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Objective: This study assesses the usability of three patient information leaflets and attempts to improve them while complying with the current EU regulations. Methods: Three original leaflets were tested among 154 potential users. Every participant answered 15 scenario questions for one of the leaflets. The leaflets were subsequently redesigned based on the test results and evidence-based Document Design principles. The revised texts were tested among 164 participants. Results: All three original leaflets suffered from usability problems, especially problems related to finding relevant information. On average, only 75% of the topics could be located. Comprehension of the information, once found, was around 90%. The revisions led to better performance. Information was found faster and more successful. Comprehension scores were higher as well. A follow-up study shows that these findings can be generalized over paper formats. Conclusion: Although the current EU regulations for patient information leaflets do not guarantee leaflet usability, the leaflets can be improved somewhat within the regulations. However, further research should evaluate the text structure currently imposed on leaflets. Practical implications: Information leaflets must be written, or rewritten, according to Document Design principles. Furthermore, they must be user tested in a rigorous way. [Copyright &y& Elsevier]

Objective: This paper first illustrates the general potential of the short message service (SMS) for symptom and behavior monitoring and the provision of tailored feedback. Second, an SMS-based maintenance treatment (SMSMT) is introduced aimed at enhancing the treatment of childhood overweight.Methods: After a 12-week cognitive behavioral group treatment (CBGT), 40 children were assigned to the SMSMT for a period of 36 weeks. Children were asked to send weekly self-monitoring data on eating behavior, exercise behavior, and emotions and received tailored feedback. The adherence to SMSMT and changes in Body Mass Index Standard Deviation Scores (BMI-SDS) during the first and second treatment phase were analysed.Results: Children (mean age=10.05, SD=1.28) submitted 67% of the weekly SMS that they were expected to send in. During CBGT a significant reduction by 0.20 BMI-SDS was observed. The reduction by 0.07 BMI-SDS during the SMSMT did not reach statistical significance.Conclusion: The results support the feasibility of SMSMT in the treatment of childhood overweight. The efficacy of the intervention needs to be demonstrated in an RCT.Practice Implications: SMSMT is a promising intervention that may extend the reach of treatment centers for childhood overweight at reasonable cost and effort. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This paper aims to provide an overview of different theoretical approaches in the study of determinants of energy balance-related behaviors (EBRBs). METHODS: The Environmental Research framework for weight Gain prevention (EnRG) is used as a general framework to guide the overview. RESULTS: Theoretical approaches in the integrated study of EBRBs are discussed, as well as theories addressing environmental factors, mediating factors, moderating factors and automatic environment-behavior links. CONCLUSION: Five distinct topics should be deliberated when researchers conceptualize their research model: (1) to apply a theory-based approach in their determinants study within the broader perspective of systematic obesity prevention, (2) to incorporate the notion of potential clustering of (motives to engage in) EBRBs, (3) to accompany research towards environmental determinants of EBRBs with the operationalization of factors that may mediate the environmental influence, (4) to hypothesize both mediated and unmediated paths in environment-behavior relations, and (5) to incorporate potential moderators of the studied influences on EBRBs in the research design. PRACTICE IMPLICATIONS: The choice for change objectives and subsequent obesity prevention intervention strategies may be optimized when relevant determinants are interpreted as either primary (direct) causal factors, mediated determinants, mediating determinants or as moderators of causal factors. [ABSTRACT FROM AUTHOR]

Objective: This paper first illustrates the general potential of the short message service (SMS) for symptom and behavior monitoring and the provision of tailored feedback. Second, an SMS-based maintenance treatment (SMSMT) is introduced aimed at enhancing the treatment of childhood overweight. Methods: After a 12-week cognitive behavioral group treatment (CBGT), 40 children were assigned to the SMSMT for a period of 36 weeks. Children were asked to send weekly self-monitoring data on eating behavior, exercise behavior, and emotions and received tailored feedback. The adherence to SMSMT and changes in Body Mass Index Standard Deviation Scores (BMI-SDS) during the first and second treatment phase were analysed. Results: Children (mean age=10.05, SD=1.28) submitted 67% of the weekly SMS that they were expected to send in. During CBGT a significant reduction by 0.20 BMI-SDS was observed. The reduction by 0.07 BMI-SDS during the SMSMT did not reach statistical significance. Conclusion: The results support the feasibility of SMSMT in the treatment of childhood overweight. The efficacy of the intervention needs to be demonstrated in an RCT. Practice implications: SMSMT is a promising intervention that may extend the reach of treatment centers for childhood overweight at reasonable cost and effort. [Copyright &y& Elsevier]

Objective: This paper aims to provide an overview of different theoretical approaches in the study of determinants of energy balance-related behaviors (EBRBs). Methods: The Environmental Research framework for weight Gain prevention (EnRG) is used as a general framework to guide the overview. Results: Theoretical approaches in the integrated study of EBRBs are discussed, as well as theories addressing environmental factors, mediating factors, moderating factors and automatic environment–behavior links. Conclusion: Five distinct topics should be deliberated when researchers conceptualize their research model: (1) to apply a theory-based approach in their determinants study within the broader perspective of systematic obesity prevention, (2) to incorporate the notion of potential clustering of (motives to engage in) EBRBs, (3) to accompany research towards environmental determinants of EBRBs with the operationalization of factors that may mediate the environmental influence, (4) to hypothesize both mediated and unmediated paths in environment–behavior relations, and (5) to incorporate potential moderators of the studied influences on EBRBs in the research design. Practice implications: The choice for change objectives and subsequent obesity prevention intervention strategies may be optimized when relevant determinants are interpreted as either primary (direct) causal factors, mediated determinants, mediating determinants or as moderators of causal factors. [Copyright &y& Elsevier]

