Office system interventions supporting primary care-based health behavior change counseling.

CONTENT: This article reviews the literature on the effectiveness of office system interventions to improve behavior-change counseling in primary care. These instructions consist of two principle components: tools and teamwork. Tools have been developed to assist providers with health risk assessment (questionnaires, health risk appraisals), prompting and reminding (chart stickers, checklists, flow charts, reminder letters), and education (manuals and handbooks). Teamwork entails the coordination and delegation of tasks between providers and staff. CONCLUSIONS: A number of clinical trials, particularly in the area of smoking cessation, have demonstrated the effectiveness of tools and teamwork for increasing counseling rates and counseling effectiveness. Although no one type of tool or method of teamwork is consistently more effective than another-with effectiveness varying according to practice, provider, and patient characteristics-the use of different tools and teamwork approaches leads to additive improvements in counseling and patient behavior-change rates. More high-quality research is needed, particularly in the areas of health risk assessment and electronic reminder systems, to develop effective office interventions that can be readily implemented into a wide variety of primary care practices.

Risk factors for excess mortality in Harlem. Findings from the Harlem Household Survey.

INTRODUCTION: In 1980, age-adjusted mortality rates in Central Harlem were the highest among New York City's 30 health districts. This population-based study was designed to describe the self-reported frequency of selected health conditions, behavioral risk factors, preventive health practices, and drug use in the Harlem community. METHODS: From 1992 to 1994, in-person interviews were conducted among 695 adults aged 18 to 65 years who were randomly selected from dwelling-unit enumeration lists for the Central Harlem health district. Descriptive statistics were computed for men and women separately, and compared to other population-based surveys. RESULTS: Self-reported medical insurance coverage in Harlem was unexpectedly high (74% of men, 86% of women) as was lifetime use of preventive health practices, e.g., blood cholesterol screening (58% of men, 70% of women). However, lifetime rates of substance use, e.g. crack cocaine (14%) and self-reported history of traumatic events, e.g., witnessing someone seriously injured or violently killed (49% of men, 21% of women) were also high in Harlem, especially in comparison to other populations. CONCLUSIONS: This study has identified important patterns of similarities and differences in risk behaviors between Harlem and other populations. Potential solutions to the health problems of Harlem may lie in the creation of strategies that operate at the community, municipal, and regional level, as well as at the level of individual behavior and risk-taking.

Laying down the law: reducing illegal tobacco sales to minors in central Harlem.

OBJECTIVES: This study compared the impact of educational and enforcement interventions on retailers' sale of tobacco to minors in Central Harlem, New York. METHODS: In a randomized trial with repeated measures, 152 stores were randomly divided into control, education, and enforcement groups. RESULTS: Overall tobacco sales to 12- and 13-year-old minors at baseline (98%) were among the highest in the nation. At 6-month and 1-year follow-ups, decreases in rates of tobacco sales to minors were modest among education stores and substantial among enforcement stores. CONCLUSIONS: Effective reduction of tobacco sales to minors may require ongoing enforcement measures, including fines for retailers who violate state and local laws.

Acceptance and use of Put Prevention into practice materials at an inner-city hospital.

Many studies indicate that physicians' prevention practices frequently differ from published guidelines. Put Prevention into Practice (PPIP) consists of a variety of paper-based materials for providers, patients, and the office setting designed to enhance the delivery of clinical preventive services. Prototype PPIP materials were distributed to physicians and patients at the Harlem Hospital medical clinic in conjunction with a series of prevention lectures for physicians. Acceptance and use of these materials were assessed through self-administered questionnaires for physicians and structured interviews for patients. A regression analysis was conducted to assess correlates of physician use of PPIP materials. Physicians reported a high degree of use of and satisfaction with PPIP materials. Multiple regression analysis indicated that the physicians' perceived self-efficacy in their ability to provide preventive counseling to patients at baseline was significantly associated with increased use of PPIP materials. When controlling for baseline physician self-efficacy, physicians whose self-efficacy increased during the study period were more likely to have used the materials. A majority of patients (53%) reported that the main patient-based component of the program-a pocket-sized booklet providing health education information and record-keeping of preventive tests and procedures-was very useful. Results from this study indicate a high degree of acceptance of prototype PPIP materials by physicians and patients at an inner-city hospital. Educational programs for physicians that enhance physician self-efficacy may be more effective in helping practitioners to adopt office-based prevention resources. Medical Subject Headings (MeSH): prevention, primary care, preventive health services, clinical practice patterns.

