Improving inhaler adherence in a clinical trial through the use of the nebulizer chronolog.

This study examined whether utilizing an electronic medication monitor (Nebulizer Chronolog) to provide participants with detailed feedback on their metered-dose inhaler (ipratropium bromide or placebo) usage patterns would result in closer adherence to the prescribed regimen of two inhalations three times daily compared to a control group not receiving feedback. Adherence was also measured by canister weighing and self-report. Two-hundred fifty-one consecutive special intervention participants from the University of California, Los Angeles, and Johns Hopkins University centers of a National Heart, Lung, and Blood Institute-sponsored clinical trial were enrolled in this ancillary study. Compared to controls, feedback participants at the 4-month follow-up adhered more closely to the prescribed three sets per day (mean 1.95 vs 1.65) and used the prescribed two actuations in a greater percentage of sets (80 percent vs 60.3 percent). These results indicate that electronic monitoring of metered-dose inhaler use with a Nebulizer Chronolog in a clinical trial not only provides a more accurate assessment of adherence to prescribed inhaler use, but also enhances adherence when participants are given feedback of the monitoring results.

The effectiveness of smoking cessation advice given during routine medical care: physicians can make a difference.

Physicians may be hesitant to advise their patients to give up cigarette smoking partly because they doubt their own effectiveness. The three studies cited in this paper indicate that physicians can help their patients quit smoking if they briefly explain the benefits of quitting and provide concrete advice on how to go about it. This advice is effective primarily with light smokers. If smokers require medical care at least as frequently as nonsmokers and if physicians advise them (during routine care) to quit smoking, some 38 of the 54 million smokers could be reached in a single year. Further research is needed in areas such as physician motivation and the provision of information on smoking.

Seeking women's voices: setting the context for women's health interventions in two rural counties in Yunnan, China.

If interventions to improve health are truly to benefit women, they must be developed from the start with a critical understanding of women's own perceptions of their health problems and needs, and how these concerns are linked to other facets of women's lives. To obtain such understanding, it is crucial for health planners to seek out women in the communities where they live, to encourage them to speak in their own voices about their health and lives, and to be genuinely committed to listening to what the women have to say. This paper presents results of focus group discussions with village women in two rural counties in Yunnan, China. The data are derived from 28 focus group discussions conducted by the Women's Reproductive Health and Development Program in Yunnan as part of a comprehensive assessment of reproductive health needs in poorer, more remote areas of the two counties. The discussions were held to ascertain what village women themselves feel to be their most pressing health problems, and how these relate to work, family, social status and their use of health services. Results show how women's health and their use of health services are rightly intertwined with their labor roles, harsh environmental conditions and oppressive poverty. Widespread breakdowns in the village-level primary health care network lead village women to express a profound lack of confidence in local health services. The findings have several implications for planning and implementation. Demands on women's scarce time need to be explicitly considered when designing health education activities and health service delivery.(ABSTRACT TRUNCATED AT 250 WORDS)

Capacity building to improve women's health in rural China.

The Women's Reproductive Health and Development Program (WRDHP) is an ambitious attempt to operationalize two important tenets of health development thinking within a rural reproductive health context. First, it is important for communities to participate in decisions about the services and programs that affect them. Secondly, the complex nature of healthcare is best addressed by intervention processes which call for a multi-functional approach to planning and coordination. In both planning and intervention approach, the WRHDP recognizes the social, cultural and economic realities that affect women's efforts to secure the health and well-being of themselves and their families. The focus of the WRHDP is on capacity-building within a rural reproductive health environment, in this case Yunnan Province in rural China. Rather than using international donor funding to provide a specific intervention, the WRDHP used Ford Foundation funding as a lever to encourage community investment in environmental resources that affect health, to improve the technical skills of individuals within the existing health bureaucracies, and to promote structural changes within existing health and development bureaucracies to support interagency collaboration and community empowerment within the region's health and development agencies. This article describes how the WRHDP created new methods for provincial and local agencies to overcome obstacles and work with one another to improve women's health. It also describes the processes used in the rural areas of Chengjiang and Luliang counties to assess local conditions and needs, and the supported and expanded local efforts in improving woman's reproductive and family health that resulted from the processes.

