Intermittent auscultation versus continuous fetal monitoring: exploring factors that influence birthing unit nurses' fetal surveillance practice using theoretical domains framework.

BACKGROUND: Intermittent Auscultation (IA) is the recommended method of fetal surveillance for healthy women in labour. However, the majority of women receive continuous electronic monitoring. We used the Theoretical Domains Framework (TDF) to explore the views of Birthing Unit nurses about using IA as their primary method of fetal surveillance for healthy women in labour. METHODS: Using a semi-structured interview guide, we interviewed a convenience sample of birthing unit nurses throughout Ontario, Canada to elicit their views about fetal surveillance. Interviews were recorded and transcribed verbatim. Transcripts were content analysed using the TDF and themes were framed as belief statements. Domains potentially key to changing fetal surveillance behaviour and informing intervention design were identified by noting the frequencies of beliefs, content, and their reported influence on the use of IA. RESULTS: We interviewed 12 birthing unit nurses. Seven of the 12 TDF domains were perceived to be key to changing birthing unit nurses' behaviour The nurses reported that competing tasks, time constraints and the necessity to multitask often limit their ability to perform IA (domains Beliefs about capabilities; Environmental context and resources). Some nurses noted the decision to use IA was something that they consciously thought about with every patient while others stated it their default decision as long as there were no risk factors (Memory, attention and decision processes, Nature of behaviour). They identified positive consequences (e.g. avoid unnecessary interventions, mother-centered care) and negative consequences of using IA (e.g. legal concerns) and reported that the negative consequences can often outweigh positive consequences (Beliefs about consequences). Some reported that hospital policies and varying support from care teams inhibited their use of IA (Social influences), and that support from the entire team and hospital management would likely increase their use (Social influences; Behavioural regulation). CONCLUSION: We identified potential influences on birthing unit nurses' use of IA as their primary method of fetal surveillance. These beliefs suggest potential targets for behaviour change interventions to promote IA use.

Risk Perception and Disaster Preparedness in Immigrants and Canadian-Born Adults: Analysis of a National Survey on Similarities and Differences.

Research has documented that immigrants tend to experience more negative consequences from natural disasters compared to native-born individuals, although research on how immigrants perceive and respond to natural disaster risks is sparse. We investigated how risk perception and disaster preparedness for natural disasters in immigrants compared to Canadian-born individuals as justifications for culturally-adapted risk communication and management. To this end, we analyzed the ratings on natural disaster risk perception beliefs and preparedness behaviors from a nationally representative survey (N = 1,089). Factor analyses revealed three underlying psychological dimensions of risk perception: external responsibility for disaster management, self-preparedness responsibility, and illusiveness of preparedness. Although immigrants and Canadian-born individuals shared the three-factor structure, there were differences in the salience of five risk perception beliefs. Despite these differences, immigrants and Canadian-born individuals were similar in the level of risk perception dimensions and disaster preparedness. Regression analyses revealed self-preparedness responsibility and external responsibility for disaster management positively predicted disaster preparedness whereas illusiveness of preparedness negatively predicted disaster preparedness in both groups. Our results showed that immigrants' risk perception and disaster preparedness were comparable to their Canadian-born counterparts. That is, immigrant status did not necessarily yield differences in risk perception and disaster preparedness. These social groups may benefit from a risk communication and management strategy that addresses these risk perception dimensions to increase disaster preparedness. Given the diversity of the immigrant population, the model remains to be tested by further population segmentation.

A theory-based process evaluation alongside a randomised controlled trial of printed educational messages to increase primary care physicians' prescription of thiazide diuretics for hypertension [ISRCTN72772651].

