Multi-site analytical validation of an assay to detect anti-JCV antibodies in human serum and plasma

Background

JC virus (JCV) infection is a prerequisite for development of progressive multifocal leukoencephalopathy (PML). We previously described the development of a novel, two-step enzyme-linked immunosorbent assay (ELISA) that detects anti-JCV antibodies in human serum or plasma, and the potential clinical utility of anti-JCV antibody status for PML risk stratification.

Objectives

To validate the anti-JCV antibody ELISA at multiple clinical laboratories in order to demonstrate the robustness of the method.

Study design

Analytical validation of the ELISA was performed at four laboratories by evaluation of intra- and inter-assay precision, analytical specificity and sensitivity, matrix interference, robustness, sample and reagent stability.

Results

Analytical validation demonstrated that the assay is sensitive, specific, and precise. The assay sensitivity was estimated at 1.7 ng/mL using a humanized anti-JCV monoclonal antibody control. The sensitivity to detect JCV infection was estimated to be 97.5%. The specificity of the assay to discriminate JCV-specific antibodies from antibodies directed to BK virus, a related polyomavirus, was also demonstrated. The inter- and intra-assay precision was ≤6.0% and 9.8% for the screening step and 2.6% and 11.3% for the confirmation step. Results obtained for plasma and serum were highly congruent, and assay robustness was demonstrated by the highly concordant results generated by four laboratories testing a common panel of 100 blinded samples.

Conclusions

The novel, two-step ELISA to detect anti-JCV antibodies in human serum and plasma is robust, and assay performance is consistent and reproducible in multiple laboratories, making it suitable to support testing for global clinical studies.     

Improving diet and exercise in pregnancy with Video Doctor counseling: a randomized trial

Objective

To determine if an interactive, computerized Video Doctor counseling tool improves self-reported diet and exercise in pregnant women.

Methods

A randomized trial comparing a Video Doctor intervention to usual care in ethnically diverse, low-income, English-speaking pregnant women was conducted. Brief messages about diet, exercise, and weight gain were delivered by an actor-portrayed Video Doctor twice during pregnancy.

Results

In the Video Doctor group (n = 158), there were statistically significant increases from baseline in exercise (+28 min), intake of fruits and vegetables, whole grains, fish, avocado and nuts, and significant decreases in intake of sugary foods, refined grains, high fat meats, fried foods, solid fats, and fast food. In contrast, there were no changes from baseline for any of these outcomes in the usual care group (n = 163). Nutrition knowledge improved significantly over time in both groups but more so in the Video Doctor group. Clinician-patient discussions about these topics occurred significantly more frequently in the Video Doctor group. There was no difference in weight gain between groups.

Conclusion

A brief Video Doctor intervention can improve exercise and dietary behaviors in pregnant women.

Practice implications

The Video Doctor can be integrated into prenatal care to assist clinicians with effective diet and exercise counseling.     

A standardized approach to qualitative content analysis of focus group discussions from different countries

Objective

To describe the methodological procedures of a multi-centre focus group research for obtaining content categories also suitable for categorical statistical analyses.

Methods

Inductive content analyses were performed on a subsample of 27 focus groups conducted in three different countries, the Netherlands (Utrecht), the UK (Liverpool) and Italy (Verona). The analyses of the subsample of focus group discussions were performed in five steps: (1) independent development of content categories in each of the participating centres, (2) obtaining consensus categories, (3) creation of a manual with coding rules and defining criteria for categories and subcategories, (4) assessment of inter-rater reliability to identify unreliable categories to be revised, and (5) repetition of inter-rater reliability assessment.

Results

The resulting coding system considers five areas: non verbal communication, process oriented expression, task oriented or problem focused expressions, affective or emotional expressions, and physician's personal characteristics. It contains 12 categories of acceptable inter-rater reliability and 41 subcategories.

Conclusion

The coding procedures show how focus group data, obtained in an international multi-centre study can be analysed in a systematic way combining scientific rigour with the richness of data obtainable from qualitative methodologies.

Practice implication

The applied procedures may be helpful for multi-centre focus group research on other topics.     

What are the standard functions of electronic clinical pathways?

Purpose

The present study was performed to determine the standard functions of electronic clinical pathways (eCP) embedded in electronic medical records with regard to demand definition.

Methods

The standard functions of eCP were decided by the required functions determined from interviews with hospital staff, those derived from the implementation of paper-based clinical pathways (CPs), and additional functions generated through the shift from a paper-based to an electronic system. Moreover, the proposed standard functions and those of eCP embedded in electronic medical records for large hospitals were compared by interviews with five vendors.

