Evaluation of the use of an "ask-the-expert" e-consultation service for support on health-related requests.

E-consultation in health care can be used to respond to an increasing demand for care by offering support on health-related requests. In this study we evaluated the use of an "ask-the-expert" e-consultation service in order to assess whether the service is efficient and useful. A content analysis of e-mail exchange between clients and online health professionals was performed to gain insight in the purposes of use of the service. Our findings show that the e-consultation service was used for health requests on not urgent, minor ailments. Clients asked for health information to increase knowledge on the cause of their injury or disease, its consequences, possible self-care solutions and treatment options. Decision support on assessing the necessity to visit a doctor for a certain health problem was another important reason to use the service. We believe that web-based triage systems could be used to more easily assess whether certain symptoms need to be investigated.

Condom use among low-literate, rural females in Ethiopia: the role of vulnerability to HIV infection, condom attitude, and self-efficacy.

To date, studies on psychosocial determinants of condom use among adolescents in Africa have mainly focused on more literate urban youth. In this study, we investigated the psychosocial determinants of condom use among low-literate females in rural Ethiopia. Moreover, some controversy exists on the role of perceived vulnerability to HIV infection to promote HIV preventive behavior in Africa, which we also tried to clarify in this study. In this study, 200 rural females participated, aged 13-24, from the Amhara Highland in Ethiopia. Using data collectors who interviewed the low-literate females with a structured questionnaire, we assessed perceived vulnerability to HIV infection, response efficacy of condom use, self-efficacy, attitude to condom use, and subjective norm to condom use. Moreover, we assessed intended and actual condom use. Compared to non-users of condoms, users of condoms scored significantly higher on all psychosocial determinants. Regression analysis indicated that vulnerability, condom attitude, and self-efficacy were significantly related to intended condom use. Attitude, vulnerability, and response-efficacy were significantly related to actual condom use. Among low-literate females in rural Ethiopia, psychosocial determinants were strongly related to intended and actual condom use, which indicates the usability of psychosocial models of condom use among low-literate females.

[Dementia and technology. A study of technology interventions in the healthcare for dementia patients and their caregivers]. / Dementie en technologie. Een studie naar de toepassingen van techniek in de zorg voor mensen met dementie en hun mantelzorgers.

PURPOSE: To explore the possibilities for IT interventions in care of older persons with dementia. METHOD: Inventory of international and national studies on implemented technology interventions for the care of persons with dementia and their caregivers. Three categories of technology are distinguished: (1) help with symptoms of dementia (2) social contact and company for the patient, and (3) health monitoring and safety. RESULTS: Eighteen international and eight national studies are included. The first results of the effects of technology interventions for patients with dementia look promising. Evidence exists for significant improvements as to the quality of life and effects on behaviour (such as less falling). The caregivers and healthcare professionals are satisfied with the usability of the technology. The purchase and user costs, however, are often too high. The labour satisfaction of healthcare professionals in relation to the use of technology has rarely been studied. CONCLUSION: Although technology can improve the ability to cope with certain consequences of dementia, the effects of technology for dementia patients, caregivers and healthcare professionals has not yet been extensively studied. Further research may focus on effects of technology for people with dementia and their caregivers as to their quality of life, feeling of safety and work satisfaction, respectively.

Participation in online patient support groups endorses patients' empowerment.

OBJECTIVE: Although much has been expected of the empowering effect of taking part in online patient support groups, there is no direct evidence thus far for the effects of participation on patient empowerment. Hence our exploring to what extent patients feel empowered by their participation in online support groups, and which processes that occur in these groups are related to the empowering outcomes. METHODS: An online questionnaire was completed by 528 individuals who were active in online groups for patients with breast cancer, fibromyalgia and arthritis. RESULTS: The respondents felt empowered in several ways by their participation. The empowering outcomes that were experienced to the strongest degree were 'being better informed' and 'enhanced social well-being'. No significant differences in empowering outcomes between diagnostic groups were found. The empowering outcomes could only be predicted in a modest way by the processes that took place in the online support groups. CONCLUSION: This study indicates that participation in online support groups can make a valuable contribution to the empowerment of patients. PRACTICE IMPLICATIONS: Health care providers should acquaint their patients with the existence of online support groups and with the benefits that participation in these groups can offer.

