The role of effective communication with children and their families in fostering adherence to pediatric regimens

Adherence to pediatric health enhancement, disease prevention, and medical treatment, particularly for chronic disease, can be challenging because of demanding regimens, children's progressing developmental stages, and varying family perspectives and relationships. This review examines adherence in the context of communication among providers, pediatric patients, and their families. The focus is on: the delivery of prevention and treatment information; trust in the therapeutic relationship; beliefs and attitudes in shaping acceptance of health care messages; social and cultural norms; building patient and family commitment to behavior change; family habits; barriers and pressures faced by patients and their families; the role of social networks and social support in fostering adherence, and the effects of family cohesiveness and family conflict. The unique challenges of fostering preventive health care and treatment for chronic disease in the context of transition to adolescence are also considered, and effective clinical solutions are reviewed.     

HLA-DRB1 and HLA-DQB1 polymorphisms in Pacific Islands populations

Allele frequency distributions of the HLA-DRB1 and HLA-DQB1 genes were investigated in four Pacific Islands populations from the Cook Islands, Samoa, Tokelau and Tonga. Limited diversity was observed for both the HLA-DRB1 and HLA-DQB1 loci. Five HLA-DRB1 alleles were observed to be the most frequent amongst all the studied Pacific Islands populations. They were: HLA-DRB1*0403, HLA-DRB1*08032, HLA-DRB1*09012, HLA-DRB1*11011 and HLA-DRB1*1201. Cook Islanders had the largest number of low frequency DRB1 alleles followed by Samoans, Tokelauans and Tongans, most of which may be attributed to reported non-Polynesian admixture. The most frequently observed DQB1 alleles in the four studied Pacific Islands populations were those of the DQ3 subgroup of alleles HLA-DQB1*03011, HLA-DQB1*0302 and HLA-DQB1*03032 as well as HLA-DQB1*05031 and HLA-DQB1*06011. Cook Islanders had the highest number of rare HLA-DQB1 alleles, the distibution being similar to that of the HLA-DRB1 allele. While, in general, the values of homozygosity for DRB1 and DQB1 were observed to be lower then expected under neutrality, a statistical significance was observed in Tongans, Samoans and Tokelauans for the DQB1 locus and in Tongans for the DRB1 locus. Differences were observed between allele frequency distributions for Tokelauans compared to the other three populations. This was also demonstrated by principal component analysis of DRB1 and DQB1 allele frequencies, which separated the Tokelauan population from Cook Islanders, Tongans and Samoans. Tongans and Samoans were separate from the other Polynesian populations in the phylogenetic trees. Observed allele and haplotype frequencies were found to be in agreement with previously published HLA-DRB and HLA-DQB Polynesian data.     

Follow-up of abnormal screening mammograms among low-income ethnically diverse women: findings from a qualitative study

OBJECTIVE: To understand factors that women feel facilitate or hinder their receipt of diagnostic services following an abnormal screening mammogram. METHODS: This qualitative study used a purposive sampling strategy to identify low-income, ethnically diverse women aged 40 or over who had a recent abnormal mammogram. Working with a community health center, breast evaluation center, and mobile mammography van, 64 women were interviewed to identify salient themes that differentiated women who received timely follow-up from those who did not. RESULTS: Prominent themes among women who delayed follow-up included dissatisfaction with communication of results; perceived disrespect on the part of providers and clinic staff; logistical barriers to access of diagnostic services; anxiety and fear about a possible cancer diagnosis; and a lack of information about breast cancer screening and symptoms. Women who received timely care more often reported an appreciation of efforts by providers and clinic staff to support their prompt follow-up; availability of social support that facilitated appointment-keeping; confidence in their ability to advocate for their health; and a high priority placed on self-care. CONCLUSION: A comprehensive approach to improving timely diagnostic follow-up among underserved groups must address patient beliefs and attitudes, provider practices and communication, and practices at the health care systems level. PRACTICE IMPLICATIONS: Implications and strategies for improving patient education, patient-provider communication, and organizational practices are discussed.     

Psychological distress in primary care patients with heart failure: a longitudinal study.

