Factors associated with nonresponse to a computer-tailored asthma management program for urban adolescents with asthma.

BACKGROUND: The ability to identify potentially resistant participants early in the course of an intervention could inform development of strategies for behavior change and improve program effectiveness. OBJECTIVE: The objective of this analysis was to identify factors related to nonresponse (i.e., lack of behavior change) to an asthma management intervention for urban teenagers. The intervention targeted several behaviors, including medication adherence, having a rescue inhaler nearby, and smoking. METHODS: A discriminate analysis was conducted using data from a randomized trial of the intervention. Included in this analysis are participants who reported a physician diagnosis of asthma, completed a baseline questionnaire, were randomized to the treatment group, completed >or=2 of 4 educational sessions, and completed >or=2 of 3 follow-up questionnaires. Ninety students met criteria for inclusion in this subgroup analysis. RESULTS: In logistic regression models for medication adherence, nonresponse was related to low baseline asthma self-regulation, odds ratio = 3.6 (95% confidence interval = 1.3-9.5). In models for having an inhaler nearby, nonresponse was related to low baseline self-regulation and to rebelliousness, OR = 4.7 (1.6-13.2) and 5.6 (1.7-18.0), respectively. Nonresponse to smoking messages was related to rebelliousness, low emotional support, and low religiosity, ORs = 7.6 (1.8-32.3), 9.5 (1.4-63.5), and 6.6 (1.5-29.8) respectively. CONCLUSIONS: Certain variables had the ability to discriminate the likelihood of response from that of nonresponse to an asthma program for urban, African American adolescents with asthma. These variables can be used to identify resistant subgroups early in the intervention, allowing the application of specialized strategies through tailoring. These types of analyses can inform behavioral interventions.

Increasing mammography utilization: a controlled study.

BACKGROUND: Despite the effectiveness of breast cancer screening for women older than 50 years of age, only about one third of these women in the United States receive annual mammography. PURPOSE: This study was designed to determine if a community-wide intervention could increase use of mammography screening for breast cancer. Secondary end points were determination of changes in women's knowledge and attitudes toward mammography and physicians' self-reported screening practices. METHODS: We conducted a controlled study from January 1987 through January 1990 in two eastern North Carolina communities--New Hanover County (the experimental community) and Pitt County (the control community). Before development and implementation of the intervention program in New Hanover County and after the program had been in operation for 1 year, 500 women of ages 50-74 years and all primary-care physicians in each community were interviewed by telephone. In these interviews, we determined the use of mammography for breast cancer screening and the knowledge and attitudes about it. We also established the number of screening mammograms performed in 1987 and 1989 in each county and reviewed medical records to determine the percentage of women the physicians had referred for mammograms. RESULTS: The percentage of women who reported receiving a mammogram in the previous year increased from 35% to 55% in the experimental community and from 30% to 40% in the control community (difference of differences, 10%; P = .03 after adjustment for race, education, age, and having a regular doctor; 95% confidence interval, 1%-18%). Increases were greater in New Hanover County regardless of age, race, income, and education. However, the increase was less for Black women than for White women, both overall and in most demographic subgroups. The total number of mammograms performed increased 89% in the experimental community and 45% in the control community. Women's knowledge about mammography changed little, but the intention to get a mammogram increased 30% in New Hanover County, compared with a 17% increase in Pitt County--a statistically significant difference (P < .01). Physician reports and medical record reviews in the two communities showed similar increases in the number of mammograms ordered. CONCLUSIONS: A community-wide effort to increase use of breast cancer screening was successful, but more work must be done to reach the National Cancer Institute's goal of annual mammograms for 80% of women of ages 50-74.

Interactive multimedia and risk communication.

As our understanding of risk factors and their interaction with individual susceptibility to disease improves, general messages designed to communicate risk seem increasingly ineffective and often misleading. Risk messages communicated through the mass media cannot convey an individual's personal susceptibility to preventable diseases or the seriousness of these diseases. The advent of new media technologies allows us to better reach the public with programs tailored to the needs and interests of individual users. Although similar in outward appearance to mass media, programs delivered through the Internet, CD-ROM, and computer kiosks offer the potential for vastly improved efficacy in communicating risk. This paper outlines the potential uses of interactive multimedia within the traditional goals of risk communication. A significant research endeavor, coupled with stronger avenues for dissemination, is recommended to achieve the potential of new media in a timely manner.