Objective: The Dietary Intake Monitoring Application (DIMA) is an electronic dietary self-monitor developed for use on a personal digital assistant (PDA). This paper describes how computer, information, numerical, and visual literacy were considered in development of DIMA.Methods: An iterative, participatory design approach was used. Forty individuals receiving hemodialysis at an urban inner-city facility, primarily middle-aged and African American, were recruited.Results: Computer literacy was considered by assessing abilities to complete traditional/nontraditional PDA tasks. Information literacy was enhanced by including a Universal-Product-Code (UPC) scanner, picture icons for food with no UPC code, voice recorder, and culturally sensitive food icons. Numerical literacy was enhanced by designing DIMA to compute real-time totals that allowed individuals to see their consumption relative to their dietary prescription. Visual literacy was considered by designing the graphical interface to convey intake data over a 24-h period that could be accurately interpreted by patients. Pictorial icons for feedback graphs used objects understood by patients.Practice Implications: Preliminary data indicate the application is extremely helpful for individuals as they self-monitor their intake. If desired, DIMA could also be used for dietary counseling. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Justifiable concerns around the use of complementary and alternative medicines (CAM) amongst cancer patients are becoming increasingly prominent. The aim was to develop evidence-based guidelines to assist oncology health professionals (HP) to have respectful, balanced and useful discussions with patients about CAM. METHODS: A systematic review was conducted, covering relevant literature from 1997 to 2007. The level of evidence was rated using a standardized rating system. The evidence was qualitatively synthesised into structured recommendations by a multidisciplinary team including a consumer. RESULTS: The search identified 78 original papers; 36 directly related to discussing CAM. No randomized controlled trials specifically addressing the methods or benefits of discussing CAM were identified. Evidence based guidelines are presented as a sequence of recommended steps: (1) Elicit the person's understanding of their situation; (2) Respect cultural and linguistic diversity and different epistemological frameworks; (3) Ask questions about CAM use at critical points in the illness trajectory; (4) Explore details and actively listen; (5) Respond to the person's emotional state; (6) Discuss relevant concerns while respecting the person's beliefs; (7) Provide balanced, evidence-based advice; (8) Summarize discussions; (9) Document the discussion; (10) Monitor and follow-up. CONCLUSION: This represents the first comprehensive guidelines for discussing CAM. PRACTICE IMPLICATIONS: Given the concerns surrounding CAM use, it is critical to encourage informed decision-making about CAM and ultimately, improve outcomes for patients. [ABSTRACT FROM AUTHOR]

Objective: The Dietary Intake Monitoring Application (DIMA) is an electronic dietary self-monitor developed for use on a personal digital assistant (PDA). This paper describes how computer, information, numerical, and visual literacy were considered in development of DIMA. Methods: An iterative, participatory design approach was used. Forty individuals receiving hemodialysis at an urban inner-city facility, primarily middle-aged and African American, were recruited. Results: Computer literacy was considered by assessing abilities to complete traditional/nontraditional PDA tasks. Information literacy was enhanced by including a Universal-Product-Code (UPC) scanner, picture icons for food with no UPC code, voice recorder, and culturally sensitive food icons. Numerical literacy was enhanced by designing DIMA to compute real-time totals that allowed individuals to see their consumption relative to their dietary prescription. Visual literacy was considered by designing the graphical interface to convey intake data over a 24-h period that could be accurately interpreted by patients. Pictorial icons for feedback graphs used objects understood by patients. Practice implications: Preliminary data indicate the application is extremely helpful for individuals as they self-monitor their intake. If desired, DIMA could also be used for dietary counseling. [Copyright &y& Elsevier]

Objective: Justifiable concerns around the use of complementary and alternative medicines (CAM) amongst cancer patients are becoming increasingly prominent. The aim was to develop evidence-based guidelines to assist oncology health professionals (HP) to have respectful, balanced and useful discussions with patients about CAM. Methods: A systematic review was conducted, covering relevant literature from 1997 to 2007. The level of evidence was rated using a standardized rating system. The evidence was qualitatively synthesised into structured recommendations by a multidisciplinary team including a consumer. Results: The search identified 78 original papers; 36 directly related to discussing CAM. No randomized controlled trials specifically addressing the methods or benefits of discussing CAM were identified. Evidence based guidelines are presented as a sequence of recommended steps: (1) Elicit the person''s understanding of their situation; (2) Respect cultural and linguistic diversity and different epistemological frameworks; (3) Ask questions about CAM use at critical points in the illness trajectory; (4) Explore details and actively listen; (5) Respond to the person''s emotional state; (6) Discuss relevant concerns while respecting the person''s beliefs; (7) Provide balanced, evidence-based advice; (8) Summarize discussions; (9) Document the discussion; (10) Monitor and follow-up. Conclusion: This represents the first comprehensive guidelines for discussing CAM. Practice implications: Given the concerns surrounding CAM use, it is critical to encourage informed decision-making about CAM and ultimately, improve outcomes for patients. [Copyright &y& Elsevier]

OBJECTIVE: This paper identifies common obstacles impeding effective self-management among patients with heart disease and explores how for disadvantaged patients access barriers interfere with typical management challenges to undermine patients' efforts to care for their illnesses. METHODS: We convened 33 focus group discussions with heart patients in 10 U.S. communities. Using content analysis, we identified and grouped the most common barriers that emerged in focus group discussions. RESULTS: We identified nine major themes reflecting issues related to patients' ability to care for and manage their heart conditions. We grouped the themes into three domains of interest: (1) barriers that interfere with getting necessary services, (2) barriers that impede the monitoring and management of a heart condition on a daily basis, and (3) supports that enable self-management and improve care. CONCLUSION: For disadvantaged populations, typical problems associated with self-management of a heart condition are aggravated by substantial obstacles to accessing care. PRACTICE IMPLICATIONS: Ensuring disadvantaged patients with chronic heart conditions are linked to formal systems of care, such as cardiac rehabilitation programs, could better develop patients' self-management skills, reduce barriers to receiving care and improve the overall health outcomes of these patients. [ABSTRACT FROM AUTHOR]

