Development of a survivorship needs assessment planning tool for head and neck cancer survivors and their caregivers: a preliminary study.

PURPOSE: The purpose of this study was to characterize primary end-of-treatment challenges in head and neck cancer (HNC) to drive the development of a survivorship needs assessment planning (SNAP) tool and evaluate its acceptability and feasibility. METHODS: Using qualitative methods (focus groups, interviews), we identified physical, emotional, and social post-treatment challenges from the perspectives of survivors (N = 17), caregivers (N = 14), and healthcare providers (N = 14) and pretested the SNAP tool. After Advisory Board ratings and consensus, the tool was finalized. RESULTS: Survivors, caregivers and clinicians consistently highlighted the importance of assessing symptoms and functional abilities (e.g., dry mouth, speech/swallowing difficulties, weight loss), health behaviors (e.g., smoking, alcohol), emotional concerns (e.g., depression, isolation, nutritional distress), and social challenges (e.g., support, finances). Caregivers were overwhelmed and intensely focused on survivors' nutrition and trach/feeding tube care while clinicians emphasized financial and access concerns. Most participants were enthusiastic about the tool and directed a flexible care plan design due to variability in dyad needs. Over 75% reported high comfort using and navigating questions on a tablet and were in strong agreement that the care plan would help families practically and emotionally. Coordination of survivorship visits with follow-up care was critical to address travel and time barriers. While survivors and clinicians recommended waiting 1-6 months after treatment, caregivers preferred earlier survivorship visits. CONCLUSIONS: Results pinpointed optimal end-of-treatment domains for routine assessment and support the feasibility of implementing a SNAP tool in the clinic. IMPLICATIONS FOR CANCER SURVIVORS: Capitalizing on technology to direct HNC survivorship care is promising.

Feasibility of universal screening mammography. Lessons from a community intervention.

It is estimated that 44,500 American women will die of breast cancer in 1991. The breast cancer screening guidelines of the American Cancer Society and the National Cancer Institute calling for annual mammography for all women older than 50 years have been endorsed by numerous professional groups. Third-party reimbursement for screening mammography is becoming more prevalent, and payment for screening mammography is now a Medicare benefit. Our studies, conducted as part of a National Cancer Institute grant to increase the routine use of screening mammography and clinical breast examination in women 50 to 75 years of age, have uncovered a number of significant barriers to the implementation of screening guidelines among women, primary care physicians, and providers of mammography services. These barriers, as well as methods to assure the quality of mammography, need to be addressed before universal screening is feasible.

Predictors of AIDS-preventive behavior among homosexually active men: a longitudinal study.

Predictors of adoption of safer sexual behaviors were examined in a cohort of 278 homosexually active men with stable HIV-antibody status followed over 12 months at a Boston community health center. The behaviors examined included: (1) restriction of partners to one monogamous or steady relationship and (2) among men who maintained multiple or non-steady partners, the avoidance of unprotected receptive and insertive anogenital contact. For each behavior, men who adopted consistently safer behavior were compared with those who remained unsafe, using bivariate analyses and multiple logistic regression modelling. The strongest predictor of all behaviors was the initial level of the unsafe behavior. After controlling for this, weak effects of several health beliefs were found, including perceived susceptibility and medical efficacy. Men who became aware of a positive HIV-antibody test result and who reported greater effort to change their behavior were more likely to adopt safer insertive anogenital contact. In this generally well-educated cohort with high levels of knowledge about AIDS, adoption of safer sexual behaviors is best predicted from previous levels of unsafe behavior.

Maintenance of behavioral change in a cohort of homosexually active men.

