Reported cessation advice given to African Americans by health care providers in a community health clinic

Physician smoking cessation advice has been shown to be effective in encouraging patients to attempt cessation. Few studies have examined factors associated with patient-reported physician advice in an inner city community health clinic. Smokers identified via chart review and provider referral met with a study smoking specialist. Eligible participants self-identified as African American, smoked at least 1 cigarette per day in the prior 7 days, were 18 or older, had access to a telephone, and agreed to consider blood testing for genetic susceptibility to lung cancer. Of the 869 smokers identified, 487 were eligible and completed a brief in-person and a more extensive follow-up telephone survey within one week after their visit. Patient reports of smoking cessation advice by providers were regressed on patient demographic, smoking, health, and social support variables. Seventy percent of participants reported that they had been advised to quit smoking. Smokers who were older, did not smoke menthol cigarettes, were in poorer health, and who had a regular health care provider were most likely to report having received advice. Patients in this community health setting reported high rates of provider advice to quit smoking. Yet, even in this optimal condition, young healthy smokers did not report receiving advice, even when they were ready to quit smoking. Providers may need additional training and prompting to counsel young healthy smokers about the importance of cessation.     

Determinants of physical activity initiation and maintenance among community-dwelling older persons

BACKGROUND: Understanding determinants of initiation and maintenance of an active lifestyle among older individuals is of great concern to public health because of the increasing evidence that lifestyle may alter the course of frequently occurring chronic diseases. METHOD: Two thousand five hundred seven community-dwelling Medicare beneficiaries age 65 and over were interviewed at three points over 4 years regarding their physical activity, defined as a self-report of walking briskly, gardening, or heavy housework at least three times a week. Extensive data were also collected on health status, health services use, sociodemographics, and, at the final interview, self-mastery, importance of various factors in the decision to be physically active, and interaction with their physician regarding physical activity. Determinants of initiation and maintenance of physical activity were identified using logistic regressions. RESULTS: Forty-one percent maintained an active lifestyle; 12% initiated an active lifestyle; 22% declined to become sedentary; 25% were sedentary at all observation. Predictors of both initiation and maintenance of physical activity were younger age, moderate to excellent health, and the patient's belief that physical activity was important to his/her health. Among the 301 patients who initiated activity, 40% said their physician was a very important influence. CONCLUSIONS: Strengthening the belief of older individuals in the benefits to their health of physical activity holds promise for increasing the proportion of community-dwelling older persons who move from a sedentary lifestyle to a more physically active lifestyle and for maintaining such activity.     

Establishing a welfare advice service in family practices: views of advice workers and primary care staff

BACKGROUND: The placement of welfare advice services in family practice to assist patients with health-related social and economic issues (e.g. disability benefits) has gathered momentum over the last decade in the UK. This expansion of primary care raises a number of issues for practices hosting these services. OBJECTIVES: To gain the views of advice workers and primary care staff about the issues raised in hosting a welfare advice service across 30 practices in inner city Bradford. METHODS: Views were obtained through focus groups with six advice workers, and primary care staff in 14 practices. A questionnaire was also posted to all practice managers asking their opinions about the service. RESULTS: The focus groups highlighted a number of advantages for patients, including improvements in health and quality of life through increased income and reduced stress from social and economic issues. For practice staff, the service provided a resource to refer patients for welfare advice, reducing the time spent dealing with welfare issues, thereby reducing workload. This was confirmed in the questionnaire to practice managers where 72% said the service had saved time for GPs and reception/office staff. The advice workers raised concerns about the perceived level of commitment to the service from some staff at some practices. Practice staff were particularly concerned about the need for feedback about referrals. CONCLUSION: Providing welfare advice in family practice can act as a valuable resource for primary care staff helping to address their patients health-related social and economic needs.     

