The silent consumer: women's reports and ratings of abortion services.

BACKGROUND: Abortion is one of the most common surgical procedures performed on women in the United States, and its safety has been demonstrated. Little research has focused, however, on women's reports and ratings of the service. OBJECTIVES: This study explored the association of demographic factors, medical outcomes, and client ratings of service dimensions with global satisfaction. RESEARCH DESIGN: For this cross-sectional study, permission to access clinic medical records was obtained. Surveys were distributed after the procedure, with instructions to return by mail. SUBJECTS: Study subjects were 797 women who underwent an outpatient surgical abortion at 1 of 2 New England health centers in 1996 and 1997. MEASURES: Demographic data, pregnancy history, and information on the procedure were collected from medical records. Survey items measured reports of access, medical outcomes, and satisfaction ratings with service domains. RESULTS: Women with positive ratings of staff sensitivity and of the counseling process and information received and those who had the procedure at a younger gestational age were less likely to report that care could be better. Although very few women reported a medical complication, this was associated with agreement that care could have been better, as was reporting agreement that the wait between the preexamination visit and the procedure was too long. CONCLUSIONS: Satisfaction with abortion services is high. Education and counseling play very important roles. Survey items could routinely be used to monitor services.

Patient delay in seeking care for heart attack symptoms: findings from focus groups conducted in five U.S. regions.

BACKGROUND: Patient delay in seeking health care for heart attack symptoms is a continuuing problem in the United States. METHODS: Investigators conducted focus groups (N = 34; 207 participants) in major U.S. regions (NE, NW, SE, SW, MW) as formative evaluation to develop a multi-center randomized community trial (the REACT Project). Target groups included adults with previous heart attacks, those at higher risk for heart attack, and bystanders to heart attacks. There were also subgroups reflecting gender and ethnicity (African-American, Hispanic-American, White). FINDINGS: Patients, bystanders, and those at higher risk expected heart attack symptoms to present as often portrayed in the movies, that is, as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. Patients and those at higher risk also unrealistically judge their personal risk as low, understand little about the benefits of rapid action, are generally unaware of the benefits of using EMS/9-1-1 over alternative transport, and appear to need the "permission" of health care providers or family to act. Moreover, participants reported rarely discussing heart attack symptoms and appropriate responses in advance with health care providers, spouses, or family members. Women often described heart attack as a "male problem," an important aspect of their underestimation of personal risk. African-American participants were more likely to describe negative feelings about EMS/9-1-1, particularly whether they would be transported to their hospital of choice. CONCLUSIONS: Interventions to reduce patient delay need to address expectations about heart attack symptoms, educate about benefits and appropriate actions, and provide legitimacy for taking specific health care-seeking actions. In addition, strategy development must emphasize the role of health care providers in legitimizing the need and importance of taking rapid action in the first place.

Provider education to promote implementation of clinical practice guidelines.

STUDY OBJECTIVES: Although the interest in and promulgation of clinical practice guidelines have significantly increased in the past 2 decades, concern exists about their actual implementation. This article focuses on one strategy to encourage guideline implementation at the clinician level: clinician education. The objectives of the article are to review educational strategies, to consider them within the context of complementary strategies carried out at the organizational and clinic setting levels, and to outline challenges and recommendations for clinicians' continuing education. METHODS: Experience and data from relevant randomized clinical trials within an educational framework are reviewed. OBSERVATIONS: Implementation of clinical practice guidelines requires a variety of skills, including assessment, appropriate delineation of a treatment and monitoring plan, patient tracking, and patient counseling and education skills. Continuing education strategies must reflect the content and teaching methods that best match the learning objectives. The pressures of current-day practices place limits on the resources, particularly clinician time, that are available for continuing education. Organizational resources must be committed to build the complementary supportive systems necessary for improved clinician practice. In addition to physicians, education must be directed at nonphysician clinicians, office staff, and administrators who also are responsible for guideline implementation. CONCLUSIONS: To meet the challenges of developing clinician motivation, balancing competing demands, and treating patients with complex medical conditions, all within time constraints, clinical leaders need to design education activities that have leadership support, reflect compelling evidence, use multiple strategies and teaching techniques, and engage learners in skill building and problem solving.

Cancer control knowledge, attitudes, and perceived skills among medical students.