OBJECTIVES: To assess associations of perceptions of sexual behavior change with actual risk behaviors and psychosocial variables, and to determine whether perceptions of behavior change predict subsequent behavior. DESIGN: Cohort study of homosexually active men. SETTING: Community health center in Boston, Massachusetts, USA. PATIENTS, PARTICIPANTS: Two hundred and sixty-two cohort members who participated in follow-up in 1989 and who had at least one subsequent visit. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Composite risk behavior variable, based on unprotected anogenital contact and number of partners. RESULTS: Of the 96% who had effected behavior change, 47% perceived that they were able to maintain those changes consistently and 58% wanted to make more changes. Perceptions of consistent maintenance were associated with lower risk behavior, lower perceived riskiness of behaviors and susceptibility to AIDS, and fewer barriers to behavior change. Desire for more change was associated with increased behavioral effort, fewer barriers to condom use, and greater perceived riskiness of current behavior. Among those with lower risk behaviors, perceived inconsistent maintenance predicted relapse to more risky behavior at the following visit. CONCLUSIONS: Perceived maintenance of behavior change is potentially useful in identifying individuals at risk of relapse from safer sex.

PIP: Public health researchers followed a cohort of 322 homosexually active male clients enrolled at a community health center in Boston, Massachusetts between January 1985-April 1987 at 6-month intervals to examine cross-sectional and longitudinal data on perceptions of sexual behavior change among initially asymptomatic and homosexually active men. Only 262 completed the questionnaire addressing perceptions of behavior change. 40% of the 60 students who did not complete the questionnaire tested positive for HIV compared with 22% of those who did complete the questionnaire (p.01). High risk included unprotected anogenital contact with multiple partners. HIV status was not associated with behavior change. Behavior change was associated with alcohol or drug use during sex for men of low or modified high risk at baseline (p=.01). 96% of 262 men achieved sexual behavior change after learning about AIDS. 58% hoped to make additional changes. 47% thought that they could always sustain the changes. Men who were not consistent in practicing behavioral changes were more likely to want to make more changes (p.001). Men who perceived themselves to practice inconsistent behavior did indeed practice high risk behavior (p=.005). Those who perceived themselves to consistently practice lower risk behavior at follow up were 2.07 times more likely to practice safer behavior than those who did not see themselves as practicing consistent behavior. Follow up data showed that men were somewhat more likely to return to risky behavior than change to safe behavior (p=.07). In fact, men who at baseline participated in high risk behavior were 1.57 times likely to continue the high risk behavior. For men who at baseline participated in low risk behavior tended to continue that behavior (odds ratio=8.88). The researchers concluded that perceived maintenance of behavior change could help health professionals determine which people are at a risk of reverting to risky sex behavior.

Use of drugs and alcohol by homosexually active men in relation to sexual practices.

The use of alcohol and recreational drugs in relationship to sexual practices was investigated longitudinally and cross-sectionally in a cohort of homosexually active men at a Boston community health center. Use of marijuana, nitrite inhalants, and cocaine decreased by approximately 25-48% during 42 months of follow-up, whereas use of alcohol showed little change. Men who initially reported both high-risk sexual practices and some use of alcohol or marijuana and who subsequently stopped using marijuana or reduced their frequency of alcohol use were significantly more likely to stop those unsafe sexual practices than were those who continued to use these substances. Men who at their most recent visit reported impaired judgement during sexual activity due to substance use, and particularly due to drug use, had significantly higher levels of perceived susceptibility to AIDS and barriers to behavior change, and lower levels of self-efficacy, which were independent of their unsafe sexual practices.

Impact of a physician intervention program to increase breast cancer screening.

In order to improve compliance with the National Cancer Institute's breast cancer screening guidelines, we developed a multifaceted intervention designed to alter physician screening practice. A pre-post test, two-community design was used. Primary care physicians in one community served as the control. Data were collected by two mailed surveys (1987 and 1990). Response rates were 61% and 64%, respectively. The physician intervention program consisted of a hospital-based continuing medical education program and an outreach component which focused on implementing a reminder system. Outcome measures were self-reported attitudinal, knowledge, and screening practices changes. In spite of an impressive change in comparison community physicians' practice, the difference in change over time in the intervention community physicians' ordering of annual mammography compared to the change in the comparison community physicians' ordering was significant (P = 0.04). The adjusted odds ratio is nearly 8. We conclude that our in-service continuing medical education program was successful in improving breast cancer screening practices among primary care physicians.