Putting prevention into practice. Impact of a multifaceted physician education program on preventive services in the inner city.

BACKGROUND: Physicians' prevention practices often differ from guidelines published by national authorities. Effective preventive services are most needed in inner city settings that suffer disproportionately from preventable diseases. This study examined the impact of a multifaceted physician prevention education program on the provision of preventive services in an inner city municipal hospital. METHODS: The study used a controlled intervention comparative design at two inner city municipal hospitals--Harlem Hospital Center, New York, NY (intervention site) and Kings County Hospital, Brooklyn, NY (comparison site)--serving predominantly African-American patient populations. The intervention site received prototype materials for physicians, patients, and the office setting from the US Public Health Service's Put Prevention Into Practice campaign and a series of prevention lectures from November 1991 through April 1992. Change in physician prevention practices and knowledge was assessed by self-administered questionnaires and change in patients' reports of preventive services received was assessed by structured interviews. RESULTS: Physicians at Harlem Hospital Center reported a greater postintervention increase in prevention practices and demonstrated a greater increase in prevention knowledge in comparison with physicians at Kings County Hospital. Patients at Harlem Hospital Center reported receiving increased preventive services from physicians after the intervention, while patients at Kings County Hospital did not report any significant change in preventive services received. CONCLUSIONS: A multifaceted physician education program using prototype materials from the Put Prevention Into Practice campaign with prevention lectures significantly increased the prevention knowledge and practices reported by physicians and the preventive services reported received by patients at an inner city municipal hospital.

Efficacy of computerized health risk appraisal as part of a periodic health examination at the worksite.

PURPOSE: To evaluate the efficacy of computerized health risk appraisal (HRA) when it is incorporated into a periodic health examination at the worksite. DESIGN: A randomized, controlled trial comparing change in health behaviors for a 6-month follow-up period was conducted. SETTING: A large financial services firm in New York City. SUBJECTS: A total of 161 employees who volunteered for a worksite periodic health examination. INTERVENTION: All employees received a physician-based history and physical examination, including laboratory tests, and were counseled on the basis of the results. Half the employees were randomly assigned to receive an HRA report with counseling from the 1984 version of the Centers for Disease Control HRA, whereas the other half completed the HRA questionnaire but received no HRA report or counseling. MEASURES: Blood pressure, cholesterol, and weight were measured by project staff, physical activity and seatbelt use were measured by self-report, and change in computerized appraised age was calculated by the HRA program. RESULTS: Evaluation of the 90 participants who returned for follow-up revealed a statistically significant improvement in computerized appraised age and physical activity in those who has received the HRA report and counseling compared with those who had not (p < or = .05), and also showed trends toward greater improvement in blood pressure, weight, and seatbelt use. CONCLUSIONS: Results provide support for the efficacy of HRA when incorporated into a periodic health examination at the worksite.

Safety information provided to customers of New York City suntanning salons.

Little is known about the safety information tanning salon operators provide to customers or the extent to which artificial tanning salons adhere to federal regulations designed to protect customers from excessive ultraviolet radiation (UVR) exposure. We surveyed the operators of 20 artificial tanning salons in New York City from 1988 to 1989 concerning salon operating procedures and information provided to potential customers. Results revealed a disparity between known health risks of UVR exposure and safety information provided to tanning salon customers. For example, 75% of salon operators informed potential customers that artificial tanning would not cause a sunburn, and 80% informed potential customers that they would not get skin cancer from artificial tanning. Artificial tanning salons are a rapidly growing industry in the United States, with over two million customers annually. Results from this survey indicate a need for greater regulation of the tanning salon industry and for education of tanning salon operators in the risks associated with the use of artificial tanning devices.

