Self-management interventions for chronically ill patients with limited health literacy: A descriptive analysis.

OBJECTIVES: To support patients with limited health literacy with the challenges they face in the day-to-day management of their disease(s), numerous self-management interventions (SMIs) have been developed. To date, it is unclear to what extent SMIs have been developed for chronically ill patients with limited health literacy. This study aims to provide a description of these SMIs and to provide insight in their methodological components. METHODS: A secondary analysis of the COMPAR-EU database, consisting of SMIs addressing patients with diabetes, chronic obstructive pulmonary disease, obesity and heart failure, was conducted. The database was searched for SMIs addressing health literacy, including cognitive aspects and the capacity to act. RESULTS: Of the 1681 SMIs in the COMPAR-EU database, 35 studies addressed health literacy, describing 39 SMIs. The overview yields a high variety in interventions given, with overlapping information, but also lacking of specific details. DISCUSSION: This descriptive analysis shows that there was a large variety in the extensiveness of the description of intervention characteristics and their justification or explanation. A focus on the broad concept of health literacy, including functional skills, cognitive skills and the capacity to act could improve the effectiveness. This should be taken into account in the future development of SMIs.

The impact of health literacy on beliefs about medication in a Dutch medication-using population.

PURPOSE: Medication beliefs are likely contingent on aspects of health literacy: knowledge, motivation, and competences to access, understand, appraise, and apply health information. An association between medication beliefs and health literacy is expected as they both influence self-management. The aim of this study was to examine the association between health literacy and the beliefs about overuse and harmful effects of medication and to examine modifying effects of age, gender, and number of medications on this association. METHODS: The data were collected using the online "Medication panel" of the Dutch Institute for Rational Use of Medicine. A linear regression model was used to examine the association between health literacy and beliefs about medication and the modifying effects of age, gender, and number of medications on this association. RESULTS: Respondents with a lower level of health literacy had more concerns about overuse (ß adj.= -.174, p<.001) and harmful (ß adj.= -.189, p<.001) effects of medication. This study found no modifying effects. CONCLUSIONS: A lower health literacy level is associated with more concerns about the overuse and harmful effects of medication. The results of this study suggest that extra attention should be given to persons with low health literacy level by healthcare professionals, to decrease their concerns about overuse and harmful effects, and improve adherence to self-management behavior.

How are medication related problems managed in primary care? An exploratory study in patients with diabetes and primary care providers.

BACKGROUND: Medication self-management is important for patients who are controlling diabetes. Achieving medication self-management goals, may depend on treatment complexity and patients' capacities such as health literacy, knowledge and attitude. OBJECTIVES: The aims of this study were to explore how patients with diabetes self-manage their medications, how patients seek support when experiencing problems and how primary healthcare providers identify patients' medication related problems and provide support. METHODS: Semi-structured interviews were conducted among patients with diabetes receiving primary care and with their primary healthcare providers - GPs, nurses, pharmacists and technicians - between January and June 2017. A purposive sampling strategy was used to identify and select participants. An interview guide based on the Cycle of Complexity model was developed. Interviews were audiotaped and transcribed verbatim. Transcripts were coded with a combination of deductive and inductive codes. A thematic analysis was performed to identify categories and themes in the data. Findings were compared with the Cycle of Complexity model. RESULTS: Twelve patients and 27 healthcare providers were included in the study. From the transcripts 95 codes, 6 categories and 2 major themes were extracted. Patients used practical solutions and gaining knowledge to manage their medication. Their problems were often related to stress and concerns about using medications. A trusted relationship with the healthcare provider was essential for patients to share problems and ask for support. Informal support was sought from family and peer-patients. Healthcare providers perceive problem identification as challenging. They relied on patients coming forward, computer notifications, clinical parameters and gut-feeling. Healthcare providers were able to offer appropriate support if a medication management problem was known. CONCLUSION: Patients are confident of finding their way to manage their medications. However, sharing problems with healthcare providers requires a trusted relationship. This is acknowledged by both patients and healthcare providers.

Exploring young patients' perspectives on rehabilitation care: methods and challenges of organizing focus groups for children and adolescents.