Randomized controlled trial of physical activity counseling for older primary care patients

BACKGROUND: Regular physical activity reduces the risk for chronic diseases among older adults. Older adults are likely to be seen by primary care clinicians who can play a role in promoting physical activity among their patients. DESIGN: In this randomized controlled trial (1998-2003; data analyzed 2004-2005), we compared the effects of brief advice to exercise from a clinician supplemented by telephone-based counseling by health educators (extended advice) to brief advice from a clinician alone (brief advice). SETTING/PARTICIPANTS: A total of 100 primary care patients (63.2% female, 14.7% minority, mean age=68.5 years) participated in the trial. INTERVENTIONS: The extended-advice intervention consisted of clinician advice plus exercise counseling via telephone provided by research staff, and the brief advice condition consisted of clinician advice alone. Both interventions focused on promoting moderate-intensity physical activity. MAIN OUTCOME MEASURES: Self-reported physical activity using the 7-Day Physical Activity Recall instrument and objective activity monitoring using Biotrainers were assessed at baseline, and at 3 and 6 months. RESULTS: Participants in the extended-advice arm reported significantly greater participation in moderate-intensity physical activity than the brief-advice group at 3 months (+57.69 minutes vs 12.45 minutes; 3.84 kcal/week vs 0.83 kcal/week) and 6 months (+62.84 minutes vs 16.60 minutes; 4.19 kcal/week vs 1.1 kcal/week). Objective activity monitoring also showed significantly increased physical activity among extended-advice versus brief-advice participants at both time points (+50.79 vs -11.11; +42.39 vs -24.18, respectively). CONCLUSIONS: These data indicate that clinician advice with follow-up counseling can promote adoption of moderate-intensity physical activity among older, primary care patients.     

Physical activity levels and sedentary time during school hours of 6th-grade girls in Germany

Aim

Regular physical activity and low levels of sedentary time have positive health effects on youth, and data are needed to base public health recommendations on. Here, findings of device-based physical activity and sedentary time in sixth graders are presented. Data below are presented as mean (SD).

Subject and methods

Three hundred and eight sixth-grade girls [11.6 (0.6) years] from the CReActivity study in Germany wore accelerometers (ActiGraph GT3X) for 7 consecutive days. Moderate to vigorous physical activity (MVPA), light physical activity (LPA), and sedentary time (ST) was obtained during school days with a focus on recess times.

Results

Girls spent 79.9 (23.2) minutes in MVPA and 9.4 (1.2) hours in ST during schooldays, of which 20.5 (8.2) minutes and 3.8 (0.4) hours respectively were accumulated during school hours. On average, students had 35.4 (4.5) minutes break, of which 6.3 (3.2) minutes (17.8%) were spent in MVPA activity and 16.5 (6.2) minutes (46.6%) in ST.

Conclusion

School setting is an important factor for physical activity and sedentary time. Therefore policy, curriculums, and school environment should promote physical activity und reduce sedentary time during school hours.

     

Knowledge based commissioning: can a national clinical effectiveness policy be compatible with seeking local professional advice?

OBJECTIVES: To help develop a means, based on the views of purchasers and providers of health care, of incorporating national research on clinical effectiveness into local professional advisory mechanisms in order to inform health care purchasing and contracting. METHODS: Three geographically based multidisciplinary workshops attended by National Health Service (NHS) staff drawn from the principal purchaser and provider groups in one English region were organized around the discussion of three health care purchasing case studies: coronary artery disease, diabetes and management of clinical depression in general practice. The proceedings were transcribed and analyzed using content analysis methods. RESULTS: 95 people took part. There were major differences between the purchasers' and health care providers' views on the right balance between local and national information and advisory sources for purchasing. In general, providers wanted the provision of advice to purchasers to be local, in which their opinion was sought, either individually or collectively, acted on and the results fed back to them. In contrast, health authority purchasers considered that local professionals were only one source of professional advice, albeit an important one, to be utilized in coming to decisions. General practitioner fundholders as purchasers, however, preferred to rely on their own experiences and contacts with local providers in making purchasing decisions. CONCLUSIONS: Professional specialist advisory groups are necessary to inform the purchasing of health care, but should extend beyond advising on the placement of individual contracts. Involving health care providers in all short-term contracting is unlikely to be cost-effective given the time commitment required. The emphasis at purchaser/provider meetings should be on education: providing an opportunity for purchasers and providers to develop closer relationships to discuss political imperatives and financial constraints; increasing communication and understanding of providers' and purchasers' roles; and providing an environment for professionals and purchasers to share their views on purchasing. As currently presented, elements of the national policies in the NHS advocating the use of both national evidence on clinical effectiveness and local professional advice are contradictory and should be clarified.     

