Accuracy of recall of exercise counseling among primary care patients

BACKGROUND: In evaluating the efficacy of health care provider counseling to encourage patients to modify health behaviors such as physical activity, it is important to be able to accurately measure the extent of health care provider counseling. METHODS: The Physical Activity Exit Interview (PAEI) is a brief measure of a patient's perception of the content of physical activity promotion counseling received during a visit with his or her physician. Forty-three primary care patients, and their physicians, completed a PAEI following a visit, which was compared to an audiotape of the visit that was coded to identify the physical activity counseling steps taken. RESULTS: Participants were 67% female, 81.7% white, and had a mean age of 47.1 years. Overall, there was good concordance in the overall number of counseling activities reported between patients and audiotapes (r = 0.47, P < 0.01), patients and physicians (r = 0.51, P < 0.01), and between physicians and audiotapes (r = 0.57, P < 0.01). Significant differences between the three measurement methods (patient exit interview, physician exit interview, audiotape) existed for only 4 of 12 items. CONCLUSIONS: The PAPEI was overall accurate in measuring the content of physical activity counseling, though accuracy differed between items. When discrepancy occurred, it was typically due to patient overreporting of counseling steps.     

Patient smoking cessation advice by health care providers: the role of ethnicity, socioeconomic status, and health

OBJECTIVES: We assessed differences by ethnicity in ever receiving advice from providers to quit smoking. We evaluated whether socioeconomic status and health status were moderators of the association. METHODS: We used 2000 Behavioral Risk Factor Surveillance Survey data, a population-based cross-sectional survey. RESULTS: After adjusting for complex survey design, 69% of the 14089 current smokers reported ever being advised to quit by a provider. Hispanics (50%) and African Americans (61%) reported receiving smoking counseling less frequently compared with Whites (72%, P<.01 for each). Ethnic minority status, lower education, and poorer health status remained significantly associated with lower rates of advice to quit after adjustment for number of cigarettes, time from last provider visit, income, comorbidities, health insurance, gender, and age. Smoking counseling differences between African Americans and Whites were greater among those with lower income and those without health insurance. Compared with Whites, differences for both Hispanics and African Americans were also greater among those with lower education. CONCLUSION: We found lower rates of smoking cessation advice among ethnic minorities. However, we also found complex interactions of ethnicity with socioeconomic factors.     

Recommendations for and warnings against physical activity given to older people by health care professionals

BACKGROUND: Little is known about how health care professionals advice older people with chronic conditions about physical exercise. This study investigated exercise counseling in the context of health care as perceived by older people, and factors associated with perceived advice. DESIGN AND METHODS: Participants were 580 non-institutional 73- to 92-year-old people who reported at least one contact with health care during the previous 12 months. RESULTS: Of all the participants, 23% recalled solely recommendations to exercise, and 9% solely warnings against exercise. Additionally, 34% recalled receiving both recommendations for and warnings against physical activity, and 34% did not recall exercise-related advice at all. Recalling solely recommendations to exercise was associated with having musculoskeletal diseases and impaired mobility. Reporting solely warnings against physical activity was more common among those having heart conditions. Recalling both recommendations for and warnings against exercise was associated with being physically active despite of having heart conditions, musculoskeletal diseases, and impaired mobility. Recalling no exercise-related advice was most common among people who were sedentary and older, had fewer chronic conditions and reported no mobility limitation. CONCLUSIONS: A substantial proportion of older people recalled negative, no, or contradicting advice about exercise. As warnings against physical activity may outweigh recommendations to exercise, special attention should be paid to the content of advice in order to avoid discouraging older people from being active.     