BACKGROUND: In research on quality of care, the experiences of children and (pre)adolescents are usually assessed by asking their parents. However, these young patients may have preferences of their own, and their experiences do not necessarily concur with those of their parents. Therefore, our research aimed to give young patients an opportunity to speak up for themselves. METHODS: Focus group meetings and online focus groups were organized for two age groups (8­11 and 12­15 years) of young patients from two Dutch rehabilitation centres, with the use of a tailored interview technique. The feasibility and applicability of both types of focus groups were assessed. RESULTS: For both types of focus groups, recruitment proved a major problem. The focus group meetings with (pre)adolescents proved both feasible and applicable in obtaining information regarding the preferences and experiences towards rehabilitation care. Regarding children's meetings, there were mixed results. The setting suited most of them, but some were more anxious. In general, online focus groups were less successful than expected for both age groups. CONCLUSIONS: Possibilities for enhancing the recruitment rate should be considered, as the low participation rates limited generalizability of focus group results. The tailored design proved useful for obtaining relevant input from (pre)adolescents through meetings, but, especially for children, repeated meetings or other locations (e.g. at home) could be considered. This may make participants more at ease. For both age groups, the online focus groups proved far less useful, in terms of participation.

Development of an instrument to assess professional behaviour of foreign medical graduates.

BACKGROUND: Foreign medical graduates have to overcome challenges such as language proficiency and cultural differences. Several studies indicate that foreign medical graduates show deficiencies in professional behaviour. For the assessment of foreign medical graduates' professional behaviour, a more specific and sensitive instrument was needed. The aim of this study was to develop such an instrument. The starting point was the Amsterdam Attitudes and Communications Scale (AACS). Two research questions were addressed: (a) What adaptations of the AACS are needed in order to assess foreign medical graduates' professional behaviour adequately? (b) Is the developed instrument reliable, valid and feasible? METHODS: Our study consisted of 4 phases: (1) a brief literature search; (2) consulting a panel of experts; (3) establishing the content-validity of the instrument; and (4) establishing the feasibility of the instrument as an assessment tool. RESULTS: From the literature and experts in the field we learned that deficiencies in professional behaviour of foreign medical graduates concern mainly language skills and culture related issues. In the instrument we developed special attention was given to these deficiencies. Sub-items were added to every dimension. These sub-items are behavioural descriptions of the respective dimension and serve as a basis for feedback. CONCLUSIONS: The sub-items should enhance constructive feedback, not only focussing on inappropriate behaviour but also by emphasizing adequate behaviours. The validity and reliability of the instrument has to be investigated further and confirmed along the way.

Progress testing with short answer questions.

The concept of progress testing was developed in the 1970s. Significant features of progress tests are that the content is not linked to any specific course or unit, and that it reflects the final objectives of the curriculum as a whole. The questions are taken from a broad domain and cover a range of disciplines. Furthermore, the test is taken repeatedly over a period of time, to monitor students' progress. Known progress tests all use closed format questions. In 2002-2003 the University Medical Center Utrecht initiated a progress test with short answer questions. The test consists of 40 cases, each with a clinical and a basic science short-answer key feature question. This differs from other progress tests that use close format items, but also in the philosophy of mastery level testing and in the deliberate linking of basic science concepts to clinical case vignettes. The first four executions of the test show high internal consistencies (Cronbach's alpha 0.85 to 0.87) and satisfactory item parameters. The effort of marking answers is reasonable, the effort of writing case vignettes with short-answer items is less than writing MC-items if similar test reliabilities are to be achieved.

Students' conceptions of the medical profession; an interview study.

Students' beliefs and attitudes towards the medical profession have been studied in relation to career choices, but most research has been restricted to either predetermined aspects or to a limited number of specialties. This study aimed at getting unprompted insight in the students' perceptions of their future profession in dimensions that may be determinants of study success and career choice. Undergraduate and graduated medical students were interviewed and asked to characterize the medical profession in general and four contrasting specialties in particular. Grounded Theory methodology was used to analyse the data. Participants were medical students at the start of their training (n = 16), during clerkships (n = 10) and after graduation (n = 37). Beginning students perceive the medical profession in limited dimensions: the activities of a physician, their relationship to patients and the physician's knowledge, skills and personality. They do not see many differences between specialties, in contrast with students with clinical experience and graduate students. Undergraduate students' perception is focussed more on social aspects of the profession compared to graduates.

Diversity in sexual health: problems and dilemmas.