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.

The risk factors of age and family history and their relationship to screening mammography utilization.

OBJECTIVE: To study the association of two well known risk factors for breast cancer and the association of knowledge of those risk factors with mammography utilization. DESIGN: Cross sectional: two independent random telephone surveys. SETTING: Two Northeastern metropolitan communities surveyed in 1987 and in 1989. PARTICIPANTS: Women without breast cancer who spoke English and who were between 45 and 75 years of age. MAIN OUTCOME MEASURES: The two risk factors measured were a family history of breast cancer and being 65 or older. Participants were surveyed about their knowledge of risk factors, presence of risk factors, selected beliefs, attitudes, reinforcing factors and mammography use. Results were analyzed for women 50-75. RESULTS: There was a substantial increase in mammography use over the 2-year period. Having a positive family history or being older is not associated with increased mammography utilization. Knowledge that family history and/or age are risks is associated with increased utilization. However, knowledge of risk factors is not associated with having those risks. Older women have lower utilization than younger women regardless of their knowledge of age as a risk. Increased physician recommendation is associated with increased utilization. CONCLUSION: Since knowing that a factor is a risk and having a physician recommend mammography are each associated with increased use, we conclude that the primary care physicians' role in increasing mammography utilization is critical.

Nicotine replacement prescription practices of obstetric and pediatric clinicians.

OBJECTIVE: To assess smoking cessation counseling and nicotine replacement therapy prescription and recommendation practices among obstetric and pediatric providers. METHODS: We sent out a self-administered survey to 61 obstetric and pediatric nurse practitioners and physicians at six community health centers in the Boston area. RESULTS: Obstetric providers were more likely to view smoking cessation counseling as their responsibility in treating pregnant women than pediatric providers did in treating infants with mothers who smoked (mean +/- standard deviation [95% confidence interval] 4.5 +/- 0.76 [4.2, 4.8] versus 4.0 +/- 0.8 [3.7, 4.3] on a five-point scale; P <.05). Obstetric providers believed that smoking cessation counseling was more effective than did pediatric providers (3.45 +/- 1.1 [3.0, 3.9] versus 2.8 +/- 0.8 [2.5, 3.1] on a five-point scale; P <.05) and were more likely to report provision of cessation assistance than pediatric providers (63% [44%, 82%] versus 17% [5%, 29%]; P <.05). Obstetric providers were more likely to prescribe or recommend over-the-counter nicotine replacement therapy than pediatric providers (44% [25%, 63%] versus 11% [1%, 21%], P =.004). Reasons for not prescribing nicotine replacement differed according to specialty; however, perceived lack of efficacy was not a typical reason given by clinicians in either specialty. Only two of 47 practitioners who did not prescribe or recommend those therapies listed that as a factor in their decisions. CONCLUSION: We found that nicotine replacement therapies are commonly prescribed or recommended to pregnant smokers by obstetric providers, but less commonly to lactating women by pediatric providers.

Breast self-examination by young women: I. Characteristics associated with frequency.

We surveyed a stratified random sample of college women (n = 869) to investigate correlates of the frequency of breast self-examination (BSE) in two young, relatively low risk populations, undergraduate and graduate women. The findings from this study compared to those from studies on older women suggest that certain factors are associated with BSE frequency for women of all ages (i.e., confidence in one's ability to perform the exam and exposure to information on breast cancer). There also appear to be distinct factors associated with the frequency of BSE performances among women within specific age-groups. For the younger, undergraduate women, attitudinal barriers; medical services use; skill knowledge; perception of personal control in detecting lumps; reinforcement through clinical breast exam; and the discussion of BSE with others were important factors in accounting for the variation in frequency of BSE performance. For the graduate women, in addition to confidence in one's ability to perform the test and exposure to breast cancer messages, one's perceived susceptibility, knowledge of risk factors, and perception of personal control in detecting lumps were important. The independent variables examined within each age-group accounted for a substantial amount of the variance in the dependent measure (34 percent and 42 percent, respectively, for undergraduate and graduate women), as compared to previous research, which has explained only 7-15 percent of the variance in BSE performance. This tends to validate our approach of using a multidimensional conceptual framework drawn from existing theoretical orientations.(ABSTRACT TRUNCATED AT 250 WORDS)

