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Lower urinary tract symptoms (LUTS) are highly prevalent in women, and are expected to impose a growing burden to individuals and society as the population ages. The predominance of research related to LUTS has focused on underlying pathology, disease mechanisms, or the efficacy of treatments for women with LUTS. Although this research has been vital for helping to reduce or ameliorate LUTS conditions, it has done little to prevent the onset of LUTS. Health promotion and prevention require an expansion of scientific inquiry beyond the traditional paradigm of studying disease mechanisms and treatment to the creation of an evidence base to support recommendations for bladder health promotion and, in turn, prevention of LUTS. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) introduced the concept of prevention as an important priority for women's urologic research as a prelude to supporting the formation of the Prevention of Lower Urinary Tract Symptoms (PLUS) research consortium. In this article, we introduce the PLUS research consortium to the scientific community; share the innovative paradigms by which the consortium operates; and describe its unique research mission: to identify factors that promote bladder health across the life course and prevent the onset of LUTS in girls and women.

As the nation's premier biomedical research agency, the National Institutes of Health (NIH) has supported most of the research that underlies the prevention services that are provided to citizens in the United States and around the world. Within the NIH, the Office of Disease Prevention (ODP) has as its mission to improve the public health by increasing the scope, quality, dissemination, and effect of prevention research supported by the NIH. In today's environment, the ODP needs to focus its efforts to address this mission. To do so, the ODP has developed a strategic plan for 2014 to 2018. We provide background on the ODP and key points from the strategic plan.

Social-ecological (SE) models are becoming more widely used in health behavior research. Applying SE models to the design of interventions is challenging because models must be tailor-made for each behavior and population, other theories need to be integrated into multi-level frameworks, and empirical research to guide model development is limited. The purpose of the present paper is to describe a SE framework that guided the intervention and measurement plans for a specific study. The trial of activity for adolescent girls (TAAG) is a multi-center study of interventions to reduce the decline of physical activity in adolescent girls. The TAAG framework incorporates operant learning theory, social cognitive theory, organizational change theory and the diffusion of innovation model in a multi-level model. The explicit and practical model developed for TAAG has already benefited the study and may have elements that can generalize to other health promotion studies.

Background: The main 6-month results from the PREMIER trial showed that comprehensive behavioral intervention programs improve lifestyle behaviors and lower blood pressure., Objective: To compare the 18-month effects of 2 multicomponent behavioral interventions versus advice only on hypertension status, lifestyle changes, and blood pressure., Design: Multicenter, 3-arm, randomized trial conducted from January 2000 through November 2002., Setting: 4 clinical centers and a coordinating center., Patients: 810 adult volunteers with prehypertension or stage 1 hypertension (systolic blood pressure, 120 to 159 mm Hg; diastolic blood pressure, 80 to 95 mm Hg)., Interventions: A multicomponent behavioral intervention that implemented long-established recommendations ("established"); a multicomponent behavioral intervention that implemented the established recommendations plus the Dietary Approaches to Stop Hypertension (DASH) diet ("established plus DASH"); and advice only., Measurements: Lifestyle variables and blood pressure status. Follow-up for blood pressure measurement at 18 months was 94%., Results: Compared with advice only, both behavioral interventions statistically significantly reduced weight, fat intake, and sodium intake. The established plus DASH intervention also statistically significantly increased fruit, vegetable, dairy, fiber, and mineral intakes. Relative to the advice only group, the odds ratios for hypertension at 18 months were 0.83 (95% CI, 0.67 to 1.04) for the established group and 0.77 (CI, 0.62 to 0.97) for the established plus DASH group. Although reductions in absolute blood pressure at 18 months were greater for participants in the established and the established plus DASH groups than for the advice only group, the differences were not statistically significant., Limitations: The exclusion criteria and the volunteer nature of this cohort may limit generalizability. Although blood pressure is a well-accepted risk factor for cardiovascular disease, the authors were not able to assess intervention effects on clinical cardiovascular events in this limited time and with this sample size., Conclusions: Over 18 months, persons with prehypertension and stage 1 hypertension can sustain multiple lifestyle modifications that improve control of blood pressure and could reduce the risk for chronic disease.

Background: Initial findings from the Dietary Approaches to Stop Hypertension (DASH)-Sodium Trial demonstrated that reduction of sodium intake in two different diets decreased blood pressure in participants with and without hypertension., Objective: To determine effects on blood pressure of reduced sodium intake and the DASH diet in additional subgroups., Design: Randomized feeding study., Setting: Four clinical centers and a coordinating center., Participants: 412 adults with untreated systolic blood pressure of 120 to 160 mm Hg and diastolic blood pressure of 80 to 95 mm Hg., Intervention: Participants followed the DASH diet or a control (typical U.S.) diet for three consecutive 30-day feeding periods, during which sodium intake (50, 100, and 150 mmol/d at 2100 kcal) varied according to a randomly assigned sequence. Body weight was maintained., Measurements: Systolic and diastolic blood pressure., Results: In all subgroups, the DASH diet and reduced sodium intake were each associated with significant decreases in blood pressure; these two factors combined produced the greatest reductions. Among nonhypertensive participants who received the control diet, lower (vs. higher) sodium intake decreased blood pressure by 7.0/3.8 mm Hg in those older than 45 years of age (P < 0.001) and by 3.7/1.5 mm Hg in those 45 years of age or younger (P < 0.05)., Conclusion: The DASH diet plus reduced sodium intake is recommended to control blood pressure in diverse subgroups.

Objective: To determine the relationship between angiotensinogen (ANG) genotype and blood pressure response to the dietary patterns of the Dietary Approaches to Stop Hypertension (DASH) trial. The angiotensin converting enzyme (ACE) gene was also tested., Design: The DASH trial was a randomized outpatient feeding study comparing the effects on blood pressure (BP) of three dietary patterns: a control diet, similar to typical American intake; a 'fruits and vegetables' diet (F/V) that is rich in fruits and vegetables but otherwise resembles the control diet; and the DASH diet that is reduced in fats and that emphasizes fruits, vegetables and low-fat dairy products. Participants' genotype was also determined., Setting: Four clinical sites., Participants: Adults with above-optimal BP or stage 1 hypertension., Intervention: Participants ate one of the three dietary patterns for 8 weeks. Sodium intake and weight were held constant. In 355 of 459 DASH participants, DNA was extracted from leukocytes and genotyped for the G-6A ANG polymorphism and the D/I ACE polymorphism, by the polymerase chain reaction., Main Outcomes: Genotype at ANG and ACE loci; BP after 8 weeks of intervention diet., Results: There was no association between ACE genotype and BP response. Associations with ANG polymorphism were significant: net systolic and diastolic BP response to the DASH diet was greatest in individuals with the AA genotype (-6.93/-3.68 mmHg) and least in those with the GG genotype (-2.80/0.20 mmHg). A similar relationship existed for the F/V diet., Conclusions: ANG genotype is associated with BP response to the DASH diet. The AA genotype confers excess risk of hypertension and is associated with increased responsiveness to diet.