Women's opinions about attending for breast cancer screening: stability of cognitive determinants during three rounds of screening.

OBJECTIVES: To examine the stability of beliefs and intentions towards repeat attendance at breast cancer screening, using the Theory of Planned Behaviour. The aims of the study were to examine whether and how cognitions changed in the course of the programme, and whether intentions that were assessed proximally were better predictors of behaviour than those assessed distally. DESIGN AND METHODS: A total of 2,657 women filled out a baseline questionnaire (T(1)), 2 months after being invited for an initial mammogram in the Dutch Breast Cancer Screening Programme. Actual attendance data in the second and third screening rounds were subsequently collected and follow-up questionnaires were sent to parts of the sample at four points in time: shortly before (T(2)) and after (T(3)) the second screening round, and shortly before (T(4)) and after (T(5)) the third screening round. RESULTS: Only minor changes in beliefs and intentions were found. In the assessments shortly before screening, women were somewhat less positive about attending than in the assessments shortly after screening. Throughout the course of the programme, women's opinions about attending remained positive. In fact, women became somewhat more convinced that they were vulnerable to getting breast cancer, and that participating in screening was beneficial to them. Actual attendance in subsequent rounds of screening was higher than expected. Proximal beliefs and intentions were only slightly more predictive of actual behaviour than distal beliefs. CONCLUSIONS: In organized breast cancer screening, beliefs and intentions remain positive and rather stable. Although our results should be interpreted with caution, due to little variation in behaviour, they suggest that the gap between intentions and behaviour could not be substantially reduced by proximal assessment of determinants.

Monitoring women's experiences during three rounds of breast cancer screening: results from a longitudinal study.

OBJECTIVES: (a) To monitor experiences of women during three successive rounds of breast screening; (b) to examine the impact of previous experiences (obtained either immediately after the latest mammogram or shortly before the subsequent one) on reattendance; and (c) to examine which factors are associated with the experience of pain and distress during screening. SETTING: The Dutch Breast Cancer Screening Programme METHODS: 2657 women completed a baseline measurement (response rate 67%) about 8 weeks after they had been invited for an initial mammogram (T(1)). Actual participation data of these women in the second and third rounds of screening were collected. Follow up questionnaires were sent to subgroups of the sample at different times: shortly before the second screening (T(2); response rate 86%), shortly after the second screening (T(3); response rate 85%), shortly before the third screening (T(4); response rate 80%), and shortly after the third screening (T(5); response rate 78%). RESULTS: Most women were satisfied with the first screening round and remained positive about subsequent screens. Although pain and anxiety were not uncommon, only a few (10%-15%) experienced moderate or severe levels of distress or pain. Experiences were relatively stable: women who experienced pain in the first screen were more likely to experience pain in subsequent screens (r values from 0.39 to 0.50). Fear of breast cancer was associated with increased distress related to mammography and, to a lesser extent, with increased pain during the mammography. Evidence was found for a relief effect: women were more positive about their previous screen when asked shortly after this screen, than when asked just before the subsequent one. Previous experiences (obtained either proximally or distally) were only slightly predictive for future attendance. CONCLUSION: Experiences during mammography are fairly stable. Negative experiences were generally not a reason to drop out of the programme.

Does mammographic screening and a negative result affect attitudes towards future breast screening?

OBJECTIVES: To investigate the impact of an experience of a benign mammographic result on intention to seek medical help immediately in the case of breast abnormalities, and on intentions and thoughts about future participation in screening. SETTING: The Dutch Breast Cancer Screening Programme for women aged 50-69. METHODS: Subjects were women who were invited for an initial breast examination: 223 women filled out a questionnaire about 10 days before and about 6 weeks after their initial breast examination. To be able to control for possible test effects, another group of 293 women filled out a questionnaire only after mammography. Changes in thoughts and intentions were examined. RESULTS: Most women were very satisfied with the course of their initial breast examination, although pain or discomfort was often mentioned. No clues to suggest false reassurance were found: more than 99% of the women would consider the possibility of breast cancer if they felt a lump in one of their breasts. In such a situation, most women intended to seek medical help within a week. These variables were not influenced by the experience of mammography with a benign result. In general, women were very positive about (repeat) participation, both before and after screening. After screening, the average woman perceived fewer costs in participating, and perceived her own ability to engage in future screening as higher. However, the experience of pain and anxiety during the initial screening did lead to reverse effects. Women who were less satisfied about their treatment by the staff were more likely to change their intentions to reparticipate in a negative way. CONCLUSIONS: As, in general, women became more positive about regular participation after they had attended breast cancer screening, efforts to improve first round attendance must be continued. At the same time, the screening organisations must continue to prioritise the high level of client friendliness throughout the screening. No evidence for detrimental effects of screening through false reassurance among participants was found.