Breast self-examination by young women: II. Characteristics associated with proficiency.

Studying a stratified random sample of university women (n = 869) we investigated the correlates of proficiency (i.e., the correctness or competence) of breast self-examination (BSE). A 19-item BSE quality index score was developed based on the recommended steps a woman should perform when doing the exam in the three BSE positions. A comprehensive set of independent variables including knowledge, attitudes and perceptions, personal characteristics, and environmental factors were studied. While proficiency scores for both undergraduates and graduates were relatively low, the mean score for graduates was significantly higher than for undergraduates. This study corroborates the few recent studies that indicate that frequency of performance is not highly correlated with proficiency (relationships were r = .14 and .04, respectively, for undergraduate and graduate women). Bivariate and multivariate regression analyses demonstrate that the relevance of such factors varies by age (undergraduate and graduate). Results of the regression model indicate that the skill knowledge variable regarding time of month BSE should be performed, awareness of BSE, perceived effect of cancer detection, and perceived benefit of BSE were predictors of more proficient practice for undergraduates. Knowledge of time of month to do BSE and mammogram as a detection technology and discussion of BSE with others were important for graduate women. The independent variables examined accounted for 22 percent and 30 percent of the variance, respectively, for undergraduate and graduate women.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Effect of a community health center intervention on breast cancer screening among Hispanic American women.

OBJECTIVE: A multiple component intervention in a community health center is presented, and its effect on breast cancer screening participation by Hispanic American women between the ages of 45 and 75 years is discussed. DATA SOURCES/STUDY SETTING: In 1990, data were collected through a retrospective audit (at least as far back as 1987) of community health center medical records, as well as from a client referral log. The health center, located in a small Massachusetts city, primarily serves clients of Latino heritage. STUDY DESIGN: The study used a nonexperimental pretest-posttest intervention design to document clients' screening activities. To control for uneven length of enrollment, aging of the population, and sporadic utilization, the unit of analysis chosen for the principle study variables was an "eligible year." DATA COLLECTION: Variables of interest included screening (clinical breast exam and mammography), periodicity of screening, and compliance with referrals. PRINCIPAL FINDINGS: Postintervention, considerably greater screening mammography occurred among all age groups, more women had at least one screening mammogram during the period, more clinical breast exams included a mammogram referral, and the compliance rate improved. The rate of clinical breast exam did not significantly improve, showing a downward trend.

Age and sex differences in presentation of symptoms among patients with acute coronary disease: the REACT Trial. Rapid Early Action for Coronary Treatment.

BACKGROUND: There are few data on possible age and sex differences in presentation of symptoms for patients with acute coronary disease. OBJECTIVE: To investigate demographic differences in presentation of symptoms at the time of hospital presentation for acute myocardial infarction (AMI) and unstable angina. METHODS: The medical records of patients who presented with chest pain and who also had diagnoses of AMI (n = 889) or unstable angina (n = 893) on discharge from 43 hospitals were reviewed as part of data collection activities of the Rapid Early Action for Coronary Treatment trial based in 10 pair-matched communities throughout the USA. RESULTS: Dyspnea (49%), arm pain (46%), sweating (35%), and nausea (33%) were commonly reported by men and women of all ages in addition to the presenting complaint of chest pain. After we had controlled for various characteristics through regression modeling, older persons with AMI were significantly less likely than were younger persons to complain of arm pain and sweating, and men were significantly less likely to report vomiting than were women. Among persons with unstable angina, arm pain and sweating were reported significantly less often by elderly patients. Nausea and back, neck, and jaw pain were more common complaints of women. CONCLUSIONS: Results of this study suggest that there are differences between symptoms at presentation of men and women, and those in various age groups, hospitalized with acute coronary disease. Clinicians should be aware of these differences when diagnosing and managing patients suspected to have coronary heart disease.

