Does precontemplation represent a homogeneous stage category? A latent class analysis on German smokers

The authors examined the subtype structure of smokers classified in the precontemplation stage of change within the transtheoretical model. From a general practice-based sample of 1,499 daily smoking patients from Germany (participation rate 80%), they used a subgroup of 929 smokers who were classified in the precontemplation stage and applied latent class analysis, using the pros and cons of nonsmoking and smoking cessation self-efficacy as the defining variables. Cross-sectional validation of the emerging classes was based on smoking behavior and processes of change variables. For longitudinal validation, generalized estimation equation analyses were used on motivational and abstinence criteria from 6-, 12-, 18-, and 24-month follow-ups. A 4-class model best represented the data. Three subtypes (labeled progressive, immotive, and disengaged pessimistic) were similar to clusters identified in U.S. studies. The 4th (disengaged optimistic), by contrast, was reminiscent of a type that had previously only emerged in a Dutch study. Cross-sectional and longitudinal validation results confirmed the distinctiveness and predictive power of the classes. The findings highlight the importance of tailoring interventions for smoking behavior change to the needs of different subgroups of precontemplating smokers.     

A qualitative study of healthcare professionals’ perceptions of men and women's mental healthcare seeking in Rwanda

This study aimed to explore health care professionals (HCP’) perceptions about mental-health-seeking behaviours in men and women and its social and gender implications in Rwanda. Six focus group discussions including 43 HCPs working at mental health facilities and district hospitals in Rwanda were conducted. Data were analysed using qualitative content analysis. The emerging theme “Traditional gender role patterns and stigma are displayed in mental health care seeking, adherence to treatment and family effects” illustrated how HCPs perceived gender differences and outcomes in mental healthcare seeking. The theme was based on three categories: “Gender differences in health care seeking patterns,” “Gender roles and stigma affect adherence to counselling and treatment,” and “Gender roles exert an influence on family support” and related subcategories, with which each described various aspects contributing to the result. According to HCPs who regularly encountered people with mental health problems, neither men nor women with mental health problems could adequately benefit from the available mental health services because of the strong influence stigma and prevailing traditional gender roles had on men's and women's mental-healthcare-seeking behaviour. There is an urgent need for comprehensive societal interventions involving policy makers, HCPs, and the general population to diminish the stigma tied to mental illness and the traditional gender norms that negatively influence healthcare-seeking patterns; such actions can improve the health of many citizens.     

Is smoking a risk factor for decreased semen quality? A cross-sectional analysis

BACKGROUND: Previous studies suggest a deleterious effect of cigarette smoking on semen quality, but their results have not been consistent. We studied the association between current smoking and semen characteristics and hormonal levels in a large group of healthy men. METHODS: From 1987 to 2004, seven separate occupational or environmental semen quality studies were co-ordinated by our department. A total of 2562 men participated, each providing semen and blood sample and answering a questionnaire about lifestyle and factors related to health. Appropriate semen and smoking data were available for 2542 men. RESULTS: Adjusting for study, age and other covariates, we observed an inverse dose-response relation between smoking and semen volume, total sperm count and percentage motile sperm. Heavy smokers had a 19% lower sperm concentration than non-smokers. We found a positive dose-response relationship between smoking and testosterone, LH and the LH/free testosterone ratios. CONCLUSION: Current smoking in adult life moderately impairs the semen quality. It is well known that semen quality is associated to fecundity. Therefore, it would be sensible to advise men to abstain from smoking to avoid decreased fecundity.     

Treatment for tobacco smoking: A new alternative?

Smoking is a very common addiction and is associated with several kinds of diseases including different forms of cancer. Nicotine is the only substance present in cigarettes that can cause dependence. There are pharmacological treatments available to smoking cessation, but all of them are associated with side effects and low efficacy. Therefore, the development of new strategies and treatments is necessary. A possibility is the supplementation with polyunsaturated fatty acids (PUFAs) of the omega 3 series. It is known that low concentration of omega 3 can affect the dopaminergic neurotransmission, resulting in hypofunctioning of the mesocortical system. This system controls the mesolimbic system, associated in rewarding and dependence mechanisms. New perspectives of treatment focus on the reestablishment of the omega 3 levels, having as a result the normalization of the dopaminergic system and the reduction of the negative symptoms of withdrawal.     