Objective: This paper identifies common obstacles impeding effective self-management among patients with heart disease and explores how for disadvantaged patients access barriers interfere with typical management challenges to undermine patients’ efforts to care for their illnesses. Methods: We convened 33 focus group discussions with heart patients in 10 U.S. communities. Using content analysis, we identified and grouped the most common barriers that emerged in focus group discussions. Results: We identified nine major themes reflecting issues related to patients’ ability to care for and manage their heart conditions. We grouped the themes into three domains of interest: (1) barriers that interfere with getting necessary services, (2) barriers that impede the monitoring and management of a heart condition on a daily basis, and (3) supports that enable self-management and improve care. Conclusion: For disadvantaged populations, typical problems associated with self-management of a heart condition are aggravated by substantial obstacles to accessing care. Practice implications: Ensuring disadvantaged patients with chronic heart conditions are linked to formal systems of care, such as cardiac rehabilitation programs, could better develop patients’ self-management skills, reduce barriers to receiving care and improve the overall health outcomes of these patients. [Copyright &y& Elsevier]

OBJECTIVE: This paper describes the development of patient education from the 1960s until now and identifies future challenges to improve patient education. RESULTS: Patient education developed from the health care professional deciding what the patient needed to know to a shared decision making design where physician and patient are equally influential on the decision making process. The development of patient education is described for primary and secondary health care, as well as the impact of biomedical advances, an ageing population and cultural diversity on patient education. Some of the challenges for future patient education are identified: training health professionals as well as patients, involvement of the patient's social environment and application of e-Health techniques to patient education. CONCLUSION: Patient education has made several developmental changes, has spread to different settings in health care and has now finally established itself as a valuable part of health care for patients. Nevertheless, both patients and health professionals still need to be provided with skills to optimize patient education. A good science-practice fit for future interventions to facilitate patient education is paramount. PRACTICE IMPLICATION: Lessons from the past of patient education are important for the growth and future development of patient education. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This paper presents a historical overview of patient education in French speaking (parts of) countries of Europe, as well as the emergence of new concepts in Health care and education. Further it describes the results of research and studies on current practice and political decisions and positions about patient education, based upon laws and regulations. The present trends will be discussed, and propose an overview of the next possible developmental steps. METHODS: Articles, reports and policy documents about publications on patient education in French speaking (parts of) countries of Europe. RESULTS: In the last years, in France, Belgium, Switzerland, Luxemburg, patient education has undergone a lot of changes whether in theories, models, policies or practice. These changes came with the emergence of concepts such as effectiveness of care, chronic disease follow-up, compliance, adherence, health promotion, empowerment, salutogenesis, resilience, patients' rights, health care costs control, coaching, disease management, consumer choice, and participation. Each of these concepts seems to have been defined and implemented in various ways, according to settings or countries. Political and social choices seem to have oriented choices from humanistic approaches to pragmatic decisions, with ethical problems rising. Consensus on definitions are often hard to reach, especially among policy makers, health care teams, health managers, and patient organizations, even though these concepts do coexist in daily practice, sometimes in very conflictual ways. CONCLUSIONS: Hard or subtle, changes are happening in patient education and cannot be ignored. PRACTICE IMPLICATION: Many questions rise on the future of patient education, wondering how to anticipate next models of health care practice, and their ethical and social stakes. Clear positions need to be taken. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To get insights into the decision-making strategy of health-care consumers when confronted with comparative consumer information. METHODS: Qualitative descriptive study among 18 consumers who had a hip or knee replacement no longer than five years ago. To study their decision-making strategies a paper draft for a website was used providing comparative consumer information. Data were collected by cognitive interviews and focus-group meetings and subjected to thematic analysis. RESULTS: Consumers were able to understand the presented information, but had problems to use it as a decision aid. They primarily relied on previous experiences. Four themes were revealed: decision making, perceived benefits, unmet information needs, and trustworthiness. Consumers used different decision strategies and showed unpredictable behavior when choosing a hospital. CONCLUSION: Individual decision strategies, unsatisfied information needs, limited tenability and too coarse aggregation levels of quality scores are barriers for a proper use of comparative consumer information. Personal experience remains a valuable information source for hospital selection. We suggest that a website presenting comparative consumer information should be flexible in various ways and should include functionality to share personal experience. [ABSTRACT FROM AUTHOR]

Objective: This paper describes the development of patient education from the 1960s until now and identifies future challenges to improve patient education. Results: Patient education developed from the health care professional deciding what the patient needed to know to a shared decision making design where physician and patient are equally influential on the decision making process. The development of patient education is described for primary and secondary health care, as well as the impact of biomedical advances, an ageing population and cultural diversity on patient education. Some of the challenges for future patient education are identified: training health professionals as well as patients, involvement of the patient''s social environment and application of e-Health techniques to patient education. Conclusion: Patient education has made several developmental changes, has spread to different settings in health care and has now finally established itself as a valuable part of health care for patients. Nevertheless, both patients and health professionals still need to be provided with skills to optimize patient education. A good science-practice fit for future interventions to facilitate patient education is paramount. Practice implication: Lessons from the past of patient education are important for the growth and future development of patient education. [Copyright &y& Elsevier]

