Computer-generated tailored feedback letters for smoking cessation: theoretical and empirical variability of tailoring

Purpose

This study examines tailored feedback letters of a smoking cessation intervention that is conceptually based on the transtheoretical model, from a content-based perspective.

Methods

Data of 2 population-based intervention studies, both randomized controlled trials, with total N = 1044 were used. The procedure of the intervention, the tailoring principle for the feedback letters, and the content of the intervention materials are described in detail. Theoretical and empirical frequencies of unique feedback letters are presented.

Results

The intervention system was able to generate a total of 1040 unique letters with normative feedback only, and almost half a million unique letters with normative and ipsative feedback. Almost every single smoker in contemplation, preparation, action, and maintenance had an empirically unique combination of tailoring variables and received a unique letter. In contrast, many smokers in precontemplation shared a combination of tailoring variables and received identical letters.

Conclusion

The transtheoretical model provides an enormous theoretical and empirical variability of tailoring. However, tailoring for a major subgroup of smokers, i.e. those who do not intend to quit, needs improvement. Conceptual ideas for additional tailoring variables are discussed.     

Does the effect go up in smoke? A randomized controlled trial of pictorial warnings on cigarette packaging

Objective

Placing a combination of a written warning and a graphic image on cigarette packaging (so called “pictorial warnings”) is one of the WHO Framework Convention on Tobacco Control's most controversial recommendations. Our randomized controlled trial investigated if pictorial warnings lead to significantly higher motivation to quit, as compared to written warnings alone.

Methods

Four pictorial warnings were selected from the EU Commission's official image catalogue. Study arm 1 (44 adult smokers) viewed only the written warnings while study arm 2 (44 adult smokers) viewed the corresponding pictorial warnings. Self-affirmation was a second randomly manipulated factor, and nicotine dependence a quasi-experimental third factor. The main outcome measured was the motivation to quit, with fear intensity as one of the secondary outcomes.

Results

Pictorial warnings were associated with a significantly higher motivation to quit. A pictorial warning was also associated with higher fear intensity. The effect of warnings appears to be independent of nicotine dependence and self-affirmation.

Conclusions

Nationwide implementation of pictorial warnings may be effective in increasing heavy smokers’ motivation to quit.

Practice implication

Due to the fact that perceived vulnerability, response and self-efficacy are not more strongly affected by pictorial warnings this effect may turn out to be short-term.     

Coping with infertility online: An examination of self-help mechanisms in an online infertility support group

Objective

To examine communication within an online infertility support group.

Methods

A content analysis of 3500 messages posted to infertility bulletin boards.

Results

The most frequently used self-help mechanisms were support or empathy (45.5%) and sharing personal experiences (45.4%), followed by the provision of information and advice (15.9%), gratitude (12.5%), friendship (9.9%), chit-chat (9.4%), requests for information or advice (6.8%) and universality (4.8%), with negative statements (0.3%) and creative expressions (0.2%) being the least frequent categories.

Conclusion

These findings suggest that online support groups can provide a viable alternative source of support for couples dealing with infertility.

Practice implications

Health care professionals interested in developing online support interventions should look to tailor support resources to the specific needs of patients at different stages of the infertility journey.     

Lifestyle, health and the ethics of good living. Health behaviour counselling in general practice

Objective

To present theory that illustrates the relevance of ethics for lifestyle counselling in patient-centred general practice, and to illustrate the theory by a qualitative study exploring how doctors may obstruct or enhance the possibilities for ethical dialogue.

Methods

The theoretical part is based on theory of common morality and Habermas’ communication theory. The empirical study consists of 12 consultations concerning lifestyle changes, followed by interviews of doctors and patients. Analysis: Identification of two contrasting consultations holding much and little ethical dialogue, “translation” into speech acts, and interpretation of speech acts and interviews guided by theory.

Results

General advice obstructed possibilities for ethical clarification and patient-centredness. Ethical clarification was asked for, and was enhanced by the doctor using communication techniques such as interpretation, summarization, and exploration of the objective, subjective and social dimensions of the patients’ lifeworlds. However, to produce concrete good decisions an additional reflection over possibilities and obstacles in the patient's lifeworld is necessary.

Conclusion

Consultations concerning lifestyle changes hold opportunities for ethical clarification and reflection which may create decisions rooted in the patient's everyday life.