Characteristics of women having abortion in China.

A pre-coded, closed response questionnaire was administered to women at abortion clinic sites in August 1985. The convenience sample was comprised of 1200 women, 200 samples in both Chengdu and the Lianshan Yi Autonomous Region in Sichuan Province, 400 in Nanjing and Jiangsu Province, and 400 in the municipality of Shanghai. The women were interviewed by physicians as part of the women's intake medical history. The sample yielded 574 respondents who were urban and 624 who were rural. The number of previous abortions reported ranged from 0 to 5. Nearly half of the abortion recipients had had at least one prior abortion and 18% had had two or more prior abortions. Education, age, marriage duration and residence have apparent effect on abortion order. The urban respondents reported an average of 1.08 children vs 1.60 children for the rural respondents. Approximately 72% of the respondents claimed to have been using a contraceptive method at the time they became pregnant. The most commonly used method was the IUD (41.6%), followed by the pill (21.3%) and the condom only (16.5%). Residence appeared to be the greatest factor determining the type of contraceptive methods. The data presented here are limited and cannot be generalized to the larger population. However, they do shed some light on the contraception characteristics of a group of women who undergo abortion procedures in China. Their response to questions to contracepting behavior prior to abortion suggests that the problem, in part, is behavioral. For example after the expulsion of the IUD, no other method was substituted to avert pregnancy. In order to alleviate the problem of contraceptive failure, and subsequent abortion, there are policy as well as training and education implications for the state.

AIDS and sexual practices: knowledge, attitudes, behaviors, and practices of health professionals in the People's Republic of China.

PIP: 68 upper level health professionals from 20 provinces in China completed to a questionnaire while attending either a health education workshop in Guangzhou in August 1989 or a similar workshop in Beijing in December 1989. The aim of the study was to determine their knowledge and attitudes since they were opinion leaders and key players in future AIDS prevention programs and to learn about sexual practices. 90% knew that a pregnant woman can transmit HIV to her infant and that sharing unclean needles can transmit HIV, but only 82.1% knew that someone with HIV can transmit it to a partner during sexual intercourse. 29.9% thought one can tell if someone has AIDS by looking at him or her. Newspapers and professional journals provided most of them with information on AIDS (80.6% and 73.1% respectively), but friends and government only provided this information to 29.9% and 19.4%. Overall the participants viewed AIDS as a threat to others and not themselves or families. 85-95% believed certain population groups such as policy makers, high school students, and the public should undergo sex education. Only 43.3% believed elementary schools should provide sex education, however. Participants tended to approve premarital sex and sex between individuals with emotional or long term ties more than extramarital sex. Nevertheless considerable percentage did condone extramarital sex. 95.8% experienced their 1st sexual relationship with their spouses. Even though participants tended to feel condoms did not make sex enjoyable, 81.6% and 72.5% believed condoms prevent pregnancy and sexually transmitted diseases respectively. 82% thought they were easy to use. 35% used condoms for contraception. Before using these upper level health workers to conduct AIDS training for lower level workers, they need to have a more thorough understanding of HIV transmission and the signs and symptoms of AIDS.^ieng

Characteristics of risk-taking behaviors, HIV and AIDS knowledge, and risk perception among young males in southwest China.

A cross-sectional survey was undertaken to describe risk-taking behaviors and to assess the knowledge and risk perception of HIV and AIDS among young males aged 18 to 29 years in 82 villages in Longchuan, Yunnan, China, in 1994. Information on demographic, behavioral, and drug-using factors, and knowledge of HIV transmission and prevention, and risk perception was collected using an interviewer-administered anonymous questionnaire. A total of 1,548 individuals were interviewed and 433 drug users, including 52 nonsharing injectors and 140 sharing injectors, were identified. Over half the individuals scored 0 on HIV knowledge, but knowledge was greater among nonsharing drug injectors. Most drug injectors had initiated drug injection after 1990. The reported incidence continues to increase in all three major ethnic groups. Sharing of equipment was common (73%) among injectors. Drug users were four times more likely to have had premarital or extramarital sex, but condoms were used by only 2.5%. Thus, factors promoting spreading of HIV are common in this area. We recommend that a community-based intervention program, targeting both young men and women, be implemented and evaluated in Longchuan as soon as possible.