BACKGROUND: The Cancer Prevention and Control Education (CPACE) program aims to strengthen and coordinate curriculum offerings in cancer prevention and control for medical, graduate nursing and public health students. METHODS: Students were surveyed on cancer-related knowledge and confidence as part of needs assessment and evaluation efforts. The students completed self-administered surveys (response rate 78%). Descriptive and stratified analysis and ANOVA were conducted. RESULTS: Knowledge and confidence generally increased with each successive class year, but confidence varied markedly across specific counseling scenarios and by gender. While the students overall reported greater confidence in performing an examination than in interpreting the results, confidence varied significantly across specific types of examinations. CONCLUSIONS: Understanding of basic information about common cancers was disappointing. Confidence to perform and interpret examinations could be higher, especially for opposite-gender screening examinations. Implications of the findings for CPACE curriculum development are discussed.

Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: The Rapid Early Action for Coronary Treatment (REACT) Trial.

CONTEXT: Delayed access to medical care in patients with acute myocardial infarction (AMI) is common and increases myocardial damage and mortality. OBJECTIVE: To evaluate a community intervention to reduce patient delay from symptom onset to hospital presentation and increase emergency medical service (EMS) use. DESIGN AND SETTING: The Rapid Early Action for Coronary Treatment Trial, a randomized trial conducted from 1995 to 1997 in 20 US cities (10 matched pairs; population range, 55,777-238,912) in 10 states. PARTICIPANTS: A total of 59,944 adults aged 30 years or older presenting to hospital emergency departments (EDs) with chest pain, of whom 20,364 met the primary population criteria of suspected acute coronary heart disease on admission and were discharged with a coronary heart disease-related diagnosis. INTERVENTION: One city in each pair was randomly assigned to an 18-month intervention that targeted mass media, community organizations, and professional, public, and patient education to increase appropriate patient actions for AMI symptoms (primary population, n=10,563). The other city in each pair was randomly assigned to reference status (primary population, n=9801). MAIN OUTCOME MEASURES: Time from symptom onset to ED arrival and EMS use, compared between intervention and reference city pairs. RESULTS: General population surveys provided evidence of increased public awareness and knowledge of program messages. Patient delay from symptom onset to hospital arrival at baseline (median, 140 minutes) was identical in the intervention and reference communities. Delay time decreased in intervention communities by -4.7% per year (95% confidence interval [CI], -8.6% to -0.6%), but the change did not differ significantly from that observed in reference communities (-6. 8% per year; 95% CI, -14.5% to 1.6%; P=.54). EMS use by the primary study population increased significantly in intervention communities compared with reference communities, with a net effect of 20% (95% CI, 7%-34%; P<.005). Total numbers of ED presentations for chest pain and patients with chest pain discharged from the ED, as well as EMS use among patients with chest pain released from the ED, did not change significantly. CONCLUSIONS: In this study, despite an 18-month intervention, time from symptom onset to hospital arrival for patients with chest pain did not change differentially between groups, although increased appropriate EMS use occurred in intervention communities. New strategies are needed if delay time from symptom onset to hospital presentation is to be decreased further in patients with suspected AMI. JAMA. 2000;284:60-67

Missed opportunities to impact fast response to AMI symptoms.

The potential for reducing cardiovascular disease mortality rates lies both in prevention and treatment. The earlier treatment is administered, the greater the benefit. Thus, duration of time from onset of symptoms of acute myocardial infarction to administration of treatment is important. One major factor contributing to failure to receive efficacious therapy is the delay time from acute myocardial infarction (AMI) symptom onset to hospital arrival. This paper examines the relationship of several factors with regard to intentions to seek care promptly for symptoms of AMI. A random-digit dialed telephone survey (n = 1294) was conducted in 20 communities located in 10 states. People who said they would wait until they were very sure that symptoms were a heart attack were older, reported their insurance did not pay for ambulance services, and reported less confidence in knowing signs and symptoms in themselves. When acknowledging symptoms of a heart attack, African-Americans and people with more than a high school education reported intention to act quickly. No measures of personal health history, nor interaction with primary care physicians or cardiologists were significantly related to intention to act fast. The study confirms the importance of attribution and perceived self-confidence in symptom recognition in care seeking. The lack of significant role of health history (i.e. those with chronic conditions or risk factors) and clinician contact highlights missed opportunities for health care providers to educate and encourage patients about their risk and appropriate action.

Smoking cessation counseling with pregnant and postpartum women: a survey of community health center providers.

OBJECTIVES: This study assessed providers' performance of smoking cessation counseling steps with low-income pregnant and postpartum women receiving care at community health centers. METHODS: WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) program staff, obstetric clinicians, and pediatric clinicians at 6 community health centers were asked to complete surveys. Smoking intervention practices (performance), knowledge and attitudes, and organizational facilitators were measured. Factors associated with performance were explored with analysis of variance and regression analysis. RESULTS: Performance scores differed significantly by clinic and provider type. Providers in obstetric clinics had the highest scores and those in pediatric clinics had the lowest scores. Nurse practitioners and nutritionists had higher scores than other providers. Clinic type, greater smoking-related knowledge, older age, and perception of smoking cessation as a priority were independently related to better counseling performance. CONCLUSIONS: Mean performance scores demonstrated room for improvement in all groups. Low scores for performance of steps beyond assessment and advice indicate a need for emphasis on the assistance and follow-up steps of national guidelines. Providers' own commitment to helping mothers stop smoking was important.