Practice implications

The study suggests that GPs should encourage active reflection and deliberation on values and norms in consultations concerning lifestyle changes.     

Chronic condition self-management: Expectations of responsibility

Objective

While self-management may be beneficial for many patients it assumes and encourages a particular conception of responsibility and self-management that may not fit with all patients’ experience of their chronic conditions and their management. It therefore warrants further examination.

Methods

We examine the concept of self-management and responsibility from a range of standpoints, focusing on the Australian context.

Results

Attempts to meet people's needs run the risk of imposing specific conceptions of how people should live their lives. While self-management appears to be consistent with placing patients’ needs, values and priorities at the heart of healthcare, ill-defined assumptions about responsibility may confound these goals.

Conclusions

Reflection on social determinants of health, the context in which patients seek self-management support from health services, and how their needs and preferences are listened to by health professionals, is critical for the collaborative self-management partnership between them to be effectively realized.

Practice implications

Providing services without reflecting on the meaning of self-management for the person with chronic conditions creates unintended assumptions about responsibility, engagement and care provision which may serve to alienate and further stigmatise some patients. Often, these are the very patients with complex needs who need such service support the most.     

The physical examination in telecardiology and televascular consultations: A study using conversation analysis

Objective

This paper describes communication in the physical examination phases of telemedicine consultations.

Methods

Using the method of conversation analysis, we draw on 10 telemedicine consultations (five telecardiology and five televascular) between primary and tertiary care in the UK.

Results

Physical examination is absent in telecardiology consultations. In televascular consultations the professionals try to compensate for the lack of physical proximity by getting involved in a form of collaboration that constitutes a novel environment for all. Separated from the patient by physical space, the specialist orchestrates the positioning of the patient, the camera and the primary care nurse's activity via the use of a video-link.

Conclusion

Telemedicine offers primary care nurses a unique opportunity to engage in active collaboration with hospital specialists. The nurses’ examination skills are recruited because physical examination is conducted from distance and the specialist cannot touch the patient or see parts of the body with ease. We speculate that difficulties with the physical examination may have contributed to the relatively slow adoption of telemedicine.

Practice implications

The analysis reveals some new communication practices that participants in telemedicine are called to adopt. This can be used to inform training interventions that focus both on patient and professional.     

General practice counseling for patients with chronic obstructive pulmonary disease to quit smoking: Impact after 1 year of two complex interventions

Objective

To evaluate two counseling programs in general practice to help smokers with chronic obstructive pulmonary disease (COPD) to quit smoking.

Methods

Cluster randomized controlled trial including 68 general practices (667 patients) using a randomly assigned intervention program with counseling and advice about nicotine replacement therapy (and additional bupropion-SR in one of the programs) or usual care. Usual care consisted of periodic regular check-ups and COPD information. The main outcome measure was biochemically verified point prevalence at 12 months.

Results

The two intervention groups were treated as one in the analysis because they were equally effective. The intervention resulted in a significantly self-reported higher success rate (14.5%) compared to usual care (7.4%); odds ratio = 2.1, 95% confidence interval = 1.1-4.1. Biochemically verified quit rates were 7.5% (intervention) and 3.4% (usual care); odds ratio = 2.3, 95% confidence interval = 0.9-6.0.

Conclusion

The program doubled the cessation rates (statistically nonsignificant). Too few participants used the additional bupropion-SR to prove its effectiveness.

Practice implications

The protocols can be used for COPD patients in general practice, but expectations should be modest. If quitting is unsuccessful, a stepped care approach should be considered.     

Third year medical students perceptions towards learning communication skills: implications for medical education

Objective

To analyze students’ perceptions towards learning communication skills pre-and-post training in a Communication and Clinical Skills Course (CCSC) at a Portuguese Medical School.

Methods

Content analysis was used to describe and systematically analyze the content written by students (n = 215 from a total of 229) in an open-ended survey. In addition, content analysis association rules were used to identify meaning units.

Results

Students’ pre-training definitions of communication skills were not specific; their post-training definitions were more precise and elaborated. Students perceived communications skills in Medicine as important (61%), but recommended that teaching methodologies (52%) be restructured. There appeared to be no connection between criticism of teaching skills performance and perceptions of the other aspects of the course.

Conclusion

Students’ experiences at CCSC are associated with their perceptions of communications skills learning. Content analysis associations indicated that these perceptions are influenced by context.