The nature and content of physician telephone calls in a private practice

Telephone encounters received by two physicians in a private rural family practice setting were examined over a 61-day sampling period. A total of 1,264 calls were received during the study period, with 905 (71.6 percent) being received in the office setting. An average of 10.4 calls per physician were received each day, and a mean of 16.2 minutes per physician was spent each day with telephone encounters. Each call was brief, lasting 1.6 minutes (standard deviation 1.5 minutes); administrative and personal calls each lasted significantly longer than other call categories (F = 20.8, P = .0001). More chronic disease diagnoses tended to be handled during office when compared with nonoffice telephone encounters. The majority of calls (932, or 83.1 percent) did not require a face-to-face visit as judged by the physician. Of the office calls, 58.2 percent were handled by the physicians through a message system rather than a direct physician telephone call. It is estimated that uncharged care over the telephone saved patients in this practice up to $150,000 per year.     

北京西城区高一学生校内体力活动评估

了解北京市西城区高中生校内不同强度体力活动情况,为学校采取措施促进学生体力活动提供客观依据.方法 抽取北京市西城区的一类、二类和三类高中各2所,每所高中随机抽取健康高一学生40名,共采集有效样本208人(男生102名,女生106名).使用ActiGraph GT3X+加速度计,记录并分析学生1周在校期间体力活动水平.结果 在校期间,女生静坐少动时间高于男生,低强度体力活动(LPA)和中等强度至较大强度体力活动(MVPA)时间均低于男生(P值均<0.01),体育课也显示出相同的情况.三类高中学生在校期间静坐少动行为占比高于一类和二类高中学生,而MVPA总时间占比较低(P值均<0.05).在体育课中,男女生平均分别有13,19 min处于静坐少动状态,15,10 min进行MVPA.本研究中受试者均未能达到体力活动指南所推荐的“每天参与至少60 min中高强度运动”的目标.结论 女生体力活动水平低于男生,体育课中学生用于中高强度运动的时间偏少,一类和二类学校学生在校期间体力活动水平整体高于三类学校学生.     

Objectively measured physical activity and sedentary time in European adolescents: the HELENA study

The authors' aim in this cross-sectional study was to characterize levels of objectively measured physical activity and sedentary time in adolescents from 9 European countries. The study comprised 2,200 European adolescents (1,184 girls) participating in the HELENA cross-sectional study (2006-2008). Physical activity was measured by accelerometry and was expressed as average intensity (counts/minute) and amount of time (minutes/day) spent engaging in moderate- to vigorous-intensity physical activity (MVPA). Time spent in sedentary behaviors was also objectively measured. Cardiorespiratory fitness was measured by means of the 20-m shuttle run test. Level of maternal education was reported by the adolescents. A higher proportion of boys (56.8% of boys vs. 27.5% of girls) met the physical activity recommendations of at least 60 minutes/day of MVPA. Adolescents spent most of the registered time in sedentary behaviors (9 hours/day, or 71% of the registered time). Both average intensity and MVPA were higher in adolescents with high cardiorespiratory fitness, and sedentary time was lower in the high-fitness group. There were no physical activity or sedentary time differences between maternal education categories. These data provide an objective measure of physical activity and amount of time spent in sedentary behaviors in a relatively large number of European adolescents.     

Quality and correlates of physical activity counseling by health care providers in Israel

BACKGROUND: The quantity and quality of physical activity counseling by the health care provider can have a profound impact on improving the physical activity of the older population. This study presents an estimate of the quality and quantity of physical activity counseling and tests the associations of different variables with physical activity. METHODS: A random telephone survey of 793 Israeli residents between the ages of 45 and 75 was conducted. Counseling by a health care provider was evaluated using a three-stage approach--assess, advise, and assist. RESULTS: Of those visiting a doctor in the last 3 months 22, 16, and 7% were assessed, advised, and assisted, respectively, regarding physical activity by a health care provider. At all three stages, receiving weight reduction counseling was a main variable correlated with receiving physical activity counseling (OR 3.38-2.43). Having a chronic disease was associated with being assessed; smoking and being a recent immigrant were associated with getting assistance on physical activity. Visiting a health care provider in the last 3 months, and being physically active were also associated with counseling. The dietitians and the physicians had the highest quality and rates of counseling in all three stages. CONCLUSION: It seems that a sedentary lifestyle is not regarded as an independent risk factor during counseling, but more as an important part of weight reduction. An evaluation of physical activity counseling by the three stages can be used to assess the quality of the counseling.     