BACKGROUND: Pragmatic trials of implementation interventions focus on evaluating whether an intervention changes professional behaviour under real-world conditions rather than investigating the mechanism through which change occurs. Theory-based process evaluations conducted alongside pragmatic randomised trials address this by assessing whether the intervention changes theoretical constructs proposed to mediate change. The Ontario Printed Educational Materials (PEM) cluster trial was designed to increase family physicians' guideline-recommended prescription of thiazide diuretics. The trial found no intervention effect. Using the theory of planned behaviour (TPB), we hypothesised that changes in thiazide prescribing would be reflected in changes in intention, consistent with changes in attitude and subjective norm, with no change to their perceived behavioural control (PBC), and tested this alongside the RCT. METHODS: We developed and sent TPB postal questionnaires to a random sub-sample of family physicians in each trial arm 2 months before and 6 months after dissemination of the PEMs. We used analysis of covariance to test for group differences using a 2 × 3 factorial design. We content-analysed an open-ended question about perceived barriers to thiazide prescription. Using control group data, we tested whether baseline measures of TPB constructs predicted self-reported thiazide prescribing at follow-up. RESULTS: Four hundred twenty-six physicians completed pre- and post-intervention questionnaires. Baseline scores on measures of TPB constructs were high: intention mean = 5.9 out of 7 (SD = 1.4), attitude mean = 5.8 (SD = 1.1), subjective norm mean = 5.8 (SD = 1.1) and PBC mean = 6.2 (SD = 1.0). The arms did not significantly differ post-intervention on any of the theory-based constructs, suggesting a possible ceiling effect. Content analysis of perceived barriers suggested post-intentional barriers to prescribing thiazides most often focused on specific patient clinical characteristics and potential side effects. Baseline intention (ß = 0.63, p < 0.01) but not PBC (ß = 0.04, p = 0.78) predicted 42.6 % of the variance in self-reported behaviour at follow-up in the control group. CONCLUSIONS: Congruent with the Ontario Printed Educational Messages trial results and aligned with the TPB, we saw no impact of the intervention on any TPB constructs. The theoretical basis of this evaluation suggests possible explanations for the failure of the PEM intervention to change professional behaviour, which can directly inform the design and content of future theory-based PEM interventions to change professional behaviour. TRIAL REGISTRATION: ISRCTN, Canada ISRCTN72772651.

Attitudes to incorporating genomic risk assessments into population screening programs: the importance of purpose, context and deliberation.

BACKGROUND: The use of an overall risk assessment based on genomic information is consistent with precision medicine. Despite the enthusiasm, there is a need for public engagement on the appropriate use of such emerging technologies in order to frame meaningful evaluations of utility, including the practical implementation and acceptability issues that might emerge. Doing so requires the involvement of the end users of these services, including patients, and sections of the public who are the target group for population based screening. In the present study we sought to explore public attitudes to the potential integration of personal genomic profiling within existing population screening programs; and to explore the evolution of these attitudes as part of a deliberative process. METHODS: We conducted a mixed methods study presented in the format of a deliberative workshop. Participants were drawn from communities in Ottawa, Ontario (ON) and St John's, Newfoundland and Labrador (NL), Canada. Individuals were approached to take part in a workshop on the incorporation of genomic risk profiling for either colorectal cancer screening (CRC), or newborn screening for type 1 diabetes mellitus (T1DM). RESULTS: A total of N = 148 (N = 65 ON, N = 83 NL) participants provided data for analysis. Participants in both groups were supportive of public funding for genomic risk profiling, although participants in the T1DM groups expressed more guarded positive attitudes than participants in the CRC groups. These views were stable throughout the workshop (CRC, p = 0.15, T1DM, p =0.39). Participants were less positive about individual testing, with a significant decrease in support over the course of the workshop (CRC p = 0.02, T1DM, p = 0.003). Common concerns related to access to test results by third parties. CONCLUSIONS: The findings of this study suggest that members of the target populations for potential genomic profiling tests (designed for screening or risk prediction purposes) can engage in meaningful deliberation about their general acceptability and personal utility. Evaluations of whether a test would be personally useful may depend on the experience of the participants in personal health decision making, the purpose of the test, and the availability of interventions to reduce disease risk.

Managing children during a radiological or nuclear emergency--Canadian perspectives.

