed questionnaire. Factor analyses were used to identify seven subscales containing a total of 31 items. Subsequent analyses provided strong support for the reliability and validity of the revised measure. Each subscale exhibited a high level of reliability (Cronbach's alpha ranged from 0.82 to 0.94). Each subscale also correlated in a predictable manner with measures used for validation. The revised measure should improve the ability of both researchers and clinicians to assess the impact of non-fatal burn injury accurately and comprehensively.

Appraisal of and coping with arthritis-related problems in household activities, leisure activities, and pain management

PURPOSE

We examined whether or not there are systematic differences in how people appraise different types of illness-related problems and in how they cope with these problems.

METHODS

Two hundred thirty-five adults with recently diagnosed rheumatoid arthritis completed a mailed questionnaire followed by a telephone interview. A series of stress appraisal and coping variables were assessed in relation to three areas: household activities, leisure activities, and pain management.

RESULTS

Pain differed significantly from household and leisure activities with regard to several appraisal and coping variables. Participants reported the least control over problems with pain, while attaching the most importance to pain control. Leisure activities also stood out as unique on several variables. Participants perceived greater ability and were more satisfied with their ability in relation to leisure activities.

CONCLUSION

These findings show that, at least early in the disease, appraisal and coping strategies differ across the areas of household activities, leisure activities, and pain management.

Development and validation of the Parent Health Locus of Control scales

We describe the development and validation of the Parent Health Locus of Control (PHLOC) scales. Using factor analytic and item analytic methods, 30 items comprising six scales were extracted from a pool of 84 items. The individual scales correspond to beliefs in Child, Divine, Fate, Media, Parental, and Professional Influence over child health. Results were compared for six samples totalling 822 parents. Internal consistency reliabilities were above .70 for all scales with all samples. Test-retest correlations based on a separate sample were all above .60. Validity was assessed by means of a known groups strategy that made use of presumed differences among the six samples studied. The results generally agreed with predicted differences, offering good initial evidence of the validity for the PHLOC scales.

Psychological and educational interventions to reduce arthritis disability

The extent of disability attributable to arthritis is briefly summarized and the World Health Organization's (WHO) classification scheme for progression from pathology to disability described. The types of outcomes that have been examined in evaluations of psychological and educational interventions aimed at preventing arthritis disability are described and classified according to the WHO scheme where appropriate. Next, the most common components included in psychological and educational interventions for arthritis are reviewed. These are (1) providing general information, (2) teaching illness self-management skills, (3) training in biofeedback, (4) applying cognitive-behavioural techniques, (5) using other psychotherapeutic techniques, and (6) enhancing social support. This is followed by a discussion of issues pertinent to assessing the efficacy of various intervention components, citing specific examples of intervention research. Finally, the conclusion that certain types of psychological interventions appear to be effective in mitigating arthritis disability is drawn and the contribution of social science theory to intervention efficacy acknowledged.

A brief measure of helplessness in rheumatic disease: the helplessness subscale of the Rheumatology Attitudes Index

A short 5-item unifactorial form of the Rheumatology Attitudes Index was demonstrated to constitute an acceptable scale of helplessness for research or for clinical screening purposes. These items are the exact counterparts of the Arthritis Helplessness Index items that were identified as constituting a helplessness factor. These brief measures appear to be superior to their longer counterparts because they are conceptually less ambiguous and more convenient.

Physician-based diet counseling for cholesterol reduction: current practices, determinants, and strategies for improvement

BACKGROUND

Physicians face increasing pressure to counsel their hypercholesterolemic patients about diet. To design effective physician-based treatment programs, a better understanding of current dietary counseling practice and its determinants is needed.

METHODS

Using a survey previously tested for reliability and validity, we examined the relationship of dietary knowledge, attitudes, beliefs, organizational barriers, and treatment practices for cholesterol management among 60 resident and attending physicians practicing in the general medicine clinic of a university medical center that serves primarily rural and disadvantaged patients. The survey was administered in October of 1988 prior to the release of the National Cholesterol Education Program Guidelines.