Acquired immunodeficiency syndrome prevention. Knowledge, attitudes, and practices of primary care physicians.

We conducted a telephone survey of a probability sample of 473 internists, family practitioners, general practitioners, and obstetrician-gynecologists in New York City (NY) in 1988 to assess their knowledge, attitudes, and practices with respect to the prevention of the acquired immunodeficiency syndrome (AIDS). Although 71% of the physicians had cared for a patient with AIDS and 90% had been involved in ordering the human immunodeficiency virus antibody test, only about a third of them took appropriate sexual histories of new patients and only about a quarter (28%) counseled new patients about reducing the risk of contracting AIDS. Multivariate analysis revealed that physician knowledge about AIDS prevention was associated with younger age, more positive attitude toward homosexual males and intravenous drug users, confidence that counseling would result in behavioral change among patients, and specialty other than obstetrics-gynecology. Results indicate a need for increased training and education of primary care physicians about AIDS prevention.

Health promotion and disease prevention in HMOs: a survey of newly established IPAs in New York City.

Independent Practice Associations (IPAs) are the fastest growing segment of the Health Maintenance Organization (HMO) industry, but little is known about their provision of health promotion and disease prevention to subscribers. To examine the extent to which IPA policies encourage health promotion and disease prevention, we interviewed medical directors and other senior administrators of six newly developing IPA-HMOs in New York City. We also reviewed promotional literature to assess how extensively health promotion and disease prevention were marketed to the potential subscriber. Although medical protocols for preventive screening exist in most IPAs, compliance with guidelines is left largely to the individual physician's judgment for implementation. IPA respondents suggested that their physician panels are oriented toward prevention, but there is uncertain evidence in this regard, and incentive payments could discourage referrals for screening. Health education programs are sporadic. Health promotion and disease prevention do not appear to be a high priority among six newly established IPAs in New York City. We recommend several steps that would encourage IPA-HMOs to increase their health promotion activities.

Management of high blood cholesterol by primary care physicians: diffusion of the National Cholesterol Education Program Adult Treatment Panel guidelines.

OBJECTIVE: To study knowledge of and adherence to National Cholesterol Education Program Adult Treatment Panel (ATP) guidelines among primary care physicians. DESIGN: Cross-sectional telephone survey. SETTING: New York State primary care practitioners; survey conducted November 1988-January 1989. PARTICIPANTS: Physicians in general practice, family practice, internal medicine without subspecialty, and cardiology who reported greater than or equal to 10 hours/week of clinical practice (n = 329; response rate = 63%). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: While 84% of physicians had heard of the ATP guidelines, gaps in knowledge and inconsistencies between ATP recommendations and clinical practices were found. Although the ATP guidelines recommend six months of dietary therapy before starting drug treatment, 41% of physicians would initiate drug treatment for a healthy 40-year-old man with total cholesterol of 7.8 mmol/L (300 mg/dl) either at the initial visit or after one month of lipid-lowering diet. Multivariate analysis of a 24-item knowledge scale revealed that less knowledgeable physicians were more likely to be older, lack board certification, and have a specialty other than cardiology (p less than 0.01). Less knowledgeable physicians were also more likely to consider drug company literature and drug company representatives very useful sources of information about cholesterol (p = 0.02). CONCLUSION: This study suggests that hard-to-reach physician groups may require special efforts to communicate consensus guidelines of major importance to clinical practice.

A public health model for cardiovascular risk reduction. Impact of cholesterol screening with brief nonphysician counseling.