Children have a higher chance of being contaminated by radioactive materials during a radiological or nuclear (RN) emergency. They are more sensitive to radiation health effects and suffer more significant psychosocial impacts than adults during emergency response. This paper presents a summary of recommendations on effective management of children during an RN emergency. These recommendations intend to be additional considerations for existing RN response protocols and procedures implemented at local, state/provincial, or national level.

Looking inside the black box: results of a theory-based process evaluation exploring the results of a randomized controlled trial of printed educational messages to increase primary care physicians' diabetic retinopathy referrals [Trial registration number ISRCTN72772651].

BACKGROUND: Theory-based process evaluations conducted alongside randomized controlled trials provide the opportunity to investigate hypothesized mechanisms of action of interventions, helping to build a cumulative knowledge base and to inform the interpretation of individual trial outcomes. Our objective was to identify the underlying causal mechanisms in a cluster randomized trial of the effectiveness of printed educational materials (PEMs) to increase referral for diabetic retinopathy screening. We hypothesized that the PEMs would increase physicians' intention to refer patients for retinal screening by strengthening their attitude and subjective norm, but not their perceived behavioral control. METHODS: Design: A theory based process evaluation alongside the Ontario Printed Educational Material (OPEM) cluster randomized trial. Postal surveys based on the Theory of Planned Behavior were sent to a random sample of trial participants two months before and six months after they received the intervention. Setting: Family physicians in Ontario, Canada. Participants: 1,512 family physicians (252 per intervention group) from the OPEM trial were invited to participate, and 31.3% (473/1512) responded at time one and time two. The final sample comprised 437 family physicians fully completing questionnaires at both time points. Main Outcome Measures: Primary: behavioral intention related to referring patient for retinopathy screening; secondary: attitude, subjective norm, perceived behavioral control. RESULTS: At baseline, family physicians reported positive intention, attitude, subjective norm, and perceived behavioral control to advise patients about retinopathy screening suggesting limited opportunities for improvement in these constructs. There were no significant differences on intention, attitude, subjective norm, and perceived behavioral control following the intervention. Respondents also reported additional physician- and patient-related factors perceived to influence whether patients received retinopathy screening. CONCLUSIONS: Lack of change in the primary and secondary theory-based outcomes provides an explanation for the lack of observed effect of the main OPEM trial. High baseline levels of intention to advise patients to attend retinopathy screening suggest that post-intentional and other factors may explain gaps in care. Process evaluations based on behavioral theory can provide replicable and generalizable insights to aid interpretation of randomized controlled trials of complex interventions to change health professional behavior. TRIAL REGISTRATION: ISRCTN72772651.

The EnRiCH Community Resilience Framework for High-Risk Populations.

INTRODUCTION: Resilience has been described in many ways and is inherently complex. In essence, it refers to the capacity to face and do well when adversity is encountered. There is a need for empirical research on community level initiatives designed to enhance resilience for high-risk groups as part of an upstream approach to disaster management. In this study, we address this issue, presenting the EnRiCH Community Resilience Framework for High-Risk Populations. METHODS: The framework presented in this paper is empirically-based, using qualitative data from focus groups conducted as part of an asset-mapping intervention in five communities in Canada, and builds on extant literature in the fields of disaster and emergency management, health promotion, and community development. RESULTS: Adaptive capacity is placed at the centre of the framework as a focal point, surrounded by four strategic areas for intervention (awareness/communication, asset/resource management, upstream-oriented leadership, and connectedness/engagement). Three drivers of adaptive capacity (empowerment, innovation, and collaboration) cross-cut the strategic areas and represent levers for action which can influence systems, people and institutions through expansion of asset literacy. Each component of the framework is embedded within the complexity and culture of a community. DISCUSSION: We present recommendations for how this framework can be used to guide the design of future resilience-oriented initiatives with particular emphasis on inclusive engagement across a range of functional capabilities.

Presenteeism and absenteeism: differentiated understanding of related phenomena.