REACT theory-based intervention to reduce treatment-seeking delay for acute myocardial infarction. Rapid Early Action for Coronary Treatment.

Coronary heart disease (CHD) remains the leading cause of mortality in the U.S. Innovations in reperfusion therapies can potentially reduce CHD morbidity and mortality associated with acute myocardial infarction (AMI) when treatment is initiated within the first few hours of symptom onset. However, delay in seeking treatment for AMI is unacceptably lengthy, resulting in most patients being ineligible for reperfusion therapies. The Rapid Early Action for Coronary Treatment (REACT) Trial is a four-year, 20-community, randomized trial to design and test the effectiveness of a multi-component intervention to reduce patient delay for hospital care-seeking for AMI symptoms. This manuscript describes the development and content of the theoretically-based REACT intervention and summarizes: (1) the research literature used to inform the intervention; (2) the behavioral theories used to guide the development, implementation, and evaluation of the intervention; (3) the formative research undertaken to understand better decision-making processes as well as barriers and facilitators to seeking medical care as perceived by AMI patients, their families, and medical professionals; (4) the intervention design issues that were addressed; (5) the synthesis of data sources in developing the core message content; (6) the conceptualization for determining the intervention target audiences and associated intervention components and strategies, their integration with guiding theoretical approaches and implementation theories for the study, and a description of major intervention materials developed to implement the intervention; and (7) the focus of the outcome, impact, and process measurement based on the intervention components and theories on which they were developed.

The perceptions and practices of pediatricians: tobacco intervention.

OBJECTIVES: To investigate pediatrician self-reported intervention practices related to tobacco use and cessation. We queried about practices with three groups 1) children/adolescents who do not smoke; 2) children/adolescents who smoke; and 3) parents, and the relationship of counseling practices with the personal and professional practice-related factors of pediatricians. DESIGN: Mailed anonymous survey regarding their self-reported tobacco use prevention and cessation intervention practices. POPULATION: Random sample of 350 pediatricians in one state. RESULTS: A response rate of 75% was achieved. Pediatricians reported the greatest counseling practice in encouraging children/adolescents to not start smoking, followed by counseling adolescents who smoke. The lowest practice score was for intervening with parents who smoke. The age, gender, site of practice (eg, HMO, solo practice), and subspecialty status of the pediatricians were not related to practice. Pediatricians who reported at least some community involvement in local tobacco control efforts reported significantly higher levels of smoking cessation counseling with both children and adolescents and with parents who smoke. Pediatricians who reported previous training in counseling about tobacco issues also reported significantly higher levels of counseling of both adolescent smokers and parents who smoke but not of children and adolescents who do not smoke. Higher role perception, believing that smoking cessation counseling provided by pediatricians can be effective, and self-efficacy, were predictive of intervention with all three groups. The perceived barriers scale was not related to intervention with any group. CONCLUSIONS: Pediatricians are missing opportunities to help their patients to stop smoking and to prevent smoking initiation. Pediatricians are intervening least frequently with parents who smoke. Practices should be tailored to the specific target group.

Physicians and smoking cessation. Development of survey measures.

Data from a mailed survey to primary care physicians (N = 122) were used to construct and evaluate psychosocial scales related to performance of smoking cessation counseling. Scales measuring counseling barriers, self-efficacy, and motivation demonstrated considerable promise with excellent or reasonable internal consistency. The correlation for each scale with performance of cessation counseling and with stage of change was statistically significant. Physicians who report they are currently assisting patients had higher performance and self-efficacy rating. Physicians who had participated in formal smoking cessation training had higher self-efficacy; however, their scores on the Barriers, Motivation, and Performance Scales did not differ. Further study with a representative group is encouraged.

Smoking cessation benefits in HMOs.

A survey was undertaken in the Spring of 1994 to understand the types of smoking cessation services offered by HMOs to one state's employees. Responses documented that the vast majority of HMOs offered nicotine replacement therapy, as well as behavioral classes and courses, with no difference in availability of programs by HMO model type. Considerable variance was found among plans with respect to the structure of the services, and the conditions for accessing benefits. This variation in part may reflect the lack of empirical evidence concerning which approach is most effective. HMOs have provided leadership within the health services and insurance industry with respect to inclusion of cessation benefits. A challenge for HMOs is to design coordinated systems for their smoking cessation services including development of appropriate monitoring systems. Such monitoring will allow plans to better assess participation and effectiveness, and to make benefit and operational decisions on the basis of performance.