Smoking behavior, cessation techniques, and the health decision model.

The magnitude of the problem of smoking challenges health providers to persuade patients of the importance of trying to quit. Smoking behavior and cessation techniques are discussed in terms of the health decision model, a third-generation model combining health beliefs, decision analysis, and behavioral decision theory. This review suggests the need for physicians to emphasize factors such as health beliefs, self-efficacy, social support, and reduction of stress in smoking cessation efforts. Patients experiencing symptoms, particularly relating to the lungs or heart, may have stronger health beliefs and are clearly more likely to quit smoking. In the absence of a clear-cut advantage for any particular smoking cessation technique, physicians should provide advice about smoking as a regular part of every patient visit.

Interactive computer technology for skin cancer prevention targeting children.

BACKGROUND: Computer technology has become an integral part of health care, yet there have been few studies exploring the use of multimedia technology in the prevention of cancer, especially targeting children. OBJECTIVE: The aims of this study were to develop and evaluate a new multimedia computer program for the primary prevention of skin cancer among a childhood population. DESIGN AND PARTICIPANTS: An interactive CD-ROM program was developed, then pilot tested in a public elementary school in rural North Carolina. This intervention trial involved 8 third- and fourth-grade classes (N = 209 students), randomized into 3 groups: computer intervention, standard teacher-led intervention, and controls. MAIN OUTCOME MEASURES: Students were tested using pre- and postintervention surveys that measured knowledge, attitudes, and self-reported behaviors. A 7-month follow-up survey was performed. RESULTS: There was a significant increase in postintervention knowledge for the computer group when compared to either the teacher-led or control groups (mean scores out of 100: 75.2, 59.5, 55.0, respectively; p < 0.001). Attitudes about suntanning demonstrated a significant difference between the 3 groups (mean scores out of 100: 64.0, 53.0, 48.6, respectively; p = 0.002). There were slight improvements in the behavioral scores, especially among the computer group, but the overall differences were not significant. Similar overall results were found for the long-term follow-up survey, except that attitudes about suntanning no longer demonstrated a significant difference. CONCLUSION: These results indicate that this new educational tool is an effective way to introduce health education programs for young children in typical classroom settings. This prototype may serve as a model for the development of future preventive school-based programs, including applications to other conditions associated with high-risk behaviors among children.

Changing inaccurate perceptions of health risk: results from a randomized trial.

We sought to identify and correct inaccurate perceptions of risk among 1,317 adult patients in a primary care setting. Patients' perceived risks of heart attack, stroke, cancer, and motor vehicle crash were assessed and compared with a measure of risk derived from a health risk appraisal. Patients were then randomly assigned to receive computer-generated individualized risk feedback, risk feedback plus behavioral change feedback, or no feedback. Changes in perceived risk from baseline to a 6-month follow-up were compared across study groups. Results showed that individualized risk feedback was effective in increasing perceived stroke risk among patients who had underestimated their stroke risk at baseline and in reducing perceived risk of cancer among patients who had overestimated their cancer risk at baseline. Individualized risk feedback did not alter patients' perception of their heart attack and motor vehicle crash risks.

Computer-tailored smoking cessation materials: a review and discussion.

Tailored smoking cessation materials combine many of the interactive, diagnostic elements of a clinical encounter with the dissemination potential of mass media. In this article, the differences between general, targeted and tailored smoking cessation materials are discussed, and the impact of tailored versus the general or targeted modalities is examined. A review of ten randomized trials of tailored materials found a significant impact of these materials in a majority of the studies. Very few patterns, in terms of the characteristics associated with the tailored materials, subject recruitment, subject characteristics, or follow-up procedures were found when comparing positive versus negative trials. The two trials that combined tailored materials with nicotine replacement therapy found a strong impact on smoking cessation; studies that examine the combined effects of tailored behavioral and pharmacological interventions are suggested. Another notable finding was the effect tailored materials had among precontemplators. Most studies that included precontemplators found a significant positive impact of materials tailored to this group. Taken together, these findings suggest important new avenues for reaching smokers.

Psychosocial aspects of changes in cigarette-smoking behavior.