Treatment for tobacco smoking: A new alternative?

Smoking is a very common addiction and is associated with several kinds of diseases including different forms of cancer. Nicotine is the only substance present in cigarettes that can cause dependence. There are pharmacological treatments available to smoking cessation, but all of them are associated with side effects and low efficacy. Therefore, the development of new strategies and treatments is necessary. A possibility is the supplementation with polyunsaturated fatty acids (PUFAs) of the omega 3 series. It is known that low concentration of omega 3 can affect the dopaminergic neurotransmission, resulting in hypofunctioning of the mesocortical system. This system controls the mesolimbic system, associated in rewarding and dependence mechanisms. New perspectives of treatment focus on the reestablishment of the omega 3 levels, having as a result the normalization of the dopaminergic system and the reduction of the negative symptoms of withdrawal.     

Re-examining phone counseling for smoking cessation: Does the evidence apply to low-SES smokers?

IntroductionA 2019 Cochrane review concluded telephone counseling is an effective intervention for smoking cessation. However, the review did not assess the role of socioeconomic status (SES) indicators on the effectiveness of telephone counseling.MethodsWe reviewed 65 U.S. studies from the Cochrane review. We abstracted data on education, income, employment status and insurance status, and examined associations with targeted recruitment, intervention uptake, attrition, and cessation outcomes.ResultsExcept for education, SES indicators were seldom reported or used in analysis: 61 studies reported education, 24 reported insurance status, 23 reported employment status, and 17 reported income. Nine studies exclusively recruited low-SES samples. Thirteen studies examined associations between SES and smoking cessation. Among these, two reported lower education predicted greater cessation and two reported higher education predicted greater cessation. Other studies found higher income (n = 2) or employment type (n = 1) predicted cessation.ConclusionsEvidence supporting telephone counseling for cessation is less clear when applied to low-SES smokers. Future research should directly assess intervention effectiveness in this priority population.Practice implicationsGiven the evidence, it may be hard to justify future studies not focusing on low-SES populations. Innovative counseling solutions from providers helping low-income smokers quit should be evaluated to inform best practice.     

Is there evidence for a latent class called 'hypomanic temperament'?

BACKGROUND: Affective disorders belong to the most common psychiatric disorders. Several risk factors have been postulated and empirically investigated. Researchers like Akiskal [Interpersonal Factors in the Origin and Course of Affective Disorders, Gaskell, London, 1996] have pointed out the associations between sub-affective temperaments and affective disorders. However, no study has dealt with the issue whether there is a latent class of such sub-affective temperaments or if such temperaments are best conceptualized as fully dimensional. We investigated whether the Hypomanic Personality Scale [J. Abnorm. Psychol. 121 (1986) 214-222] as an indicator of hyperthymia is taxonic in structure. METHODS: We chose two different samples to address this issue: A sample of young adults (n = 1,966) and another sample of adolescents (n = 4,045). We ran MAXCOV-HITMAX analyses based on identical subsets of items in both samples. RESULTS: Neither in the sample of young adults nor in the sample of adolescents there was evidence for a latent class called 'hypomanic temperament'. LIMITATION: Only one indicator for vulnerability and one procedure to test for latent classes was used. Furthermore, we do not know how many of our sample had a life-time history or current affective disorders. CONCLUSIONS: The hypomanic-hyperthymic temperament is best conceptualized as a dimension in the general population. However, before drawing final conclusions about the taxonicity of the risk for affective disorders, more research is needed using different measures, samples and methods to resolve this question of the dimensionality of vulnerability. Additionally, the question remains open how to conceptualize mania itself.     

What mediates the effect of confrontational counselling on smoking cessation in smokers with COPD?

Objective

Within the framework of a randomized, active treatment controlled trial, we used a mediation analysis to understand the mechanisms by which an intervention that uses confrontation with spirometry for smoking cessation achieves its effects.

Methods

Participants were 228 smokers from the general population with previously undetected chronic obstructive pulmonary disease (COPD), who were detected with airflow limitation by means of spirometry. They received two equally intensive behavioural treatments by a respiratory nurse combined with nortriptyline for smoking cessation: confrontational counselling with spirometry versus conventional health education and promotion (excluding confrontation with spirometry and COPD).