Social network, support and influence: relationships with drug use and protective AIDS behavior.

One reason for difficulty in long-term maintenance of behavior changes by injection drug users (IDUs) is the concomitant support or distraction from the IDUs social environment. This study explored the relationship of social factors--e.g., encouragement from friends, beliefs about social norms--with drug injection behaviors. Subjects were clients in a short-term residential detoxification program. Self-reports of drug and AIDS-protective behaviors were gathered at baseline and at least 6 months following a trial of enhanced vs. informational educational interventions. Results provide support both for the general hypothesis about the influence of peers and drug-use partners prior and subsequent to detoxification and for the greater effectiveness of the enhanced intervention on social factors. Particularly important to improved drug use behavior were decreased number of friends who inject drugs (social network), increased number of people to talk with when upset (social support), and increased argument skills about safe drug use (social influence).

Assessment of chest pain onset and out-of-hospital delay using standardized interview questions: the REACT Pilot Study. Rapid Early Action for Coronary Treatment (REACT) Study Group.

OBJECTIVE: To determine the consistency of responses to a standardized 2-part "key" question (Key-Q) about acute symptom onset in patients presenting with chest pain when measured using alternative questions (Qs) about symptom perception and decisions to seek treatment. METHODS: A structured patient interview was performed at 3 university teaching hospitals and 1 community hospital. Convenience samples of adult patients presenting to these EDs with chest pain were asked specific questions related to their symptoms and recognition of illness. Information obtained included the 2-part Key-Q: "What are the symptoms that brought you here today?" and "When did those symptoms start?" The alternative Qs (in order of use) were as follows: Q1 = "When did your very first symptom or sensation begin?"; Q2 = "When did your symptoms lead you to think something was wrong or that you were ill?"; Q3 = "When did your symptoms become serious enough for you to seek medical care?"; and Q4 = "When did you actually call 9-1-1/emergency medical services (EMS) or go to the hospital?" The documented ED arrival time, demographic variables, and whether the patient arrived by ambulance were obtained from the medical record. Patients also were queried regarding potential barriers to seeking medical care and their cardiac risk factors. RESULTS: Of the 135 patients surveyed, 9 were unsure of the date and time of symptom onset. For the 126 patients with analyzable data, the mean (+/- SD) patient age was 62 +/- 16 years, and 59% were male. The general sequence of events reported from acute symptom onset until hospital care was Q1/Key-Q-->Q2-->Q3-->Q4-->ED arrival. The median differences and interquartile ranges (IQRs) in minutes between Q times and the Key-Q response were: Q1 = 0 (0-0); Q2 = 30 (0-210); Q3 = 140 (30-720); Q4 = 265 (90-1,215); and ED arrival = 340 (120-1,230). The interval from the Key-Q response until calling 9-1-1/EMS or going to the hospital was shorter for those who used an ambulance and for those who did not consult a physician first. The interval from the Key-Q response until considering symptoms to be serious was shorter for those with a family history of heart disease, but longer for non-white patients. CONCLUSION: The Key-Q elicited a response recalled near the time of first symptoms and generally before the patient had concluded something was "wrong or that he or she was ill." Measurement of the out-of-hospital delay in chest pain patients using the Key-Q appears promising.

Rapid early action for coronary treatment: rationale, design, and baseline characteristics. REACT Research Group.