Objective: To get insights into the decision-making strategy of health-care consumers when confronted with comparative consumer information. Methods: Qualitative descriptive study among 18 consumers who had a hip or knee replacement no longer than five years ago. To study their decision-making strategies a paper draft for a website was used providing comparative consumer information. Data were collected by cognitive interviews and focus-group meetings and subjected to thematic analysis. Results: Consumers were able to understand the presented information, but had problems to use it as a decision aid. They primarily relied on previous experiences. Four themes were revealed: decision making, perceived benefits, unmet information needs, and trustworthiness. Consumers used different decision strategies and showed unpredictable behavior when choosing a hospital. Conclusion: Individual decision strategies, unsatisfied information needs, limited tenability and too coarse aggregation levels of quality scores are barriers for a proper use of comparative consumer information. Personal experience remains a valuable information source for hospital selection. We suggest that a website presenting comparative consumer information should be flexible in various ways and should include functionality to share personal experience. [Copyright &y& Elsevier]

Objective: This paper presents a historical overview of patient education in French speaking (parts of) countries of Europe, as well as the emergence of new concepts in Health care and education. Further it describes the results of research and studies on current practice and political decisions and positions about patient education, based upon laws and regulations. The present trends will be discussed, and propose an overview of the next possible developmental steps. Methods: Articles, reports and policy documents about publications on patient education in French speaking (parts of) countries of Europe. Results: In the last years, in France, Belgium, Switzerland, Luxemburg, patient education has undergone a lot of changes whether in theories, models, policies or practice. These changes came with the emergence of concepts such as effectiveness of care, chronic disease follow-up, compliance, adherence, health promotion, empowerment, salutogenesis, resilience, patients’ rights, health care costs control, coaching, disease management, consumer choice, and participation. Each of these concepts seems to have been defined and implemented in various ways, according to settings or countries. Political and social choices seem to have oriented choices from humanistic approaches to pragmatic decisions, with ethical problems rising. Consensus on definitions are often hard to reach, especially among policy makers, health care teams, health managers, and patient organizations, even though these concepts do coexist in daily practice, sometimes in very conflictual ways. Conclusions: Hard or subtle, changes are happening in patient education and cannot be ignored. Practice implication: Many questions rise on the future of patient education, wondering how to anticipate next models of health care practice, and their ethical and social stakes. Clear positions need to be taken. [Copyright &y& Elsevier]

OBJECTIVE: To evaluate the effectiveness of intervention programs at the workplace or elsewhere aimed at preventing burnout, a leading cause of work related mental health impairment. METHODS: A systematic search of burnout intervention studies was conducted in the databases Medline, PsycINFO and PSYNDEX from 1995 to 2007. Data was also extracted from papers found through a hand search. RESULTS: A total of 25 primary intervention studies were reviewed. Seventeen (68%) were person-directed interventions, 2 (8%) were organization-directed and 6 (24%) were a combination of both interventions types. Eighty percent of all programs led to a reduction in burnout. Person-directed interventions reduced burnout in the short term (6 months or less), while a combination of both person- and organization-directed interventions had longer lasting positive effects (12 months and over). In all cases, positive intervention effects diminished in the course of time. CONCLUSION: Intervention programs against burnout are beneficial and can be enhanced with refresher courses. Better implemented programs including both person- and organization-directed measures should be offered and evaluated. PRACTICE IMPLICATIONS: A combination of both intervention types should be further investigated, optimized and practiced. Institutions should recognize the need for and make burnout intervention programs available to employees. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To evaluate the effectiveness of intervention programs at the workplace or elsewhere aimed at preventing burnout, a leading cause of work related mental health impairment. Methods: A systematic search of burnout intervention studies was conducted in the databases Medline, PsycINFO and PSYNDEX from 1995 to 2007. Data was also extracted from papers found through a hand search. Results: A total of 25 primary intervention studies were reviewed. Seventeen (68%) were person-directed interventions, 2 (8%) were organization-directed and 6 (24%) were a combination of both interventions types. Eighty percent of all programs led to a reduction in burnout. Person-directed interventions reduced burnout in the short term (6 months or less), while a combination of both person- and organization-directed interventions had longer lasting positive effects (12 months and over). In all cases, positive intervention effects diminished in the course of time. Conclusion: Intervention programs against burnout are beneficial and can be enhanced with refresher courses. Better implemented programs including both person- and organization-directed measures should be offered and evaluated. Practice implications: A combination of both intervention types should be further investigated, optimized and practiced. Institutions should recognize the need for and make burnout intervention programs available to employees. [Copyright &y& Elsevier]

OBJECTIVE: To describe the challenges to blinding in behavioral interventions, specifically those for asymptomatic medical conditions, where the intervention is through counseling, and to provide recommendations for achieving blinding in behavioral randomized controlled trials (RCTs). METHODS: This paper reviews the challenges of preserving blinding in behavioral RCTs with a focus on interventions for asymptomatic medical conditions. This is illustrated using a case study of an ongoing behavioral intervention to improve hypertension control. RESULTS: In contrast to easily keeping study investigators and participants masked to treatment assignment through the use of identical pills or sham treatments, the need to have differing levels of blinding among study personnel and participants in randomized behavioral intervention trials is presented. Recommendations for achieving this are provided. CONCLUSIONS: Despite the challenges inherent in behavioral interventions, it is possible to achieve differing levels of blinding across study personnel and participants to minimize bias and generate valid data in RCTs that test interventions for asymptomatic medical conditions such as hypertension. Modifications may be needed for RCTs in symptomatic medical conditions. PRACTICE IMPLICATIONS: Researchers designing behavioral RCTs should be aware of the challenges to blinding all staff and study participants, and plan to have procedures in place to standardize outcome data collection and intervention delivery without compromising the varying levels of blinding. The challenges and recommendations described may need modifications in behavioral intervention studies for symptomatic conditions. [ABSTRACT FROM AUTHOR]