This paper examines the relationships between patients' perceptions of susceptibility to illness, self-efficacy, anxiety, social support and subsequent changes in cigarette-smoking behavior through a prospective study involving 213 patients using a Veterans Administration Medical Center (VAMC). During an inpatient or outpatient visit to the VAMC, veterans received a questionnaire and were then enrolled in a smoking cessation intervention trial wherein some patients received a practitioner-initiated minimal-contact intervention and other patients received usual care. Smoking status was assessed 3 months following hospital discharge. Analyses revealed that patients most likely to have reduced their smoking, whether in the intervention or control group, were those reporting both high perceived susceptibility and high expectations of efficacy. Those least likely to have reduced their smoking were those reporting high susceptibility but low efficacy--what has been characterized as a 'learned helplessness' mode. Expectations of efficacy were inversely associated with general level of anxiety; that is, those reporting high levels of anxiety tended to report lower levels of self-efficacy. This relationship was powerfully buffered by a measure of social support. The results of this study suggest a number of potentially effective counseling strategies for practitioners who are trying to get their patients to quit smoking.

Evaluation of a minimal-contact smoking cessation program in a health care setting.

A controlled evaluation of a minimal-contact smoking cessation intervention was conducted with 213 inpatients and outpatients at a Veterans Administration Medical Center (VAMC). The intervention had three components: Brief consultation from a health practitioner; administration of a self-help smoking cessation manual; and provision of an incentive to adhere to recommendations in the manual. Enrollment procedures differed from those of many other smoking-intervention trials in that, instead of enrolling only smokers who were motivated to quit, all patients who smoked and who would normally be considered eligible for a smoking-cessation intervention were included. The evaluation examined acceptability of the program to patients who smoked, overall effectiveness of the intervention, and efficacy of the intervention for specific patient demographic, social status, and health status groups. The program had a high degree of acceptance by patients who smoked, with over 60% agreeing to participate and take home the self-help smoking-cessation manual. The program was effective in getting patients to reduce their daily smoking, and marginally effective in influencing smoking cessation, with some patient groups exhibiting higher cessation rates than others. Special problems to be considered when attempting to influence groups of smokers at high levels of psychological stress and with low levels of education and income--factors normally associated with high rates of smoking and failure in traditional smoking-cessation programs--are discussed in light of the results obtained.

The potential of computers in patient education.

Typical computer programs for patient education are didactic and fail to tailor information to an individual's specific needs. New technology greatly enhances the potential of computers in patient education. Computer-assisted instruction programs can now elicit information from users before leading them through problem-solving exercises. New authoring systems enable health professionals to develop their own programs. The capacity to elicit and report back information about factors that influence patients' health behaviors give the newest computer programs one of the strengths of face-to-face patient counseling: the ability to tailor an educational message for an individual patient. These programs are not intended to replace but rather to enhance personal interaction between providers and patients. This article describes the advantages of using computers for individualizing patient education and assessing trends across groups of patients. Innovative programs and features to look for in programs and equipment selection are also described.

A minimal-contact smoking cessation program in a health care setting.

A minimal-contact smoking cessation program, designed for use in a health care setting, is described. Smokers receiving medical care as inpatients or outpatients at the Ann Arbor (Mich.) Veterans Administration Hospital receive a brief consultation about their smoking from a health practitioner. (For inpatients, the consultation occurs near the time of the patient's discharge from the hospital.) Toward the end of the consultation, if the patient decides to try to quit smoking, he or she is given a self-help smoking cessation kit in a 3-week-diary format. With the practitioner, the smoker fills out the first series of exercises in the kit, including a smoking awareness test, and signs a stop-smoking contract, which is cosigned by the practitioner. The patient takes the kit home, where the remainder of the kit's instructions and exercises are to be followed. Compliance is encouraged by weekly telephone calls from the health practitioner to check on the patient's progress and by offering the patient a State lottery ticket for each week of the diary completed. Although the materials for this program were created for veterans using the Veterans Administration medical care system, the program can be adapted to a variety of health settings and can employ different types of health care practitioners--physicians, nurses, physician's assistants, and allied health care providers.

A longitudinal analysis of predictors of quitting smoking among participants in a self-help intervention trial.