Benefit from the inclusion of self-treatment guidelines to a self-management programme for adults with asthma.

This study assessed the long-term efficacy of adding self-treatment guidelines to a self-management programme for adults with asthma. In this prospective randomized controlled trial, 245 patients with stable, moderate to severe asthma were included. They were randomized into a self-treatment group (group S) and a control group (group C). Both groups received self-management education. Additionally, group S received self-treatment guidelines based on peak expiratory flow (PEF) and symptoms. Outcome parameters included: asthma symptoms, quality of life, pulmonary function, and exacerbation rate. The 2-yr study was completed by 174 patients. Both groups showed an improvement in the quality of life of 7%. PEF variability decreased by 32% and 29%, and the number of outpatient visits by 25% and 18% in groups S and C, respectively. No significant differences in these parameters were found between the two groups. After 1 yr, patients in both groups perceived better control of asthma and had more self-confidence regarding their asthma. The latter improvements were significantly greater in group S as compared to group C. There were no other differences in outcome parameters between the groups. Individual self-treatment guidelines for exacerbations on top of a general self-management programme does not seem to be of additional benefit in terms of improvements in the clinical outcome of asthma. However, patients in the self-treatment group had better scores in subjective outcome measures such as perceived control of asthma and self-confidence than patients in the control group.

Behavioural effect of self-treatment guidelines in a self-management program for adults with asthma.

To assess the efficacy of self-management programs it is important to know what behavioural changes take place. This paper assesses whether including self-treatment guidelines (action plans) in a self-management program for adult asthmatics, leads to greater behavioural changes than a program without these guidelines. Patients were randomised into a self-treatment group (n=123) or an active control group (n=122). All subjects received self-management training. Discussed topics included the pathophysiology of asthma, medication and side-effects, triggers, symptoms, smoking, physical exercise, and compliance. The only difference was that the self-treatment group received instructions about self-treatment of exacerbations and the control group did not. At 1 year of follow-up asthma-specific self-efficacy expectancies, outcome expectancies, and asthma-specific knowledge improved significantly in all patients. Only self-treatment group patients demonstrated favourable changes in generalised self-efficacy, social support, and self-treatment and self-management behaviour, in case of a hypothetical scenario of a slow-onset exacerbation. We conclude that our self-management program is effective in changing the behavioural variables, and including self-treatment guidelines (action plans) has added benefit.

Effectiveness of a minimal contact smoking cessation program for Dutch general practitioners: a randomized controlled trial.

BACKGROUND: Until recently, Dutch general practitioners contributed little to tobacco control. This is due to several factors, among which is the lack of a feasible intervention program for adult smokers. Such a minimal contact behavioral intervention, using the Stage-of-Change concept, is now available. Effectiveness was tested in a randomized trial. METHOD: Twenty-two general practitioners and their practice assistants were trained in applying the program. In all, 530 smoking patients were enrolled, randomly assigned to either the intervention or the usual treatment condition. Analysis of treatment effects was performed with logistic regression analysis. In a backward stepwise procedure confounding effects of baseline differences were eliminated. RESULTS: At 12-month follow-up, self-reported abstinence rates (including nonrespondents as smokers) differed significantly between intervention subjects and controls: 13.4 vs 7.3% point prevalence (odds ratio 1.51, P < 0.05). An analysis of consecutive abstinence, defined as being abstinent at both 6- and 12-month follow-up, showed that 8.2% of the intervention group compared to 3.1% of the controls had sustained abstinence for more than 6 months (odds ratio 3.04, P < 0.001). CONCLUSIONS: Results indicate that an effective smoking cessation program for use in Dutch general practice, already shown to be feasible, is now available. Outcomes are generally consistent with recent international literature.