Mental health recovery for psychiatric inpatient services: perceived importance of the elements of recovery.

OBJECTIVES. To develop a questionnaire for measuring the perceived importance of the elements of mental health recovery in psychiatric inpatients in Hong Kong and to test the psychometric properties of the questionnaire. METHODS. Thematic content analysis of identified literature on mental health recovery was performed to identify the elements related to mental health recovery. A questionnaire was developed to assess the perceived importance of the identified elements. An expert panel was set up to evaluate the content validity and patient focus group's face validity of the questionnaire. Participants were recruited from medium-stay and rehabilitation wards of Castle Peak Hospital. RESULTS. A total of 101 psychiatric inpatients completed the questionnaire, the majority of whom suffered from schizophrenia (75%). Having meaning in life was rated by 91% of the participants as an important element of recovery, followed by hope (86%) and general health and wellness (85%). Cronbach's alpha for internal consistency was 0.91. Explorative factor analysis yielded 7 factors and intraclass correlation coefficients revealed a fair-to-good test-retest reliability. CONCLUSIONS. The results supported the psychometric properties of the questionnaire for measurement of mental health recovery and serve as a basis for the future development of recovery-oriented services in the psychiatric inpatient settings in this locality.

Critical public health problems perceived by urban chinese health workers.

This study surveyed a cross section of urban Chinese health workers' perception of problems, needs and priorities in health care delivery. Eleven categories of problems were identified by the health workers. When asked to prioritize what they perceived as critical public health problems in China, more respondents (25.9%) cited family planning and maternal child health as the most critical problem. However, in terms of response frequency, family planning and maternal child health ranked fifth (10.7%) behind disease prevention (18.4%), health education of the public (15.4%), health services administration (13.1%), and environmental health (12.1%). Other critical problems identified were medical education (10.0%). industrial health (5.3%), research (4.5%), nutrition and food sanitation (4.5%), young adults (3.6%), and the elderly (3.6%). Apparently, family planning is perceived as the most critical societal health problem affecting the welfare of the state, but heart disease, cancer, dysentery, hepatitis, and others were perceived as personal health problems critical to the individual and the public. The delineation suggests a distinction of state versus individual priorities. The Chinese health workers saw solutions to these critical problems more often in combined measures of health education, policy regulation, and medical care, than in single measures. They recognized the importance of an enlightened public and felt that educating the public must undergrid all health measures to reach the goal of Health for All by the Year 2000.

Health behavior research toward health for all: issues and schema.

Health behavior research is concerned with the social, cultural and psychological determinants of health. Implicit in this is a focus on action that will lead to real-world improvements in health for the individual and in the community. Research in this area should not lose this focus. Programmatic needs must be understood if support is to be gained from policy makers. Along with the relevance of research, staff training is a key part of bridging the gap between the discovery of new knowledge and action to improve health.

China's One Child Family Program: Policies, Barriers and Communication Network.

China's experience in the one child family campaign is impeded by forces which are political, economic, cultural and administrative. The infrastructure for family planning can be enhanced by a vigorous communication strategy directed to the citizenry and cadres. The disincentive system created by some provincial and municipal authorities may signify a trend which is crucial to China's ability to bring its population growth under control.

Family Planning Information, Education and Communication: Current Activities in the People's Republic of China.

Based on observation of family planning activities in China in 1989 and 1990, this article takes a close look at education and publicity to promote family planning. Today these activities rely heavily on modern communication technology, especially TV and video, and continue to reflect an urban bias in content. The absence of male involvement in family planning was also noted. Family planning education has been strengthened in certain areas with the "five phases" approach and with the organization of "key households." The Family Planning Association with is 200,000 grassroots associations throughout the country and its 17,000,000 members has greatly increased the manpower pool for the delivery of educational services. It has also been instrumental in developing insurance schemes for one child families, and in some areas the primary function of Association members is surveillance aimed at detecting unplanned pregnancies. There is a need for improved training in the development of educational materials for family planning and in the provision of contraceptive services in rural areas.