Results

Cotinine validated abstinence rates from smoking at 5 weeks after the target quit date were 43.1% in the confrontational counselling group versus 31.3% in the control group (OR = 1.67, 95%CI = 0.97–2.87). The effect of confrontational counselling on abstinence was independently mediated by the expectation of getting a serious smoking related disease in the future (OR = 1.76, 95%CI = 1.03–3.00), self-exempting beliefs (OR = 0.42, 95%CI = 0.21–0.84), and self-efficacy (OR = 1.38, 95%CI = 1.11–1.73).

Conclusion

We conclude that confrontational counselling increases risk perceptions and self-efficacy, and decreases self-exempting beliefs (risk denial) in smokers with previously undetected COPD. These changes in mediators are associated with a higher likelihood of smoking cessation.

Practice implications

Apart from the intensity, the content of smoking cessation counselling may be an important factor of success. A confrontational counselling approach as we applied may have the potential to alter smoking-related cognitions in such a way that smokers are more successful in quitting. Nurses can be trained to deliver this treatment.     

Are biomarkers a useful aid in smoking cessation? A review and analysis of the literature

Healthcare providers' ability to motivate people to try to quit smoking or to remain abstinent is limited. Even with our best treatments, most smokers relapse within 1 year. Therefore it is important that we constantly strive to develop and test new, effective smoking interventions. Providing feedback on one's biomarkers (e.g., biological indices of smoking-related harm, harm exposure, or genetic susceptibility to disease) have been suggested as potentially useful for increasing smokers' motivation or ability to quit smoking. In fact, variations of this strategy are commonly incorporated into behavioral smoking-cessation interventions, but little empirical evidence has specifically addressed whether this approach is effective. In this article, the author reviews the theoretical rationale and empirical evidence regarding this practice. Although the preliminary evidence is promising, more research is needed to determine the efficacy of using biomarkers and the limits of the strategy's effectiveness. Future investigations should address these issues.     

How can healthcare organizations improve cost-of-care conversations? A qualitative exploration of clinicians’ perspectives

ObjectivesClinicians increasingly believe they should discuss costs with their patients. We aimed to learn what strategies clinicians, clinic leaders, and health systems can use to facilitate vital cost-of-care conversations.MethodsWe conducted focus groups and semi-structured interviews with outpatient clinicians at two US academic medical centers. Clinicians recalled previous cost conversations and described strategies that they, their clinic, or their health system could use to facilitate cost conversations. Independent coders recorded, transcribed, and coded focus groups and interviews.ResultsTwenty-six clinicians participated between December 2019 and July 2020: general internists (23%), neurologists (27%), oncologists (15%), and rheumatologists (35%). Clinicians proposed the following strategies: teach clinicians to initiate cost conversations; systematically collect financial distress information; partner with patients to identify costs; provide accurate insurance coverage and/or out-of-pocket cost information via the electronic health record; develop local lists of lowest-cost pharmacies, laboratories, and subspecialists; hire financial counselors; and reduce indirect costs (e.g., parking).ConclusionsDespite considerable barriers to discussing, identifying, and reducing patient costs, clinicians described a variety of strategies for improving cost communication in the clinic.Practice implicationsHealth systems and clinic leadership can and should implement these strategies to improve the financial health of the patients they serve.     

Nurses’ perceptions of pain management for older-patients in the Emergency Department: A qualitative study

Objectives1) Identify themes arising from nurses’ perceptions of assessing older-patients’ pain; 2) use themes to guide development of optimal interventions to improve quality of pain assessment in the emergency department (ED).MethodsNurse interviews (n = 20) were conducted until theme saturation. They were transcribed, coded, and analyzed using qualitative methodology.ResultsTwo major themes—nurse ‘challenges’ and ‘strategies’ to overcome challenges, and their subthemes − classified as ‘patient-related’ or ‘system-related,’ were salient in nurses’ perceptions. Strategies nurses reported for managing challenges were based in their own professional lived experiences.Discussion and conclusionA 2 × 2 framework was developed to conceptualize challenges, strategies, subthemes and their classifications, yielding 4 typologies comprising challenge types matched with appropriate strategy types. While emergent challenges and strategies are corroborated in the literature, the present study is the first to develop a scheme of typologies beneficial for guiding the development of optimal interventions to improve the quality of assessing pain in older-patients.Practice implicationsThe typology framework can guide the development of pain assessment tools and the needed combinations for assessing multidimensional pain in older-patients. Using the present findings, a new clinical intervention was shown to significantly improve pain management for older-patients in the ED.     

