Cardiovascular disease risk factor intervention in low-income women: the North Carolina WISEWOMAN project.

OBJECTIVES: The North Carolina WISEWOMAN project was initiated to evaluate the feasibility of expanding an existing cancer screening program to include a cardiovascular disease (CVD) screening and intervention program among low-income women. METHODS: Seventeen North Carolina county health departments were designated as minimum intervention (MI), and 14 as enhanced intervention (EI). The EI included three specially constructed counseling sessions spanning 6 months using a structured assessment and intervention program tailored to lower income women. RESULTS: Of the 2,148 women screened, 40% had elevated total cholesterol (> or = 240 mg/dL), 39% had low high-density lipoprotein cholesterol (HDL-C) levels (< 45 mg/dL), and 63% were hypertensive (systolic blood pressure 140 and/or diastolic blood pressure > or = 90 mm Hg or on hypertensive medication). The majority of women (86%) had at least one of these three risk factors. Seventy-six percent were either overweight or obese. After 6 months of follow-up in the EI health departments, changes in total cholesterol levels, HDL-C levels, diastolic blood pressure, and BMI were observed (-5.8 mg/dL, -0.9 mg/dL, -1.7 mm Hg, and -0.3 kg/m(2), respectively), but were not significantly different from MI health departments. A dietary score that summarized fat and cholesterol intake improved by 2.1 units in the EI group, compared with essentially no change in the MI group. CONCLUSIONS: Expanding existing cancer screening programs to include CVD intervention was feasible and may be an effective means for promoting healthful dietary practices among low-income women.

Confidence of academic general internists and family physicians to teach ambulatory procedures.

OBJECTIVE: To evaluate and compare the readiness of academic general internal medicine physicians and academic family medicine physicians to perform and teach 13 common ambulatory procedures. DESIGN: Mailed survey. SETTING: Internal medicine and family medicine residency training programs associated with 35 medical schools in 9 eastern states. PARTICIPANTS: Convenience sample of full-time teaching faculty. MEASUREMENTS AND MAIN RESULTS: A total of 331 general internists and 271 family physicians returned completed questionnaires, with response rates of 57% and 65%, respectively. Academic generalists ranked most of the ambulatory procedures as important for primary care physicians to perform; however, they infrequently performed or taught many of the procedures. Overall, compared with family physicians, general internists performed and taught fewer procedures, received less training, and were less confident in their ability to teach these procedures. Physicians' confidence to teach a procedure was strongly associated with training to perform the procedure and performing or precepting a procedure at least 10 times per year. CONCLUSIONS: Many academic general internists do not perform or precept common adult ambulatory procedures. To ensure that residents have the opportunity to learn routine ambulatory procedures, training programs may need to recruit qualified faculty, train current faculty, or arrange for academic specialists or community physicians to teach these skills.

Confidence of graduating internal medicine residents to perform ambulatory procedures.

OBJECTIVE: To evaluate the training of graduating internal medicine residents to perform 13 common ambulatory procedures, 3 inpatient procedures, and 3 screening examinations. DESIGN: Self-administered descriptive survey. SETTING: Internal medicine training programs associated with 9 medical schools in the eastern United States. PARTICIPANTS: Graduating residents (N = 128); response rate, 60%. MEASUREMENTS AND MAIN RESULTS: The total number of procedures performed during residency, importance for primary care physicians to perform these procedures, confidence to perform these procedures, and helpfulness of rotations for learning procedures were assessed. The majority of residents performed only 2 of 13 outpatient procedures 10 or more times during residency: simple spirometry and minor wound suturing. For all other procedures, the median number performed was 5 or fewer. The percentage of residents attributing high importance to a procedure was significantly greater than the percentage reporting high confidence for 8 of 13 ambulatory procedures; for all inpatient procedures, residents reported significantly higher confidence than importance. Continuity clinic and block ambulatory rotations were not considered helpful for learning ambulatory procedures. CONCLUSIONS: Though residents in this sample considered most ambulatory procedures important for primary care physicians, they performed them infrequently, if at all, during residency and did not consider their continuity clinic experience helpful for learning these skills. Training programs need to address this deficiency by modifying the curriculum to ensure that these skills are taught to residents who anticipate a career in primary care medicine.

Influences on day-to-day self-management of type 2 diabetes among African-American women: spirituality, the multi-caregiver role, and other social context factors.