Results

Seventeen functions were deemed necessary for eCP, and these were classified into six categories: displaying, recording, ordering, editing, variance, and statistics. Although most of these functions are already included in eCP products, their implementations differ between products.

Conclusions

We propose 17 standard functions required for eCP embedded in electronic medical records. The functions for editing patient checklists, checking the occurrence of variance, and statistics are especially important and should be implemented as standard functions. This study will aid in the future development of eCP embedded in electronic medical records.     

The advantages and challenges of unannounced standardized patient methodology to assess healthcare communication

Objective

This paper provides an overview of the implementation of using unannounced standardized patients (USPs) to conduct health communication research in clinical settings.

Methods

Certain types of health communication situations are difficult to capture because of their rarity or unpredictable nature. In primary care the real reasons for a visit are frequently unknown until the consultation is well under way. Therefore, it is logistically difficult for communication studies to capture many real-time communications between patients and their physicians. Although the USP methodology is ideal for capturing these communication behaviors, challenges to using this method include developing collaborative relationships with clinical practices, logistical issues such as safeguarding the identity of the USP, training USPs and creating their identities, maintaining fidelity to the role, and analyzing the resultant data.

Results

This paper discusses the challenges and solutions to USP implementation. We provide an example of how to implement a USP study using an on-going study being conducted in primary care practices.

Conclusion

This paper explores the advantages and challenges as well as strategies to overcome obstacles to implementing a USP study.

Practice implications

Despite the challenges, USP methodology can contribute much to our understanding of health communication and practice.     

Human hepatoma cells transmit surface bound HIV-1 to CD4 T cells through an ICAM-1/LFA-1-dependent mechanism

Background

During the viremic phase of human immunodeficiency virus type-1 (HIV-1) infection, hepatocytes are likely to be constantly exposed to circulating virions. Knowing that a contact between hepatocytes and CD4⁺ T lymphocytes is favoured by the local slow blood flow present within the liver, we hypothesize that hepatic cells can act as a viral reservoir and thus contribute to HIV-1 propagation.

Results

We report that human hepatoma cells bind and internalize HIV-1 particles. Infection of CD4⁺ T cells was found to be much more efficient following a contact with virus-loaded hepatocytes than with cell-free virus. Additional studies suggest that infection of CD4⁺ T cells in trans with hepatocytes carrying virus is primarily due to surface bound HIV-1 particles and relies on LFA-1/ICAM-1 interactions.

Conclusion

This work represents the first demonstration by which circulating CD4⁺ T cells can be potentially infected with HIV-1 through a contact with hepatocytes in the liver.     

Rôle du virus Toscana dans les infections neuroméningées en Tunisie

Objectives

To detect the presence of Toscana virus (TOSV) circulation in Tunisia and to study its role in viral meningo-encephalitis.

Patients and methods

A total of 315 (167 sera and 178 cerobrospinal fluid [CSF]) samples was investigated. These samples are colleted from Tunisian patients with neurological diseases during the period between January 2003 and December 2009. All samples were tested negative for enterovirus, Herpes Simplex virus and West Nile virus. Detection for IgM and IgG specific to TOSV was done by ELISA tests.

Results

Specific IgM for TOSV were detected in 10 % of patients with neurological diseases (31 cases). These recent infections were distributed throughout the study period and predominated during summer and automn. Patients were originated, in the majority from the coastal region. IgG were isolated in 22 cases (7 %) corresponding to previous infection.

Conclusion

This is the first report of TOSV circulating in Tunisia and its frequent implication in neurological diseases. These results incited to include TOSV as one of the viral etiologies to target in the diagnosis of viral meningitis and encephalitis in the country.     

The placebo response: how words and rituals change the patient's brain

Objective

The placebo effect, or response, has evolved from being thought of as a nuisance in clinical and pharmacological research to a biological phenomenon worthy of scientific investigation in its own right. The study of the placebo effect and of its negative counterpart, the nocebo effect, is basically the study of the psychosocial context around the treatment and the patient, and it plays a crucial role in the therapeutic outcome.

Methods

In recent years, different types of placebo responses have been analyzed with sophisticated biological tools that have uncovered specific mechanisms at the anatomical, physiological, biochemical and cellular level.