Does smoking cessation lead to weight gain? The experience of asbestos-exposed shipyard workers.

We examined the relationship between smoking cessation and weight change in a sample of 373 asbestos-exposed workers who had participated in a smoking cessation program. Those who quit smoking for one year and those who quit for shorter periods gained significantly more weight than those who continued to smoke. Those with initially poorer health and those who quit to avoid illness gained less weight.

Increasing physicians' antismoking influence by applying an inexpensive feedback technique.

Continuing medical education that ignores motivational and environmental determinants of continued skill use will have little impact. Physicians who were trained to give antismoking advice to patients did so effectively soon after training, but their performance deteriorated during the next nine months. A subsequent study showed that antismoking effectiveness is maintained for extended periods if advice-giving rates are monitored monthly and physicians receive immediate corrective feedback whenever their performance declines.

A global review of training of community health workers.

Community Health Workers (CHWs) are often the most important deliverers of health care services. This review brings together relevant information on CHWs and their training. These materials concern themselves with training techniques as they have been developed in various programs in various countries around the world. Because of the relative newness of the field the bulk of the materials have been written only in the last ten years. Four phases in training CHWs to undertake primary health care work are reviewed. These are: assessing the community's health needs and priorities and specifying the CHWs' tasks, adapting CHW training to the community, selecting CHWs and providing the CHWs with training and support. Issues of concern relating to these phases are: who is the trainer, what training strategies are to be followed, how is the training to be monitored and evaluated and, finally, what is the cost. A guide to twenty-two manuals that have been developed in various countries for use in training CHWs is included.

HIV-related knowledge and attitudes among medical students in China.

A modified version of the 'WHO/KABP Questionnaire for Students' was administered to 302 students at a medical university in China. The instrument included items to assess the students' demographic background, knowledge of AIDS/HIV, attitudes about AIDS, as well as towards people infected with HIV, those groups commonly labelled as 'high risk' and toward sources of information. The average score on the knowledge scale was 80% correct. There was a substantial disparity in knowledge between how HIV is transmitted and how HIV is not transmitted--90% of the former items were answered correctly, while only 72% of the latter were answered correctly. Over 40% of the sample blamed prostitutes for AIDS in China, whereas 22% blamed drug addicts and 6% blamed homosexuals. Two-thirds of the sample indicated that they thought people with AIDS got what they deserve. About one-third of the sample supported quarantine measures as well as keeping infected students out of classrooms. Nearly half of the sample indicated that they did not trust any of the official sources of health information we asked about and 27% said that they thought the government was concealing information about AIDS.

PIP: A modified version of the WHO/KAP Questionnaire for Students was administered to 302 students at a medical university in China to assess their demographic background, knowledge of AIDS/HIV, attitudes about AIDS, and attitudes toward people infected with HIV. 90% responded correctly about how HIV is transmitted, but only 72% responded correctly to questions on how HIV is not transmitted; the average score on the knowledge scale was 80% correct. With regard to infected individuals in commonly considered high-risk groups, more than 40% blamed prostitutes for AIDS in China, 22% blamed drug addicts, and 6% blamed homosexuals. Two-thirds indicated that they thought people with AIDS got what they deserved; one-third supported quarantine measures as well as keeping infected students out of the classrooms; and almost 50% indicated that they did not trust any of the official sources of health information about which they were asked. 27% said that they thought the government was concealing information about AIDS.

Cancer knowledge and perceptions among Chinese factory workers: implications for cancer control and prevention.

The global "war on cancer" increasingly depends on public perceptions of primary and secondary cancer prevention and control efforts. Recognition of cancer warning signs, understanding the importance of early diagnosis, and participation in cancer screening programs are partly functions of an individual's attitudes and knowledge. A questionnaire designed to determine present knowledge and attitudes towards a variety of cancer issues was administered to a random sample of Chinese factory workers in two port cities in southeast China. Our findings revealed that, like Americans, Chinese workers are uncertain and ill informed about many cancer issues. this study also demonstrates that cancer risk factors, cancer warning signs, and harmful occupational exposures are not common knowledge among the Chinese lay public. These findings should facilitate future chinese cancer education and control efforts and further the need among health education planners to recognize and appreciate public perceptions and misperceptions of a notably complex disease.