To examine the impact of cholesterol screening with brief nonphysician counseling on cardiovascular risk factors, 886 employees at a large financial services firm underwent fingerstick screening followed by brief (3- to 5-minute) counseling by a registered nurse. At the 6-month follow-up, there were significant declines in total cholesterol levels (5.9 to 5.5 mmol/L [228 to 213 mg/dL]), weight (78 to 75 kg), blood pressure (119/78 to 115/75 mm Hg), and number of people reporting smoking (16.8% to 14.5%) among participants with a baseline cholesterol value of 5.2 mmol/L (200 mg/dL) or greater. A randomized experiment was conducted on 137 participants initially classified as having a "borderline-high blood cholesterol" level (5.2 to 6.2 mmol/L [200 to 239 mg/dL]) to test the impact of frequency of follow-up. Those receiving frequent follow-up (cholesterol measurement and brief counseling at 2, 4, and 6 months) reported significantly greater dietary change and demonstrated a trend toward greater declines in total cholesterol compared with those receiving follow-up at 6 months only. The results of this study support the feasibility and efficacy of cholesterol screening utilizing brief nonphysician counseling on multiple cardiovascular risk factors and suggest an enhanced effect when patients receive more frequent follow-up.

Nondrug treatment of hypertension: a survey of black physicians in New York State.

A survey of 64 black physicians in New York State was completed in April 1988 concerning physicians' approach to the nondrug treatment of hypertension. The physicians clearly support the use of nonpharmacologic treatment of mild hypertension, particularly for patients with diastolic blood pressure of 90 to 94 mmHg. However, very little time appears to be spent counseling patients with respect to diet and weight reduction. There was considerable variability in the degree of confidence felt by physicians in recommending nondrug approaches to hypertension control. An overwhelming majority of physicians felt that their training did not adequately prepare them for counseling patients about diet specifically or for practicing preventive medicine generally. The findings of this survey suggest a need for significantly increased attention to training physicians during both medical school and residency in prevention, patient counseling, and health promotion.

Differences in physician prevention practice patterns for white and minority patients.

A telephone survey of 120 randomly selected primary care physicians in New York City was completed in October, 1984 (response rate = 90%) concerning physicians' recommendations for health promotion and disease prevention. Responses from physicians with 50% or more Black and Hispanic patients were compared with responses from physicians with 50% or more White patients. The former were found to be less likely to follow guidelines from nationally recognized organizations for health promotion and disease prevention, although they were just as likely to value the importance of prevention in primary care. For example, physicians with predominantly Black and Hispanic patient populations were significantly less likely to recommend screening mammography (7% versus 23%) or recommend influenza vaccination for patients 65 or older (48% versus 74%) when compared with physicians with predominantly White patient populations. Factors that appeared to contribute to the difference in prevention practice patterns include physician training and education, the socioeconomic status of the patients, and the time physicians spend with patients. Differences in quality of preventive care provided to minority patients may be an additional factor in the disparity between the health status of White and non-White Americans.

Prevention in primary care: variability in physician practice patterns in New York City.

We conducted a telephone survey of 120 randomly selected primary care physicians in New York City. This survey, which was completed in October 1984, concerned physicians' recommendations for health promotion and disease prevention. The recommendations by these physicians were often at variance with the recommendations of nationally recognized organizations such as the American Cancer Society and the American College of Physicians. Multivariate analysis revealed that board-certified physicians, U.S. medical graduates, and younger physicians agreed more frequently with the recommendations of national organizations. The physicians surveyed agreed upon the need to include health promotion and disease prevention in their practices. Eighty-seven percent agreed with the statement, "Physicians should probably practice more preventive medicine than they presently do." Reasons given for the failure to practice more prevention included lack of time (70 percent), inadequate reimbursement (60 percent), and "unclear recommendations" (58 percent). Approximately four out of five of the physicians felt a task force was needed to "clarify recommendations" for preventive medicine. The findings of this survey suggest a need for increased physician training and education in disease prevention and health promotion.