RESULTS

The response rate was 100%. Ninety-two percent of physicians surveyed believe that dietary treatment effectively lowers cholesterol and 68% feel responsible for providing such therapy. However, most (72%) feel ill-prepared to give diet counseling, lack confidence in their ability to help patients make meaningful dietary changes (95%), and cite organizational barriers, such as limited time (72%) or inadequate educational materials (47%). Physicians were more likely to report behaviorally focused diet counseling practices if they felt prepared to counsel (r = 0.42, P < 0.001), were confident in their counseling skills (r = 0.39, P < 0.01), or reported personally following a prudent diet (r = 0.36, P < 0.01). We discuss the implications of these findings and how they should guide the design of physician-based dietary interventions for cholesterol reduction.

Psychological well-being among people with recently diagnosed rheumatoid arthritis. Do self-perceptions of abilities make a difference?

OBJECTIVE

Satisfaction with abilities and perceived importance of abilities are 2 factors involved in the process of self-evaluation. We examined the role that these factors play in adjustment to rheumatoid arthritis (RA).

METHODS

Data were collected, via telephone interview and mailed questionnaire, from 234 individuals with recently diagnosed RA. Disease severity information was obtained from participants' physicians.

RESULTS

Consistent with study hypotheses, satisfaction was associated with psychological well-being only among those who viewed as very important the abilities being evaluated.

CONCLUSION

These findings increase understanding of the conditions under which low levels of satisfaction are likely to be associated with psychological distress.

A brief dietary assessment to guide cholesterol reduction in low-income individuals: design and validation

Low-income Americans are at greatest risk for coronary heart disease. Dietary assessment methods are needed that can efficiently and effectively guide diet counseling to reduce serum cholesterol in this population. The Dietary Risk Assessment is a brief food frequency questionnaire designed to guide an intervention program for cholesterol reduction. It can easily be administered and scored in 10 to 15 minutes by persons who are not trained in nutrition. The assessment is culturally specific for a low-income southern population, identifies positive as well as problematic dietary behaviors, is easily interpreted, and measures potential barriers to dietary change. The assessment was validated against 3 days of dietary recall data in a sample of 42 low-income individuals recruited from the waiting room of an ambulatory care clinic. A Keys score, which measures the serum-cholesterol-raising potential of the diet, was calculated for each patient from their recall data. The Keys and Dietary Risk Assessment scores were significantly correlated (r = .60, P less than .001). We conclude that the Dietary Risk Assessment can rank individuals by level of dietary atherogenic risk adequately to guide a dietary treatment program for low-income patients, an underserved population with a high prevalence of diet-induced elevations in serum cholesterol.

Physicians' reactions to uncertainty in patient care. A new measure and new insights

Although variations in physicians' practice patterns and use of resources are well documented, the reasons for these variations are less well understood. The uncertainty inherent in patient care may be one explanation. Existing measures of intolerance to uncertainty, developed in contexts outside of patient care, fail to explain these variations. To address this limitation, the Physicians' Reactions to Uncertainty scale was developed. A questionnaire containing an initial pool of 61 items was mailed to a random sample of 700 physicians in North Carolina and Oregon, stratified by specialty. The items covered nine areas of physicians' reactions to uncertainty derived from interviews with physicians and a definition of the concept affective reactions to uncertainity in patient care. Factor analysis of the 428 responses received yielded two primary factors that accounted for 58% of the common variance among the 61 items. Items with unambiguous loadings on these factors defined two reliable and readily interpretable subscales: Stress from Uncertainty (Cronbach's alpha = 0.90, 13 items) and Reluctance to Disclose Uncertainty to Others (alpha = 0.75, 9 items). By virtue of its clarity and good psychometric properties, this new measure promises insights into the role that uncertainty plays in physicians' resource utilization and practice patterns.