Are psychoeducational smoking cessation interventions for coronary heart disease patients effective? Meta‐analysis of interventions

Purpose . This systematic review aimed to assess the effectiveness of psychoeducational smoking cessation interventions for coronary heart disease (CHD) patients; and to examine behaviour change techniques used in interventions and their suitability to change behavioural determinants. Methods . Multiple bibliographic databases and references of retrieved articles were searched for relevant randomized controlled studies. One reviewer extracted and a second reviewer checked data from included trials. Random effects meta‐analyses were conducted to estimate pooled relative risks for smoking cessation and mortality outcomes. Behaviour change techniques used and their suitability to change behavioural determinants were evaluated using a framework by Michie, Johnston, Francis, Hardeman, and Eccles. Results . A total of 14 studies were included. Psychoeducational interventions statistically significantly increased point prevalent (RR 1.44, 95% CI, 1.20–1.73) and continuous (RR 1.51, 95% CI, 1.18–1.93) smoking cessation, and statistically non‐significantly decreased total mortality (RR 0.73, 95% CI, 0.46–1.15). Included studies used a mixture of theories in intervention planning. Despite superficial differences, interventions appear to deploy similar behaviour change techniques, targeted mainly at motivation and goals, beliefs about capacity, knowledge, and skills. Conclusions . Psychoeducational smoking cessation interventions appear effective for patients with CHD. Although questions remain about what characteristics distinguish an effective intervention, analysis indicates similarities between the behaviour change techniques used in such interventions.     

Are health care providers making the most of patient encounters to promote HPV vaccination among cigarette smokers?

ObjectiveTo examine providers’ HPV vaccine communication among adult cigarette smokers with household members aged ≤26 years.MethodsIn this cross-sectional study, we used 2017 Health Information National Trends Survey (HINTS 5, Cycle 1; N = 3191) data to derive a subsample (n = 725/3191; 22.7%) of adults with household members aged ≤26 years. Forward stepwise multivariable logistic regression analyses were performed to examine providers’ HPV vaccine communication, adjusting for patients’ smoking status (main independent variable); HPV awareness and knowledge; HPV vaccine awareness and beliefs; and sociodemographic characteristics that contribute to disparities in HPV vaccine coverage.ResultsCurrent/former smokers (35.0%) had lower HPV-related awareness/knowledge than nonsmokers (65%). Few reported providers discussed (27.4%) or recommended (24.0%) HPV vaccine. Non-Hispanic Whites who knew HPV was a sexually transmitted disease and heard of HPV vaccine were 2–6 times more likely to report provider HPV vaccine communication. Provider HPV vaccine communication differences by smoking status were not statistically significant.ConclusionProviders’ HPV vaccine communication was higher among adults who had higher HPV-related awareness/knowledge. Although active/passive exposure to cigarette smoke increases cervical cancer risk, providers’ HPV vaccine communication was not increased for current/former smokers.Practice ImplicationsCurrent/former smokers’ HPV-related awareness/knowledge and providers’ HPV vaccine communication need to be increased.     

T-SPOT®.TB test and clinical risk scoring for diagnosis of latent tuberculosis infection among Thai healthcare workers

BackgroundScreening for latent tuberculosis infection (LTBI) is important to identify healthcare workers (HCWs) benefiting from preventive therapy. Interferon-gamma release assays (IGRAs) are sensitive and specific tests for LTBI diagnosis. However, in settings where IGRAs are not available, clinical risk assessment may be used as an alternative to diagnose LTBI.MethodsA cross-sectional study was conducted among HCWs of a tertiary-care university hospital in Thailand. All HCWs underwent T-SPOT®.TB test (T-SPOT) and assessment of LTBI clinical risks. Clinical risks associated with T-SPOT positivity were determined by multivariable logistic regression analysis and were given scores accordingly. The performance of the clinical risk scoring was evaluated in comparison to T-SPOT.ResultsAmong 140 enrolled HCWs, 125 (89%) were females, the median age was 27 years and 23 (16%) had T-SPOT positivity. Independent factors associated with T-SPOT positivity were age ≥30 years (adjusted odds ratio [aOR] 3.95; P = 0.002), working duration ≥60 months (aOR 3.75, P = 0.004) and frequency of TB contact ≥6 times (aOR 8.83, P = 0.005). The study's clinical risk scoring had the area under the curve by receiver operating curve analysis of 0.76 (P < 0.001) using T-SPOT positivity as a reference standard. The score of ≥3 had the best performance in diagnosing LTBI with sensitivity, specificity, positive predictive value and negative predictive value of 70%, 71%, 32% and 92%, respectively.ConclusionsIn this setting where LTBI was prevalent among HCWs but IGRAs are not widely available, the clinical risk scoring may be used as an alternative to diagnose LTBI in HCWs.     