OBJECTIVE: Early reperfusion for acute myocardial infarction (AMI) can reduce morbidity and mortality, yet there is often delay in accessing medical care after symptom onset. This report describes the design and baseline characteristics of the Rapid Early Action for Coronary Treatment (REACT) community trial, which is testing community intervention to reduce delay. METHODS: Twenty U.S. communities were pair-matched and randomly assigned within pairs to intervention or comparison. Four months of baseline data collection was followed by an 18-month intervention of community organization and public, patient, and health professional education. Primary cases were community residents seen in the ED with chest pain, admitted with suspected acute cardiac ischemia, and discharged with a diagnosis related to coronary heart disease. The primary outcome was delay time from symptom onset to ED arrival. Secondary outcomes included delay time in patients with MI/unstable angina, hospital case-fatality rate and length of stay, receipt of reperfusion, and ED/emergency medical services utilization. Impact on public and patient knowledge, attitudes, and intentions was measured by telephone interviews. Characteristics of communities and cases and comparability of paired communities at baseline were assessed. RESULTS: Baseline cases are 46% female, 14% minorities, and 73% aged > or =55 years, and paired communities have similar demographics characteristics. Median delay time (available for 72% of cases) is 2.3 hours and does not vary between treatment conditions (p > 0.86). CONCLUSIONS: REACT communities approximate the demographic distribution of the United States and there is baseline comparability between the intervention and comparison groups. The REACT trial will provide valuable information for community educational programs to reduce patient delay for AMI symptoms.

Impact of community intervention to reduce patient delay time on use of reperfusion therapy for acute myocardial infarction: rapid early action for coronary treatment (REACT) trial. REACT Study Group.

BACKGROUND: Reperfusion therapy for acute myocardial infarction (AMI) is a time-dependent intervention that can reduce infarct-related morbidity and mortality. Out-of-hospital patient delay from symptom onset until emergency department (ED) presentation may reduce the expected benefit of reperfusion therapy. OBJECTIVE: To determine the impact of a community educational intervention to reduce patient delay time on the use of reperfusion therapy for AMI. METHODS: This was a randomized, controlled community-based trial to enhance patient recognition of AMI symptoms and encourage early ED presentation with resultant increased reperfusion therapy rates for AMI. The study took place in 44 hospitals in 20 pair-matched communities in five U.S. geographic regions. Eligible study subjects were non-institutionalized patients without chest injury (aged > or =30 years) who were admitted to participating hospitals and who received a hospital discharge diagnosis of AMI (ICD 410); n = 4,885. For outcome assessment, patients were excluded if they were without survival data (n = 402), enrolled in thrombolytic trials (n = 61), receiving reperfusion therapy >12 hours after ED arrival (n = 628), or missing symptom onset or reperfusion times (n = 781). The applied intervention was an educational program targeting community organizations and the general public, high-risk patients, and health professionals in target communities. The primary outcome was a change in the proportion of AMI patients receiving early reperfusion therapy (i.e., within one hour of ED arrival or within six hours of symptom onset). Trends in reperfusion therapy rates were determined after adjustment for patient demographics, presenting blood pressure, cardiac history, and insurance status. Four-month baseline was compared with the 18-month intervention period. RESULTS: Of 3,013 selected AMI patients, 40% received reperfusion therapy. Eighteen percent received therapy within one hour of ED arrival (46% of treated patients), and 32% within six hours of symptom onset (80% of treated patients). No significant difference in the trends in reperfusion therapy rates was attributable to the intervention, although increases in early reperfusion therapy rates were noted during the first six months of the intervention. A significant association of early reperfusion therapy use with ambulance use was identified. CONCLUSIONS: Community-wide educational efforts to enhance patient response to AMI symptoms may not translate into sustained changes in reperfusion practices. However, an increased odds for early reperfusion therapy use during the initiation of the intervention and the association of early therapy with ambulance use suggest that reperfusion therapy rates can be enhanced.

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.

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.