In the past it was assumed that work attendance equated to performance. It now appears that health-related loss of productivity can be traced equally to workers showing up at work as well as to workers choosing not to. Presenteeism in the workplace, showing up for work while sick, seems now more prevalent than absenteeism. These findings are forcing organizations to reconsider their approaches regarding regular work attendance. Given this, and echoing recommendations in the literature, this study seeks to identify the main behavioral correlates of presenteeism and absenteeism in the workplace. Comparative analysis of the data from a representative sample of executives from the Public Service of Canada enables us to draw a unique picture of presenteeism and absenteeism with regards not only to the impacts of health disorders but also to the demographic, organizational, and individual factors involved. Results provide a better understanding of the similarities and differences between these phenomena, and more specifically, of the differentiated influence of certain variables. These findings provide food for thought and may pave the way to the development of new organizational measures designed to manage absenteeism without creating presenteeism.

Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the Theoretical Domains Framework.

BACKGROUND: The Theoretical Domains Framework (TDF) was developed to investigate determinants of specific clinical behaviors and inform the design of interventions to change professional behavior. This framework was used to explore the beliefs of chiropractors in an American Provider Network and two Canadian provinces about their adherence to evidence-based recommendations for spine radiography for uncomplicated back pain. The primary objective of the study was to identify chiropractors' beliefs about managing uncomplicated back pain without x-rays and to explore barriers and facilitators to implementing evidence-based recommendations on lumbar spine x-rays. A secondary objective was to compare chiropractors in the United States and Canada on their beliefs regarding the use of spine x-rays. METHODS: Six focus groups exploring beliefs about managing back pain without x-rays were conducted with a purposive sample. The interview guide was based upon the TDF. Focus groups were digitally recorded, transcribed verbatim, and analyzed by two independent assessors using thematic content analysis based on the TDF. RESULTS: Five domains were identified as likely relevant. Key beliefs within these domains included the following: conflicting comments about the potential consequences of not ordering x-rays (risk of missing a pathology, avoiding adverse treatment effects, risks of litigation, determining the treatment plan, and using x-ray-driven techniques contrasted with perceived benefits of minimizing patient radiation exposure and reducing costs; beliefs about consequences); beliefs regarding professional autonomy, professional credibility, lack of standardization, and agreement with guidelines widely varied ( social/professional role & identity); the influence of formal training, colleagues, and patients also appeared to be important factors ( social influences); conflicting comments regarding levels of confidence and comfort in managing patients without x-rays ( belief about capabilities); and guideline awareness and agreements ( knowledge). CONCLUSIONS: Chiropractors' use of diagnostic imaging appears to be influenced by a number of factors. Five key domains may be important considering the presence of conflicting beliefs, evidence of strong beliefs likely to impact the behavior of interest, and high frequency of beliefs. The results will inform the development of a theory-based survey to help identify potential targets for behavioral-change strategies.

"We don't have a back-up plan": an exploration of family contingency planning for emergencies following stroke.

Little research has explored emergency preparedness among families coping with stroke. In this longitudinal qualitative study, we explored contingency caregiving planning by interviewing (N = 18) family caregivers providing care for a stroke survivor at home during the first 6 months post-discharge from the hospital. Emergent themes showed most families did not have a concrete "back-up plan" for a crisis or disaster situation involving the primary caregiver being unable to provide care. Furthermore, they assumed formal respite services or long-term care would be available should the need arise. Despite increased awareness over time, most caregivers had not devised contingency plans at 6 months.

Uncertainty beyond probabilities of BSE: appraisals predicting worry and coping strategies in the Canadian public.

The impact of bovine spongiform encephalopathy (BSE) is not limited to the infection with the BSE agent but also affects psychosocial responses, such as worry and loss of confidence in public authorities. It was shown in past crises that these reactions depended upon the way the event was perceived by the public. Understanding the nature of the perceptions of BSE is therefore of great importance for risk management in all phases of the risk, including the period before the onset of a crisis, when BSE is still only a pending threat to human health. This study analyzed data from a representative national survey of Canadians (n = 1,517) on the perceived risk of prion diseases. Factor analysis revealed emerging dimensions of BSE appraisals and regression analysis identified variables that predicted worry and coping strategies. Results yielded three significant factors, each relating differently to reactions to BSE: (1) Perceived impact, which combined perceived risk for health and likelihood of occurrence of BSE crises, was the main predictor of worry about eating tainted beef; (2) perceived mastery, consisting of personal knowledge and control, predicted taking action to avoid the disease; and (3) perceived intricacy, composed of perceived complexity and uncertainty, uniquely predicted trying to ignore BSE-related risks. Further regression analysis and analysis of variance exposed a moderating role of perceived intricacy on the relationship between perceived impact of BSE crises and worry. The implications of these findings for risk communication and management are described.