The increase in migrant populations in western Europe has led to specific problems and dilemmas in the area of sexual and reproductive health and service provision. In general, these problems and dilemmas can be divided into four categories: (1) epidemiology of diseases and risk factors; (2) psychosocial and cultural aspects; (3) communication; and (4) moral and ethical dilemmas. Regarding epidemiology, there is an increased prevalence in migrant groups of unwanted pregnancy and abortion, HIV/STDs, and sexual violence. Effective contraceptive use is hampered by knowledge deficits, uncertain living conditions, ambivalence regarding the use of contraceptives, and problems accessing (information on) contraception. Psychosocial and cultural aspects relate to the norms and attitudes individuals and groups have regarding the family, social relationships, sexuality, and gender. These norms and attitudes have an impact on the sexual and reproductive choices people make and the possibilities and restrictions they feel in this respect. Problems in communication concern not only language but also communication styles, the way patients present their problems, and the expectations they have from the service provider. Communication problems inevitably lead to a lower quality of care. Moral and ethical dilemmas arise where cultures collide, for example regarding sexuality education and virginity problems. Two examples of practical situations in which migrant patients ask for help with sexual or reproductive health problems will be described.

Medical abortion as an alternative to vacuum aspiration: first experiences with the 'abortion pill' in The Netherlands.

OBJECTIVE: To establish to what extent medical abortion is desired as a supplement to existing care provision in The Netherlands and to establish the (dis)advantages of medical abortion versus surgical vacuum aspiration. METHODS: The research project began in November 1999 and ended in September 2000. In two abortion clinics, the clients were asked to answer some questions about their expectations (before treatment) and their experiences with the treatment (at the post-treatment check-up). At the post-treatment check-up, the clients were also asked to fill out the Hopkin's Symptom Checklist (HSCL) which is an objective measure for the psychological and physical well-being of the clients during the previous week. RESULTS: One hundred and thirty-one clients who chose medical abortion and 131 clients who chose surgical vacuum aspiration participated in the study. The failure rate was 3.3% for medical abortion and 1.5% for surgical vacuum aspiration. Of the medical abortion clients, 80.2% reported they were satisfied with this treatment and 68.1% said they would choose the same treatment procedure in the future. For vacuum aspiration, these figures were 92.9% and 83.2%, respectively. The most reported advantage of medical abortion was the fact that it was a pill, and no surgical procedures were necessary. The most reported disadvantages of medical abortion were the amount of blood loss and insecurity concerning the time of abortion. CONCLUSIONS: Medical abortion seems to be a good supplement to the existing care provision in The Netherlands and should be offered in other clinics.

Antioxidant properties of indapamide, 5-OH indapamide and hydrochlorothiazide evaluated by oxygen-radical absorbing capacity and electron paramagnetic resonance.

The aim of these experiments was to investigate the radical scavenging properties of three diuretics: indapamide (IND) and its major metabolite, 5-OH indapamide (5-OH IND), compared to a reference diuretic, hydrochlorothiazide (HTZ). Electron Paramagnetic Resonance (EPR) was used to determine the scavenging abilities of these compounds on enzymatically produced superoxide radical anion, with 5,5-dimethyl-1-pyrroline N-oxide (DMPO) used as a spin-trap. These experiments revealed that IND and specially 5-OH IND were effective superoxide radical anion scavengers at 0.2 mg/ml. In the second part of these studies, allophycocyanin was used as an indicator of free radical mediated protein damage. In the assay, 2,2'-azobis(2-amidinopropane) hydrochloride (AAPH) was used as a peroxyl radical generator, Trolox (a water-soluble analogue of vitamin E) as a control standard, and the loss of allophycocyanin fluorescence was monitored. The antioxidant effects of the diuretics were expressed in oxygen-radical absorbing capacity (ORAC), where one ORAC unit equals the net protection produced by 1 microM Trolox. HTZ showed no protection up to 100 microM final concentration, whereas IND and 5-OH IND showed linear correlation with respect to concentration when expressed in ORAC units: 5-OH IND induced the highest protection against peroxyl radical. The above observations suggested that IND and 5-OH IND are potent radical scavengers, with the metabolite 5-OH IND having a superior antioxidant potency than IND. By contrast, HTZ had no effect. These radical scavenging properties of 5-OH IND may be of clinical interest for vascular protection and may help to protect the heart from oxidative injury.