OBJECTIVE: Many African-American women are affected by diabetes and its complications, and culturally appropriate lifestyle interventions that lead to improvements in glycemic control are urgently needed. The aim of this qualitative study was to identify culturally relevant psychosocial issues and social context variables influencing lifestyle behaviors--specifically diet and physical activity--of southern African-American women with diabetes. RESEARCH DESIGN AND METHODS: We conducted 10 focus group interviews with 70 southern African-American women with type 2 diabetes. Group interviews were audiotaped and transcripts were coded using qualitative data analysis software. A panel of reviewers analyzed the coded responses for emerging themes and trends. RESULTS: The dominant and most consistent themes that emerged from these focus groups were 1) spirituality as an important factor in general health, disease adjustment, and coping; 2) general life stress and multi-caregiving responsibilities interfering with daily disease management; and 3) the impact of diabetes manifested in feelings of dietary deprivation, physical and emotional "tiredness," "worry," and fear of diabetes complications. CONCLUSIONS: Our findings suggest that influences on diabetes self-management behaviors of African-American women may be best understood from a sociocultural and family context. Interventions to improve self-management for this population should recognize the influences of spirituality, general life stress, multi-caregiving responsibilities, and the psychological impact of diabetes. These findings suggest that family-centered and church-based approaches to diabetes care interventions are appropriate.

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.

Patient preferences for care by general internists and specialists in the ambulatory setting.

OBJECTIVE: To investigate patients' preferences for care by general internists and specialists for common medical conditions. DESIGN: Telephone interview. SETTING: A convenience sample of general internal medicine practices at 10 eastern academic medical centers. PATIENT/PARTICIPANTS: A probability sample of 314 participants who had at least one visit with their primary care physician during the preceding 2 years. MEASUREMENTS AND MAIN RESULTS: Items addressed patients' attitudes concerning continuity of care, preferences for care by general internists or specialists for common medical problems, and perceptions about the competency of general internists and specialists to manage these problems. Continuity was important to participants, with 63% reporting they preferred having one doctor. Respondents were willing to wait 3 or 4 days to see their regular doctor (85%) and wanted their doctor to see them in the emergency department (77%) and monitor their care while in the hospital (94%). A majority (>60%) preferred care from their regular doctor for a variety of new conditions. Though respondents valued continuity, 84% felt it was important to be able to seek medical care from any type of physician without a referral, and 74% responded that if they needed to see a specialist, they were willing to pay out-of-pocket to do so. Although most participants (98%) thought their regular doctor was able to take care of usual medical problems, the majority thought that specialists were better able to care for allergies (79%) and better able to prescribe medications for depression (65%) and low-back pain (72%). CONCLUSIONS: Participants preferred to see their general internist despite their perceptions that specialists were more competent in caring for the conditions we examined. However, they wanted unrestricted access to specialists to supplement care provided by general internists.

A diabetes management program for African American women with type 2 diabetes.

PURPOSE: This paper describes a clinic- and community-based diabetes intervention program designed to improve dietary, physical activity, and self-care behaviors of older African American women with type 2 diabetes. It also describes the study to evaluate this program and baseline characteristics of participants. METHODS: The New Leaf ... Choices for Healthy Living With Diabetes program consists of 4 clinic-based health counselor visits, a community intervention with 12 monthly phone calls from peer counselors, and 3 group sessions. A randomized, controlled trial to evaluate the effectiveness of this intervention is described. RESULTS: Seventeen focus groups of African American women were used to assessed the cultural relevance/acceptability of the intervention and measurement instruments. For the randomized trial, 200 African American women with type 2 diabetes were recruited from 7 practices in central North Carolina. Mean age was 59, mean diabetes duration was 10 years, and participants were markedly overweight and physically inactive. CONCLUSIONS: Participants found this program to be culturally relevant and acceptable. Its effects on diet, physical activity, and self-care behaviors will be assessed in a randomized trial.

A cholesterol intervention program for public health nurses in the rural southeast: description of the intervention, study design, and baseline results.

Residents of the rural South are at high risk for heart disease and are frequently identified as having high blood cholesterol, but sources for nutrition counseling in rural areas are often limited. To increase the availability of high quality nutrition counseling, the Food for Heart Program was developed for public health nurses and is designed to circumvent many of the obstacles common to dietary counseling. We conducted a randomized trial to assess the effectiveness of this program to lower blood cholesterol. In this report, we describe the study design, intervention program, and baseline characteristics of participants. Nurses at 17 health departments screened 781 subjects to enroll 468 with high blood cholesterol: three-quarters of the subjects were female, the mean age was 55, and 80% were white. Participants were at high risk for heart disease: 60% had two or more risk factors for coronary disease, the majority were overweight with a mean BMI of 29, and the mean cholesterol was 257 mg/dL. Reported baseline dietary intake included relatively modest consumption of high fat meats and snack foods, excessive consumption of sweets, modest intake of complex carbohydrates, and inadequate consumption of fruits and vegetables.