Abstract: Objective: When deciding how many embryos to transfer during in vitro fertilisation (IVF), clinicians and patients have to balance optimizing the chance of pregnancy against preventing multiple pregnancies and the associated complications. This paper describes the development and pilot test of a patient decision aid (DA) for this purpose. Methods: The development of the DA consisted of a literature search, establishment of the format, and a pilot test among IVF patients. The DA development was supervised by a panel of experts in the fields of subfertility, obstetrics and DA-research and it was based on the criteria of the International Patient Decision Aid Standards. Results: One Cochrane review and 34 articles were selected for the DA content. The DA presents information in text, summaries, tables, figures and through an interactive worksheet. The DA was reviewed positively and as acceptable for use in clinical practice by patients and professionals. Conclusion: The DA was thoroughly developed and is likely to be helpful for the decision-making process for the number of embryos transferred after IVF. Practice implications: Physicians and researchers can use the DA without restriction in clinical practice or research related to decision-making. [Copyright &y& Elsevier]

OBJECTIVE: The aim of this paper is to describe how the process of developing and maintaining trust is related to how and if smoking cessation advice is given in general practice consultations. METHODS: The study consisted of interviews with six Danish GPs and with 11 of their patients, on the basis of observations of their consultations. RESULTS: According to the findings of this study, both the GPs and the patients expected GPs to demonstrate in interaction with the patients their intent to evaluate and possibly resolve the patient's health problem. The GPs were also expected to show that they recognized the patient's health problem. Both GPs and patients felt that this would help to develop patients' trust in their GPs. Smoking cessation advice during consultations could negate these demonstrations of GPs intents. Smoking cessation advice, however, could demonstrate interest and a desire to help and so develop trust. CONCLUSION: Smoking cessation advice has the potential both to put trust under strain and to strengthen trust. The outcome depends on whether the advice conforms to what both patients and GPs expect from the interaction in general practice consultations. PRACTICE IMPLICATIONS: To develop and maintain patients' trust GPs should consider the specific expectations from the interaction with patients during consultations when giving smoking cessation advice. [ABSTRACT FROM AUTHOR]

OBJECTIVE: When deciding how many embryos to transfer during in vitro fertilisation (IVF), clinicians and patients have to balance optimizing the chance of pregnancy against preventing multiple pregnancies and the associated complications. This paper describes the development and pilot test of a patient decision aid (DA) for this purpose. METHODS: The development of the DA consisted of a literature search, establishment of the format, and a pilot test among IVF patients. The DA development was supervised by a panel of experts in the fields of subfertility, obstetrics and DA-research and it was based on the criteria of the International Patient Decision Aid Standards. RESULTS: One Cochrane review and 34 articles were selected for the DA content. The DA presents information in text, summaries, tables, figures and through an interactive worksheet. The DA was reviewed positively and as acceptable for use in clinical practice by patients and professionals. CONCLUSION: The DA was thoroughly developed and is likely to be helpful for the decision-making process for the number of embryos transferred after IVF. PRACTICE IMPLICATIONS: Physicians and researchers can use the DA without restriction in clinical practice or research related to decision-making. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The aim of this paper is to describe how the process of developing and maintaining trust is related to how and if smoking cessation advice is given in general practice consultations. Methods: The study consisted of interviews with six Danish GPs and with 11 of their patients, on the basis of observations of their consultations. Results: According to the findings of this study, both the GPs and the patients expected GPs to demonstrate in interaction with the patients their intent to evaluate and possibly resolve the patient''s health problem. The GPs were also expected to show that they recognized the patient''s health problem. Both GPs and patients felt that this would help to develop patients’ trust in their GPs. Smoking cessation advice during consultations could negate these demonstrations of GPs intents. Smoking cessation advice, however, could demonstrate interest and a desire to help and so develop trust. Conclusion: Smoking cessation advice has the potential both to put trust under strain and to strengthen trust. The outcome depends on whether the advice conforms to what both patients and GPs expect from the interaction in general practice consultations. Practice implications: To develop and maintain patients’ trust GPs should consider the specific expectations from the interaction with patients during consultations when giving smoking cessation advice. [Copyright &y& Elsevier]

Abstract: Objective: To describe the challenges to blinding in behavioral interventions, specifically those for asymptomatic medical conditions, where the intervention is through counseling, and to provide recommendations for achieving blinding in behavioral randomized controlled trials (RCTs). Methods: This paper reviews the challenges of preserving blinding in behavioral RCTs with a focus on interventions for asymptomatic medical conditions. This is illustrated using a case study of an ongoing behavioral intervention to improve hypertension control. Results: In contrast to easily keeping study investigators and participants masked to treatment assignment through the use of identical pills or sham treatments, the need to have differing levels of blinding among study personnel and participants in randomized behavioral intervention trials is presented. Recommendations for achieving this are provided. Conclusions: Despite the challenges inherent in behavioral interventions, it is possible to achieve differing levels of blinding across study personnel and participants to minimize bias and generate valid data in RCTs that test interventions for asymptomatic medical conditions such as hypertension. Modifications may be needed for RCTs in symptomatic medical conditions. Practice implications: Researchers designing behavioral RCTs should be aware of the challenges to blinding all staff and study participants, and plan to have procedures in place to standardize outcome data collection and intervention delivery without compromising the varying levels of blinding. The challenges and recommendations described may need modifications in behavioral intervention studies for symptomatic conditions. [Copyright &y& Elsevier]