Psychosocial considerations for mass decontamination.

Mass exposure to explosions, infectious agents, foodborne illnesses, chemicals or radiological materials may require mass decontamination that have critical psychosocial implications for the public and for both traditional and non-traditional responders in terms of impact and of response. Five main issues are common to mass decontamination events: (i) perception, (ii) somatisation, (iii) media role and communication, (iv) information sharing, (v) behavioural guidance and (vi) organisational issues. Empirical evidence is drawn from a number of cases, including Chernobyl; Goiania, Brazil; the sarin gas attack in Tokyo; the anthrax attacks in the USA; Three Mile Island; and by features of the 2003 severe acute respiratory syndrome pandemic. In this paper, a common platform for mass casualty management is explored and suggestions for mass interventions are proposed across the complete event timeline, from pre-event threat and warning stages through to the impact and reconstruction phases. Implication for responders, healthcare and emergency infrastructure, public behaviour, screening processes, risk communication and media management are described.

Psychosocial considerations about children and radiological events.

Children are identified as a vulnerable population in the case of radiological events because of their increased physical sensitivity to radiation and its impact on critical development stages. Using a comprehensive integrated risk framework, psychosocial risk protective factors are discussed in a social ecology paradigm. Children have been shown to be both vulnerable and resilient; they are both easily impressionable and also quick to adapt and learn. Psychosocial interventions during, after and most efficiently before an event can improve outcome, especially if they involve parents and schools, media and work organisations. Public education through children should be encouraged to increase knowledge of radiation and strategies to minimise exposure and irradiation. Children can become vectors of prevention, preparedness and mitigation through information and behavioural rehearsal. Special consideration must therefore be given to education, school programmes, practice rehearsal and media exposure.

Psychological Stress Measure (PSM-9): integration of an evidence-based approach to assessment, monitoring, and evaluation of stress in physical therapy practice.

Stress can be a primary or secondary contributor to ill health via excessive and sustained sympathetic arousal leading to ischemic heart disease, hypertension, stroke, obesity, and mental ill health, or through related behaviors such as smoking, substance abuse, and over or inappropriate eating; or as a contextual variable in terms of risk factor and lifestyle outcome. In addition, psychosocial stress can impair recovery from any pathological insult or injury. Most assessments of stress relate to life events, and both past and current life stressors, acute and chronic, play a major role. However, beyond the impact of stressors, it is the reported state of feeling stressed that is the critical predictor of ill health. This article describes stress and its correlates, discusses models of stress, and presents the nine-item Psychological Stress Measure (PSM-9). This tool is aimed directly at the state of feeling stressed, is suited for assessing stress clinically in the general population and serving as an outcome measure. The tool is valid and reliable and easy to administer in health care settings; it has a normal distribution, which makes it a very sensitive-to-change instrument in repeated measures to document progress.

If schools are closed, who will watch our kids? Family caregiving and other sources of role conflict among nurses during large-scale outbreaks.