Multiple inhalers confuse asthma patients.

This study investigated the influence of the use of different types of inhalers on the adequacy of inhalation technique among adult asthmatics. Three hypotheses were tested: first, patients using only one type of inhaler will demonstrate adequate inhalation technique more often than those with two or more types. Secondly, patients using a combination of dry powder inhalers (DPIs) will demonstrate correct inhalation technique more often than those using the combination of a metered dose inhaler (MDI) and a DPI. Thirdly, some inhalers or combinations of inhalers are more prone to erroneous inhalation technique than others. Adult outpatients with asthma who regularly used inhaled steroid therapy (n=321) participated in the study. The inhalers investigated were MDIs on the one hand, and the DPIs Turbuhaler, Diskhaler, Cyclohaler, Inhaler Ingelheim and Rotahaler on the other. Of 208 adult asthmatics with only one inhaler, 71% made no inhalation errors versus 61% of 113 patients with two or more different inhalers. Of patients with a combination of DPIs 68% performed all essential checklist items correctly, versus 54% of patients with the combination of "regular" MDI and DPI. Patients using only the Diskhaler made fewest errors. Whenever possible, only one type of inhaler should be prescribed. If a combination is unavoidable, combinations of DPIs are preferable to MDI and DPI. The Diskhaler seems to be the most foolproof device.

Inhalation technique of 166 adult asthmatics prior to and following a self-management program.

Self-management of asthma and self-treatment of exacerbations are considered important in the treatment of asthma. For successful self-treatment, medication has to be inhaled correctly, but the percentage of patients inhaling effectively varies widely. As part of a self-management program we checked and corrected inhalation technique. This paper addresses differences among inhalers in relation to patient characteristics and the effect of instruction, 1 year after enrollment. Maneuvers that are essential for adequate inhalation were identified. When errors in inhalation technique were observed, patients were instructed in the correct use of their devices. One year later, inhalation technique was checked again. Only patients who used the same inhaler throughout the entire study period were analyzed. Of the 245 adult asthmatic patients who were enrolled in the self-management program, 166 used the same inhaler throughout the study period. One hundred twenty patients (72%) performed all key items correctly at baseline and this increased to 80% after 1 year. At follow-up, older patients were less likely to demonstrate a perfect inhalation. Patients with a Diskhaler made fewest errors. Adjustment for differences in patient characteristics did not significantly change the results. Because many patients with asthma use their inhaler ineffectively, there is a need to know which inhaler leads to fewest errors. Diskhaler was nominated by this study. When patients are not able to demonstrate adequate inhalation technique in a "tranquil" setting, it is doubtful that they can do so when they experience an exacerbation. Therefore, inhalation instruction should be considered an essential ingredient, not only of self-management programs, but also of asthma patient care in general.

Development of a needs assessment system in rehabilitation.

The aim of this project was to develop a standardized, valid and reliable instrument for determining needs of patients and quality of care as perceived by patients. A questionnaire was constructed based upon the Service Quality Model. This model, patient expectations and experiences all play an important role in the questionnaire. The questionnaire contains a general part which includes ten determinants of care, the information the patient got and the perceived quality of care in general. The questionnaire also contains a specific part which includes questions about the actual care for diagnosis related problems. Twenty-four spinal cord injured patients, staying at a Dutch rehabilitation centre, participated in this study. It is concluded that with the developed questionnaire the perceived quality of care according to the Service Quality Model can be assessed. Major contributions of the questionnaire to rehabilitation care will be its ability to highlight patient needs related to identified symptoms, and to provide a tool to signal aspects in the organization that can be improved. Thus it becomes a tool for quality management. Recommendations have been made for further research to make future use of the questionnaire in other settings and populations possible.

Medical opinions, beliefs and prescription of orthopaedic footwear: a survey of Dutch orthopaedists and rehabilitation practitioners.