Objective: Diets reduced in fat and cholesterol are recommended for children over 2 years of age, yet long-term safety and efficacy are unknown. This study tests the long-term efficacy and safety of a cholesterol-lowering dietary intervention in children., Methods: Six hundred sixty-three children 8 to 10 years of age with elevated low-density lipoprotein cholesterol (LDL-C) were randomized to a dietary intervention or usual care group, with a mean of 7.4 years' follow-up. The dietary behavioral intervention promoted adherence to a diet with 28% of energy from total fat, <8% from saturated fat, up to 9% from polyunsaturated fat, and <75 mg/1000 kcal cholesterol per day. Serum LDL-C, height, and serum ferritin were primary efficacy and safety outcomes., Results: Reductions in dietary total fat, saturated fat, and cholesterol were greater in the intervention than in the usual care group throughout the intervention period. At 1 year, 3 years, and at the last visit, the intervention compared with the usual care group had 4.8 mg/dL (.13 mmol/L), 3.3 mg/dL (.09 mmol/L), and 2.0 mg/dL (.05 mmol/L) lower LDL-C, respectively. There were no differences at any data collection point in height or serum ferritin or any differences in an adverse direction in red blood cell folate, serum retinol and zinc, sexual maturation, or body mass index., Conclusion: Dietary fat modification can be achieved and safely sustained in actively growing children with elevated LDL-C, and elevated LDL-C levels can be improved significantly up to 3 years. Changes in the usual care group's diet suggest that pediatric practices and societal and environmental forces are having positive public health effects on dietary behavior during adolescence.

Background: The effect of dietary composition on blood pressure is a subject of public health importance. We studied the effect of different levels of dietary sodium, in conjunction with the Dietary Approaches to Stop Hypertension (DASH) diet, which is rich in vegetables, fruits, and low-fat dairy products, in persons with and in those without hypertension., Methods: A total of 412 participants were randomly assigned to eat either a control diet typical of intake in the United States or the DASH diet. Within the assigned diet, participants ate foods with high, intermediate, and low levels of sodium for 30 consecutive days each, in random order., Results: Reducing the sodium intake from the high to the intermediate level reduced the systolic blood pressure by 2.1 mm Hg (P<0.001) during the control diet and by 1.3 mm Hg (P=0.03) during the DASH diet. Reducing the sodium intake from the intermediate to the low level caused additional reductions of 4.6 mm Hg during the control diet (P<0.001) and 1.7 mm Hg during the DASH diet (P<0.01). The effects of sodium were observed in participants with and in those without hypertension, blacks and those of other races, and women and men. The DASH diet was associated with a significantly lower systolic blood pressure at each sodium level; and the difference was greater with high sodium levels than with low ones. As compared with the control diet with a high sodium level, the DASH diet with a low sodium level led to a mean systolic blood pressure that was 7.1 mm Hg lower in participants without hypertension, and 11.5 mm Hg lower in participants with hypertension., Conclusions: The reduction of sodium intake to levels below the current recommendation of 100 mmol per day and the DASH diet both lower blood pressure substantially, with greater effects in combination than singly. Long-term health benefits will depend on the ability of people to make long-lasting dietary changes and the increased availability of lower-sodium foods.

Background: Although many primary care patients are inactive, being able to classify even small amounts and intensities of activity and factors associated with these activity levels could be helpful for physicians who are trying to motivate their patients to become more physically active., Methods: Sociodemographics, physical activity, fitness, other cardiovascular risk factors, and psychosocial measures were measured at baseline in the 874 patients in the Activity Counseling Trial. Patients were categorized into three groups: (1) no moderate-to-vigorous physical activity (MVPA), (2) some moderate but no vigorous activity, and (3) some vigorous activity. Multiple logistic regression was used to determine factors cross-sectionally associated with activity intensity., Results: One or more cardiovascular risk factors in addition to physical inactivity were present in 84% of participants. Maximal oxygen uptake averaged 25.2 ml/kg/min; 85% had poor to fair aerobic fitness. Physical activity averaged 32.7 kcal/kg/day, with 13.5 min of MVPA/day; 26% engaged in some vigorous activity, 11% engaged in no MVPA. In unadjusted analyses, gender, age, race, education, income, employment, smoking, alcohol use, and exercise self-efficacy were associated with activity intensity (P = 0.05-0.001). A greater percentage engaged in moderate than in vigorous activity in all subgroups. In multiple logistic regression analyses, odds ratios (95% confidence intervals) for engaging in vigorous activity were 0. 39 (0.28, 0.56) for women, 0.38 (0.19, 0.75) for 65+ compared with 35- to 44-year-olds, and 1.14 (1.06, 1.22) for 10-unit increases in performance self-efficacy score., Conclusions: Most primary care patients who are physically inactive have additional cardiovascular risk factors, particularly overweight and obesity. All subgroups pursue moderate-intensity activity more often than vigorous activity. Women, older persons, and those with lower exercise self-efficacy are less likely to engage in vigorous activity., (Copyright 2000 American Health Foundation and Academic Press.)