Telephone medical care administered by internal medicine residents: concerns of program directors and implications for residency training.

The objective of this study was to determine the need for telephone medicine curricula and to help define important content for internal medicine residencies using scales that measure program director attitudes toward telephone medicine. Data were collected by surveying all 416 program directors of accredited internal medicine residencies in the United States. We applied factor analysis to develop reliable attitudinal scales and employed regression models to identify predictors of these attitudes. Response rate was 60%. Formal training for telephone medicine was available in only 6% of programs. The factor analysis showed three attitudinal concepts; all described marked program director discomfort with aspects of resident telephone prescription. Predictors of improved program director comfort included more frequent documentation of resident telephone calls, chart availability, and clear definition of resident roles pertaining to telephone interactions with patients (P < 0.02 for all predictor variables). These results identify a need for telephone curricula and suggest components that might alleviate program director discomfort with resident telephone practices.

Self-efficacy as a predictor of dietary change in a low-socioeconomic-status southern adult population.

There is an increasing emphasis on designing health promotion interventions for low-socioeconomic-status (SES) individuals. However, many previously developed behavior change tools have not been tested in this population. Self-efficacy was measured at pre- and postintervention as part of a randomized clinical trial to reduce cholesterol levels in rural low-SES Southern adults. A 22-item scale was designed and validated to measure subjects' confidence in their abilities to make dietary changes. High mean self-efficacy was noted in both control and intervention subjects at pre- and postintervention. Mean self-efficacy score was a significant predictor of dietary change at both preintervention and postintervention. This study demonstrates that self-efficacy is a predictor of ability to make dietary changes in a low-SES rural population. This finding is of significance to researchers and practitioners wishing to design theory-based health promotion interventions in this population.

Patients' use of health-teaching materials at three readability levels.

The extent to which patients use and learn from drug literature written at three different readability levels was examined. A two-way analysis of variance showed an interaction effect on knowledge score between the readability level of the leaflet and the amount of schooling subjects reported: persons with higher education learned most from the hardest pamphlet and persons with the least formal education learned the most from the easiest pamphlet. A similar interaction was found in testing the likelihood that patients had read the leaflet. The results suggest that persons with little formal education would benefit from teaching materials with a readability level considerably lower than even many "easy-to-read" health-teaching materials available today.

A randomized controlled trial of a physician-directed treatment program for low-income patients with high blood cholesterol: the Southeast Cholesterol Project.

OBJECTIVE: To assess the effectiveness of a cholesterol-lowering intervention designed to facilitate the management of hypercholesterolemia by primary care clinicians. DESIGN: Randomized controlled trial, with randomization of clinician-patient groups. SETTING: Twenty-one community and rural health centers in North Carolina and Virginia. PARTICIPANTS: Primary care clinicians (n = 42, 71% physicians) and the patients they enrolled with high cholesterol (n = 372). Twenty-two clinicians were randomized to give the special intervention (184 patients) and 20 to give usual care (188 patients). Two thirds of participating patients were women, 40% were African American, and 11% were Native American. INTERVENTION: A 90-minute tutorial to train clinicians how to use a structured assessment and treatment program (Food for Heart Program) consisting of a brief dietary assessment and three 5- to 10-minute dietary counseling sessions given by the primary care clinician, referral to a local dietitian if the low-density lipoprotein cholesterol (LDL-C) remained elevated at 4-month follow-up, and a prompt for the clinician to consider lipid-lowering medication based on the LDL-C at 7-month follow-up. MAIN OUTCOME MEASURES: Changes in total and LDL cholesterol at 4-month follow-up and averaged over a 1-year follow-up period (4-, 7-, and 12-month follow-up). RESULTS: At 4-month follow-up, total cholesterol decreased 0.33 mmol/L (12.6 mg/dL) in the intervention group and 0.21 mmol/L (8.3 mg/dL) in the control group: the difference was 0.11 mmol/L (4.2 mg/dL) (90% confidence interval [CI], -0.02 to 0.24 mmol/L [-0.7 to 9.1 mg/dL]). The average reduction during the 1-year follow-up period was 0.09 mmol/L (3.6 mg/dL) greater in the intervention group (90% CI, -0.01 to 0.19 mmol/L [-0.3 to 7.5 mg/dL]). Eight percent of intervention patients were taking lipid-lowering medication at follow-up visits compared with 15% of control patients. In a subgroup analysis restricted to the 89% of returnees who were not taking lipid-lowering medication, the reduction in total cholesterol at 4-month follow-up was 0.14 mmol/L (5.5 mg/dL) greater in the intervention group (95% CI, 0.01 to 0.28 mmol/L [0.3 to 10.7 mg/dL]); averaged over 1 year, it was 0.14 mmol/L (5.3 mg/dL) greater (95% CI, 0.03 to 0.24 mmol/L [1.2 to 9.4 mg/dL]). Changes in LDL-C were similar. CONCLUSIONS: Total cholesterol and LDL-C decreased more in the intervention group than in the control group. Overall, the difference in lipid reduction between groups was modest and of borderline statistical significance; among participants who did not take lipid-lowering medication during follow-up, the difference in lipid reduction between groups was larger. We conclude that primary care clinicians can be trained to give a cholesterol-lowering intervention to low-income patients that results in modest, short-term reductions in total cholesterol and LDL-C.