Providers' assessment of barriers to effective management of hypertension and hyperlipidemia in community health centers

We explored 251 providers' (47% licensed practical nurses, 27% registered nurses, 10% physicians, 10% physician assistants, 6% other) perceptions of barriers to effective management of hypertension and hyperlipidemia from 72 Midwest community health centers (CHCs). Optimal care for these diseases is difficult in any setting; little is known about the specific barriers CHCs face. Community health centers often have a multidisciplinary team that participates in patient care. Current models of quality improvement and chronic care management require virtually all CHC providers to know clinical guidelines. Providers in this study generally chose hypertension and hyperlipidemia target levels that met or were more stringent than national guidelines, but lacked confidence to address behavioral change and reported obstacles to modifying patient lifestyle. Community health centers should strengthen providers' skills in facilitating lifestyle change. Improving quality of care requires supporting providers' efforts to take patients' psychosocial and financial challenges into account, and revised policies to eliminate financial and cultural barriers to care.     

Caught in the competitive crossfire: safety-net providers balance margin and mission in a profit-driven health care market

This paper describes how intensifying competitive pressures in the health system are simultaneously driving increased demand for safety-net care and taxing safety-net providers' ability to maintain the mission of serving all, regardless of ability to pay. Although safety-net providers adapted to previous challenges arising from managed care, health system pressures have been more intense and more generalized across different sectors in recent years than in the past. Providers are adopting some of the same strategies being used in the private sector to attract higher-paying patients and changing their "image" as a safety-net provider.     

The relationships between indicators of physical activity, indicators of sedentary behaviour and adiposity in French adults: the FLVS II study

Increasing habitual physical activity and decreasing sedentary behaviour have both been identified as targets for the prevention of unhealthy weight gain and obesity. To improve health monitoring in the context of nutrition-related disease prevention, there is a need to better define relevant indicators of sedentary behaviour. The aim of this study was to investigate the relationships between indicators of physical activity, indicators of sedentary behaviour and body fat in French adults. We analysed cross-sectional data from a community-based survey in northern France (213 men, age: 44±5 years; 192 women, age: 42±4 years; mean±SD). Physical activity and sedentary behaviour during the past year were assessed using the Modifiable Activity Questionnaire. Indicators of physical activity were leisure-time and occupational physical activity, indicators of sedentary behaviour during leisure were reading and “screen viewing” (including time spent watching television/video, playing video games, and using a computer). Body-fat percentage was assessed using bio-impedance analysis. In univariate analysis (Spearman rank correlations), reading and screen viewing were not significantly correlated; reading was positively associated with leisure-time physical activity in women and negatively associated with occupational physical activity in men. In multivariate analyses (stepforward regression models) stratified by gender and educational level, independent predictors of percent body fat included, in women, screen viewing (positive association), occupational physical activity (positive association) and leisure-time activity (negative association), but not reading; in men, only reading was associated with percent body fat, with a negative relationship in those with a high educational level. Relationships between indicators of sedentary lifestyle and body fat differ according to gender and type of sedentary pasttime. The data emphasise that sedentary lifestyle represents a complex set of behaviours and that various sedentary behviours may have distinct effects with regard to health outcomes. These results point out the need to assess selected indicators of sedentary behaviour when considering health monitoring in public health nutrition.     

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.     

Organizational determinants of psychosocial treatment activity of providers in Va mental health facilities

OBJECTIVE: To identify the determinants of level and intensity of psychosocial treatment activity among staff who deliver services to the severely and mentally ill. METHODS: The study sample consisted of 769 treatment providers working in 77 units in 29 VA mental health facilities. Level of psychosocial care was measured as the number of patient contacts and total hours spent in psychosocial care over a 1 week period. Intensity of psychosocial care was measured as the average time per patient contact. We used hierarchical linear modeling (HLM) to examine the association between level and intensity of care and three categories of determinants - individual provider attributes, work characteristics and treatment setting characteristics. RESULTS: Providers' occupation is related to both the level and intensity of care. Providers with administrative responsibilities also have fewer patient contacts and lower intensity of such contacts. Providers who perceived their pay and benefits more positively had fewer patient contacts and less intensive patient contacts. Positive relationships with patients and providers were also associated with greater levels and intensity of psychosocial treatment activity among providers. Finally, statistically significant differences in psychosocial treatment activity among units were identified although such differences are not attributable to unit size, patient cohort severity or unit workload. CONCLUSIONS: Level and intensity of psychosocial treatment activity vary systematically by individual attributes of providers, characteristics of the work they perform and attributes of the treatment setting. These factors may provide the basis for designing interventions to modify provider behavior in a manner consistent with emerging financial pressures and treatment modalities for the seriously mentally ill.     