The beneficial effect of a beta-D-xyloside, Iliparcil, in the prevention of postthrombolytic rethrombosis in the rat.

The effect of Iliparcil, a new orally active beta-D-xyloside venous antithrombotic, was studied on the rethrombosis following thrombolytic therapy in rats, using a modified Umetsu model. The drug was administered by oral route prior to thrombolytic therapy, which consisted of administering a combination of heparin and urokinase (H/U) at 37.5 and 70,000 IU/kg, respectively. Time to reocclusion increased from 3.9 min with saline to 10.5 min following H/U injection. When Iliparcil (30 mg/kg, oral route) was administered 4 h before H/U injection, the time to reocclusion was increased by 250% compared with H/U alone (p < 0.001). Similarly, dermatan sulfate (DS), administered intravenously (3 mg/kg) 5 min before thrombus induction, also increased the time to reocclusion (300% compared with H/U alone; p < 0.001). It was also shown that times to reocclusion following Iliparcil or DS treatments were still increased even when heparin dosage was decreased. These results suggest that an antithrombotic product derived from the beta-D-xyloside family could be advantageously used in combination with thrombolytic treatment instead of heparin, which causes complications and side effects.

Lessons from the Dutch abortion experience.

PIP: Not only does the Netherlands have the lowest induced abortion rate in the world, but Dutch youth have the lowest rates of both adolescent pregnancy and abortion. This record is attributed to a general stance of openness and acceptance of sexuality as a healthy part of life that emerged in 1965-75 in response to recognition of the public health impact of unwanted pregnancy. Modern contraceptives (excluding condoms) are provided at no charge by the national health service and are easily accessible to teenagers. Sex education, which begins at an early age, seeks to instill skills that enhance partner communication and negotiation. By the late 1980s, unplanned births represented only 6% of all first births. In 1992, 38% of Dutch women terminated their first pregnancy compared with 47% in the US; that same year, the Dutch adolescent pregnancy rate was 9.2/1000 women 15-19 years old compared with 95.9/1000 in the US. In 1995, 85% of Dutch youth used contraception at first intercourse (46% condom, 13% pill, 24% pill and condom, and 1% other method). Overall, the Dutch experience suggests that a less ambivalent public approach to sexuality might encourage more responsible reproductive behavior in the US.^ieng

Ocular manifestations of relapsing polychondritis. Three case histories.

Relapsing polychondritis is a rare, presumably inflammatory autoimmune disorder affecting cartilagenous structures throughout the body. The ears, nose, joints, eyes and the respiratory tract are most frequently involved. The main ocular manifestations are episcleritis and scleritis, conjunctivitis, iridocyclitis and chorioretinitis, cataract and corneal infiltrates and melting. Extraocular signs and symptoms often are indicative of the diagnosis. Therapy includes systemic steroids, immunosuppressive drugs and dapsone. Three case histories are reported and the literature of ocular manifestations of relapsing polychondritis is reviewed.

[Contraception in young subjects]. / Anticonceptie bij jongeren.

PIP: In the last 2 decades have investigated the quality and determinants of contraceptive use among young people. The findings signified that a certain level of knowledge about fertility and contraception and a positive attitude regarding contraception are the preconditions of effective contraceptive use. Ambivalent and negative feelings of young people about their own sexuality affected the quality of contraceptive use negatively. Contraceptive use improved as young people became more experienced in sex with more sexual contact, the nature of their relationship was fundamental for contraceptive use, and peer groups influenced contraceptive behavior more decisively than parents. In the Netherlands sociodemographic variables, life experience, education level, religion, urbanization, and social class did not affect significantly their contraceptive use. Surveys conducted in 1990 and 1991 involving 337 young people aged 13-19 indicated that 20.7% of them used the pill at 1st coitus, 41.3% used the condom, 9.1% used both, 5.8% relied on coitus interruptus, and 16.5% used nothing. During the most recent coitus 47.7% used the pill, 29.4% used the condom, 8.3% used both, 2.8% used coitus interruptus, and 7.3% used nothing. The risk of getting AIDS has not induced young people to restrain their sexual activity. In a 1990 study 60% of young people thought of the possibility of getting infected with AIDS, and 87% had such a fear. 20% of adolescents ages 16-19 used condoms during the last coitus in 1981 compared with 55% in 1989. Annually 5500 girls ages 15-19 become pregnant (most unplanned) in the Netherlands: 9.2/1000 women in 1987. 43% of these were aborted according to 1989 data. In a 1986 comparative study the Netherlands featured with 14 pregnancies/1000 girls ages 15-19 (1980/81 figures) decreasing to 9/1000 since then; Sweden had 35/1000; France had 43/1000; England and Wales 45/1000; and the US had 96/1000.^ieng

Netherlands: study of teenagers gives pointers for better sex education.