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.

Research in the community: recruiting and retaining practices.

Medical investigators increasingly attempt to demonstrate the effectiveness of treatments given in routine practice settings as well as in research settings. We identified and describe several key issues in practice-based research: identifying the appropriate population; drawing the sample; recruitment of physicians and patients; maintenance of the physician-researcher relationship; and data management. Three on-going practice-based projects are described from the perspective of these key issues. Two are practice-based randomized trials, one is a larger cohort study. Common characteristics are identified which contributed to the success of the three projects: direct recruitment of clinicians by clinicians; close liaison with local medical organizations; on-going personal contact with the practices; and recognition of the value of the practicing physician's time.

Telephone management training in internal medicine residencies: a national survey of program directors.

BACKGROUND: Little is known about how internal medicine residents train for and practice telephone management. To address this deficiency, a national survey of program directors at accredited internal medicine training sites was conducted to evaluate residents' training for and practice of telephone medicine. METHOD: A 43-item questionnaire was mailed in December 1993 to all program directors at the 416 accredited internal medicine training sites in the United States. A limited questionnaire, regarding the most essential training questions, was mailed to all non-responders. RESULTS: The response rate was 60% (250) for the full questionnaire. Only 15 (6%) of the programs offered formal training in telephone management to their residents. This training usually consisted of single lectures (nine programs) or reading materials (seven programs). The respondents felt that formal training in telephone management was very important (155, 62%) and that such training should be a part of every internal medicine curriculum (150, 60%). CONCLUSION: Few internal medicine programs offered training in telephone management. When training occurred, it was usually limited and informal. Most program directors felt that training was important and that current training efforts were unsatisfactory, emphasizing the need for curriculum development and implementation in telephone management.

Putting medical practice guidelines into practice: the cholesterol model.

As more and more medical practice guidelines are developed in the United States, commensurate evaluation efforts should assess their impact on professional practice and patient outcomes. We describe an ongoing research program designed to develop and test practice models for applying the 1988 Adult Treatment Panel Guidelines for the clinical management of high blood cholesterol. Four studies are evaluating different models to assist nonacademic community practices in the detection, evaluation, and treatment of high blood cholesterol. We have designed randomized controlled trials set in solo and small-group primary care practices of family or general practitioners and internists situated in rural, suburban, and urban settings. Patients include adult men and women who represent diverse socioeconomic and ethnic backgrounds. We are measuring rates of cholesterol screening; dietary and drug treatment and follow-up; changes in dietary intake and compliance with drug therapy; changes in quality of life and cost of intervention; and reduction in cholesterol level. Scheduled for completion in 1994, this program will provide insights into practical and effective methods of lipid management. It serves as a model for studying the application of health guidelines in the context of nonacademic primary care practices serving diverse patient populations.

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.

Nutrition education for cardiovascular disease prevention among low income populations--description and pilot evaluation of a physician-based model.

Low income Americans are at greatest risk for coronary heart disease but have least access to health promotion programs for life style modification. Primary care physicians may represent one of the few sources of preventive care available to the poor. However, the majority of physicians feel unprepared to help patients achieve dietary change, and few existing nutrition intervention programs address the special needs of low literacy populations. The Food for Heart Program was developed to facilitate dietary counseling experienced by primary care physicians who care for low literacy patients and to overcome barriers to behavior change faced by patients. The program consists of three components: (1) a validated dietary risk assessment that rapidly identifies atherogenic eating habits and requires no nutritional expertise to administer or interpret, (2) a structured diet treatment program that is culturally specific for a southern patient population and links practical behavior change recommendations with results of the diet assessment, and (3) a system for monitoring and reinforcement that prompts physicians to review progress, reinforce prior messages, and reward positive change. Behavior change theory is used to guide the intervention and readability of the material has been assessed at the 5-6th grade level. An evaluation study of the Food for Heart Program suggests that it has a positive impact on physician counseling and that patients are responding favorably to these efforts.