BACKGROUND: Psychological distress is a common phenomenon in patients with heart failure. Depressive symptoms are often under-diagnosed or inadequately treated in primary care. AIM: To analyse anxiety and/or depression in primary care patients with heart failure according to psychosocial factors, and to identify protective factors for the resolution of psychological distress. DESIGN OF STUDY: Longitudinal observation study. SETTING: Primary care practices in lower Saxony, Germany. METHOD: In 291 primary care patients with heart failure the following factors were measured using validated questionnaires at baseline and 9 months later: anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), quality of life (Minnesota Living with Heart Failure Questionnaire), coping with illness (Freiburg questionnaire for coping with illness), and social support (social support questionnaire). Severity of heart failure (New York Heart Association [NYHA] classification and Goldman's Specific Activity Scale), and sociodemographic characteristics were documented using self-report instruments. RESULTS: Twenty-six (32.5%) of the 80 patients who were distressed at baseline had normal HADS scores 9 months later, while the remainder stayed distressed. In logistic regression, baseline distress (odds ratios [OR] 5.51; 95% confidence intervals [CI] = 2.56 to 11.62), emotional problems (OR = 1.08; 95% CI = 1.00 to 1.17), social support (OR = 0.54; 95% CI = 0.35 to 0.83), and NYHA classification (OR = 1.70; 95% CI = 1.05 to 2.77) independently predicted distress at follow up. High social support contributed to a resolution of anxiety or depression, while partnership and low levels of emotional problems protected patients who began the study in a good emotional state from psychological distress. CONCLUSION: In everyday practice it is important to consider that a high NYHA classification and emotional problems may contribute to anxiety or depression, while high social support and living in a relationship may positively influence the psychological health of patients with heart failure.     

Stress and changing lifestyles in the Pacific: Physiological stress responses of Samoans in rural and urban settings

The lifestyles and social environments of Pacific Islanders have changed profoundly as a result of local development and migration to urban, cosmopolitan centers. These changes have often been accompanied by an increase in chronic diseases, alcoholism, and suicide. As a result, the health effects of psychological and physiological stress have become an increasing concern in Pacific Island nations and in countries with significant Pacific migrant communities. Several studies in the Samoan Studies Project have examined catecholamine excretion rates in order to understand how the behavioral, psychological, and environmental changes of modernization affect the physiological stress responses of young Samoan adults. The results of studies in rural and urban Western Samoa, American Samoa, and Honolulu, Hawaii show that several complex factors associated with urban, more cosmopolitan lifestyles tend to increase stress hormone levels. Specifically, lifestyle differences in physical activity, diet, and social interaction have significant independent and interactive contributions. These behavioral factors can lead to a high degree of day-to-day variability in catecholamine excretion. The implications of these findings for future research designs are discussed. However, the data suggest that it is a complex interaction of lifestyle factors, not any specific single factor, that determines the physiological stress responses of Samoans in different environments. © 1993 Wiley-Liss, Inc.     

Are HIV/AIDS conspiracy beliefs a barrier to HIV prevention among African Americans?

OBJECTIVES: This study examined endorsement of HIV/AIDS conspiracy beliefs and their relations to consistent condom use and condom attitudes among African Americans. METHODS: We conducted a telephone survey with a random sample of 500 African Americans aged 15 to 44 years and living in the contiguous United States. RESULTS: A significant proportion of respondents endorsed HIV/AIDS conspiracy beliefs. Among men, stronger conspiracy beliefs were significantly associated with more negative condom attitudes and inconsistent condom use independent of selected sociode-mographic characteristics, partner variables, sexually transmitted disease history, perceived risk, and psychosocial factors. In secondary follow-up analyses, men's attitudes about condom use partially mediated the effects of HIV/AIDS conspiracy beliefs on condom use behavior. CONCLUSIONS: HIV/AIDS conspiracy beliefs are a barrier to HIV prevention among African Americans and may represent a facet of negative attitudes about condoms among black men. To counter such beliefs, government and public health entities need to work toward obtaining the trust of black communities by addressing current discrimination within the health care system as well as by acknowledging the origin of conspiracy beliefs in the context of historical discrimination.     

Psychosocial and health belief variables associated with frequent attendance in primary care

BACKGROUND: The reasons for high use of primary care, and in particular the role of psychosocial factors, remain unclear. METHODS: We identified and interviewed 236 frequent attenders and 420 normal users, matched by age and sex, of a public Health Centre in Granada, Spain. Users were questioned about mental health (GHQ-28), social support (Duke-UNC-11), family dysfunction (family APGAR) and health beliefs (health belief model, locus of health control and medical care expectations). We also measured a set of individual, social and illness variables. RESULTS: Multiple logistic regression analyses showed that mental health was the main factor associated with frequent attender status (odds ratio = 3.1; 2.4-3.9). The association was stronger than that between frequent attender status and perceived illness, and between the former and reported chronic illness. Family dysfunction and perceived susceptibility to and severity of disease were also significantly but more weakly associated with frequent attender status. Affective support was more strongly associated with FA status than was confidant support, but both associations disappeared when mental health and family function were controlled for. CONCLUSIONS: Our findings document the association of psychosocial factors and primary health care use. We suggest that the effective management of mental health problems from a family-based approach may reduce primary health care high use.     