Background: Few studies have shown the efficacy and safety of lower-fat diets in children., Objective: Our objective was to assess the efficacy and safety of lowering dietary intake of total fat, saturated fat, and cholesterol to decrease LDL-cholesterol concentrations in children., Design: A 6-center, randomized controlled clinical trial was carried out in 663 children aged 8-10 y with LDL-cholesterol concentrations greater than the 80th and less than the 98th percentiles for age and sex. The children were randomly assigned to either an intervention group or a usual care group. Behavioral intervention promoted adherence to a diet providing 28% of energy from total fat, <8% from saturated fat,

Background: Reperfusion therapy for acute myocardial infarction (AMI) is a time-dependent intervention that can reduce infarct-related morbidity and mortality. Out-of-hospital patient delay from symptom onset until emergency department (ED) presentation may reduce the expected benefit of reperfusion therapy., Objective: To determine the impact of a community educational intervention to reduce patient delay time on the use of reperfusion therapy for AMI., Methods: This was a randomized, controlled community-based trial to enhance patient recognition of AMI symptoms and encourage early ED presentation with resultant increased reperfusion therapy rates for AMI. The study took place in 44 hospitals in 20 pair-matched communities in five U.S. geographic regions. Eligible study subjects were non-institutionalized patients without chest injury (aged > or =30 years) who were admitted to participating hospitals and who received a hospital discharge diagnosis of AMI (ICD 410); n = 4,885. For outcome assessment, patients were excluded if they were without survival data (n = 402), enrolled in thrombolytic trials (n = 61), receiving reperfusion therapy >12 hours after ED arrival (n = 628), or missing symptom onset or reperfusion times (n = 781). The applied intervention was an educational program targeting community organizations and the general public, high-risk patients, and health professionals in target communities. The primary outcome was a change in the proportion of AMI patients receiving early reperfusion therapy (i.e., within one hour of ED arrival or within six hours of symptom onset). Trends in reperfusion therapy rates were determined after adjustment for patient demographics, presenting blood pressure, cardiac history, and insurance status. Four-month baseline was compared with the 18-month intervention period., Results: Of 3,013 selected AMI patients, 40% received reperfusion therapy. Eighteen percent received therapy within one hour of ED arrival (46% of treated patients), and 32% within six hours of symptom onset (80% of treated patients). No significant difference in the trends in reperfusion therapy rates was attributable to the intervention, although increases in early reperfusion therapy rates were noted during the first six months of the intervention. A significant association of early reperfusion therapy use with ambulance use was identified., Conclusions: Community-wide educational efforts to enhance patient response to AMI symptoms may not translate into sustained changes in reperfusion practices. However, an increased odds for early reperfusion therapy use during the initiation of the intervention and the association of early therapy with ambulance use suggest that reperfusion therapy rates can be enhanced.

Context: Delayed access to medical care in patients with acute myocardial infarction (AMI) is common and increases myocardial damage and mortality., Objective: To evaluate a community intervention to reduce patient delay from symptom onset to hospital presentation and increase emergency medical service (EMS) use., Design and Setting: The Rapid Early Action for Coronary Treatment Trial, a randomized trial conducted from 1995 to 1997 in 20 US cities (10 matched pairs; population range, 55,777-238,912) in 10 states., Participants: A total of 59,944 adults aged 30 years or older presenting to hospital emergency departments (EDs) with chest pain, of whom 20,364 met the primary population criteria of suspected acute coronary heart disease on admission and were discharged with a coronary heart disease-related diagnosis., Intervention: One city in each pair was randomly assigned to an 18-month intervention that targeted mass media, community organizations, and professional, public, and patient education to increase appropriate patient actions for AMI symptoms (primary population, n=10,563). The other city in each pair was randomly assigned to reference status (primary population, n=9801)., Main Outcome Measures: Time from symptom onset to ED arrival and EMS use, compared between intervention and reference city pairs., Results: General population surveys provided evidence of increased public awareness and knowledge of program messages. Patient delay from symptom onset to hospital arrival at baseline (median, 140 minutes) was identical in the intervention and reference communities. Delay time decreased in intervention communities by -4.7% per year (95% confidence interval [CI], -8.6% to -0.6%), but the change did not differ significantly from that observed in reference communities (-6. 8% per year; 95% CI, -14.5% to 1.6%; P=.54). EMS use by the primary study population increased significantly in intervention communities compared with reference communities, with a net effect of 20% (95% CI, 7%-34%; P<.005). Total numbers of ED presentations for chest pain and patients with chest pain discharged from the ED, as well as EMS use among patients with chest pain released from the ED, did not change significantly., Conclusions: In this study, despite an 18-month intervention, time from symptom onset to hospital arrival for patients with chest pain did not change differentially between groups, although increased appropriate EMS use occurred in intervention communities. New strategies are needed if delay time from symptom onset to hospital presentation is to be decreased further in patients with suspected AMI. JAMA. 2000;284:60-67

The potential for reducing cardiovascular disease mortality rates lies both in prevention and treatment. The earlier treatment is administered, the greater the benefit. Thus, duration of time from onset of symptoms of acute myocardial infarction to administration of treatment is important. One major factor contributing to failure to receive efficacious therapy is the delay time from acute myocardial infarction (AMI) symptom onset to hospital arrival. This paper examines the relationship of several factors with regard to intentions to seek care promptly for symptoms of AMI. A random-digit dialed telephone survey (n = 1294) was conducted in 20 communities located in 10 states. People who said they would wait until they were very sure that symptoms were a heart attack were older, reported their insurance did not pay for ambulance services, and reported less confidence in knowing signs and symptoms in themselves. When acknowledging symptoms of a heart attack, African-Americans and people with more than a high school education reported intention to act quickly. No measures of personal health history, nor interaction with primary care physicians or cardiologists were significantly related to intention to act fast. The study confirms the importance of attribution and perceived self-confidence in symptom recognition in care seeking. The lack of significant role of health history (i.e. those with chronic conditions or risk factors) and clinician contact highlights missed opportunities for health care providers to educate and encourage patients about their risk and appropriate action.

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

Background: The use of thrombolytic therapy for patients with myocardial infarction has been limited by patient delay in seeking care. We sought to characterize prehospital delay in patients hospitalized for evaluation of heart attack symptoms., Methods and Results: The Rapid Early Action for Coronary Treatment (REACT) is a multicenter, randomized community trial designed to reduce patient delay. At baseline, data were abstracted from the medical records of 3783 patients hospitalized for evaluation of heart attack symptoms in 20 communities. The median prehospital delay was 2.0 hours; 25% of patients delayed longer than 5.2 hours. In a multivariable analysis, delay time was longer among non-Hispanic blacks than among non-Hispanic whites, longer at older ages, longer among Medicaid-only recipients and shorter among Medicare recipients than among privately insured patients, and shorter among patients who used an ambulance., Conclusions: The observed pattern of differences is consistent with the contention that demographic, cultural, and/or socioeconomic barriers exist that impede rapid care seeking.