Practice implications

Improvement of curricula, teaching and assessment methods, and investment in faculty development are likely to foster positive perceptions towards learning communication skills in these students.     

Role PKA and p38 MAPK on ROS production in neutrophil age-related: Lack of IL-10 effect in older subjects

Background

There is a large increase in the number of elderly people in modern societies. This demographic phenomenon has been paralleled by an epidemic of chronic diseases and inflammatory processes usually associated with advanced age.

Objective

We studied the role of protein kinase A (PKA), protein kinase B (Akt/PKB) and p38 mitogen-activated protein kinase (p38 MAPK) signaling pathways in ROS produced by neutrophils induced by pro-interferon-gamma (IFN-γ) or anti-inflammatory interleukin 10 (IL-10) cytokines age-related.

Methods

The ROS generation was studied in healthy subjects in age ranging from 20 to 80 years old divided in five age groups: (20-39), (40-49), (50-59), (60-69) and (70-80) years old. ROS production was quantified in a luminol-dependent chemiluminescence assay and the results were expressed as relative light units/min).

Results

ROS production in human neutrophil was activated by IFN-γ in all the groups studied. This activation was down-regulated by IL-10. The inhibitory effect of IL-10 on 20-49 years old group was reversed by the pre-treatment with H89 (PKA inhibitor) but not with PD169316 (p38 MAPK inhibitor). This differential effect of IL-10 associated with age was not observed with the neutrophil pre-treatment with Akt/PKB or NADPH-oxidase inhibitor (DPI). Lack of IL-10 effect on ROS production was observed in older subjects (50-80 years old). The effect of IL-10 showed a significant inhibition of ROS production similar to those got with PD169316 alone as compared to that of p38 MAPK.

Conclusion

The results suggest that inhibitory effect of the ROS production mediated by IL-10 depends on PKA for the younger and the lack effect on the elderly is p38 MAPK dependent.     

Effects of an interactive tailored patient assessment tool on eliciting and responding to cancer patients' cues and concerns in clinical consultations with physicians and nurses

Objective

To test the effect of Choice, an interactive tailored patient assessment tool (ITPA), on cancer patients’ expressed cues and concerns (C&Cs), and clinicians’ responses to these C&Cs.

Methods

97 experimental group consultations, where patients used the Choice ITPA to report their symptoms and problems in preparation to their consultation, were compared to 99 control group consultations. All consultations were audio-taped and coded using the Verona Coding Definitions of Emotional Sequences (VR-CoDES).

Results

We identified 473 cues and 109 concerns with a mean number of 3.0 (SD = 3.2). The most frequent utterance was cue B (45.2%), indicating expression of uncertainty or hope. We found more C&Cs in consultations with the Choice ITPA compared to the control group (p < 0.01), and in consultations with nurses compared to physicians (p < 0.001). No differences in clinicians’ response types in the two groups were found. However, significant differences in response type between nurses and physicians were found.

Conclusion

The Choice ITPA was an effective tool to disclose cancer patients’ cues and concerns.

Practice implications

The Choice ITPA proved to be an effective intervention for cancer patients to express more C&Cs, but should be accompanied with communication skills training to potentially produce more patient-centered responses from the clinicians. (ClinicalTrials.gov number NCT00857103.)     

Sleep disorders screening, sleep health awareness, and patient follow-up by community pharmacists in Australia

Introduction

Community pharmacies are well placed to deliver education and counseling to improve sleep health.

Objective

To develop, implement and evaluate a pharmacist led sleep health program.

Methods

Participating pharmacists (n = 23) were trained to screen, counsel and follow up patients at risk of sleep disorders. Patients were screened for specific sleep disorders, counseled, provided written information and/or referred to physicians. Patient outcomes were evaluated by questionnaire at 3 or 12 months post screening.

Results

A total of 325 patients were screened, with 142 (44%) patients at risk of one or more sleep disorders. A total of 847 interventions were recorded by pharmacists: verbal counseling (49%), written information (34%), and referrals (16%). A total of 63 patients (of 99 recalling being referred) reported acting on their referral. Positive changes were made with smoking (4%), caffeine intake (10%), alcohol intake (9%) and improved sleep environment (19%).

Conclusion

Pharmacists can raise awareness through educating patients on sleep health, and through counseling initiate behavior change in those at risk of having or developing a sleep disorder.

