Low-income women with early-stage breast cancer: physician and patient decision-making styles.

BACKGROUND: Poor women have low rates of breast conservation therapy not explained by differences in insurance status or treatment preferences. The purpose of this study was to explore how low-income women make decisions about breast cancer treatment. METHODS: Twenty-five women diagnosed with early-stage breast cancer through the Nebraska Every Woman Matters program were interviewed about their experiences selecting treatment options. These interviews were transcribed and then analysed using established qualitative techniques. RESULTS: More than half of the women (n=16) described playing a passive role in decision making. Choice was determined by medical factors or not offered by their physicians. Intense emotional distress affected some women's ability to compare options. The women who did engage in a rational decision-making process (n=9) based their choices on concerns about body image and fear of recurrence. CONCLUSIONS: When presented with a choice, and when able to objectively weigh treatment options, low-income women base their treatment decisions on the same issues as those of higher income. Whether differences in income strata alter the doctor-patient power dynamic in favor of physician control over decision making, or whether low-income women are less prepared to engage in a rational deliberative process warrants further study.

The organization and distribution of patient education materials in family medicine practices.

BACKGROUND: Millions of dollars are spent annually on the production and distribution of patient education materials; however, there are no studies describing their actual use by physicians. Using qualitative data from a large comparative case study, our analysis evaluates how patient education materials are organized and used in family practices. METHODS: Eighteen purposefully selected family medicine practices were directly observed for 4 to 12 weeks each. A total of 57 providers were shadowed by a research nurse, and detailed field notes on 1600 patient encounters were recorded. A 3-member analysis team reviewed the qualitative data and identified emergent patterns. RESULTS: Clinics' use of patient education materials fell mostly into 2 distinct patterns. "Stockpilers" were providers who relied on the clinic staff to develop and organize a common library of patient education handouts. Providers with a "personal stash" collected much smaller numbers of materials that they personally maintained. Providers in the latter group had a known repertoire of a limited amount of educational material and used it more often than providers with access to a greater variety and number of handouts. In all practices, providers distributed most handouts; staff and self-selection by patients played a minor role. CONCLUSIONS: It appears that provider involvement and familiarity with patient education materials are key to their use in clinical practice. Clinicians use written patient education materials most efficiently by personally selecting and maintaining a small number of handouts that address topics most relevant to their practice.

The role of breastfeeding in sudden infant death syndrome.

The objective of this article is to review the literature regarding the risk of sudden infant death syndrome (SIDS) in bottle-fed infants compared to those that are breastfed. A meta-analysis and qualitative literature review were performed. Cohort and case-control studies were included if they met a minimum SIDS definition and presented data allowing calculation of an odds ratio (OR). Twenty-three studies were included in the meta-analysis. The studies were heterogeneous, and a majority (14) were of "fair" or "poor" quality. Crude ORs from 19 individual studies favored breastfeeding as protective against SIDS. The combined analysis indicated that bottle-fed infants were twice as likely to die from SIDS (pooled OR = 2.11; 95% CI 1.66-2.68). The results of the analysis show that there is an association between bottle-feeding and SIDS, but this may be related to confounding variables.

Dissemination and implementation of Put Prevention into Family Practice.

INTRODUCTION: The Put Prevention into Practice (PPIP) program was developed and disseminated to address patient, clinician, and office barriers that result in less than optimal delivery of preventive services in the United States. METHODS: To study the dissemination of PPIP by the American Academy of Family Physicians (AAFP), pre- and post-dissemination surveys of knowledge about PPIP and purchase order data were obtained from the AAFP. In addition, a mail questionnaire was sent to a random sample of purchasers to study their use of PPIP. RESULTS: After two years of active promotion, 27% of AAFP members had heard about PPIP, and PPIP components were purchased by 2,004 individuals during its inital dissemination. Flow sheets, health guides, exam room wall charts, and the Clinician's Handbook of Preventive Services were the PPIP items most frequently purchased and used. Excluding the Clinician's Handbook of Preventive Services, 58% of purchasers used one or more parts of the kit with an average of less than four items used per purchaser. CONCLUSIONS: Initial dissemination and implementation of PPIP among family physicians was limited; continued promotion will likely improve dissemination of PPIP. However, this study, and others suggest that the simple availability of a kit of materials is not sufficient to enhance the delivery of preventive services as envisioned by clinicians or policy makers. Additional strategies for dissemination and implementation of preventive services will be required, such as providing external consultation services to practices, incorporation of preventive services into HMO organizations, and training of residents in strategies for change in their future practices.

Lay injection practices among migrant farmworkers in the age of AIDS: evolution of a biomedical folk practice.

The practice of injecting vitamins and antibiotics by lay people is common among Hispanic migrant farmworkers in the U.S.A. This practice has recent roots in the Latin American cultures from which these farmworkers originate, but it presents a public health concern in its new context because of the high prevalence of HIV infection among this disenfrachised population. Reasons for use of lay injections include cultural beliefs about the superiority of injections over oral forms of medications, perceived irrelevance of a professional diagnostician in prescribing empirical treatment, and a multitude of barriers to access to Western medicine. Although HIV educational materials directed at migrant farmworkers do not address the issue of sharing needles for these types of injections, some farmworkers indicated they had already modified their injection techniques in response to simple directives from physicians in their home country. In contrast to other folk treatment practices that have been resistant to change mediated solely through the provision of information, lay injection is such a new development that considerable experimentation and incorporation of new knowledge are still actively shaping its use. In this process, physicians are seen as legitimate sources of information about the use of Western pharmaceuticals; they should use this role to discourage unsafe injection practices. Efforts to extinguish the practice of lay injection entirely are less likely to meet with success so long as other means of accessing Western medicine are limited.

An ounce of prevention? Evaluation of the 'Put Prevention into Practice' program.

BACKGROUND: The "Put Prevention into Practice" (PPIP) program was designed to enhance the capacity of health care providers to deliver clinical preventive services. This study was designed to evaluate the program's effectiveness when applied to family physicians in private practice settings. METHODS: Eight Midwestern practices that had purchased PPIP kits were identified and agreed to participate in the study. A comparative case study approach encompassing a variety of data collection techniques was used. These techniques included participant observation of clinic operations and patient encounters, semistructured and key informant interviews with physicians and staff members, chart reviews, and structured postpatient encounter and office environment checklists. Content analysis of the qualitative data and construction of the individual cases were done by consensus of the research team. RESULTS: PPIP materials are not being used, even by the clinics that ordered them. Physicians already providing quality preventive services prefer their existing materials to those in the PPIP kit. Sites that are underutilizing preventive services are unable or unwilling to independently implement the PPIP program. CONCLUSIONS: Development of technical support may facilitate implementation of PPIP materials into those practices most deficient in providing preventive services. Given the diversity of practice environments it is unlikely that a "one size fits all" approach will ever be able to address the needs of all providers.