Diabetes self-management: perspectives of Latino patients and their health care providers

Lifestyle modification programs tailored to experience, culture, psychosocial characteristics, and world-view can improve knowledge, self-care behaviors, and glucose control among Latinos with diabetes. Few data exist, however, on improving diabetes self-management among Latinos. In addition, views and practices of practitioners caring for these patients have received little attention. OBJECTIVE: This study describes findings from qualitative research to inform the refinement of self-management interventions tailored to Latino patients with type 2 diabetes. METHODS: Two practitioner focus groups assessed perceptions of patients' knowledge, attitudes, and behaviors. Four patient focus groups examined knowledge, beliefs, practices, barriers, and facilitators. Data were transcribed and subjected to content analysis. RESULTS: Thirty-seven patients seeking care at a community clinic participated, along with 15 health care practitioners. Important knowledge gaps regarding diabetes causation and self-management were identified. Negative attitudes towards self-management were common among patients. Key facilitators included strong religious faith and support of medical practitioners. Families both facilitated and prevented adoption of self-management practices. CONCLUSION: This study provides unique insights into the knowledge, attitudes, practices, and perceived barriers facing Latino patients and their providers regarding diabetes self-management. PRACTICE IMPLICATIONS: Study findings underscore the need to develop tailored programs for this population and to train practitioners on their implementation.     

Provider and patient perspectives regarding health care for war-related health concerns

OBJECTIVE: To gain insight about Department of Defense providers' and health care beneficiaries' opinions regarding provider-patient communication of health care for post-deployment health concerns. METHODS: Thirty-five Department of Defense primary care providers and 14 military beneficiaries participated in focus groups at five military medical treatment facilities. We audiotaped, transcribed, and qualitatively analyzed semi-structured focus group interviews to determine attitudes and beliefs about war-related health concerns, symptoms, and health care quality. RESULTS: Focus groups revealed important insights about provider and patient perspectives of communication and care in four general areas: physician-patient trust, validity of symptoms and concerns, exchange of health information, and barriers to care. CONCLUSION: Provider-patient communication contributes to patient satisfaction with medical care; poor communication may contribute to decreased patient satisfaction and provider effectiveness. The military health care system poses several challenges to provider-patient communication: the dual nature of the provider's role, the occupational relationship between illness and health care, pre- and post-deployment issues, and continuity of care impact patient and provider perspectives. The prevalence of various beneficiary and provider concerns regarding health care communication requires further study, particularly for the severely wounded. PRACTICE IMPLICATIONS: The quality of information exchanged and of the interpersonal relationship impact medical decision making, particularly in occupational health settings such as the military. Attention to these issues may improve patient outcomes including satisfaction, adherence, trust, health status, and quality of life.     

Healthy, wealthy, wise? Psychosocial factors influencing the socioeconomic status-health gradient

The present research investigated psychosocial factors: control beliefs; social relations moderating the SES-health gradient. Participants included 3775 respondents from a national probability sample, Midlife in United States (t(1): Age, M = 46.40, SD = 13.00, t(2): Age, M = 55.47, SD = 12.43), who provided reports on control beliefs, social relations, and health at two assessment occasions (1994/1995 and 2002/2003). Hierarchical regression demonstrated that control beliefs, social support, and strain uniquely moderated relationships between SES and longitudinal health. The present study highlights the importance of psychosocial factors as protective mechanisms of socioeconomic disadvantages and associated long-term deleterious health outcomes.     

Stress and health among polynesian migrants to New Zealand

A survey study of 228 Samoans, 212 Cook Islanders, and 224 native-born New Zealanders of European background randomly selected from the same working-class neighborhoods of Auckland was interviewed in their own language by same-sex interviewers on their adaptation to life in New Zealand's major industrial city. Strong positive associations were found between the number of symptoms of poor health reported and both the frequency of external situational stressors and the strength of Type A psychological attributes, which together account for 25% of the variance in health status. These statistical relationships were replicated within all ethnic and both sex groups. Social support systems, however, did not provide the stress-buffering effects anticipated, raising the issue of the possible psychic costs of maintaining these kinship ties, particularly among Samoan migrants.The survey research reported in this paper was conducted under the auspices of the South Pacific Research Institute, Inc., supported by Grants AA03231-01, 01S1, 02, and 03 from the National Institute on Alcohol Abuse and Alcoholism (1979–1982) and a Summer Community Service Award from the New Zealand government (1979–1980). The support of these agencies is gratefully acknowledged.     