Predictors of 7-day abstinence from smoking were identified among participants in a randomized self-help smoking-cessation intervention trial conducted from 1985 to 1988 in Seattle, WA. Subjects were adult smokers belonging to a health maintenance organization who responded to an offer of free quitting assistance. Self-reported smoking status was assessed at 8, 16, and 24 months following enrollment. Predictors of abstinence were identified by longitudinal data analysis using Generalized Estimating Equations (GEEs), a modeling approach which handles repeated-measures data and accommodates time-dependent as well as time-independent covariates. Seventeen items emerged as significant (p < .05) predictors, with odds ratios ranging from 1.3 to 2.1. While much of the previous work in smoking-cessation research has focused on demographic and smoking history variables, results of this study indicate that emphasis should also be placed on psychosocial/motivational factors and quitting activities as important predictors of abstinence. Longitudinal data analysis represents a powerful technique for handling correlated (repeated measures) data, which may prove very useful for future studies of smoking cessation as well as other dynamic processes.

Perceived and actual breast cancer risk: optimistic and pessimistic biases.

Perceived risk can influence health behaviors. Studies using various populations and breast cancer risk bias assessment methods have identified both risk over- and underestimation. Among 1803 women in primary care settings, 47 percent were at average epidemiologic risk (Gail calculated relative risk ±50 percent of age-adjusted population average) and 55 percent perceived themselves to be at average risk (compared to same-age others) but there were mismatches or 'biases': 31 percent underestimated personal risk; 26 percent overestimated. Multiple logistic regression revealed that smokers were more likely to overestimate risk. Overestimation decreased with more education. Mammography use did not independently predict perception bias but, among never-screened women aged over 40 years, those contemplating mammograms were most likely to overestimate risk; precontemplators were most likely to underestimate. Implications for research and intervention are discussed.

Handheld computer-assisted self-interviews: user comfort level and preferences.

OBJECTIVES: To examine the comfort level and survey preferences of participants who completed handheld computer-assisted self-interviews (H-CASI). METHODS: Obstetrics patients (N=187) were surveyed about their comfort with the H-C

Opportunities for alcohol screening and counseling in primary care.

BACKGROUND: The physician can be an important part of a comprehensive strategy to assist persons with alcohol problems. This study was designed to contribute to the development of physician-initiated brief interventions for patients with alcohol problems by incorporating into an existing screening instrument questions that solicit information relevant to behavior change strategies. METHODS: Adult patients from 12 family practices in North Carolina (N = 2716) completed a self-administered questionnaire assessing alcohol consumption and other health-related behaviors. Alcohol problems were assessed using the four-item CAGE (Have you ever felt you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves, or to get rid of a hangover?). For this study, CAGE was adapted to address only the past 12 months. Patient interest in reducing the amount of alcohol consumed was measured using the Transtheoretical Model developed by Prochaska and colleagues. Patients were also asked about their motives for and barriers to reducing consumption. RESULTS: Five percent of all patients and 9% of patients who reported drinking alcohol gave positive responses on at least two CAGE items. Patients with three or four positive CAGE responses were 74% more likely to report an interest in reducing alcohol consumption than were those with one or two. Intrinsic reasons were the most important motives for reducing consumption. No pattern was found in barriers. CONCLUSIONS: We found that in the management of patients with alcohol-related problems, there are many clinical opportunities for patient counseling and referral in the family practice setting. Individually tailored brief interventions that take into consideration the patient's interest in, motives for, and barriers to reducing alcohol consumption are likely to be successful for the family practice physician.

The effects of computer-tailored smoking cessation messages in family practice settings.

BACKGROUND: Many conventional health education materials, such as pamphlets and booklets, are designed to reach as wide an audience as possible; they are therefore often lengthy and contain information irrelevant to many consumers. Computer technologies allow sophisticated tailoring of messages targeted to individual patients and free of irrelevant information. METHODS: In two studies in North Carolina (study 1, N = 51; study 2, N = 197), adult cigarette smokers were identified from a cohort of family practice patients. Cigarette consumption, interest in quitting smoking, perceived benefits and barriers to quitting, and other characteristics relevant to smoking cessation were collected. Based on this information, smoking cessation letters were tailored by computer to individuals. Smokers were randomly assigned to experimental (tailored health letters) or comparison groups (generic health letter in study 1, no health letter in study 2). Smoking status was assessed again at 4 months (study 1) or 6 months (study 2). RESULTS: Both studies found statistically significant positive effects of tailored health letters among moderate to light smokers. In study 1, 30.7% reported quitting after 6 months vs 7.1% in the control group (P < .05); in study 2, 19.1% vs 7.3% (P < .05). CONCLUSIONS: Results from both studies indicate positive effects of computer-tailored smoking messages among moderate to light smokers. These findings are consistent with the focus of our computer-tailored program on psychological and behavioral factors related to smoking cessation. Smoking cessation outcomes may be enhanced by combining tailored messages with nicotine replacement therapies to treat physical dependency. Methods of tailoring health messages and incorporating the results into family practice are described.