OBJECTIVES: To get insight into medical opinions about the use of orthopaedic footwear and the medical and social factors related to the prescription of orthopaedic footwear by orthopaedists and rehabilitation practitioners. METHODS: In this study 85 orthopaedists and 96 rehabilitation practitioners filled out a questionnaire measuring perceived desirability of prescribing orthopaedic footwear in specific medical conditions, the perceived advantages of orthopaedic footwear, the perceived disadvantages of orthopaedic footwear, the attitude to orthopaedic footwear and satisfaction with the co-operation with the pedorthist. Clinicians were asked to estimate their referral rate of orthopaedic footwear. RESULTS: Orthopaedists and rehabilitation practitioners agree that the prescription of orthopaedic footwear should be considered in the case of rheumatoid arthritis, amputation of the foot and diabetic foot and not be considered in the case of sprain and back pain. In the case of hallux valgi, dermatological problems and clavus (severe corn) a reticent prescription policy seems to be the optimal choice. In the other medical conditions studied no unequivocal prescription policy could be derived. Respondents who prescribed orthopaedic footwear more than the median (more than 50 prescriptions per year) were more often rehabilitation practitioner, perceived more advantages of prescription footwear, perceived less disadvantages of prescription footwear and were more satisfied about the co-operation with the pedorthist. CONCLUSION: In some medical conditions orthopaedists and rehabilitation practitioners agree about the optimal use of orthopaedic footwear. In some other medical conditions orthopaedists and rehabilitation practitioners are divided about the use of orthopaedic footwear. Reported rate of prescription was not related to desirability of prescription, but was related to beliefs such as perceived advantages, perceived disadvantages and satisfaction with co-operation with the pedorthist, underlining the importance of cognitive factors in prescription style.

[Knowledge about drugs used by adult patients with asthma for self-treatment]. / Medicijnkennis van volwassenen met astma onvoldoende voor zelfbehandeling.

OBJECTIVE: To assess the knowledge of adult asthmatics about medication for self-treatment. DESIGN: Descriptive. SETTING: Department of Pulmonary Diseases, Medisch Spectrum Twente, Enschede, the Netherlands. METHODS: As a part of a larger project aimed at improvement of self-management and self-treatment, all adults aged 18-65 years in Enschede (population 146,000) reported by the city pharmacists as using medication for asthma or chronic obstructive pulmonary disease, in 1994 were sent a questionnaire including 7 items pertaining to knowledge about lung medication. From among those who failed to respond after a written reminder and an appeal in local papers, a random group of 9% were interviewed by telephone. Of the responders who reported that according to their GPs they had asthma and who had answered the questions on medication, the number of questions answered correctly was counted; in addition, the question was investigated whether their level of knowledge was related to sex, education, use of (inhalation) corticosteroids and the form of explanation received. RESULTS: A total of 4563 questionnaires were sent out: 2259 (50%) usable forms were returned. The responders were better educated than the 192 non-responders interviewed, but did not differ as to age or sex. Of the responders, 1262 (56%) reported that their GPs had told them they had asthma. On average they had answered 2.4 (range: 0-7) out of 7 questions correctly. Previous instruction, number of sources of information, duration of taking medication, use of inhaled steroids, female sex and better education were all positively related with a higher knowledge score in this group. CONCLUSION: Adult asthmatics did not have sufficient knowledge about their medication. Improving such knowledge should therefore be an important element in the development of a self-management programme.

Are high generalised and asthma-specific self-efficacy predictive of adequate self-management behaviour among adult asthma patients?

In asthma self-management training, often self-treatment guidelines are included, because increased knowledge of asthma alone is not sufficient to change behaviour. One way to achieve behavioural changes is by increasing the patient's general and asthma-specific self-efficacy expectancies. This refers to beliefs in one's capabilities to execute the recommended course of action successfully. We wanted to assess whether high generalised and asthma-specific self-efficacy expectancies were predictive of adequate self-management and self-treatment behaviour. A questionnaire was sent to 4563 persons (18-65 years) who had used inhaled medication in 1993. Self-management and self-treatment behaviour were operationalised through a hypothetical scenario of a slow-onset asthma exacerbation. Of all 1262 asthmatic patients, 39.3% showed adequate self-treatment behaviour (self-adjusting their inhaled or oral steroids when appropriate). Age, asthma-specific outcome expectancies and knowledge were predictive of adequate self-treatment. Adequate self-management behaviour (self-treatment or seeking medical help) was observed in 56.4% of patients. Intentions towards self-management and asthma-specific knowledge were significant. Only knowledge has a relevant influence on both. Asthma-specific knowledge is the only factor that seems relevant for adequate self-management and self-treatment behaviour, which might be explained by the hypothetical nature of the scenario. When patients experience a real asthma exacerbation, self-efficacy expectancies will become more important. Only if knowledge of what to do is present will patients be able to show proper self-management and self-treatment behaviour. Our results suggest that self-treatment guidelines are only effective in combination with patient education, which is important for optimal control of their disease.