PIP: Even though the Dutch have the lowest teenage pregnancy rate, an effort has been made to better understand contraceptive and abortion behavior. For 15-19 year olds, the Netherlands pregnancy rate was 14/1000 girls in 1980-81 compared with 35 in Sweden, 43 in France, 44 in Canada, 45 in England, and 96 in the US. The reasons given for the low rate were 1) easily accessible contraceptives through health practitioners or the 36 family planning clinics; 2) open, tolerant attitudes to sexuality; and 3) high quality sex education in or out of school. A 3-year study was begun in 1986 comparing sexual life styles and interaction skills of clinical contraceptive clients and abortion clients. Other participants were drawn from the general teen population. Findings were that 70% of both sexes used contraceptives at 1st intercourse (40% condoms, 20% the pill, 10% both). At the most recent intercourse, 85% used the pill and/or condoms. But 25% used no contraceptive at 1st intercourse or an ineffective method such as withdrawal. Of recent users, only 50% always used protection, and 1 in 10 made love more than 5 times without protection. Abortion clients, ineffective contraceptors, took more risks as a rule. 3 reasons account for this: 1) good contraceptors used contraceptives to prevent unwanted pregnancy. Ineffective ones identified contraception as a symbol of sexual readiness. 2) Good contraceptors were better communicators, while ineffective ones left the decision to the other partner. 3) Good contraceptors learned how to control and manipulate the situation, while abortion clients exercised no control. The importance for sex education is that it should include information as well as developing skills in responsible behavior. Understanding and accepting without disapproval the teen viewpoint and experience is very important. Peers need to learn how to negotiate and not take a passive role. Unwanted pregnancy, AIDS, and STDs should be included in the focus on sexuality.^ieng

Contraception and interaction among Dutch boys and girls.

PIP: In 1986, 337 Dutch youths aged 15-19 were asked to complete a questionnaire on their sexual and contraceptive behavior, their behavior with respect to AIDS prevention, and the sex education they had received. Of those who completed the questionnaire, 42% of the men and 33% of the women had experienced sexual intercourse. 71% of the men and 65% of the women who had experienced sexual intercourse expected to do so on their first episode, while 50% of the women had explicitly discussed it with their boyfriends beforehand. More than 70% used effective contraception at first intercourse, with 40% using condoms, 20% using the pill, and almost 10% combining both methods. At most recent intercourse, 85% used the pill and/or condoms. While 50% of the sexually active teens reported having always used contraception, 10% had had sexual intercourse more than five times without contraceptive protection. Further, 43% of boys compared to 15% of girls reported either initiating condom use or using condoms more regularly to protect themselves against HIV infection. 75% of the teens received sex education from one or both parents, although boys tended to be comparatively more neglected in this regard by their parents than girls. The central element of the three-year study on the sexual and contraceptive behavior of adolescents was, however, a qualitative comparison between the sexual lifestyles and interaction skills of 39 girls who visited a family planning clinic to obtain contraception and 34 girls who visited a clinic for an abortion. The abortion clients were less effective contraceptors than the girls from the other group, while the effectiveness of contraceptive use was more permanent in the family planning clinic group. While family planning seekers view contraception as a functional tool to prevent unwanted pregnancies, abortion seekers were more preoccupied by the sexual aspect of contraception rather than by its original function such that sex seemed to be less self-evident for the abortion clients than for the girls from the family planning clinic. Furthermore, abortion clients were less active than contraception seekers during precoital negotiation with their sex partners, and had comparatively less control over what happened during sexual contacts. The author stresses that sex education programs must educate young audiences, but also explicitly focus upon the possibilities of changes in attitude and behavior, negotiation skills, and the need for equal responsibility among sex partners about what happens during intercourse.^ieng