Results

Most of our knowledge about the neurobiological mechanisms of the placebo response comes from pain and Parkinson's disease, whereby the neuronal circuits involved in placebo responsiveness have been identified. In the first case, opioidergic, dopaminergic and cholecystokinergic networks have been found to be involved. In the second case, dopaminergic activation in the striatum and neuronal changes in basal ganglia have been described.

Conclusion

This recent research has revealed that these placebo-induced biochemical and cellular changes in a patient's brain are very similar to those induced by drugs. This new way of thinking may have profound implications both for clinical trials and for medical practice.     

Spatial memory is enhanced in long-living Ames dwarf mice and maintained following kainic acid induced neurodegeneration

Introduction

Age associated cognitive impairment is associated with low levels of IGF-1, oxidative stress, and neuronal loss in the hippocampus. Ames dwarf mice are long-lived animals that exhibit peripheral IGF-1 deficiency. Hippocampal-based spatial memory (a homolog of cognitive function) has not been evaluated in these long-living mice.

Materials and methods

We evaluated the hippocampal-based spatial memory in 3-, 12- and 24-month-old Ames dwarf and wild type mice using the Barnes maze and the T-maze. We also examined the effect of a hippocampal-specific toxin, kainic acid (KA), on spatial memory to determine whether Ames mice were resistant to the cognitive impairment induced by this compound.

Results

We found that Ames dwarf mice exhibit enhanced learning, making fewer errors and using less time to solve both the Barnes and T-mazes. Dwarf mice also have significantly better short-term memory as compared to wild type mice. Both genotypes exhibited neuronal loss in the CA1 and CA3 areas of the hippocampus following KA, but Ames dwarf mice retained their spatial memory.

Discussion

Our results show that Ames dwarf mice retained their spatial memory despite neurodegeneration when compared to wild type mice at an “equiseizure” dose of KA.     

Knowledge on hepatitis B infection among pregnant women in a high endemicity area

Objective

To assess the knowledge on hepatitis B virus (HBV) infection and associated factors among expectant mothers in an endemic region.

Methods

A questionnaire was administered to pregnant Chinese women (n = 1623) attending the antenatal clinic to examine their knowledge on HBV infection, and correlating this with socio-demographic, medical and obstetric factors.

Results

Independent factors associated with insufficient reduced HBV knowledge include women outside the healthcare sector, lower education level, and no previous HBV testing. The majority of respondents could provide correct responses about the common aspects of HBV infection, including screening, blood-borne and perinatal transmissions, prevention by vaccination, and sequelae of HBV infection, but 47.1% did not know that HBV is transmissible by sexual intercourse. Over 75% respondents misunderstood the fact that HBV cannot be transmitted through food, or prevented by a balanced life style and nutrition.

Conclusions

Misconceptions about HBV transmission are still common among the obstetric population, and the provision of appropriate and correct information is warranted to improve further the control of HBV infection to the target group.

Practice implications

Appropriate emphasis should be given to educating the general population about horizontal transmission of HBV.     

Molecular characterization of methicillin-resistant Staphylococcus aureus isolates in Algeria

Introduction

The epidemiology of Staphylococcus aureus has changed radically since 1999, in particular, methicillin-resistant S. aureus (MRSA), originally restricted to hospital, has emerged as a significant pathogen in the community, and true community-acquired MRSA (CA-MRSA) infections have been reported in patients with no clear risk factors. CA-MRSA strains frequently produce Panton-Valentine leukocidin (PVL).

Objectives

The objectives of this study were: (i) to monitor the prevalence of PVL and toxic shock syndrome toxin-1 (TSST-1) isolates MRSA; (ii) to identify the staphylococcal cassette chromosome (SCCmec) types of MRSA isolates.

Material and methods

Sixty-four isolates, collected between 2005 and 2007 in Didouche Mourad hospital of Algeria. The isolates were identified by conventional methods. The antibiotic susceptibility of the isolates was performed using the disk diffusion method and automat Vitek2. The presence of gene mecA, the genes encoding SCCmec type, PVL and TSST-1 toxins were investigated by real-time PCR.

Results

All strains were gene mecA positives, 32 (50%) harboured SCCmec IV type, 28 (43.75%) harboured SCCmec V type. 19 (29.68%) have been identified positive for the leukocidin toxin (PVL), they harboured SCCmec type IV. The virulence factor TSST-1 was not present among these isolates.

Conclusion

These results show a high prevalence of PVL-positive H-MRSA in our wards.     