We measured ambulatory blood pressure (ABP) in 354 participants in the Dietary Approaches to Stop Hypertension (DASH) Trial to determine the effect of dietary treatment on ABP (24-hour, day and night) and to assess participants' acceptance of and compliance with the ABP monitoring (ABPM) technique. After a 3-week run-in period on a control "typical" American diet, subjects (diastolic blood pressure [BP], 80 to 95 mm Hg; systolic BP, <160 mm Hg; mean age, 45 years) were randomly assigned to 1 of 3 diets for an 8-week intervention period: a continuation of the control diet; a diet rich in fruits and vegetables; and a "combination" diet that emphasized fruits, vegetables, and low-fat dairy products. We measured ABP at the end of the run-in and intervention periods. Both the fruit/vegetable and combination diets lowered 24-hour ABP significantly compared with the control diet (P<0. 0001 for systolic and diastolic pressures on both diets: control diet, -0.2/+0.1 mm Hg; fruit/vegetable diet, -3.2/-1.9 mm Hg; combination diet, -4.6/-2. 6 mm Hg). The combination diet lowered pressure during both day and night. Hypertensive subjects had a significantly greater response than normotensives to the combination diet (24-hour ABP, -10.1/-5.5 versus -2.3/-1.6 mm Hg, respectively). After correction for the control diet responses, the magnitude of BP lowering was not significantly different whether measured by ABPM or random-zero sphygmomanometry. Participant acceptance of ABPM was excellent: only 1 participant refused to wear the ABP monitor, and 7 subjects (2%) provided incomplete recordings. These results demonstrate that the DASH combination diet provides significant round-the-clock reduction in BP, especially in hypertensive participants.

Coronary heart disease (CHD) remains the leading cause of mortality in the U.S. Innovations in reperfusion therapies can potentially reduce CHD morbidity and mortality associated with acute myocardial infarction (AMI) when treatment is initiated within the first few hours of symptom onset. However, delay in seeking treatment for AMI is unacceptably lengthy, resulting in most patients being ineligible for reperfusion therapies. The Rapid Early Action for Coronary Treatment (REACT) Trial is a four-year, 20-community, randomized trial to design and test the effectiveness of a multi-component intervention to reduce patient delay for hospital care-seeking for AMI symptoms. This manuscript describes the development and content of the theoretically-based REACT intervention and summarizes: (1) the research literature used to inform the intervention; (2) the behavioral theories used to guide the development, implementation, and evaluation of the intervention; (3) the formative research undertaken to understand better decision-making processes as well as barriers and facilitators to seeking medical care as perceived by AMI patients, their families, and medical professionals; (4) the intervention design issues that were addressed; (5) the synthesis of data sources in developing the core message content; (6) the conceptualization for determining the intervention target audiences and associated intervention components and strategies, their integration with guiding theoretical approaches and implementation theories for the study, and a description of major intervention materials developed to implement the intervention; and (7) the focus of the outcome, impact, and process measurement based on the intervention components and theories on which they were developed.

Objective: To determine the effects of dietary patterns on blood pressure in subgroups., Methods: Dietary Approaches to Stop Hypertension (DASH) was a randomized controlled feeding study conducted at 4 academic medical centers. Participants were 459 adults with untreated systolic blood pressure less than 160 mm Hg and diastolic blood pressure 80 to 95 mm Hg. For 3 weeks, participants were fed a "control" diet. They were then randomized to 8 weeks of (1) control diet; (2) a diet rich in fruits and vegetables; or (3) a combination diet rich in fruits, vegetables, and low-fat dairy foods, and reduced in saturated fat, total fat, and cholesterol (the DASH combination diet). Weight and salt intake were held constant. Change in diastolic blood pressure was the primary outcome variable, and systolic blood pressure a secondary outcome. Subgroups analyzed included race, sex, age, body mass index, years of education, income, physical activity, alcohol intake, and hypertension status., Results: The combination diet significantly lowered systolic blood pressure in all subgroups (P<.008), and significantly lowered diastolic blood pressure (P<.01) in all but 2 subgroups. The fruits-and-vegetables diet also reduced blood pressure in the same subgroups, but to a lesser extent. The combination diet lowered systolic blood pressure significantly more in African Americans (6.8 mm Hg) than in whites (3.0 mm Hg), and in hypertensive subjects (11.4 mm Hg) than in nonhypertensive subjects (3.4 mm Hg) (P<.05 for both interactions)., Conclusions: The DASH combination diet, without sodium reduction or weight loss, significantly lowered blood pressure in virtually all subgroups examined, and was particularly effective in African Americans and those with hypertension. The DASH combination diet may be an effective strategy for preventing and treating hypertension in a broad cross section of the population, including segments of the population at highest risk for blood pressure-related cardiovascular disease.

Introduction: This paper reviews studies of physical activity interventions in health care settings to determine effects on physical activity and/or fitness and characteristics of successful interventions., Methods: Studies testing interventions to promote physical activity in health care settings for primary prevention (patients without disease) and secondary prevention (patients with cardiovascular disease [CVD]) were identified by computerized search methods and reference lists of reviews and articles. Inclusion criteria included assignment to intervention and control groups, physical activity or cardiorespiratory fitness outcome measures, and, for the secondary prevention studies, measurement 12 or more months after randomization. The number of studies with statistically significant effects was determined overall as well as for studies testing interventions with various characteristics., Results: Twelve studies of primary prevention were identified, seven of which were randomized. Three of four randomized studies with short-term measurement (4 weeks to 3 months after randomization), and two of five randomized studies with long-term measurement (6 months after randomization) achieved significant effect on physical activity. Twenty-four randomized studies of CVD secondary prevention were identified; 13 achieved significant effects on activity and/or fitness at twelve or more months. Studies with measurement at two time points showed decaying effects over time, particularly if the intervention were discontinued. Successful interventions contained multiple contacts, behavioral approaches, supervised exercise, provision of equipment, and/or continuing intervention. Many studies had methodologic problems such as low follow-up rates., Conclusion: Interventions in health care settings can increase physical activity for both primary and secondary prevention. Long-term effects are more likely with continuing intervention and multiple intervention components such as supervised exercise, provision of equipment, and behavioral approaches. Recommendations for additional research are given.