OBJECTIVE: This paper examines from a qualitative approach the role of a patient-centered website - named 'Oneself' - on patients' chronic low back pain self-management attitudes and behaviors in the Italian part of Switzerland. METHODS: In-depth interviews have been conducted with a purposive and convenient sample of 18 chronic low back pain sufferers who had used Oneself during 6 months. Data collection and analysis were driven by grounded theory. RESULTS: Reported positive effects of the use of Oneself on self-management attitudes and behaviors include self-comprehension, improvement of argumentative abilities, orientation, development of self-confidence and maintenance of a high level of attention. In some cases, participants affirm to have experienced negative effects such as confusion and discouragement. The individual's previous awareness of cLBP and level of self-management plays a main role in the way people use the website and in its impact. Based on this criterium, a typology of four patterns of use is drawn. CONCLUSION: Patient-centered websites are useful for enhancing self-management of chronic low back pain. However, individuals take advantage of this means differently, based on their stage of advancement in the self-management process. PRACTICE IMPLICATIONS: Information and supports provided online should be tailored according to people's stage of advancement. [ABSTRACT FROM AUTHOR]

Objective: This paper examines from a qualitative approach the role of a patient-centered website--named “Oneself”--on patients’ chronic low back pain self-management attitudes and behaviors in the Italian part of Switzerland. Methods: In-depth interviews have been conducted with a purposive and convenient sample of 18 chronic low back pain sufferers who had used Oneself during 6 months. Data collection and analysis were driven by grounded theory. Results: Reported positive effects of the use of Oneself on self-management attitudes and behaviors include self-comprehension, improvement of argumentative abilities, orientation, development of self-confidence and maintenance of a high level of attention. In some cases, participants affirm to have experienced negative effects such as confusion and discouragement. The individual's previous awareness of cLBP and level of self-management plays a main role in the way people use the website and in its impact. Based on this criterium, a typology of four patterns of use is drawn. Conclusion: Patient-centered websites are useful for enhancing self-management of chronic low back pain. However, individuals take advantage of this means differently, based on their stage of advancement in the self-management process. Practice implications: Information and supports provided online should be tailored according to people's stage of advancement. [Copyright &y& Elsevier]

OBJECTIVES: This paper describes the development and pilot testing of a communication skills curriculum based on medical student curriculum and modified for use with patients. METHODS: Six key concepts from our introductory medical education communication skills curriculum were identified. The core knowledge and skills related to these concepts were reorganized into six modules, including presentation materials, handouts and active learning components. The curriculum was pilot tested with three independent groups of non-medical participants, representing a broad cross-section of the community. RESULTS: Participants reported a high level of satisfaction; over 80% found the program helpful for learning new information and skills, and 92% for working with their physicians. Over 90% would recommend the program to others. Participant self-assessments revealed the greatest change in knowledge of medical interviewing. Skill changes were greatest in expressing emotion and efficiently telling the medical story. The pilot tests also highlighted the importance of other issues related to recruitment and health literacy. CONCLUSIONS: This project demonstrates that key concepts underlying doctor-patient communications can be simplified and repackaged for use from the patient's perspective. PRACTICE IMPLICATIONS: Similar curricula can empower patients from all walks of life to better communicate with their health care providers and enhance their healthcare experience. [ABSTRACT FROM AUTHOR]

Objectives: This paper describes the development and pilot testing of a communication skills curriculum based on medical student curriculum and modified for use with patients. Methods: Six key concepts from our introductory medical education communication skills curriculum were identified. The core knowledge and skills related to these concepts were reorganized into six modules, including presentation materials, handouts and active learning components. The curriculum was pilot tested with three independent groups of non-medical participants, representing a broad cross-section of the community. Results: Participants reported a high level of satisfaction; over 80% found the program helpful for learning new information and skills, and 92% for working with their physicians. Over 90% would recommend the program to others. Participant self-assessments revealed the greatest change in knowledge of medical interviewing. Skill changes were greatest in expressing emotion and efficiently telling the medical story. The pilot tests also highlighted the importance of other issues related to recruitment and health literacy. Conclusions: This project demonstrates that key concepts underlying doctor–patient communications can be simplified and repackaged for use from the patient's perspective. Practice implications: Similar curricula can empower patients from all walks of life to better communicate with their health care providers and enhance their healthcare experience. [Copyright &y& Elsevier]

OBJECTIVE: This paper explores the behavior change method of goal-setting and reviews the literature on goal-setting in primary care for patients with chronic conditions. METHODS: A literature search was conducted resulting in eight articles meeting the criteria of goal-setting interventions in primary care for adults or adolescents with chronic conditions. RESULTS: Hypotheses are advanced that goal-setting is generally conducted by collaboratively working with patients to set short-term and specific goals, with follow-up to provide feedback to patients. The articles reviewed generally confirmed these hypotheses. This review did not focus on clinical outcomes, but on the processes of engaging patients in goal-setting discussions. CONCLUSION: Evidence that goal-setting is superior to other behavior change methods has not been shown. Since goal-setting is being utilized as a behavior change technique in many primary care sites, primary care practices can benefit from information on how best to implement this innovation. PRACTICE IMPLICATIONS: Generally, clinicians are minimally involved in goal-setting discussions with their patients. Engaging patients in goal-setting can be done with interactive computer programs and non-clinical members of the primary care team. [ABSTRACT FROM AUTHOR]