CD4 T cell nadir independently predicts the magnitude of the HIV reservoir after prolonged suppressive antiretroviral therapy

Background

The level of HIV-1 integrated DNA in CD4 T cells was reported to predict the evolution of untreated HIV-1 infection independently of CD4 cell counts or plasma HIV-1 RNA levels. However, the relevance of reservoir level while on efficient antiretroviral therapy (ART) is still unknown.

Objectives

To evaluate factors that may contribute to the establishment and maintenance of HIV-1 reservoir size in ART-treated HIV-1-infected adults with complete suppression of viremia.

Study design

35 subjects receiving ART with plasma HIV-1 RNA below the limit of detection for an average duration of 3.2 years were studied. A highly sensitive PCR was used to assess HIV-1 integrated DNA levels in sorted CD4 T cells.

Results

The mean HIV-1 integrated DNA was 300 ± 7 copies/10⁶ CD4 cells (range 10-1408). In univariate analysis, the levels of HIV-1 proviral DNA appeared to be independent of duration of HIV-1-infection, duration on ART, time since HIV-1 viral load was undetectable, delay between HIV-1 infection and starting ART, or viral load before starting ART. Conversely, CD4 T cell nadir, CD4/CD8 ratio and, to lesser degree, CD4 T cell counts were inversely associated with HIV-1 proviral DNA levels. In multivariate analysis, only CD4 T cell nadir significantly predicted levels of HIV-1 proviral DNA (P = 0.025).

Conclusions

CD4 T cell nadir strongly predicted reservoir size independently of other factors in HIV-1-infected adults with complete suppression of viremia. Collectively, these results indicate that the extent of CD4 T cell depletion before ART drives the size of the viral reservoir after prolonged therapy.     

Conceptual-driven classification for coding advise in health insurance reimbursement

Objective

With the non-stop increases in medical treatment fees, the economic survival of a hospital in Taiwan relies on the reimbursements received from the Bureau of National Health Insurance, which in turn depend on the accuracy and completeness of the content of the discharge summaries as well as the correctness of their International Classification of Diseases (ICD) codes. The purpose of this research is to enforce the entire disease classification framework by supporting disease classification specialists in the coding process.

Methodology

This study developed an ICD code advisory system (ICD-AS) that performed knowledge discovery from discharge summaries and suggested ICD codes. Natural language processing and information retrieval techniques based on Zipf's Law were applied to process the content of discharge summaries, and fuzzy formal concept analysis was used to analyze and represent the relationships between the medical terms identified by MeSH. In addition, a certainty factor used as reference during the coding process was calculated to account for uncertainty and strengthen the credibility of the outcome.

Results

Two sets of 360 and 2579 textual discharge summaries of patients suffering from cerebrovascular disease was processed to build up ICD-AS and to evaluate the prediction performance. A number of experiments were conducted to investigate the impact of system parameters on accuracy and compare the proposed model to traditional classification techniques including linear-kernel support vector machines. The comparison results showed that the proposed system achieves the better overall performance in terms of several measures. In addition, some useful implication rules were obtained, which improve comprehension of the field of cerebrovascular disease and give insights to the relationships between relevant medical terms.

Conclusion

Our system contributes valuable guidance to disease classification specialists in the process of coding discharge summaries, which consequently brings benefits in aspects of patient, hospital, and healthcare system.     

The landscape of postgraduate education in palliative care for general practitioners: results of a nationwide survey in Flanders, Belgium

Objective

To describe the offer of continuing medical education (CME) in palliative care in Flanders, Belgium and to explore the way providers of CME address the preferences of general practitioners (GP's) towards CME.

Methods

Questionnaire-survey among official providers of formal CME.

Results

The response rate was 43%, equally distributed over all 5 provinces of Flanders. Data show large content gaps, an under usage of appropriate educational techniques and an absence of evaluation of the impact of CME on clinical practice. Providers of CME explain how they take the preferences of GP's concerning education in palliative care into account.

Conclusions

The present offer of CME is insufficient to educate GP's in palliative care. The absence of quality criteria and the lack of coordination between different providers results in an unattractive labyrinth of courses leaving GP's and their patients in the cold.

Practice implications

A comprehensive offer of CME sessions should be installed in a coordination between all providers. This could render the use of means (logistics and speakers) more efficient. Further research could look into other ways of acquiring palliative care competences such as evaluating the learning effect of GP's working together with specialized palliative home care teams.     