OBJECTIVES: The global impact of severe acute respiratory syndrome (SARS) brought attention to the role of healthcare professionals as "first receivers" during infectious disease outbreaks, a collateral aspect to their role as responders. This article records and reports concerns expressed by Canadian emergency and critical care nurses in terms of organizational and social supports required during infectious disease outbreaks. The nature of work-family and family-work conflict perceived and experienced by nurses during infectious disease outbreaks, as well as the supports needed to enable them to balance their social roles during this type of heightened stress, are explored. METHODS: Five focus groups consisting of 100 nurses were conducted using a Structured Interview Matrix facilitation technique. RESULTS: Four emergent themes included: (1) substantial personal/professional dilemmas; (2) assistance with child, elder, and/or pet care; (3) adequate resources and vaccinations to protect families; and (4) appropriate mechanisms to enable two-way communication between employees and their families under conditions of quarantine or long work hours. CONCLUSIONS: Social and organizational supports are critical to help buffer the effects of stress for nurses and assist them in managing difficult role conflicts during infectious disease outbreaks. These supports are necessary to improve response capacity for bio-disasters.

A social-cognitive perspective of terrorism risk perception and individual response in Canada.

The volume of research on terrorism has increased since the events of September 11, 2001. However, efforts to develop a contextualized model incorporating cognitive, social-contextual, and affective factors as predictors of individual responses to this threat have been limited. Therefore, the aim of this study was to evaluate a series of hypotheses drawn from such a model that was generated from a series of interviews with members of the Canadian public. Data of a national survey on perceived chemical, biological, radiological, nuclear, and explosives (CBRNE) terrorism threat and preparedness were analyzed. Results demonstrated that worry and behavioral responses to terrorism, such as individual preparedness, information seeking, and avoidance behaviors, were each a function of cognitive and social-contextual factors. As an affective response, worry about terrorism independently contributed to the prediction of behavioral responses above and beyond cognitive and social-contextual factors, and partially mediated the relationships of some of these factors with behavioral responses. Perceived coping efficacy emerged as the cognitive factor associated with the most favorable response to terrorism. Hence, findings highlight the importance of fostering a sense of coping efficacy to the effectiveness of strategies aimed at improving individual preparedness for terrorism.

Emergency preparedness for higher risk populations: psychosocial considerations.

This paper was meant to be on 'vulnerable populations', as some population sub-groups do require special care, special planning and special integration of needs. However, the issue should be reframed in terms of groups at higher risks. The text explains how (1) there are contextual vulnerabilities, in (a) higher susceptibility, i.e. higher exposure to risk, (b) higher sensitivity, i.e. higher damage or higher brittleness, and (c) weaknesses and gaps in the emergency system; (2) that these higher susceptibility, sensitivity and system weaknesses involve important psychosocial considerations, which may stem from socio-demographic status or ripple effects in the community; and finally, (3) that addressing those 'soft spots' using the phrase 'vulnerable populations' can be misleading and disserving because it disempowers, stigmatises and deters one from a more thorough analysis.

Income and psychological distress: the role of the social environment.

BACKGROUND: This article examines the relationship between lower income and the risk of experiencing high psychological distress over twelve years. DATA AND METHODS: Data from the first 12 years of the longitudinal National Population Health Survey (1994/1995 through 2006/2007) were analysed. Proportional hazards modelling was conducted to determine whether lower household income was associated with a greater risk of experiencing high distress, when adjusting for sociodemographic characteristics and baseline health status. It was also used to examine the relationship between reporting a stressor and experiencing a subsequent episode of distress. RESULTS: Overall, 11% of the initial sample experienced at least one episode of high distress during the 12 years of the study. Low-income respondents were at a significantly higher risk of becoming psychologically distressed, and many of the stressors were associated with a significantly higher risk of becoming distressed. Stressors accounted for 22% of the relationship between low income and distress for men, and more than a third of this relationship for women. INTERPRETATION: Low income is an important risk factor for becoming psychologically distressed, and stressors account for part of this increased risk.

Health risk perceptions as mediators of socioeconomic differentials in health behaviour.

Differentials in health status and behaviour by socioeconomic status (SES) constitute a scientific and policy challenge. In this article, data from a national survey on Canadians' perceptions of population health risks were analysed to determine whether various types of health risk perceptions mediated SES differentials in health behaviour. As expected, health behaviours and risk perceptions both varied with SES. Results suggested a mediating role of health risk perceptions-particularly those of a social nature-in the association between SES and smoking. Findings underscore the importance of improving the social environment to fostering better lifestyle and health among disadvantaged individuals.