Objectives: To test the feasibility and effectiveness of a diet intervention (consisting of interactive mailings, computer-generated phone calls, and classes) in hypercholesterolemic low-income public clinic patients., Methods: Clinic patients with serum cholesterol > 200 mg/dl, referred by their primary care physician were randomized to a 6-month special intervention (SI) or usual care (UC). The intervention included mailings, computer phone calls, and four 1-hour classes. Serum total cholesterol (TC) was measured before and after intervention, and participation was monitored., Results: One hundred sixty-five of the 212 patients referred (77.8%) agreed to participate. A medical records review revealed 123 (74.5%) met eligibility criteria. Eligible subjects had a mean age of 56.7 years, 80.0% were African American, 74.8% were female, 33.6% were married, and 89.4% had a high school or lower education. Subjects were randomized with 80.5% (99) completing follow-up cholesterol measures. SI subjects were encouraged to use all three components, with 84.6% (55 of 65) actively participating in at least one component. Seventy-two percent (47 of 65) returned at least one mailing, 49.1% (28 of 57) of those with touch-tone phones accessed the computer system, and 43.1% (28 of 65) attended classes. The TC in SI decreased from 273.2 mg/dl to 265.0 mg/dl (P = 0.05) and in UC 272.4 mg/dl to 267.6 mg/dl (P = 0.32). The net reduction in SI compared with UC was 3.4 mg/dl (P = 0.58)., Conclusions: (1) Low-income public clinic patients will participate in diet interventions, (2) computer-generated interactive phone calls are feasible in this population, and (3) clinically meaningful decreases in serum cholesterol are difficult to achieve with interventions of practical intensity.

Counseling by health care providers has the potential to increase physical activity in sedentary patients, yet few studies have tested interventions for physical activity counseling delivered in health care settings. The Activity Counseling Trial (ACT) is a 5-yr randomized clinical trial to evaluate the efficacy of two primary care, practice-based physical activity behavioral interventions relative to a standard care control condition. A total of 874 sedentary men and women, 35-75 yr of age, have been recruited from primary care physician offices at three clinical centers for 2 yr of participation. They were randomly assigned to one of three experimental conditions that vary, in a hierarchical fashion, by level of counseling intensity and resource requirements. The interventions, which are based on social cognitive theory and the transtheoretical model, are designed to alter empirically based psychosocial mediators that are known to be associated with physical activity. The present paper describes the theoretical background of the intervention, the intervention methods, and intervention training and quality control procedures.

The Activity Counseling Trial (ACT) is a multicenter, randomized controlled trial to evaluate the effectiveness of interventions to promote physical activity in the primary health care setting. ACT has recruited, evaluated, and randomized 874 men and women 35-75 yr of age who are patients of primary care physicians. Participants were assigned to one of three educational interventions that differ in amount of interpersonal contact and resources required: standard care control, staff-assisted intervention, or staff-counseling intervention. The study is designed to provide 90% power in both men and women to detect a 1.1 kcal.kg-1.day-1 difference in total daily energy expenditure between any two treatment groups, and over 90% power to detect a 7% increase in maximal oxygen uptake, the two primary outcomes. Primary analyses will compare study groups on mean outcome measures at 24 months post-randomization, be adjusted for the baseline value of the outcome measure and for multiple comparisons, and be conducted separately for men and women. Secondary outcomes include comparisons between interventions at 24 months of factors related to cardiovascular disease (blood lipids/lipoproteins, blood pressure, body composition, plasma insulin, fibrinogen, dietary intake, smoking, heart rate variability), psychosocial effect, and cost-effectiveness, and at 6 months for primary outcome measures. ACT is the first large-scale behavioral intervention study of physical activity counseling in a clinical setting, includes a generalizable sample of adult men and women and of clinical setting, and examines long-term (24 months) effects. ACT has the potential to make substantial contributions to the understanding of how to promote physical activity in the primary health care setting.

The National Heart Attack Alert Program (NHAAP) was launched by the National Heart, Lung, and Blood Institute in 1991 with the goal of reducing morbidity and mortality from acute myocardial infarction (AMI) through the rapid identification and treatment of individuals with symptoms and signs of an AMI. To achieve this goal, the NHAAP established objectives for each of three phases of action where treatment delays can occur: in the hospital, the prehospital setting, and the patient/bystander arena. The NHAAP initially directed its educational efforts toward emergency department professionals. Recommendations for reducing delays in emergency department identification of patients presenting with heart attack symptoms were developed by a working group convened in late 1991. These recommendations were published in February 1994 in a peer-reviewed journal reaching more than 17,000 emergency physicians. The NHAAP worked in a partnership with its coordinating committee, representing 40 health professional, voluntary, and government organizations, to extend the reach of the report's recommendations to their members. Strategies for promoting the emergency department recommendations included publication of excerpts in newsletters and journals of the medical, nursing, and prehospital provider organizations represented on the NHAAP Coordinating Committee, and through symposia at annual meetings. Industry assisted with dissemination efforts and with implementing a continuous quality improvement program based on the paper's recommendations. The NHAAP also developed, with the Joint Committee on Accreditation of Health Care Organizations, a time-to-treatment indicator for thrombolytic therapy to be incorporated into their Indicator Measurement System (IMSystem). To track achievement of the objectives related to the Hospital Action Phase, national data sources for emergency department management of patients with AMI were evaluated at the 5-year point of the NHAAP. Data from a national registry showed that the median time from presentation at the emergency department to receiving thrombolytic therapy declined by about one third between 1992 and the last half of 1995. The percentage of all Medicare patients receiving thrombolytic therapy within the recommended 30 minutes after emergency department arrival nearly doubled between 1992 and 1995. Based on these and other results presented at the 5-year juncture of the program, the NHAAP Coordinating Committee assessed progress and identified new areas of focus for the next 5 years. Improvements in emergency departments' ability to identify and treat AMI patients progressed during the first 5 years of the NHAAP, when the program was highlighting this as a priority. This model is continuing to be used to address delays in the Prehospital Action Phase. Further research from a National Heart, Lung, and Blood Institute (NHLBI) community intervention trial will guide the program in its plans for full-scale public education to address the Patient/Bystander Recognition and Action Phase.