Polyomavirus Shedding in the Stool of Healthy Adults

We recently reported the frequent detection of polyomaviruses (BK virus [BKV] or simian virus 40 [SV40]) in 46% of stool samples from hospitalized children. In order to determine if adults exhibit fecal shedding of polyomavirus, single stool specimens from healthy adults were evaluated by PCR. Overall, 20 (18.2%) of 110 specimens were positive for human polyomaviruses: 9 with BKV, 9 with JC virus (JCV), 1 with SV40, and 1 with both JCV and SV40. Among the 94 subjects without immune compromise, 17 (18.1%) were excreting polyomaviruses. This shedding frequency in adults was significantly lower than that observed in children (P < 0.001). These findings support the hypothesis that the gastrointestinal tract may be a site of polyomavirus persistence, and they suggest a fecal-oral route of viral transmission.Seroprevalence studies from various parts of the world have documented the ubiquity of early childhood infection with BK virus (BKV), a polyomavirus whose host-range is limited to humans (15, 35). Infection with BKV has not been associated with any known clinical syndrome in healthy individuals, and BKV persistence is believed to be lifelong, primarily in the kidney and in leukocytes (32). BKV is occasionally excreted in the urine of healthy adults and children (20). BKV viruria may be common among pregnant women, perhaps reflecting the mild immune compromise of pregnancy (2, 10). Among kidney transplant recipients, BKV reactivation can lead to high titers of virus in the urine and the development of polyomavirus-associated nephropathy, which has emerged as a significant cause of renal allograft loss (13, 17, 18). After hematopoietic stem cell transplantation, BKV reactivation can cause hemorrhagic cystitis, a painful syndrome that usually resolves following engraftment of T-cell lineages (24, 25).JC virus (JCV) infection occurs somewhat later in life, more commonly in the second and third decades (22). As with BKV, there is no recognized clinical syndrome associated with primary JCV infection, and it has emerged as an important cause of disease among severely immunocompromised patients (4, 31, 41). JCV reactivation in patients with AIDS and other T-lymphocyte deficiencies can result in progressive multifocal leukoencephalopathy, which is uniformly fatal in the absence of restored T-lymphocyte function. JCV has been detected in both colon and gastric cancers and adjacent normal tissues, suggesting that the gastrointestinal tract is a site of JCV persistence, but it has not previously been detected in feces (23, 30, 34, 39). SV40 has been detected in urine and feces from humans and in mixed fecal and urine specimens from cynomolgus monkeys (3, 39, 40).Despite the ubiquity of BKV infection, its route of transmission has not been clearly determined. In addition to urinary excretion, BKV has been detected rarely in respiratory secretions and tonsil tissue (16, 37). It has also been detected in placental tissue, but whether it is transmitted in utero has not been determined (5, 28). Recent studies by our laboratory have detected polyomaviruses in stool specimens from a large proportion of hospitalized children (46%), independent of immune status and age (39). Thirty-eight percent were positive for BKV and 8% for simian virus 40 (SV40); JCV shedding was not detected. This observation raises the possibility of a fecal-oral route of spread for BKV and perhaps for other polyomaviruses. In the present study, we analyzed stool specimens from healthy adults in order to determine the presence and prevalence of polyomavirus fecal shedding by older individuals.     

Use of real-time polymerase chain reaction (rtPCR) as a diagnostic tool for influenza infection in a vaccine efficacy trial

Background

Conventional techniques for diagnosing influenza based on viral cell culture or disease serology have limitations, and molecular assays, such as real-time polymerase chain reaction (rtPCR) are increasingly used.

Objectives

To evaluate the use of rtPCR as a diagnostic tool for the determination of influenza virus infection.

Study design

This prospective, double-blind, placebo-controlled, randomised efficacy study was conducted in persons aged 18-64 years. Cases of influenza-like-illness (ILI), defined as at least one systemic symptom [fever ≥37.8 °C and/or myalgia] and at least one respiratory symptom [cough and/or sore throat] were identified by active and passive surveillance. For each case of suspected ILI, nasal and throat swabs were collected and analysed by viral culture and rtPCR.

Results

227 ILI cases were positive by rtPCR while 64% (145/227) were positive by both rtPCR and culture. For both assays, the maximum percentage of swabs that tested positive was on Day 0, thereafter positive samples by rtPCR remained constant until Day 5 but decreased progressively by culture. All rtPCR positive cases with a viral load of below 4.5 log₁₀ copies/sample were negative by culture. There were however culture negative cases with high viral loads. Vaccine efficacy for influenza was estimated as 54.7% by rtPCR (culture positive or negative) and 61.6% by culture irrespective of match to vaccine strain. Clinical severity was not significantly different between culture positive cases and culture negative but rtPCR positive cases.