Objective: This paper explores the behavior change method of goal-setting and reviews the literature on goal-setting in primary care for patients with chronic conditions. Methods: A literature search was conducted resulting in eight articles meeting the criteria of goal-setting interventions in primary care for adults or adolescents with chronic conditions. Results: Hypotheses are advanced that goal-setting is generally conducted by collaboratively working with patients to set short-term and specific goals, with follow-up to provide feedback to patients. The articles reviewed generally confirmed these hypotheses. This review did not focus on clinical outcomes, but on the processes of engaging patients in goal-setting discussions. Conclusion: Evidence that goal-setting is superior to other behavior change methods has not been shown. Since goal-setting is being utilized as a behavior change technique in many primary care sites, primary care practices can benefit from information on how best to implement this innovation. Practice Implications: Generally, clinicians are minimally involved in goal-setting discussions with their patients. Engaging patients in goal-setting can be done with interactive computer programs and non-clinical members of the primary care team. [Copyright &y& Elsevier]

Objective: Current health literacy measures are too long, imprecise, or have questionable equivalence of English and Spanish versions. The purpose of this paper is to describe the development and pilot testing of a new bilingual computer-based health literacy assessment tool.Methods: We analyzed literacy data from three large studies. Using a working definition of health literacy, we developed new prose, document and quantitative items in English and Spanish. Items were pilot tested on 97 English- and 134 Spanish-speaking participants to assess item difficulty.Results: Items covered topics relevant to primary care patients and providers. English- and Spanish-speaking participants understood the tasks involved in answering each type of question. The English Talking Touchscreen was easy to use and the English and Spanish items provided good coverage of the difficulty continuum.Conclusion: Qualitative and quantitative results provided useful information on computer acceptability and initial item difficulty. After the items have been administered on the Talking Touchscreen (la Pantalla Parlanchina) to 600 English-speaking (and 600 Spanish-speaking) primary care patients, we will develop a computer adaptive test.Practice Implications: This health literacy tool will enable clinicians and researchers to more precisely determine the level at which low health literacy adversely affects health and healthcare utilization. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Current health literacy measures are too long, imprecise, or have questionable equivalence of English and Spanish versions. The purpose of this paper is to describe the development and pilot testing of a new bilingual computer-based health literacy assessment tool. Methods: We analyzed literacy data from three large studies. Using a working definition of health literacy, we developed new prose, document and quantitative items in English and Spanish. Items were pilot tested on 97 English- and 134 Spanish-speaking participants to assess item difficulty. Results: Items covered topics relevant to primary care patients and providers. English- and Spanish-speaking participants understood the tasks involved in answering each type of question. The English Talking Touchscreen was easy to use and the English and Spanish items provided good coverage of the difficulty continuum. Conclusion: Qualitative and quantitative results provided useful information on computer acceptability and initial item difficulty. After the items have been administered on the Talking Touchscreen (la Pantalla Parlanchina) to 600 English-speaking (and 600 Spanish-speaking) primary care patients, we will develop a computer adaptive test. Practice implications: This health literacy tool will enable clinicians and researchers to more precisely determine the level at which low health literacy adversely affects health and healthcare utilization. [Copyright &y& Elsevier]

OBJECTIVE: To review the literature to identify external influences on information exchange and shared decision-making in healthcare consultations and conceptualise how information is used both outside and within a consultation. METHODS: A 'meta-study' approach (meta-data-analysis, meta-theory, meta-method, and meta-synthesis) was used to locate, review, synthesise and summarise the findings, methodology, theoretical orientation and interpretation of qualitative research papers. RESULTS: In a model of external influences on information exchange within healthcare consultations, practitioner influences were: receptiveness to informed patients and patient choice, lack of knowledge of cultural difference, patient centredness vs. stereotyping. Patient influences were: motivation to seek and engage with information; the appraisal of information before a consultation, expression of cultural identity, and ways of managing the risk of poor information. Shared influences were: differing illness notions, role expectations and language. Empowerment, disempowerment and non-empowerment were outcomes of information exchange and health literacy was a mediator of external influences and empowerment. CONCLUSION: This meta-study provides a conceptualisation of external influences on information exchange in shared decision-making where health literacy mediates patient related influences and is also an influence on empowerment. PRACTICE IMPLICATIONS: Our model can inform the development of interventions aimed at improving information exchange and shared decision-making, potentially contributing to more equitable healthcare encounters. [ABSTRACT FROM AUTHOR]

Objective: To review the literature to identify external influences on information exchange and shared decision-making in healthcare consultations and conceptualise how information is used both outside and within a consultation. Methods: A ‘meta-study’ approach (meta-data-analysis, meta-theory, meta-method, and meta-synthesis) was used to locate, review, synthesise and summarise the findings, methodology, theoretical orientation and interpretation of qualitative research papers. Results: In a model of external influences on information exchange within healthcare consultations, practitioner influences were: receptiveness to informed patients and patient choice, lack of knowledge of cultural difference, patient centredness vs. stereotyping. Patient influences were: motivation to seek and engage with information; the appraisal of information before a consultation, expression of cultural identity, and ways of managing the risk of poor information. Shared influences were: differing illness notions, role expectations and language. Empowerment, disempowerment and non-empowerment were outcomes of information exchange and health literacy was a mediator of external influences and empowerment. Conclusion: This meta-study provides a conceptualisation of external influences on information exchange in shared decision-making where health literacy mediates patient related influences and is also an influence on empowerment. Practice implications: Our model can inform the development of interventions aimed at improving information exchange and shared decision-making, potentially contributing to more equitable healthcare encounters. [Copyright &y& Elsevier]