Practice implications

Further research using this feasibility study can help in understanding the utility of pharmacists screening patients for sleep disorders and educating the public in sleep health.     

Novelty-seeking behavior predicts vulnerability in a rodent model of depression

Background

The onset of major depressive disorder is likely precipitated by a combination of heredity and life stress. The present study tested the hypothesis that rats selectively bred on a trait related to emotional reactivity would show differential susceptibility or resilience to the development of depression-like signs in response to chronic mild variable intermittent stress (CMS).

Methods

Male Sprague-Dawley rats that were bred based on the trait of either high or low locomotor activity in response to a novel environment were exposed to 4 weeks of CMS or control conditions. Changes in hedonic behavior were assessed using weekly sucrose preference tests and anxiety-like behavior was evaluated using the novelty-suppressed feeding test.

Results

During 4 weeks of CMS, bred low responder (bLR) rats became anhedonic at a faster rate and to a larger degree than bred high responder (bHR) rats, based on weekly sucrose preference tests. Measures of anxiety-like behavior in the novelty-suppressed feeding test were also significantly increased in the CMS-exposed bLR rats, though no differences were observed between CMS-exposed bHR rats and their unstressed controls.

Conclusions

These findings present further evidence that increased emotional reactivity is an important factor in stress susceptibility and the etiology of mood disorders, and that bHR and bLR rats provide a model of resistance or vulnerability to stress-induced depression. Furthermore, exposing bHR and bLR rats to CMS provides an excellent way to study the interaction of genetic and environmental factors in the development of depression-like behavior.     

Mixed methods evaluation: pharmacists' experiences and beliefs toward an interactive communication approach to patient interactions

Objective

To characterize pharmacists’ experience and explore their beliefs toward an interactive communication technique, the three prime questions (3PQs),where pharmacists ask about patients’ understanding of medication's purpose, directions, and monitoring.

Methods

Mixed method design. Pharmacists were briefly trained and then integrated the 3PQs into their practice for two weeks. Pharmacists recorded their perceptions of patient interactions, completed a survey addressing self-efficacy and role beliefs toward the 3PQs, and participated in a focus group.

Results

Eleven pharmacists participated and the 3PQs were used with 176 patients. Most interactions were under 5 min. Pharmacists reported that questions about directions and monitoring were most effective in gathering new information with refills whereas medication purpose question was preferred for new fills. The majority of pharmacists were certain they could use the 3PQs and agreed it was their role. Five themes arose from the qualitative analysis: established communication routines, enhanced patient-pharmacist relationships, good medication history, tailoring of the 3PQs, and impact of pharmacy organization.

Conclusion

The 3PQs enabled pharmacists to briefly assess patient medication experiences and tailor education while fostering patient-centered relationships in pharmacy practice.

Practice implications

While the 3PQs may enhance pharmacists’ patient assessment; integration may challenge pharmacists’ work routine.     

Post-coordination in practice: evaluating compositional terminological system-based registration of ICU reasons for admission

Background

Re-use of patient data from an electronic patient record heavily relies on structured, coded data. Terminological systems (TSs) are meant to support this. TSs are more commonly implemented nowadays, especially those that support post-coordination. The effect of using a compositional TS on correctness and specificity of captured patient data is unknown.

Objective

To evaluate the agreement between free-text reasons for admission to intensive care captured in a patient data management system (PDMS) and reasons for admission that were recorded using a compositional TS embedded in the PDMS.

Methods

Observational study comparing pairs of free-text reasons for admission to intensive care with reasons for admission that were recorded using a compositional TS. Both reasons for admission were captured in the PDMS by clinicians during regular care practice. Each pair was judged as exact match, partial match or mismatch by two independent raters. Partial matches were further analyzed to investigate whether free-text or TS-based reasons for admissions included more detail and whether these differences could be explained by the content, the interface of the TS or by user or usability characteristics.

Results

Eleven percent of the pairs matched exactly, 79% of the pairs matched partially and 10% of the pairs did not match. Compared to free-text registration TS-based registration resulted in more detail for 21% of the partial matches, in less detail for 43% of the partial matches and in 36% of the partial matches some detail was added while at the same time other detail was lacking. In 65% of the cases in which the TS-based registration lacked some detail, this detail was available in the content of the TS. Physicians who used the TS occasionally had a significantly higher percentage of mismatches.