Acceptability and feasibility of integration of HIV care services into antenatal clinics in rural Kenya: a qualitative provider interview study

The aim of this study was to explore the perspectives of healthcare providers on the advantages and disadvantages of integrating HIV care services, including highly active antiretroviral therapy (HAART), into antenatal care (ANC) clinics in rural Kenya. We conducted a qualitative study using in-depth interviews and thematic analysis; 36 healthcare providers from six health centres in Nyanza Province, Kenya participated. Effects on service providers included increased workload due to the incorporation of specialised HIV services into ANC clinics. Providers observed that integration results in decreased patient time spent at the health facility, increased efficiency and closer provider-patient relationships; all leading to increased patient satisfaction. Providers also said that women would be more likely to receive HAART and adhere to their treatment as a result of improved confidentiality and decreased stigma. However, a minority of providers noted that integration could result in longer appointment times for HIV-positive women at ANC clinics leading to inadvertent disclosure. Integration could lead to strengthened ANC, postpartum care, prevention of mother-to-child transmission and HIV care for women and their families. However, integration efforts need to take into account potential negative effects on ANC provider workload, disclosure and the quality of care.     

Acceptability and feasibility of integration of HIV care services into antenatal clinics in rural Kenya: A qualitative provider interview study

Abstract

The aim of this study was to explore the perspectives of healthcare providers on the advantages and disadvantages of integrating HIV care services, including highly active antiretroviral therapy (HAART), into antenatal care (ANC) clinics in rural Kenya. We conducted a qualitative study using in-depth interviews and thematic analysis; 36 healthcare providers from six health centres in Nyanza Province, Kenya participated. Effects on service providers included increased workload due to the incorporation of specialised HIV services into ANC clinics. Providers observed that integration results in decreased patient time spent at the health facility, increased efficiency and closer provider-patient relationships; all leading to increased patient satisfaction. Providers also said that women would be more likely to receive HAART and adhere to their treatment as a result of improved confidentiality and decreased stigma. However, a minority of providers noted that integration could result in longer appointment times for HIV-positive women at ANC clinics leading to inadvertent disclosure. Integration could lead to strengthened ANC, postpartum care, prevention of mother-to-child transmission and HIV care for women and their families. However, integration efforts need to take into account potential negative effects on ANC provider workload, disclosure and the quality of care.     

Emerging issues associated with HIV patients seeking advice from health food stores

OBJECTIVES: To ascertain the recommendations, training and education of health food store employees and determine how they communicate the costs, benefits and risks associated with natural health products for the HIV/AIDS community. METHODS: Four male research assistants, posing as asymptomatic HIV-positive individuals, inquired of employees of all retail health food stores in a major Canadian city as to what is recommended for their condition. The research assistants asked about product costs, side effects, potential drug interactions and efficacy. They also inquired as to employee education related to Complementary and Alternative Medicine (CAM) and noted whether employees asked about which conventional medications they were taking and whether they recommended that the subjects seek physician or CAM provider advice. RESULTS: A total of 32 stores were included. Eight store employees (25%) offered no advice; eight (25%) inquired whether the subjects were currently taking medications; six (19%) suggested visiting a physician; and eight (25%) suggested visiting a CAM provider. A total of 36 different products (mean 2.3 per employee) were recommended with considerable variability in product evidence and cost. The education of the employees varied from postgraduate education (n=3), to undergraduate degree (n=3), college level (n=5) in CAM, or no formal education in CAM (n=21). CONCLUSION: There was considerable heterogeneity in advice on natural food products provided by employees of natural food stores and, in general, these individuals had limited formal training in CAM. The products they recommended had limited evidence supporting their efficacy and in some instances were potentially harmful and had considerable costs. The findings of this study support the need to further examine how best to regulate this growing component of the health care system.