Improving physician-patient interactions: a review.

The interaction between physician and patient comprises aspects of communication common to any two human beings and other aspects peculiar to the roles exclusively adopted by physicians and patients. In this review, nonverbal and verbal elements of general communication are discussed, detailing important aspects of vocal tone, body postures, appearance, and verbal cues that may influence attributions made of physicians by patients. Role-related elements of physician-patient interactions are discussed in light of findings from research on interactions between physicians and patients. Developmental elements of general communication are discussed, relating stages tht evolve in interactions to physician-patient interactions. Finally, an examination is made of how interpersonal skills are taught to physicians and medical students. Discussion of what skills are specified for teaching, whether they are effectively taught, and whether the learning of these skills produces desired patient health-related outcomes is presented.

Do tailored behavior change messages enhance the effectiveness of health risk appraisal? Results from a randomized trial.

Health risk appraisal (HRA) remains one of the most widely used health promotion tools despite only equivocal evidence for its effectiveness. Theories of behavior change predict conventional HRA's ineffectiveness because risk information alone is seldom sufficient to change complex behaviors. In this study, a randomized trial compared the effects of feedback from an enhanced HRA with a typical HRA and a control group among adult patients from eight family medicine practices. The enhanced HRA assessed behavior-specific psychosocial factors and provided patients with computer-generated, individually-tailored behavior change information in addition to typical HRA risk feedback. Changes in seven behaviors were assessed at a 6 month follow-up. Overall, patients receiving enhanced HRA feedback were 18% more likely to change at least one risk behavior than were patients receiving typical HRA feedback or no feedback (OR = 1.18, 95% CI = 1.00, 1.39). The enhanced HRA feedback appeared to promote changes in cholesterol screening, dietary fat consumption and physical activity, but not in smoking, seat belt use, mammography and Pap smears. We conclude that the addition of theory-based, individually-tailored behavior change information may improve the effectiveness of HRA.

Social learning theory and the Health Belief Model.

The Health Belief Model, social learning theory (recently relabelled social cognitive theory), self-efficacy, and locus of control have all been applied with varying success to problems of explaining, predicting, and influencing behavior. Yet, there is conceptual confusion among researchers and practitioners about the interrelationships of these theories and variables. This article attempts to show how these explanatory factors may be related, and in so doing, posits a revised explanatory model which incorporates self-efficacy into the Health Belief Model. Specifically, self-efficacy is proposed as a separate independent variable along with the traditional health belief variables of perceived susceptibility, severity, benefits, and barriers. Incentive to behave (health motivation) is also a component of the model. Locus of control is not included explicitly because it is believed to be incorporated within other elements of the model. It is predicted that the new formulation will more fully account for health-related behavior than did earlier formulations, and will suggest more effective behavioral interventions than have hitherto been available to health educators.

Attributions for previous failures and subsequent outcomes in a weight reduction program.

This prospective study examines the effects of causal attributions given to previous weight control failures on subsequent success in controlling weight. Adult participants enrolled in a weight control program were screened to identify those who had made previous weight reduction attempts through a formal program. Once identified, subjects (n = 158) were asked to make causal attributions for their previous failures. Subjects were then followed through the 15-week program to determine their degree of success. Subjects who attributed the cause of previous failures to stable, immutable conditions were more likely to have low expectations of success. Low success expectancies, in turn, were associated with lack of goal attainment through the program. The number of previous failures in formal weight control programs was associated with a perception of the respondents that previous failures had stable causes. Neither the number of former failures nor the attributions of their causes were directly related to goal attainment. Practice implications of the results are discussed.