“What My Doctor Didn't Tell Me”: Examining Health Care Provider Advice to Overweight and Obese Pregnant Women on Gestational Weight Gain and Physical Activity

BackgroundAppropriate gestational weight gain (GWG) is vital, as excessive GWG is strongly associated with postpartum weight retention and long-term obesity. How health care providers counsel overweight and obese pregnant women on appropriate GWG and physical activity remains largely unexplored.MethodsWe conducted semistructured interviews with overweight and obese women after the birth of their first child to ascertain their experiences with GWG. A grounded theory approach was used to identify themes on provider advice received about GWG and physical activity during pregnancy.ResultsTwenty-four women were included in the analysis. Three themes emerged in discussions regarding provider advice on GWG: 1) Women were advised to gain too much weight or given no recommendation for GWG at all, 2) providers were perceived as being unconcerned about excessive GWG, and 3) women desire and value GWG advice from their providers. On the topic of provider advice on exercise in pregnancy, three themes were identified: 1) Women received limited or no advice on appropriate physical activity during pregnancy, 2) women were advised to be cautious and limit exercise during pregnancy, and 3) women perceived that provider knowledge on appropriate exercise intensity and frequency in pregnancy was limited.ConclusionsThis study suggests that provider advice on GWG and exercise is insufficient and often inappropriate, and thus unlikely to positively influence how overweight and obese women shape goals and expectations in regard to GWG and exercise behaviors. Interventions to help pregnant women attain healthy GWG and adequate physical activity are needed.     

Influences of Socio-Demographic Factors and Health Utilization Factors on Patient-Centered Provider Communication

Patient-centered care has been documented as a measure of quality of health care and has been associated with positive health outcomes. However, the effect of health utilization on improving patient-centered communication has not been investigated. This study examined the effect of three important kinds of health utilization: routine check-up, frequency of provider visits in the last year, and quality of health care to patient-centered provider communication. Cross-sectional data from 3,608 respondents to Health Information National Trends Survey-Cycle 4 2014 were analyzed. Multiple regressions were used to examine the association of sociodemographic factors and health utilization to patient-centered provider communication. Results showed that adults above 50 years and women reported higher patient-centered provider communication. Hispanic and Asian versus White respondents reported poorer patient-centered provider communication. Respondents with routine checkups between 1 and 2 years, 2 and 5 years, 5 or more years and none were all negatively associated with patient-centered provider communication in comparison with routine checkup within 1 year. Respondents who didn’t visit health provider within past year had poorer patient-centered provider communication when compared to those who visited once. Finally, higher quality of healthcare experience was associated with higher patient-centered provider communication. Thus, this study highlights that race and ethnicity, age, and gender are significant factors that influence patient-centered provider communication; and specifically higher quality of healthcare experience, one provider visit within past year, and annual routine checkup as measures of health utilization predicts improved patient-centered provider communication.     

Does provider prevention orientation influence female patients' preventive practices?

BACKGROUND: Health care provider encouragement for particular preventive behaviors is associated with patient adherence, but it is unclear whether a provider's overall prevention approach influences whether patients engage in recommended preventive measures. We examined whether older women who perceived that their health care provider encouraged a particular preventive behavior were more likely to follow that recommendation if they also perceived that the provider encouraged other preventive behaviors. DATA AND METHODS: The sample included 1119 women aged 50 to 79 enrolled in a health maintenance organization. We examined associations of reported provider encouragement for post-menopausal hormone use, physical activity, fecal occult blood testing (FOBT), and flexible sigmoidoscopy with one another and with adherence to these measures according to recommended guidelines. RESULTS: Among women reporting provider encouragement for physical activity, the likelihood of reporting regular physical activity was greater among women who reported encouragement for one other (odds ratio [OR]=1.99; confidence interval [CI]=1.35 to 2.95) and at least two other (OR=2. 38; 95% CI=1.62 to 3.48) preventive measures compared with women who reported no other encouragement. The likelihood of reporting adequate counseling for post-menopausal hormone use was greater among women reporting encouragement for at least two other preventive measures compared with those reporting no other encouragement. The likelihood of having had an FOBT or sigmoidoscopic examination was related to encouragement for those procedures, but not with greater encouragement for other preventive measures. CONCLUSIONS: Patient perceptions of a provider's overall preventive practice approach may influence whether patients engage in recommended preventive practices, particularly for lifestyle factors.     