Conclusions

rtPCR is a sensitive and specific diagnostic tool for influenza vaccine efficacy studies.     

How much does trust really matter? A study of the longitudinal effects of trust and decision-making preferences on diabetic patient outcomes

Objective

To examine the impact of trust on patient outcomes (satisfaction, HbA_1C, physical and mental health-related quality of life (HRQoL)) and to investigate the role of decision-making preferences in the trust-outcome relationship.

Methods

We conducted a one-year longitudinal analysis of 614 type 2 diabetic patients (mean age: 59.3 years; mean disease duration: 6.7 years). Patients’ self-administered questionnaires and medical record were used for the research. Multiple regression analyses were conducted to investigate the relationship among variables during a 12-month follow-up. Further, we used latent growth modeling (LGM) to assess changes in health outcomes and to examine how these changes were related to trust.

Results

Regression analyses revealed that trust was positively related to glycemic control, physical HRQoL, and satisfaction at 12 months. Patients with higher decision-making preferences experienced a greater increase in subsequent satisfaction. The results of LGM showed that higher levels of trust were associated with greater increases in physical HRQoL.

Conclusion

Trust contributes to improvements in health outcomes. The relationship between trust and satisfaction may be stronger among patients with higher decision-making preferences.

Practice implications

For healthcare providers, efforts should be made to cultivate patients’ trust and enhance their decision-making preferences to maximize satisfaction and improve outcomes.     

Case-based reasoning support for liver disease diagnosis

Objectives

In Taiwan, as well as in the other countries around the world, liver disease has reigned over the list of leading causes of mortality, and its resistance to early detection renders the disease even more threatening. It is therefore crucial to develop an auxiliary system for diagnosing liver disease so as to enhance the efficiency of medical diagnosis and to expedite the delivery of proper medical treatment.

Methods

The study accordingly integrated the case-based reasoning (CBR) model into several common classification methods of data mining techniques, including back-propagation neural network (BPN), classification and regression tree, logistic regression, and discriminatory analysis, in an attempt to develop a more efficient model for early diagnosis of liver disease and to enhance classification accuracy. To minimize possible bias, this study used a ten-fold cross-validation to select a best model for more precise diagnosis results and to reduce problems caused by false diagnosis.

Results

Through a comparison of five single models, BPN and CBR emerged to be the top two methods in terms of overall performance. For enhancing diagnosis performance, CBR was integrated with other methods, and the results indicated that the accuracy and sensitivity of each CBR-added hybrid model were higher than those of each single model. Of all the CBR-added hybrid models, the BPN-CBR method took the lead in terms of diagnosis capacity with an accuracy rate of 95%, a sensitivity of 98%, and a specificity of 94%.

Conclusions

After comparing the five single and hybrid models, the study found BPN-CBR the best model capable of helping physicians to determine the existence of liver disease, achieve an accurate diagnosis, diminish the possibility of a false diagnosis being given to sick people, and avoid the delay of clinical treatment.     

Promoting advance care planning as health behavior change: development of scales to assess Decisional Balance, Medical and Religious Beliefs, and Processes of Change

Objective

To develop measures representing key constructs of the Transtheoretical Model (TTM) of behavior change as applied to advance care planning (ACP) and to examine whether associations between these measures replicate the relationships posited by the TTM.

Methods

Sequential scale development techniques were used to develop measures for Decisional Balance (Pros and Cons of behavior change), ACP Values/Beliefs (religious beliefs and medical misconceptions serving as barriers to participation), Processes of Change (behavioral and cognitive processes used to foster participation) based on responses of 304 persons age ≥ 65 years.

Results

Items for each scale/subscale demonstrated high factor loading (>.5) and good to excellent internal consistency (Cronbach α .76-.93). Results of MANOVA examining scores on the Pros, Cons, ACP Values/Beliefs, and POC subscales by stage of change for each of the six behaviors were significant, Wilks’ λ = .555-.809, η² = .068-.178, p ≤ .001 for all models.

Conclusion

Core constructs of the TTM as applied to ACP can be measured with high reliability and validity.

Practice implications

Cross-sectional relationships between these constructs and stage of behavior change support the use of TTM-tailored interventions to change perceptions of the Pros and Cons of participation in ACP and promote the use of certain Processes of Change in order to promote older persons’ engagement in ACP.