Objective: Early reperfusion for acute myocardial infarction (AMI) can reduce morbidity and mortality, yet there is often delay in accessing medical care after symptom onset. This report describes the design and baseline characteristics of the Rapid Early Action for Coronary Treatment (REACT) community trial, which is testing community intervention to reduce delay., Methods: Twenty U.S. communities were pair-matched and randomly assigned within pairs to intervention or comparison. Four months of baseline data collection was followed by an 18-month intervention of community organization and public, patient, and health professional education. Primary cases were community residents seen in the ED with chest pain, admitted with suspected acute cardiac ischemia, and discharged with a diagnosis related to coronary heart disease. The primary outcome was delay time from symptom onset to ED arrival. Secondary outcomes included delay time in patients with MI/unstable angina, hospital case-fatality rate and length of stay, receipt of reperfusion, and ED/emergency medical services utilization. Impact on public and patient knowledge, attitudes, and intentions was measured by telephone interviews. Characteristics of communities and cases and comparability of paired communities at baseline were assessed., Results: Baseline cases are 46% female, 14% minorities, and 73% aged > or =55 years, and paired communities have similar demographics characteristics. Median delay time (available for 72% of cases) is 2.3 hours and does not vary between treatment conditions (p > 0.86)., Conclusions: REACT communities approximate the demographic distribution of the United States and there is baseline comparability between the intervention and comparison groups. The REACT trial will provide valuable information for community educational programs to reduce patient delay for AMI symptoms.

Objectives: To examine the overall effectiveness of patient education and counseling on preventive health behaviors and to examine the effects of various approaches for modifying specific types of behaviors., Data Sources: Computerized databases (Medline, Healthline, Dissertation Abstracts, and Psychological Abstracts), bibliographies 1971-1994. Search terms (patient education, patient compliance, and self care) with modifiers (evaluation and specific preventive behaviors)., Study Selection: Randomized and non-randomized controlled trials measuring behavior in clinical settings with patients without diagnosed disease. Abstracts and retrieved studies screened by multiple reviewers; 13% of retrieved studies met screening criteria., Data Extraction: Replicated coding by multiple observers., Data Synthesis: Behaviors were grouped based on whether the behavior is addictive and whether the desired change required subtraction of existing behaviors or adding new behaviors. The weighted average effect size from a random effects model for smoking/alcohol studies was 0.61 (CI = 0.45, 0.77), for nutrition/weight, 0.51 (CI = 0.20, 0.82) and for other behaviors, 0.56 (CI = 0.34, 0.77) indicating that the behavioral outcomes for these subgroups were significantly different from zero. Multiple regression models for the three groups indicated that using behavioral techniques, particularly self-monitoring, and using several communication channels, e.g., media plus personal communication, produces larger effects for the smoking/alcohol and nutrition/weight groups., Conclusions: Patient education and counseling contribute to behavior change for primary prevention of disease. Some techniques are more effective than others in changing specific behaviors.

Background: The Dietary Intervention Study in Children (DISC) is a multicenter, randomized, controlled clinical trial designed to examine the efficacy and safety of a dietary intervention to reduce serum LDL cholesterol (LDL-C) in children with elevated LDL-C., Methods and Results: The effects of dietary intake of fat and cholesterol and of sexual maturation and body mass index (BMI) on LDL-C were examined in a 3-year longitudinal study of 663 boys and girls (age 8 to 10 years at baseline) with elevated LDL-C levels. Multiple linear regression was used to predict LDL-C at 3 years. For boys, LDL-C decreased by 0.018 mmol/L for each 10 mg/4.2 MJ decrease in dietary cholesterol (P<.05). For girls, no single nutrient was significant in the model, but a treatment group effect was evident (P<.05). In both sexes, BMI at 3 years and LDL-C at baseline were significant and positive predictors of LDL-C levels. In boys, the average LDL-C level was 0.603 mmol/L lower at Tanner stage 4+ than at Tanner stage 1 (P<.01). In girls, the average LDL-C level was 0.274 mmol/L lower at Tanner stage 4+ than at Tanner stage 1 (P<.05)., Conclusions: In pubertal children, sexual maturation, BMI, dietary intervention (in girls), and dietary cholesterol (in boys) were significant in determining LDL-C. Sexual maturation was the factor associated with the greatest difference in LDL-C. Clinicians screening for dyslipidemia or following dyslipidemic children should be aware of the powerful effects of pubertal change on measurements of lipoproteins.

Objective: To assess the relationship between energy intake from fat and anthropometric, biochemical, and dietary measures of nutritional adequacy and safety., Design: Three-year longitudinal study of children participating in a randomized controlled trial; intervention and usual care group data pooled to assess effects of self-reported fat intake; longitudinal regression analyses of measurements at baseline, year 1, and year 3., Participants: Six hundred sixty-three children (362 boys and 301 girls), 8 to 10 years of age at baseline, with elevated low-density lipoprotein cholesterol, who are participants of the Dietary Intervention Study in Children., Measures: Energy intake from fat assessed from three 24-hour recalls at each time point was the independent variable. Outcomes were anthropometric measures (height, weight, body mass index, and sum of skinfolds), nutritional biochemical determinations (serum ferritin, zinc, retinol, albumin, beta-carotene, and vitamin E, red blood cell folate, and hemoglobin), and dietary micronutrients (vitamins A, C, E, thiamin, riboflavin, niacin, vitamins B-6, B-12, folate, calcium, iron, zinc, magnesium, and phosphorus)., Results: Lower fat intake was not related to anthropometric measures or serum zinc, retinol, albumin, beta-carotene, or vitamin E. Lower fat intake was related to: 1) higher levels of red blood cell folate and hemoglobin, with a trend toward higher serum ferritin; 2) higher intakes of folate, vitamin C, and vitamin A, with a trend toward higher iron intake; 3) lower intakes of calcium, zinc, magnesium, phosphorus, vitamin B-12, thiamin, niacin, and riboflavin; 4) increased risk of consuming less than two-thirds of the Recommended Dietary Allowances for calcium in girls at baseline, and zinc and vitamin E in boys and girls at all visits., Conclusions: Lower fat intakes during puberty are nutritionally adequate for growth and for maintenance of normal levels of nutritional biochemical measures, and are associated with beneficial effects on blood folate and hemoglobin. Although lower fat diets were related to lower self-reported intakes of several nutrients, no adverse effects were observed on blood biochemical measures of nutritional status. Current public health recommendations for moderately lower fat intakes in children during puberty may be followed safely.