Behavioral aspects of cigarette smoking among industrial college men of Shanghai, China.

A questionnaire survey was conducted among 7,665 students and staff in the factory-operated industrial colleges in Shanghai, China. Response rate was 95.7 per cent. The proportion of smokers among the men was 50.5 per cent; only 0.33 per cent of the women reported they were smokers. Male smokers began smoking upon entering the work force, where social interaction encourages cigarette smoking. Seventy per cent of the male smokers smoked fewer than 10 cigarettes per day. Only 4.3 per cent perceived themselves as very addicted; 3.4 per cent reported they had no confidence in their ability to control the amount they smoke. The Chinese smokers are more likely to succeed in giving up cigarette smoking for at least one day, as well as for longer periods, compared to US smokers. The number of cigarettes smoked may be related to the individual's purchasing power. For China, strategic timeliness in legislative action and education is urgently needed to combat the high prevalence of cigarette smoking in males, at extremely high risk.

Smoking cessation with young women in public family planning clinics: the impact of physician messages and waiting room media.

This study evaluated the impact of a media program and a physician-delivered message in encouraging smoking cessation among young black women in public family planning clinics. Incorporated into the clinic visit, the 3- to 5-min physician message was intended to elicit a commitment from participants to take steps toward quitting, namely, to think about quitting, set a target date, enlist the help of family and friends, throw away matches and cigarettes, and to then quit "cold turkey." The media program consisted of specially designed posters in waiting rooms showing models of people in the process of quitting and a continuously run movie dealing with women and smoking. A total of 1,179 female smokers were recruited into the study when they came to three separate clinics in Baltimore, Maryland, to receive gynecological examinations and/or contraceptive services. Four separate interventions were tested: (I) a baseline questionnaire about smoking habits and related information; (II) baseline questionnaire plus media program; (III) baseline questionnaire plus physician message; and (IV) baseline questionnaire plus media program plus physician message. Conditions I and II were administered in Clinic A on alternating weeks, Condition III was administered in Clinic B, and Condition IV was administered in Clinic C. Follow-up was conducted at 3 and 12 months. Follow-up rates were 88.1% at 3 months, 79.9% at 12 months, and 84.1% for both 3 and 12 months. Among women receiving the physician message (Conditions III and IV), 9.9% reported not smoking at 12 months; the lowest selfreported cessation rate was 3.1% in Condition I. When verified through analyzing cotinine in saliva, quit rates were 0.09% in Condition I, 2.4% in Condition II, 3.7% in Condition III, and 2.1% in Condition IV. The fact that participants receiving the physician message quit smoking at a significantly greater rate than those who did not indicates the need for further study of the impact of physician-delivered smoking cessation messages and ways to increase their effectiveness.

Metered-dose inhaler adherence in a clinical trial.

We studied patterns of inhaler usage in a sample of participants from two centers in the Lung Health Study clinical trial. The inhaler, containing either ipratropium bromide or a placebo, was prescribed to be taken as two inhalations three times daily. For 4 months we recorded adherence by both self-report (n = 95) and canister weight change (n = 70). We compared these results with data obtained from a microprocessor monitoring device, the Nebulizer Chronolog (NC), which records the date and time of each inhaler actuation. Seventy-three percent of the participants reported using the inhaler an average of three times daily; however, NC data showed that only 15% of the participants actually used the inhaler an average of 2.5 or more times per day. Canister weight overestimated adherence because only 62% of the NC sets contained the prescribed two actuations. Fourteen percent showed a pattern of actuation of their inhalers more than 100 times in a 3-h interval. We interpret this usage pattern to reflect deliberate emptying of inhalers to appear to be in good compliance with the prescribed program. We conclude that self-report and weighing of inhaler canisters overestimate adherence to the prescribed regimens. Furthermore, a substantial number of monitored inhaler users appear to deliberately dump their medication prior to follow-up visits.