How do teenagers and primary healthcare providers view each other? An overview of key themes.

BACKGROUND: Teenagers have often been asked for their opinions about health services. However, relatively few studies have involved quantitative and qualitative methods of assessing them. Furthermore, there have been no United Kingdom studies of providers' views on the health of teenagers or of providers' opinions about their role in teenage health. AIM: To determine how teenagers view primary care, to discover how primary care providers view teenage patients, and to note any differences in opinions between the two groups. DESIGN OF STUDY: Questionnaire survey, focus group discussions, and semi-structured interviews. SETTING: Two thousand two hundred and sixty-five teenage patients, 16 general practitioners (GPs), 12 practice nurses, and 12 general practice receptionists in South Wales valley communities. METHOD: Selected practices provided age-sex registers of patients aged between 14 and 18 years and questionnaires were sent to these patients. Focus groups were assembled from those teenagers who had completed and returned the questionnaire. Semi-structured interviews between one member of the study team and GP surgery staff, chosen randomly from staff lists in the selected surgeries. RESULTS: The teenagers reported a lack of knowledge of services available from primary care, a feeling of a lack of respect for teenage health concerns, poor communication skills in GPs, and a poor understanding of confidentiality issues. The providers did not always share these concerns and they also had differing views on communication and confidentiality issues. CONCLUSION: The data demonstrated important findings about how teenagers would like primary care services to be improved. There was an apparent gulf between teenagers' own opinions about health care and the opinions held by primary care providers.     

“Conversational Advice”: A mixed-methods analysis of medical residents’ experiences co-managing primary care patients with behavioral health providers

Objective

When integrated behavioral health clinicians (IBHCs) and residents co-manage patients, residents may learn new approaches. We aimed to understand the effect of co-management on residents’ behavioral health (BH) management learning.

Is job a viable unit of analysis? A multilevel analysis of demand-control-support models

The literature has ignored the fact that the demand-control (DC) and demand-control-support (DCS) models of stress are about jobs and not individuals' perceptions of their jobs. Using multilevel modeling, the authors report results of individual- and job-level analyses from a study of over 6,700 people in 81 different jobs. Support for additive versions of the models came when individuals were the unit of analysis. DC and DCS models are only helpful for understanding the effects of individual perceptions of jobs and their relationship to psychological states. When job perceptions are aggregated and their relationship to the collective experience of jobholders is assessed, the models prove of little value. Role set may be a better unit of analysis.     

Can self-management programmes change healthcare utilisation in COPD?: A systematic review and framework analysis

ObjectiveThe study aims to evaluate the ability of self-management programmes to change the healthcare-seeking behaviours of people with Chronic Obstructive Pulmonary Disease (COPD), and any associations between programme design and outcomes.MethodsA systematic search of the literature returned randomised controlled trials of SMPs for COPD. Change in healthcare utilisation was the primary outcome measure. Programme design was analysed using the Theoretical Domains Framework (TDF).ResultsA total of 26 papers described 19 SMPs. The most common utilisation outcome was hospitalisation (n = 22). Of these, 5 showed a significant decrease. Two theoretical domains were evidenced in all programmes: skills and behavioural regulation. All programmes evidenced at least 5 domains. However, there was no clear association between TDF domains and utilisation. Overall, study quality was moderate to poor.ConclusionThis review highlights the need for more alignment in the goals, design, and evaluation of SMPs. Specifically, the TDF could be used to guide programme design and evaluation in future.Practice implicationsPractices have a reasonable expectation that interventions they adopt will provide patient benefit and value for money. Better design and reporting of SMP trials would address their ability to do so.