Identifying dietary factors associated with blood pressure (BP) in children and adolescents would help guide recommendations for prevention of elevated BP, which is a major public health problem. This paper reviews 46 reports of studies examining relationships between dietary nutrients and BP in children and adolescents, many of which studied more than one nutrient. Sodium is the most extensively studied nutrient, with 25 observational and 12 intervention studies identified. Although many studies suffer from methodological problems, the results suggest that higher sodium intake is related to higher BP in children and adolescents. The results of 13 observational and 2 intervention studies of potassium and BP do not provide a clear picture of a relationship. The results of 8 observational and 1 intervention study of calcium and BP are inconclusive. Five observational studies of magnesium and BP provide evidence of an inverse relationship, but no intervention studies were identified. Nine studies of macronutrients and food groups or dietary patterns are inconclusive. Additional research is needed to provide more information about the relationships between dietary nutrients and BP in children and adolescents. Recommendations are provided for methodological features of additional research on diet and BP in children and adolescents.

Delineating the role that diet plays in blood pressure levels in children is important for guiding dietary recommendations for the prevention of hypertension. The purpose of this study was to investigate relationships between dietary nutrients and blood pressure in children. Data were analyzed from 662 participants in the Dietary Intervention Study in Children who had elevated low-density lipoprotein cholesterol and were aged 8 to 11 years at baseline. Three 24-hour dietary recalls, systolic pressure, diastolic pressure, height, and weight were obtained at baseline, 1 year, and 3 years. Nutrients analyzed were the micronutrients calcium, magnesium, and potassium; the macronutrients protein, carbohydrates, total fat, saturated fat, polyunsaturated fat, and monounsaturated fat; dietary cholesterol; and total dietary fiber. Baseline and 3-year longitudinal relationships were examined through multivariate models on diastolic and systolic pressures separately, controlling for height, weight, sex, and total caloric intake. The following associations were found in longitudinal analyses: analyzing each nutrient separately, for systolic pressure, inverse associations with calcium (P < .05); magnesium, potassium, and protein (all P < .01); and fiber (P < .05), and direct associations with total fat and monounsaturated fat (both P < .05); for diastolic pressure, inverse associations with calcium (P < .01); magnesium and potassium (both P < .05), protein (P < .01); and carbohydrates and fiber (both P < .05), and direct associations with polyunsaturated fat (P < .01) and monounsaturated fat (P < .05). Analyzing all nutrients simultaneously, for systolic pressure, direct association with total fat (P < .01); for diastolic pressure, inverse associations with calcium (P < .01) and fiber (P < .05), and direct association with total and monounsaturated fats (both P < .05). Results from this sample of children with elevated low-density lipoprotein cholesterol indicate that dietary calcium, fiber, and fat may be important determinants of blood pressure level in children.

Objective: To determine in a population of low socioeconomic status (SES) patients: (a) rates of current smoking and smoking cessation, (b) persons' understanding of the adverse health impact of multiple cardiovascular disease (CVD) risk factors, and (c) if the diagnosis of other CVD risk factors, specifically hypertension or hypercholesterolemia, was related to smoking cessation., Design: Cross-sectional interview survey., Setting: Community clinics and eligibility centers of the Harris County Hospital District (HD), which provides primary care to over 166,000 indigent persons in Houston, Texas., Subjects: Randomly selected adults attending an HD setting for eligibility screening or primary care., Results: Over 93% of subjects approached participated (n = 547). Their mean age was 40.7 years, 55% were female, and 39% had > 9 years of education. The ethnic distribution was 54% Hispanic, 28% black, and 14% non-Hispanic white. Current smoking ranged from 10% among Hispanic females to 56% among black males. The percentage of ever smokers who had quit was 24% among black males, 44% among black females, 43% among Hispanic males, and 70% among Hispanic females. The majority recognized the increase in danger from smoking in the presence of hypertension or hypercholesterolemia. Among patients who were smokers when they found out they had hypertension (n = 70), 65% reported it increased their desire to quit. After adjustment for other variables including age and known CVD, predictors of being an ex-smoker were being female (OR 2.1, 95% CI 1.3-3.5), being Hispanic (OR 2.8 95% CI 1.5-5.7), and having hypertension (OR 2.3, 95% CI 1.3-4.2)., Conclusion: In this low SES population, there was substantial smoking cessation, widespread acknowledgment of the cumulative effect of smoking and other CVD risk factors, and some evidence that smoking cessation increased after the diagnosis of hypertension.

To determine knowledge, attitudes, behaviors, and self-reported cholesterol measurement in a low-income, urban patient population, we conducted an interview survey of users and potential users of primary care services in a public health care system for low-income Harris County, Texas, residents. The response rate was 93%, with a final sample of 547 randomly selected subjects 18 years of age and older, who were Hispanic (54%), black (28%), non-Hispanic white (14%), and Asian, Native American, or other (4%). Results indicated that 76% had heard of serum or blood cholesterol, and 30% reported past cholesterol measurement. Knowledge that dietary saturated fat can raise blood cholesterol ranged from 11% in Hispanic men to 51% in non-Hispanic white men and women. A lower percentage of Hispanics correctly answered all knowledge questions, and Hispanics reported higher-fat food choices than blacks and non-Hispanic whites. More than 90% of the respondents expressed interest in more information on diet, 60% reported that they read nutrition labels, and 15% said they have been trying to reduce blood cholesterol levels. A lower percentage of Hispanics reported previous cholesterol measurement than blacks or non-Hispanic whites, a difference that persisted after adjusting for multiple factors associated with cholesterol measurement. Older age (older than 50) and more physician visits in the past year also were associated with past cholesterol measurement. Comparisons with national surveys show that cholesterol knowledge and actual measurement in this low-income sample lag behind those of the national population. Yet, despite gaps in knowledge and cholesterol measurement, respondents showed positive attitudes about and interest in cholesterol-lowering interventions.

To provide further understanding of the decline in stroke mortality in the United States, data from 16 randomized controlled trials of hypertension treatment and stroke published to date are pooled. The overall weighted average blood pressure reduction was 13/6 mm Hg. The pooled odds ratio was 0.61 (95% confidence interval: 0.55, 0.68), indicating approximately a 39% (32 to 45%) reduction in stroke occurrence. Percent reduction was somewhat higher in studies of mild-moderate hypertension (47%) and somewhat lower in studies of the elderly (35%). There was no differential effect by gender (reductions of 37% for women, 34% for men) or by race (32% for blacks, 37% for whites). The magnitudes of reductions for fatal (41%) and nonfatal (37%) strokes, and for diuretics and beta-blockers (odds ratio diuretic versus beta-blocker, 0.86; 95% CI: 0.69, 1.08) were similar. Implications for the decline in stroke mortality in the United States are discussed.