The role of trust in use of preventive services among low-income African-American women

BACKGROUND: This study explored factors that predict higher trust in primary care providers, and examined the role of patient trust on the use of preventive services for low-income African-American women. METHODS: We conducted a cross-sectional, population-based telephone survey of 961 African-American women over age 40 in Washington, DC. Two dimensions of trust were examined: overall trust in one's regular primary care provider, and trust that the regular provider had no financial conflict of interest. Self-reported use of mammography, Pap tests, clinical breast exams, colorectal cancer screening, blood pressure, height and weight measurement, diet counseling, and depression screening, as delivered by one's primary care provider, were assessed. An index summarizing overall use of these interventions was the main outcome variable. RESULTS: More than two-thirds of respondents reported high trust in their physician. Older respondents (>65) were more trusting of their physicians overall than were younger respondents (P < 0.01). Primary care characteristics (continuity of care, accessibility of the practice, coordination of specialty care by one's regular provider) were more strongly associated with having high trust than were sociodemographic, health status, and insurance characteristics. Higher trust was significantly associated with greater use of recommended preventive services (OR: 2.3, 95% CI: 1.3, 4.0), controlling for the effects of insurance status, primary care, and patient characteristics. CONCLUSIONS: Trust is associated with use of recommended preventive services in low-income African-American women. Stronger patient-provider relationships, with high levels of trust, may indirectly lead to better health through adherence to recommended preventive services for low income African-American women.     

Does Satisfaction Reflect the Technical Quality of Mental Health Care?

OBJECTIVE: To analyze the relationship between satisfaction and technical quality of care for common mental disorders. DATA SOURCE: A nationally representative telephone survey of 9,585 individuals conducted in 1997-1998. STUDY DESIGN: Using multinomial logistic regression techniques we investigated the association between a five-level measure of satisfaction with the mental health care available for personal or emotional problems and two quality indicators. The first measure, appropriate technical quality, was defined as use of either appropriate counseling or psychotropic medications during the prior year for a probable depressive or anxiety disorder. The second, active treatment, indicated whether the respondent had received treatment for a psychiatric disorder in the past year. Covariates included measures of physical and mental health and sociodemographic indicators. PRINCIPAL FINDINGS: Appropriate technical quality of care was significantly associated with higher levels of satisfaction. The strength of the association was moderate. CONCLUSIONS: Satisfaction is associated with technical quality of care. However, profiling quality of care with satisfaction will likely require large samples and case-mix adjustment, which may be more difficult for plans or provider groups to implement than measuring technical indicators. More importantly, satisfaction is not the same as technical quality, and our results suggest that at this time they cannot be made to approach each other closely enough to eliminate either.     

The impact of behavioral counseling on stage of change in fat intake, physical activity, and cigarette smoking in adults at increased risk of coronary heart disease

OBJECTIVES: This study assessed stages of change in fat intake, physical activity, and cigarette smoking during a randomized controlled trial of behavioral counseling. METHODS: Twenty general practices (primary health care centers) were randomized to lifestyle counseling by behavioral methods or to usual health promotion. A total of 883 patients were selected for the presence of 1 or more of the following risk factors: cigarette smoking, high cholesterol, or a combination of a high body mass index and low physical activity. Stage of change (precontemplation, contemplation, preparation, and action/maintenance) was assessed at baseline and after 4 and 12 months. RESULTS: The odds of moving to action/maintenance for behavioral intervention vs control patients at 4 months were 2.15 (95% confidence interval [CI] = 1.30, 3.56) for fat reduction, 1.89 (95% CI = 1.07, 3.36) for increased physical activity, and 1.77 (95% CI = 0.76, 4.14) for smoking cessation. The likelihood of achieving action/maintenance was related to baseline stage for all 3 behaviors. CONCLUSIONS: Brief behavioral counseling based on advice matched to stage of readiness for change may be valuable in encouraging healthy lifestyles among patients in primary care at raised risk of cardiovascular disease.     

