Adapting the Diabetes Prevention Program for low- and middle-income countries: preliminary implementation findings from lifestyle Africa.

Rates of cardiovascular disease and diabetes are rising in low- and middle-income countries (LMIC), but there is a dearth of research devoted to developing and evaluating chronic disease interventions in these settings, particularly in Africa. Lifestyle Africa is a novel, culturally adapted version of the Diabetes Prevention Program (DPP) being evaluated in an ongoing community-based cluster-randomized trial in an underresourced urban community in South Africa. The purpose of this study is to describe the adaptations and adaptation process used to develop the program and to report preliminary implementation findings from the first wave of groups (n = 11; 200 individuals) who participated in the intervention. The RE-AIM model and community advisory boards guided the adaptation process. The program was designed to be delivered by community health workers (CHWs) through video-assisted sessions and supplemented with text messages. Participants in the trial were overweight and obese members of existing chronic disease "support groups" served via CHWs. Implementation outcomes included completion of sessions, session attendance, fidelity of session delivery, and participant satisfaction. Results indicated that 10/11 intervention groups completed all 17 core sessions. Average attendance across all sessions and groups was 54% and the percentage who attended at least 75% of sessions across all groups was 35%. Fidelity monitoring indicated a mean of 84% of all required procedures were completed while overall communication skills were rated as "good" to "excellent". These preliminary results support the feasibility of culturally adapting the DPP for delivery by CHWs in underresourced settings in LMIC.

Reasons for nonadherence and response to treatment in an adherence intervention trial for relapsing-remitting multiple sclerosis patients.

OBJECTIVES: To explore whether patients in an adherence trial who appeared not to take disease modifying therapy (DMT) for avoidance reasons could be reliably identified, by observational coding, for their main reason of not taking DMT. To determine whether reason groups could be distinguished by clinical and self-report psychological characteristics and intervention outcomes. METHOD: Participants were multiple sclerosis patients (N = 78, 88.5% female, mean age 45.64) demotivated to take DMT. Audio recordings of the sessions were coded for the main reason of not taking DMT. Reason groups were compared based on patient characteristics and intervention outcomes. RESULTS: Avoidance and three other reasons for not taking DMT (side effects, cost, and mild course) were reliably identified (κ = 0.88). Patient characteristics failed to distinguish participants in the Avoidance group, which also had poorer outcomes (X2 [2, n = 73] = 6.35, p = 0.036). CONCLUSIONS: Patients not taking DMT for avoidance reasons may need novel methods to identify them and encourage (re-)initiation.

A qualitative assessment of provider perspectives on smoking cessation counselling.

RATIONALE, AIMS AND OBJECTIVES: Few studies have examined doctors' views about counselling unmotivated smokers. This study explored doctors' perceptions of useful strategies to motivate patients to quit, how receptive they felt patients were to these strategies, and the benefits and drawbacks of discussing smoking cessation with patients. METHODS: Fourteen semi-structured qualitative interviews were conducted with doctors and resident doctors. RESULTS: Strategies reported by providers included: educating about the health risks of smoking, using 'scare tactics' to highlight the harmful effects and providing advice about how to quit. Providers believed that most patients were receptive to their strategies, but noted that they lacked feedback to know for sure. Providers saw the possibility of improving patients' health and decreasing overall health care costs as potential benefits, but cited the potential to damage rapport, competing priorities during already rushed visits and uncertainty about the effectiveness of their efforts as drawbacks that reduced their motivation to raise the issue with patients. CONCLUSIONS: Doctors believe in the potential benefits of smoking cessation counselling but predominantly report focusing on enhancing patient's risk perceptions. They did not report attempting to use the wider array of recommended and empirically supported methods to counsel their patients. Providing doctors with increased training in motivational counselling and feedback about the efficacy their efforts or supplementing doctor care with behaviour change specialists would likely increase the benefits of counselling to patients.

Physician smoking cessation counseling and adherence to a clinical practice guideline.

OBJECTIVE: The U.S. Public Health Service Clinical Practice Guideline recommends that physicians provide tobacco cessation interventions to their patients at every visit. While many studies have examined the extent to which physicians implement the guideline's "5 A's", few studies have examined the extent to which physicians implement the guideline's "5 R's" which are to be used in a Motivational Interviewing (MI) consistent style with smokers not ready to quit. This study examined the extent to which physicians in usual practice and without specific training administered the 5 R's including the use of an MI style. METHODS: Thirty-eight physicians were audio recorded during their routine clinical practice conversations with smokers.Recordings were coded by independent raters on the implementation of each of the 5 A's, 5 R's and MI counseling style. RESULTS: Results revealed that for patients not ready to quit smoking, physicians most frequently discussed the patient's personal relevance for quitting and the risks of smoking. Roadblocks and rewards were discussed relatively infrequently. MI skill code analyses revealed that physicians, on average, had moderate scores for acceptance and autonomy support, a low to moderate score for collaboration and low scores for empathy and evocation. CONCLUSION: Results suggest that for the Clinical Guideline to be implemented appropriately physicians will need specialized training or will need to be able to refer patients to counselors with the necessary expertise. Counseling efforts could increase providers' willingness to implement guideline recommendations and therefore to enhance the person-centeredness of clinical care.