Conclusion

In practice, post-coordination leads to information with different detail but a level of detail comparable to free-text registration of reasons for admission. Details missing in the TS-based reasons for admission were most often available in the TS, indicating that user interaction with the system is more of an impediment than the contents of the TS.     

Skin ultrastructural findings in type 2 Gaucher disease: diagnostic implications

Background

Type 2 Gaucher disease is a rare and progressive subtype of this lysosomal storage disorder, marked by rapid, early-onset neurodegeneration. Distinguishing type 2 from types 1 and 3 Gaucher disease has remained challenging, due to the lack of a clear correlation between phenotype and enzymatic activity or genotype. β-glucocerebrosidase, the enzyme deficient in Gaucher disease, also has an essential role in maintaining epidermal permeability function, by regulating the ratio of ceramides to glucosylceramides in the stratum corneum of the skin.

Objectives

To further assess the diagnostic utility of epidermal evaluations in distinguishing patients with type 2 Gaucher disease in an expanded cohort.

Study design

Epidermal samples were evaluated from twenty children with type 2, three patients with type 3 Gaucher disease and two adults with type 1 Gaucher disease with different clinical manifestations and genotypes. Electron microscopy on ruthenium tetroxide post-fixed tissue was performed.

Results

Compared to controls and subjects with type 1 and type 3 Gaucher disease, only patients with type 2 Gaucher disease displayed characteristic electron dense, non-lamellar clefts and immature-lamellar membranes.

Conclusion

The appearance of characteristic alterations in epidermal ultrastructure provides an early and specific diagnostic tool to help in distinguishing type 2 from the other types of Gaucher disease.     

Inter-organizational future proof EHR systems. A review of the security and privacy related issues

Objectives

Identification and analysis of privacy and security related issues that occur when health information is exchanged between health care organizations.

Methods

Based on a generic scenario questions were formulated to reveal the occurring issues. Possible answers were verified in literature.

Results

Ensuring secure health information exchange across organizations requires a standardization of security measures that goes beyond organizational boundaries, such as global definitions of professional roles, global standards for patient consent and semantic interoperable audit logs.

Conclusion

As to be able to fully address the privacy and security issues in interoperable EHRs and the long-life virtual EHR it is necessary to realize a paradigm shift from storing all incoming information in a local system to retrieving information from external systems whenever that information is deemed necessary for the care of the patient.     

Employing immersive virtual environments for innovative experiments in health care communication

Objective

This report reviews the literature for studies that employ immersive virtual environment technology methods to conduct experimental studies in health care communication. Advantages and challenges of using these tools for research in this area are also discussed.

Methods

A literature search was conducted using the Scopus database. Results were hand searched to identify the body of studies, conducted since 1995, that are related to the report objective.

Results

The review identified four relevant studies that stem from two unique projects. One project focused on the impact of a clinician's characteristics and behavior on health care communication, the other focused on the characteristics of the patient. Both projects illustrate key methodological advantages conferred by immersive virtual environments, including, ability to maintain simultaneously high experimental control and realism, ability to manipulate variables in new ways, and unique behavioral measurement opportunities.

Conclusion

Though implementation challenges exist for immersive virtual environment-based research methods, given the technology's unique capabilities, benefits can outweigh the costs in many instances.

Practice implications

Immersive virtual environments may therefore prove an important addition to the array of tools available for advancing our understanding of communication in health care.     

“I need to lead my own life in any case”—A study of patients in dialysis with or without a partner

Objective

To elicit psychological and psychosocial problems existing in patients in dialysis and their partners, its being felt that the diversity involved has important implications for how service in dialysis units is delivered to patients and their partners.

Methods

The results of a series of interviews of 39 patients in dialysis and 21 partners of theirs, each interview individual, concerning their ways of thinking and their feelings and the behaviour, were analyzed in qualitative and content-oriented terms.

Results

Five basic themes could be identified: importance of treatment being individualized, dependency on an apparatus, consequences of the disease and its treatment, hopes for the future, and thoughts concerning life and death. Diversities relating to age, civil status, cultural and gender matters were disclosed.

Conclusion

The interview approach illustrated the importance of extended professional and individualized support in handling psychological and psychosocial disparities and needs in order to make treatment regimes more acceptable to the persons involved.

Practice implications

Suggestions are made concerning efforts to improve the care of patients receiving dialysis, and the importance of working with the patients and those closest to them in multidisciplinary teams.