Associations of self-reported oral health with physical and mental health in a nationally representative sample of HIV persons receiving medical care

Background: The impact of oral health on HIV patients has not been sufficiently documented. Objective: To estimate the associations between measures of oral and generic health-related quality of life in persons receiving medical care for HIV. Design: This is a longitudinal study of interview data collected in a probability sample of adults with HIV receiving health care in the US. The data were collected at three points in time. Patients: Two thousand eight hundred and sixty-four HIV-infected adults using medical care. Measurements: Physical and mental health were assessed using 28 items and oral health was assessed using seven items on oral-related pain and discomfort, worry, appearance, and function. Clinical measures included CD4 count, oral symptoms, physical symptoms, and stage of HIV. Physical functioning and emotional well-being were measured on a 0–100 scale with higher scores indicating better health. Oral health was measured using seven items with a five point scale. Results: In multivariate analyses, oral symptoms had the strongest association with oral health-related quality of life. Each additional oral symptom was associated with an average decrease in oral health (0–100 possible range) of 3.97 points (p = 0.000). In addition, oral health was significantly associated with both physical and mental health. A one-point increase in oral health was associated with a 0.05 (p = 0.000) increase in mental health and 0.02 increase in physical health (p = 0.031). Conclusions: Oral health is strongly associated with physical and mental health but provides noteworthy unique information in persons with HIV infection. Thus, physical and mental health measures of HIV patients should incorporate indicators of oral functioning and well-being.     

The Financial Implications of Availability and Quality of a Usual Source of Care for Children with Special Health Care Needs

Objective To examine the relationship of availability and quality of a usual source of care (USC) to medical expenditures overall and for various types of health care services for children with special health care needs (CSHCN), as a group and by four diagnostic subgroups (asthma, non-asthmatic physical conditions, mental retardation, other mental illnesses). Methods Generalized linear models were used to estimate the annual average per capita medical expenditures (APCME) based on data from 820 CSHCN in the 1995 National Health Interview Survey on Disability and 1996 Medical Expenditure Panel Survey. Results In 1996, 92% of non-institutionalized CSHCN in the United States had a USC. Of these, 52% were classified as receiving accessible care, 95% received comprehensive care, and 69% received satisfactory care. Approximately 89% of CSHCN had expenditures on health care in 1996 and the APCME was $1,344 for CSHCN as a group. Having a USC was associated with higher expenditures overall and for almost all types of health care services for CSHCN across conditions. Receiving comprehensive care was associated with lower total medical expenditures for CSHCN with asthma, whereas receiving satisfactory care was associated with higher total medical expenditures for CSHCN with non-asthma physical conditions. Conclusion Having a regular care provider is associated with higher expenditures for CSHCN across diagnosis. Among CSHCN with a USC, quality of care is associated with medical expenditures, although specific associations vary by the quality characteristic and the condition of the child. These results may mask heterogeneity in severity of condition and quality of care over time.     

Incorporating physical activity advice into primary care: physician-delivered advice within the activity counseling trial

INTRODUCTION: The Activity Counseling Trial (ACT) was designed to compare the effectiveness of physician advice alone with physician advice plus behavioral counseling, provided by ACT-trained health educators, to increase levels of physical activity in healthy, sedentary patients. The objective was to determine health care providers' adherence to the ACT protocol for delivering initial "physician" advice on physical activity and to determine providers' satisfaction with the protocol. METHODS: Fifty-four physicians or physician assistants from 11 primary care practices located in California, Texas, and Tennessee volunteered to participate as ACT-trained physicians. Providers were trained to integrate 3 to 4 minutes of initial physical activity advice into the routine office visits of sedentary patients, aged 35 to 75 years, with no acute or serious chronic conditions. This advice included assessment of current physical activities, advising the patient about an appropriate physical activity goal, and referring the patient to the health educator. Providers initialed forms to document delivery of advice, and ACT health educators recorded their advice on a computerized tracking system. A provider survey measured length of time spent advising patients about physical activity and provider satisfaction with the program. RESULTS: Ninety-nine percent of patients received the initial physician advice about physical activity. Eighty-three percent of the providers spent less than 5 to 6 minutes, and 46% spent the recommended 3 to 4 minutes providing advice. Sixty-three percent said the advice resulted in little or no increase in the length of an office visit, and 83% said participation was an asset to their clinics. CONCLUSIONS: Providers incorporated brief physical activity advice into routine primary care visits with little disruption. Their response to the ACT advice protocol was positive and participation in the study was viewed as beneficial.     