Physician-based smoking intervention: a rededication to a five-step strategy to smoking research.

It is well established that physicians can have a significant effect on the smoking behavior of their patients. To do this, attention must be paid to putting in place multiple strategies or mechanisms in the organization where the physician practices, as well as in the macroenvironment (i.e., social and public policy). It has been questioned whether or not there is stagnation in the field of clinical smoking intervention requiring a rededication to basic research regarding smoking. With respect to physician-based smoking intervention, we alternatively suggest that recommitment to all phases of research is essential for moving forward physician-based smoking interventions in the rapidly changing health services and social environment. In this article, we first review the essential framework of the National Cancer Institute's research science approach to cancer prevention and control. Evidence concerning physician-based interventions is then reviewed, followed by a schematic of a comprehensive framework for thinking about the process and intervention components needed for physician-based smoking intervention to take place in the health-care setting, the impact they have, and the eventual outcome of such interventions. There is a discussion of the challenges for the delivery of smoking-cessation services presented by the rapidly changing healthy delivery system of the 1990s. Finally, we present recommendations concerning research priorities for physician-based smoking intervention and the research funding process.

Mammography use among sociodemographically diverse women: the accuracy of self-report.

OBJECTIVE: This study sought to determine the accuracy of self-report of mammography experience among 392 ethnically diverse women aged 50 to 74. METHODS: Subjects were randomized to the telephone or mail condition and surveyed. RESULTS: Thirty-one percent of women reported accurately the exact month and year of their most recent mammogram; 54% reported accurately within +/- 3 months, and 83% reported accurately within the year. Greater accuracy was associated with exam recency, White race, and non-Hispanic ethnicity, but not with age, education, or income. Most women could correctly report the reason for, the findings of, and the payor of their mammograms but knew little about how much they or their insurance paid. CONCLUSIONS: For population surveillance of mammography in the past year, self-report data are generally valid. However, clinical studies requiring more precise dates must use such data with caution. The telephone method, as compared with mail, appears to be a better option for some variables.

Relationships of patient satisfaction with experience of system performance and health status.

This article investigates the relationship between three types of measures obtained from consumer surveys: satisfaction, health status, and report of systems performance. Analyses demonstrate that patient reports of the quality of processes of care or system performance (such as receiving results of tests or receiving conflicting information from staff members) are significantly related to satisfaction independently of perception of health status. Since dissatisfaction is known to be associated with disenrollment, patient reports of system performance are of great interest to health plans.

HIV-1 antibody testing among drug users participating in AIDS education.

This study aimed to identify factors which predict participation of drug users in HIV-1 antibody testing. The study was part of a randomized controlled trial of three small group AIDS educational programs, in a 21-day in-patient drug detoxification and rehabilitation program. Subjects (n = 497) were clients admitted to the program who consented to participate in the evaluation and who completed baseline data collection. All subjects received pre-test counseling. Testing was offered after 1 week in treatment; 52% decided to be tested. Factors which predicted participation in testing included: no previously reported positive result, a longer stay in treatment, a greater frequency of injection, a greater perceived probability of being infected, and the type of AIDS education. Both actual and perceived level of risk, and the type of AIDS education provided can affect participation in testing programs.

Methodological issues for health-related surveys of multicultural older women.

Given concerns about survey nonresponse bias as well as the need to plan resources for participant recruitment, this study tracked each step of the recruitment process (location, response, consent, and completion) of sociodemographically diverse older women for a survey concerning mammography experience. Younger, less educated poor women were likely to be lost due to inability to locate them, while older middle- and upper-economic-group women were more likely to be lost due to refusal to participate. Hispanic and Black women were significantly more likely to respond on successive attempts to recruit them than were White, non-Hispanic women. There was no significant difference in refusal rates by minority women over the successive contacts, as contrasted with White women, who refused at significantly higher rates with each attempt.

Behavioral outcomes of AIDS educational interventions for drug users in short-term treatment.

This paper reports the behavioral outcomes of informational vs enhanced small-group educational interventions for drug users among 407 subjects in a short-term drug treatment program. Logistic regression was used to analyze drug use and sexual behaviors at the final follow-up visit. Among lower risk subjects, the enhanced intervention was more effective in reducing injection practices that produced risks in terms of human immunodeficiency virus infection; among those at highest risk, the informational interventions were more effective. The enhanced intervention was more effective than the informational interventions in reducing cocaine use at follow-up. No differential intervention effect on sexual risk behaviors was found.