The relative frequencies of HLA-A*10 alleles in five major United States ethnic populations

The frequency of each A*10 allele was determined in 5 major United States ethnic populations randomly selected from a pool containing 82,979 unrelated individuals. The phenotype frequency of A10 was 10.5% in Caucasians, 14.0% in African-Americans, 21.1% in Asians/Pacific Islanders, 10.6% in Hispanics, and 9.8% in Native Americans. Fifty-nine individuals who had at least one A10 antigen were randomly chosen from each ethnic group for polymerase chain reaction using sequence-specific oligonucleotide probes (PCR-SSOP) typing. Thirteen of sixteen known A10 alleles were identified in this pool. The most common alleles observed were: A*2601 in Caucasians (55%), Hispanics (58%), and Native Americans (45%); A*3402 in African-Americans (34%); and A*3401 in Asians/Pacific Islanders (61%). The African-American and Asian/Pacific Islander populations differ from all other populations in the distribution of A*10 alleles, particularly, A*2601, A*3401, and A*3402.     

Characteristics Associated with Racial Disparities in Illness Beliefs of Patients with Heart Failure

African Americans have greater misperceptions about heart failure (HF) than Caucasians. We examined socioeconomic and medical history factors to determine if they explain differences in accuracy of HF illness beliefs by race. 519 patients completed an illness beliefs and socioeconomic status survey. After establishing univariate associations by race, linear regression with backward selection was used to identify factors associated with HF illness beliefs accuracy. HF illness beliefs were less accurate among African Americans (p < .01). In multivariate models, race remained a predictor of HF illness beliefs accuracy, as did education level and living status (all ps ≤ .01). Illness beliefs of African Americans were inaccurate and independently associated with social support and education level. Health care providers must consider patient education processes as a possible cause of differences and focus on what and how they teach, literacy level, materials used, and family engagement and education.     

A medical school-based program to encourage native Hawaiians to choose medical careers.

Native Hawaiians are highly underrepresented in the field of medicine, both nationally and in Hawaii. Since 1991, the Native Hawaiian Center of Excellence (funded by the Bureau of Health Professions) at the John A. Burns School of Medicine in Honolulu has developed programs to encourage Native Hawaiians to enter and complete medical school. In this article, the authors focus on a revised version of a six-week summer enrichment program for high school students developed by the Center in 1995 and funded by the Hawaii State Department of Education and the federal government. The authors trace the difficulties in attracting Native Hawaiian students and how these difficulties were overcome. They show that once Native Hawaiians have entered the academically rigorous, culturally rich program, their academic and career ambitions have been kindled, and some are planning careers in medicine. The history of the program illustrates that a committed medical school and dedicated individuals in the community, with the support of the federal and state governments, can increase interest among underrepresented students in medical and other health professions careers. Eventually, when such students graduate, there is a likelihood that some of them will go back to serve the health needs of their communities.     

The social implications of an ageing population. Introduction

The growing proportion of older people, especially the very old, is often thought of in negative terms such as the need for more health care. But the implications are wider and affect the future of family care as well as issues of intergenerational relations, employment, living arrangements and attitudes. This paper looks at the social implications of an ageing population on people and on services.     

HLA-A*28 allele frequencies in the five major U.S. ethnic groups

The frequency of each A*28 allele was determined by PCR-SSOP typing in 5 major U.S. ethnic populations: Caucasians, African Americans, Asians/Pacific Islanders, Hispanics, and Native Americans. The percent of serologically defined A28-positive individuals in the 5 populations ranged from 2.7-17.9%. Fifty-nine individuals who were previously serologically typed as A28, A68 or A69 were randomly chosen for allele-level typing from each ethnic group from a database of 82,979 consecutively typed unrelated individuals. The most common A*28 allele for Caucasians, Asians/Pacific Islanders, Hispanics, and Native Americans was A*68012, while A*6802 was found in the majority of African Americans. Only four and three A*28 alleles were seen in Caucasians and African Americans, respectively, while five to six A*28 alleles were seen in the other population groups. The A*6804 and A*6806 alleles were not observed in any of the five ethnic groups.     