Evaluation of the long-term effectiveness of three instruction modes for inhaling medicines.

Inhaled medication is important in the treatment of chronic obstructive pulmonary disease (COPD). In this paper a comparison of the long-term efficacy of three instruction-models is presented. A total of 152 COPD-patients were randomized into one of four groups: Personal-, video-, group-instruction and a control group. Inhalation technique was assessed by means of checklists, on which essential inhalation manoeuvres were identified. Up to 9 months later, 148 patients returned for follow-up assessment. Prior to instruction 61% of patients in the control group had a perfect score on essential actions, compared to 62, 65 and 53% for those receiving group-, personal- and video-instruction respectively. At follow-up these percentages were 49, 97, 75 and 76%. For group-(35%) and video-instruction (24%) the increase from baseline was significant. Examining the different inhalers under investigation, it is striking, that only 24% of all patients with a Metered Dose Inhaler (MDI) performed all essential checklist items correctly, versus 96% for those using a Diskhaler. The fact that for the MDI this percentage improved to 90% post-instruction, shows that time spent on instruction, is time well spent. We conclude that group instruction seems superior to personal counselling, and equally effective or even better than video instruction. Personal instruction should not be dismissed and a combination with video instruction might prove to be effective as well.

Health education to improve repeat participation in the Dutch breast cancer screening programme: evaluation of a leaflet tailored to previous participants.

Participation in breast cancer screening programmes often declines in the course of the programme. The purpose of the present study was to examine whether health education could diminish the amount of drop-outs between two screening rounds. The health education was tailored to women who previously underwent mammography. Based on the Elaboration Likelihood Model two versions of the tailored leaflet were made: a simple version and a version with additional peripheral cues. In an experimental study among 2961 women the effects of the tailored leaflets on reparticipation were tested against a standard leaflet. Re-participation rates were high (> 90%) and did not differ between the 3 groups. No significant differences regarding beliefs about re-participating were found between the 3 groups. Results indicate that the tailored information leaflets did not enhance re-participation. Therefore, the required additional efforts and costs do not seem to be justified. The results of the study provide indications that less painful mammograms and friendly staff might improve re-participation.

Perceived risk, anxiety, mammogram uptake, and breast self-examination of women with a family history of breast cancer: the role of knowing to be at increased risk.

Since women with a first-degree relative with breast cancer are at increased risk for breast cancer, it is of special importance that they adhere to early detection programs. In this study, women with (389) and without (3295) a family history of breast cancer were compared with respect to risk perception, breast cancer anxiety, and early detection behavior. Special attention was paid to the role of knowing that family history is a breast cancer risk factor. It was found that 46% of "family history positives" did not know that their risk was increased by their family history. Still, family history positives had increased risk perception; our results suggest that this was partly caused by their knowing they belonged to a risk group and partly by their having experienced the disease at close range. Although family history positives had higher risk perceptions, no differences in early detection behavior were found. This could not be attributed to high anxiety levels. Implications for health education are discussed.

Group education for patients with rheumatoid arthritis.

Patients with rheumatoid arthritis must learn to adjust their exercise, rest and medication to the varying activity of the disease. Patient education can help patients in making the right decisions about adjustments in their treatment regimen and in attaining "self-management" behaviors. We developed a group education program based on social learning theory and the 'Arthritis Self-Management Course' developed in the USA by Lorig. Goal of the program is the strengthening of self-efficacy, outcome expectations and self-management behaviors of RA patients which may lead to better health status. The program has been evaluated in an experimental design. We established significant positive effects of the group training on functional disability, joint tenderness, practice of relaxation and physical exercises, self-management behavior, outcome expectations, self-efficacy function and knowledge. After 14 months we still found effects on practice of physical exercises, self-efficacy function and knowledge.