Patterns and correlates of physical activity and nutrition behaviors in adolescents

BACKGROUND: Knowledge of the prevalence, clustering, and correlates of multiple adolescent health behaviors can inform the design of health promotion interventions. METHODS: A cross-sectional design was used to assess 878 adolescents aged 11 to 15 years (53.6% girls, 58% non-Hispanic white) recruited in primary care clinics in 2001-2002. Adolescent physical activity (assessed with accelerometers), television viewing time (reported), percent calories from fat, and servings of fruits and vegetables (assessed with multiple 24-hour recalls) were dichotomized into meeting or not meeting national guidelines. Parent health behaviors were assessed with self-reported measures. Analyses were conducted in 2006. RESULTS: Fifty-five percent of adolescents did not meet the physical activity guideline, and 30% exceeded 2 hours daily of television viewing time, with boys more active and less sedentary than girls (p <0.01). The majority of the adolescents did not meet dietary guidelines. Nearly 80% had multiple risk behaviors and only 2% met all four guidelines. The number of risk behaviors was associated with being older and being at risk for overweight or being overweight, for boys and girls (p <0.05). Two parent health behaviors-history of smoking and failure to meet the fruits and vegetables guideline-were significantly associated with a higher number of risk behaviors for girls (p <0.05). CONCLUSIONS: Eight of ten adolescents in this sample failed to meet guidelines for two or more diet, physical activity, and sedentary risk behaviors. Some parent health behaviors, along with the adolescent's weight status and age, were associated with a higher number of adolescent health risk behaviors.     

Delivering quality care: adolescents' discussion of health risks with their providers.

PURPOSE: To compare adolescents' report of topics they wanted to discuss with their providers with what they actually discussed, and whether they talked to their providers about their self-reported health risks. METHODS: We analyzed the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls, a nationally representative sample of 6728 in-school adolescent boys and girls in 5th through 12th grade. Respondents reported on health risks, whether they believed their provider should discuss certain topics, and whether their provider did talk about health-related topics. Logistic regression was used to compare proportions and assess the associations among variables. RESULTS: Adolescents most frequently discussed healthy dietary habits (49%), weight (43%), and exercise (41%) with their clinicians but most frequently wanted to discuss drugs (65%), smoking (59%), and healthy dietary habits (57%). Overall, 70.9% of the sample reported at least one of eight potential health risks, but 63% of these adolescents had not spoken to their doctor about any of these risks. Using logistic regression models, having a female provider (odds ratio [OR] 1.41), obtaining health care information from a doctor (OR 1.72) and from the Internet (OR 1.50), speaking privately with their provider (OR 1.45), and reporting more total risk factors (OR 1.59) were each associated with having discussed any risks. CONCLUSIONS: Adolescents want and need to discuss health care issues with their providers but often do not. Providing quality preventive care to adolescents will require increased physician screening and counseling about these issues.     

Mental health and satisfaction with primary health care in female patients.