To determine characteristics of controlled studies (quasi-experimental and randomized) of clinical patient education/counseling for behavior change to prevent disease, we conducted an extensive literature review of published and unpublished studies from 1971 to 1989. Sixty-four studies with 101 intervention groups met specific criteria for relevance and scientific acceptability. We examine these studies in terms of prevention area, subject source, intervention characteristics, and use of educational principles. Findings reveal many controlled clinical studies in smoking cessation, nutrition, and weight control but sparcity in other areas (injury prevention, exercise, stress, drug and alcohol misuse, STD prevention); an emphasis on communication by a single clinical practitioner; and varied use of educational principles. We recommend adhering to educational principles to enhance likelihood of success.

Because selection of studies for a literature review influences conclusions, inclusion criteria are of utmost importance. For a meta-analysis of studies testing effects of patient education on preventive behaviors, we present the framework and concepts used for setting inclusion criteria for primary studies. We also present the yield in terms of number and distribution of studies that resulted from the inclusion criteria. Because we were interested in a diverse range of behaviors and a broad definition of patient education, we present a method for grouping behaviors by type of behavior change and describe parameters for subgrouping interventions by orientation and communication channel. Of 5,451 citations located and abstracts screened, 561 citations reporting potentially relevant studies were reviewed. Based on our inclusion criteria, 171 citations contained relevant studies, of which 64 studies (found in 62 citations) also met our acceptability criteria. We examine the effects of alternate inclusion criteria on the yield of primary studies and their distributions across the subgroupings.

During the school years, students encounter peer influences and role models who encourage smoking initiation. To counteract these influences, schools can provide comprehensive programs that include smoking prevention and cessation education and a supportive nonsmoking environment. In the past several years, programs and information have become available to help schools establish curricula to address smoking and to create nonsmoking environments. In addition, state and local governments have acted to legally restrict smoking in schools or to require smoking content in curricula. Efforts can be categorized into three avenues of intervention: student education, school and school system policy, and governmental regulation. Resources are suggested for each category to assist in developing a comprehensive intervention to foster nonsmoking by children and adolescents in the school setting.

Several recent articles have addressed the role of allied health professionals in health promotion and disease prevention (HP/DP). The consensus is that allied health professionals are on the threshold of making major contributions to the HP/DP initiative. The focus of these contributions usually centers on the role of allied health professionals in clinical settings and the traditional medical-model emphasis on direct patient contact. In addition, there is discussion of the programmatic changes that will be required to meet the challenge of integrating health promotion concepts, knowledge, and skills into current professional curricula. The purpose of this paper is to examine critically the rationale behind providing HP/DP education for allied health professionals and to discuss the implications of such education for professional preparation programs.

Although the medical management of epilepsy is possible with effective therapeutics, such management is complicated by patient errors of self-medication. Efforts to improve adherence to prescribed regimens of anticonvulsant medication have not been extensively studied, although several promising results have been obtained. Research on adherence to medication regimens has been more extensive in other chronic conditions, such as hypertension, that have similarities to epilepsy in their demand for long-term treatment, often in the absence of symptoms, with drugs that may produce side effects. From the combined research on factors associated with drug errors, we have analyzed characteristics of the patient, of the regimen, of the illness, and of the patient - provider relationship. The most promising areas for improving compliance appear to be the influence of family and friends, the complexity of the treatment regimen, the patient's belief in severity of the illness, and the patient - provider relationship. Strategies to improve compliance can target 3 sets of factors: predisposing factors including patients' motivation and perception, factors that enable patients to comply more easily, and factors that reinforce compliance. Physician-directed interventions tailored to each of these categories of factors, taken together, can make up a comprehensive health education program. A model for the interventions and their evaluations is presented.

Among the many alcohol-related public health concerns, motor vehicle crashes account for nearly one-third of all deaths attributable to alcohol. Adolescents and young adults, particularly males, are important target populations for intervention efforts. Taking an ecological perspective of individuals within their social and physical environments, a diagnostic framework is employed in reviewing the literature on factors associated with drinking and driving injuries and on interventions to prevent injuries due to drinking and driving. Intervention planning is conceptualized according to a multilevel intervention framework, which consists of four phases: (1) health goals selection, (2) intervention planning, (3) intervention, and (4) evaluation. Possible intervention objectives, targets of the intervention actions, intervention approaches, and evaluation criteria are identified and discussed for three societal levels and four practice settings.

Three city data sources (CDSs)--police reports, ambulance reports, and medica examiner (ME) logs--were evaluated for their usefulness in epidemiologic studies of trauma. The CDSs were employed to identify all cases of penetrating injury to the chest and/or abdomen severe enough to require care in a medical institution during 1979 and 1980 in Baltimore city. The percent of cases identified by source was: police, 66.8%; ambulance, 47.9%; ME, 16.6%; police plus ambulance, 89.4%; police plus ME, 82.9%; and ambulance plus ME, 50.1%. Hospital admissions to six study hospitals due to chest and/or abdomen penetrating injury were located and matched to the CDS reports: 89.2% of the hospitalized cases were reported in one or more CDS, and 34.7% of the cases identified by one or more CDS could not be located in the hospital records. Using hospital records as the standard, each source was determined to have the following completeness of case reporting: police, 66.2%; ambulance, 72.9%; and ME, 92.2%. The authors conclude that existing CDSs should be used with caution, and that the usefulness of data from multiple sources far outweighs that from any single source.

Despite an increase in the public's awareness of the ample health benefits of physical activity, less than 20% of US adults regularly participate in moderate to vigorous physical activity. For most adults, increasing physical activity even moderately is likely to benefit health. Physicians can prescribe physical activity and incorporate an emphasis on physical activity into clinical practice.

The practice of health promotion and disease prevention (HPDP), an increasingly important approach to healthcare, includes influencing health behaviors of the population at risk for disease as well as environmental conditions that affect health. The major role of the clinician in HPDP is at the individual level: screening for risk factors and disease and providing early treatment, advice, counseling, and referral. Primary care physicians can broaden their impact by assuming roles at organizational, community, and government levels (eg, as an active member of an organization or a consultant to an outside organization, a community leader or an agent of change, an influential constituent or a lobbyist). These roles enable primary care physicians to have an impact both on individuals and on environments to reduce disease risk factors.