Validity of the Center for Epidemiological Studies Depression Scale in arthritis populations

Using data from 3 studies of patients with rheumatoid arthritis, we examined the extent to which responses to items in the Center for Epidemiological Studies Depression Scale (CES-D) are influenced by aspects of the disease process other than depression. Our findings suggested that 4 CES-D items (i.e., "I felt that everything I did was an effort," "I felt hopeful about the future," "My sleep was restless," and "I could not get going") may be influenced by aspects of the disease process and, thus, are not necessarily indicative of depression among persons with arthritis. The impact that these items have on the interpretation of CES-D scores was assessed in relation to 2 research issues: estimation of the prevalence and severity of depression in arthritis populations and identification of the determinants of depression among individuals with arthritis. Our results suggest that the original CES-D may overestimate the prevalence and severity of depression among patients with arthritis. The magnitude of this bias is modest, however. The results also suggest that in studies designed to identify the determinants of depression among individuals with arthritis, inclusion of the 4 items identified is unlikely to have any effect on study findings.

Effects of modeling on patient communication, satisfaction, and knowledge

This experimental study investigated the efficacy of two modeling procedures on enhancing patient communication. A pretreatment interview assessed knowledge, assertiveness, and other concomitant variables. A total of 150 subjects were randomly assigned to one of three treatment conditions. The two modeling conditions were videotaped presentations of a health educator interacting with a patient (i.e., model) who either asked questions or revealed problems. The control videotape included only the educator's presentation; no patient was shown. A subsequent standardized face-to-face patient education session was used to assess the impact of the intervention on patient communicative behaviors. A posttreatment interview assessed knowledge and satisfaction. Subjects who viewed a modeling videotape spoke more than subjects who viewed a control videotape. The bulk of our findings indicated that a question-asking model was generally more effective than a disclosive model in eliciting communicative behaviors. Knowledge scores were found to increase after the intervention, regardless of subjects' verbal participation. Subjects in either of the modeling conditions who spoke more indicated higher affective satisfaction.

Continuing education for health professionals

Although continuing education in the health professions is an important endeavor, it has been largely neglected in the professional literature. Few studies have been done on (a) conceptual models to guide the design and implementation of continuing education and (b) the use of such models in continuing education. To fill this gap, two such models are described in this article: (a) instructional development and (b) community development. Combining and using these models can lead to more effective continuing education with more enduring effects. Principles to guide the implementation of these models are presented. An arthritis continuing education project based on the instructional and community development models is used to illustrate these principles. This continuing education project focused on occupational and physical therapists in clinical practice.

Development and validation of the Attitude Toward Arthritis Patients Scale (ATAPS)

The development and validation of a four-item scale, the ATAPS, measuring attitude toward working with arthritis patients is described. Three separate samples of occupational and physical therapists were surveyed. Data from the first random sample were used to select a reliable subset of items from a larger pool and to provide a baseline for comparison with the second sample. The second sample comprised arthritis workshop attendees and confirmed the scale's reliability and its ability to differentiate between therapists with an active interest in arthritis and a group with no special interest in the disorder. The third stratified random sample further confirmed the scale's reliability and demonstrated that the ATAPS scores were associated with the number of arthritis patients in therapists' practices but not with measures of professional experience unrelated to arthritis.

Effects of Information on Patient Stereotyping

The influence of information on nurse attitudes and behavior toward a member of a stereotyped group was investigated. Responsibility for the decision to be childless and the intelligence of the person making that decision were manipulated. Student nurses individually interacted with a hypothetical, childless, female patient, presented via audiotape, who was about to undergo surgery for sterilization. The patient was described (a) as seeking sterilization either voluntarily or because of medical necessity, and (b) as either retarded or not classified intellectually. It was hypothesized that the patient who freely chose childlessness would be viewed and treated less positively when thought to be of normal intelligence. When the patient was mildly retarded or seeking sterilization out of medical necessity, however, more positive attitudes and behavior were expected. Both of these hypotheses were supported. The results of this study support the importance of contextual variables on perceptions of patients.

Perception of contingency and mental retardation

It is argued that the general learning difficulties exhibited by mentally retarded persons are similar in many respects to the learning difficulties of nonretarded persons who are in a state of learned helplessness (Seligman, 1975) or who are external in locus of control orientation. It is suggested that studies of locus of control and learned helplessness as theoretical constructs both directly concern the perceiving of relationships between behavior and outcomes, and that a systematic investigation of perception of contingency might increase our understanding of some of the learning difficulties of mentally retarded persons. An overview is given of the results of the few studies that have addressed perception of contingency and mental retardation, and suggestions for future research are offered.