PURPOSE AND OBJECTIVES: Patient satisfaction is an important outcome in patient care and is increasingly being used as an indicator of quality of care within large health systems. This study examined whether consideration of specific mental health factors, including posttraumatic stress disorder (PTSD), can improve our understanding of patient satisfaction in primary care settings. METHODS: Questionnaires were mailed to all women who used the VA San Diego Healthcare System primary care clinic in 1998. Two hundred twenty-one (56%) women who were invited to participate in this study completed questionnaires. Participants provided information about physical and mental health and satisfaction with their primary medical care. RESULTS: Age and general mental health were negatively associated and PTSD was positively associated with overall satisfaction with care and satisfaction with the provider. General mental health was significantly related to satisfaction with the clinic. CONCLUSIONS: These findings support the importance of specific mental health symptoms, and trauma-related symptoms in specific, in determining satisfaction.     

河北省赵县孕产妇和儿童健康管理现状研究

目的：调查分析河北省赵县基本公共卫生服务项目中孕产妇和儿童健康管理实施现状,为改进服务质量提供研究资料和建议。方法根据国家基本公共卫生服务规范要求的服务内容设计调查问卷,主要包括体格检查、化验和咨询指导,现场观察乡镇卫生院妇幼保健人员的产前保健和儿童保健服务过程,并对保健人员进行访谈以了解其对自己的工作量、收入和提供喂养咨询指导的看法。结果调查共观察了88名孕妇的产前保健和194名儿童的保健服务。产前保健中有80％以上的孕妇进行了体格检查,但进行实验室化验者不足5％。保健人员很少提供咨询指导,没有孕妇得到母乳喂养方面的指导。儿童保健中98．5％的儿童测量了体重和身长,但分别只有6．2％和4．6％对照生长标准曲线进行了评价。只有21．6％的儿童家长接受了喂养指导。结论赵县基本公共卫生服务项目中产前保健和儿童保健的体格检查部分工作开展较好,但实验室化验和咨询指导方面的服务质量有待提高;保健人员反映工作量大、收入低,同时需要更多高质量的培训。     

Smoking cessation counseling with pregnant and postpartum women: a survey of community health center providers

OBJECTIVES: This study assessed providers' performance of smoking cessation counseling steps with low-income pregnant and postpartum women receiving care at community health centers. METHODS: WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) program staff, obstetric clinicians, and pediatric clinicians at 6 community health centers were asked to complete surveys. Smoking intervention practices (performance), knowledge and attitudes, and organizational facilitators were measured. Factors associated with performance were explored with analysis of variance and regression analysis. RESULTS: Performance scores differed significantly by clinic and provider type. Providers in obstetric clinics had the highest scores and those in pediatric clinics had the lowest scores. Nurse practitioners and nutritionists had higher scores than other providers. Clinic type, greater smoking-related knowledge, older age, and perception of smoking cessation as a priority were independently related to better counseling performance. CONCLUSIONS: Mean performance scores demonstrated room for improvement in all groups. Low scores for performance of steps beyond assessment and advice indicate a need for emphasis on the assistance and follow-up steps of national guidelines. Providers' own commitment to helping mothers stop smoking was important.     

A measuring instrument for evaluation of quality systems.

OBJECTIVE: To develop an instrument for provider organizations, consumers, purchasers, and policy makers to measure and compare the development of quality systems in provider organizations. DESIGN: Cross-sectional study of provider organizations using a structured questionnaire to survey managers. SETTING: The Netherlands. STUDY PARTICIPANTS: Provider organizations of six health care fields: primary health care, care for the disabled, mental health care, care for the elderly, hospital care and welfare care. MAIN MEASURES: Existence of quality assurance and quality improvement activities. RESULTS: The study presents a survey instrument for assessing the quality assurance and improvement activities of health care provider organizations and the developmental stage of quality systems. The survey instrument distinguishes five focal areas for quality improvement activities and four developmental stages. The study also reports data on the reliability and validity of the survey instrument. CONCLUSION: The instrument is reliable, easy to administer, and useful across health care fields as well as different kinds of organizations. Developing quality systems provide a common language across all parts of the health care sector. By assigning the activities to focal areas and developmental stages the instrument gives insight into the implementation of quality systems in health care. Comparable information on quality assurance activities increases the accountability of providers. Because of the efficient (not time consuming) approach, the instrument complements existing accreditation reviews.