Attitudes to depression and its treatment in primary care

BACKGROUND: Undertreatment of depression in primary care is common. Efforts to address this tend to overlook the role of patient attitudes. Our aim was to validate and describe responses to a questionnaire about attitudes to depression and its treatment in a sample with experience of moderate and severe depressive episodes. METHOD: Cross-sectional survey of 866 individuals with a confirmed history of an ICD-10 depressive episode in the 12 months preceding interview, recruited from 7271 consecutive general practitioner (GP) attendees in 36 general practices in England and Wales. Attitudes to and beliefs about depression were assessed using a 19-item self-report questionnaire. RESULTS: Factor analysis resulted in a three-factor solution: factor 1, depression as a disabling, permanent state; factor 2, depression as a medical condition responsive to support; and factor 3, antidepressants are addictive and ineffective. Participants who received and adhered to antidepressant medication and disclosed their depression to family and friends had significantly lower scores on factors 1 and 3 but higher scores on factor 2. CONCLUSIONS: People with moderate or severe depressive episodes have subtle and divergent views about this condition, its outcome, and appropriate help. Such beliefs should be considered in primary care as they may significantly impact on help seeking and adherence to treatment.     

Association between perceived racism and physiological stress indices in Native Hawaiians

The association between racism and the physical health of native U.S. populations has yet to be examined despite their high risk for stress-related disorders and a history of discrimination toward them. We examined the correlation between perceived racism and the two physiological stress indices of cortisol level and blood pressure in 146 adult Native Hawaiians. Attributed and felt racism were assessed with a 10-item shortened version of the Oppression Questionnaire. Height, weight, blood pressure, and salivary cortisol samples (AM and PM) were collected and analyzed along with information on Hawaiian ancestry, BMI, age, sex, marital status, education level, general psychological stress, and ethnic identity. The results indicated that Native Hawaiians reporting more attributed racism had significantly (P < .05) lower average cortisol levels than those reporting less attributed racism, after adjusting for socio-demographic, biological, and psychosocial confounders. Native Hawaiians reporting more felt racism had a significantly higher systolic blood pressure than those reporting less, but this association was not significant after adjusting for the aforementioned confounders. Racism appears to be a chronic stressor that can “get under the skin” of Native Hawaiians by affecting their physical health and risk for stress-related diseases, possibly, through mechanisms of cortisol dysregulation.     

Relative HLA-DRB1*13 allele frequencies and DRB3 associations of unrelated individuals from five US populations

The frequencies of 30 HLA-DRB1*13 alleles and 15 DRB3 alleles were determined for the 5 major U.S. ethnic populations: Caucasians, African Americans, Asian/Pacific Islanders, Hispanics, and Native Americans. A random sampling (163) of DRB1*13-positive individuals from each self-described ethnic group was selected out of a pool of 82,979 unrelated individuals, providing at least an 80% probability of detecting a rare allele that occurred at 1%. These 815 samples were subjected to allele-level SSOP typing and/or DNA sequencing which identified 11 different DRB1*13 alleles. DRB1*1301 and DRB1*1302 were the most common alleles seen in the five major ethnic groups while DRB1*1304 was not detected among Caucasians and DRB1*1305 was not detected among African Americans. DRB1*13 allele diversity was surprisingly more limited among African Americans compared to both Caucasians and Asian/Pacific Islanders. To determine the extent of DRB1*13-DRB3 associations, 504 of these samples expressing only one DRB3-associated DRB1 allele were subjected to PCR-SSOP typing and 14 DRB1*13-DRB3 haplotypes were detected. The distribution revealed that African Americans were significantly different from Caucasians, Asian/Pacific Islanders, and Hispanics. Allele frequency studies such as this further support previous findings that the distribution of HLA types can differ significantly among different ethnic populations.     

Can hopelessness and adolescents' beliefs and attitudes about seeking help account for help negation?

Avoidance of appropriate help is common in acutely suicidal samples and has been confirmed in nonclinical samples but factors that contribute to this help negation effect remain unclear. In a sample of 269 nonclinical Australian high school students, the current study examines the impact of hopelessness, previous mental health care, beliefs, and attitudes toward professional psychological help on the help negation relationship. Results revealed that suicidal ideation significantly predicted lower help seeking intentions and that although hopelessness could not explain the help negation effect, it moderated the effect for seeking help from family. They also revealed that although previous mental health care was unable to explain the effect fully for professional mental health sources, beliefs and attitudes about professional psychological help could. Implications of the findings for prevention, primary health care, and professional psychological practice are discussed.