OBJECTIVE: To establish sound empirical evidence that clinical empathy (abbreviated as CE) is a core element in the clinician-patient relationship with profound therapeutic potential, a substantial theoretical-based understanding of CE in medical care and medical education is still required. The two aims of the present paper are, therefore, (1) to give a multidisciplinary overview of the 'nature' and 'specific effectiveness' of CE, and (2) to use this base as a means of deriving relevant questions for a theory-based research agenda. METHOD: We made an effort to identify current and past literature about conceptual and empirical work focusing on empathy and CE, which derives from a multiplicity of disciplines. We review the material in a structured fashion. RESULTS: We describe the 'nature' of empathy by briefly summarizing concepts and models from sociology, psychology, social psychology, education, (social-)epidemiology, and neurosciences. To explain the 'specific effectiveness' of CE for patients, we develop the 'Effect model of empathic communication in the clinical encounter', which demonstrates how an empathically communicating clinician can achieve improved patient outcomes. Both parts of theoretical findings are synthesized in a theory-based research agenda with the following key hypotheses: (1) CE is a determinant of quality in medical care, (2) clinicians biographical experiences influence their empathic behavior, and (3) CE is affected by situational factors. CONCLUSION: The main conclusions of our review are twofold. First of all, CE seems to be a fundamental determinant of quality in medical care, because it enables the clinician to fulfill key medical tasks more accurately, thereby achieving enhanced patient health outcomes. Second, the integration of biographical experiences and situational factors as determinants of CE in medical care and medical education appears to be crucial to develop and promote CE and ultimately ensuring high-quality patient care. PRACTICE IMPLICATIONS: Due to the complexity and multidimensionality of CE, evidence-based investigations of the derived hypotheses require both well-designed qualitative and quantitative studies as well as an interdisciplinary research approach. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The evidence base of medical communication has been underdeveloped and the field was felt to be in need for thorough empirical investigation. Studying medical communication can help to clarify what happens during medical encounters and, subsequently, whether the behavior displayed is effective. However, before effectiveness can be established, one should argue what functions or goals the communication has and what outcomes are relevant in medical communication research. RESULTS AND CONCLUSIONS: In the present paper, we first suggest the six function model of medical communication based on the integration of earlier models. The model distinguishes (1) fostering the relationship, (2) gathering information, (3) information provision, (4) decision making, (5) enabling disease and treatment-related behavior, and (6) responding to emotions. Secondly, a framework for endpoints in such research is presented. Immediate, intermediate and long-term outcomes are distinguished on the one hand and patient-, provider- and process- or context-related outcomes on the other. Based on this framework priorities can be defined and a tentative hierarchy proposed. Health is suggested to be the primary goal of medical communication as are patient-related outcomes. Dilemmas are described. Finally, in medical communication research, theory is advocated to link health care provider behavior or skills to outcomes and to connect intermediate outcomes to long-term ones. PRACTICE IMPLICATIONS: By linking specific communication elements to concrete endpoints within the six function model of medical communication, communication will become better integrated within the process of medical care. This is helpful to medical teachers and motivational to medical students. This approach can provide the place to medical communication it deserves in the center of medical care. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Research and education of medical communication different perspective, making the extraction of clear recommendations from research that can be applied in education not always possible. In education, medical communication is encountered from a goal-oriented perspective, which is often lacking in quantitative research where the relationship between process variables and the content of medical practice is often ignored. The aim of this paper is to bring the worlds of research and education together by presenting a comprehensive model of determinants explaining the behavior of physicians in daily practice. A basic notion in this model is that medical communication is goal-oriented, problem-solving behavior. Goals in communication are not fixed, but permanently changing over time. Hence, communication abilities do not rely on behavioral skills only but also on perceptual skills in identifying goals. A number of determinants affect the cognitive processes of goal appraisal and response formation: knowledge, attitudes, social norms, self-efficacy, stressors and interfering goals. CONCLUSION: Modeling medical communication as goal-oriented problem-solving behavior, and recognizing the complexity of goal appraisal and other key determinants of response formation may provide a common focus for both research and education in measuring, explaining and improving the HCP's behavior. PRACTICE IMPLICATIONS: In education not only skill practicing but also reflection on the process and outcomes is important to understand how one acts in practice situations and should act in future situations. In research measurements should be expanded to take contextual and goal-oriented dimensions of the process of communication into account to make findings more relevant for education and practice. [ABSTRACT FROM AUTHOR]

Objective: To establish sound empirical evidence that clinical empathy (abbreviated as CE) is a core element in the clinician–patient relationship with profound therapeutic potential, a substantial theoretical-based understanding of CE in medical care and medical education is still required. The two aims of the present paper are, therefore, (1) to give a multidisciplinary overview of the “nature” and “specific effectiveness” of CE, and (2) to use this base as a means of deriving relevant questions for a theory-based research agenda. Method: We made an effort to identify current and past literature about conceptual and empirical work focusing on empathy and CE, which derives from a multiplicity of disciplines. We review the material in a structured fashion. Results: We describe the “nature” of empathy by briefly summarizing concepts and models from sociology, psychology, social psychology, education, (social-)epidemiology, and neurosciences. To explain the “specific effectiveness” of CE for patients, we develop the “Effect model of empathic communication in the clinical encounter”, which demonstrates how an empathically communicating clinician can achieve improved patient outcomes. Both parts of theoretical findings are synthesized in a theory-based research agenda with the following key hypotheses: (1) CE is a determinant of quality in medical care, (2) clinicians biographical experiences influence their empathic behavior, and (3) CE is affected by situational factors. Conclusion: The main conclusions of our review are twofold. First of all, CE seems to be a fundamental determinant of quality in medical care, because it enables the clinician to fulfill key medical tasks more accurately, thereby achieving enhanced patient health outcomes. Second, the integration of biographical experiences and situational factors as determinants of CE in medical care and medical education appears to be crucial to develop and promote CE and ultimately ensuring high-quality patient care. Practice implications: Due to the complexity and multidimensionality of CE, evidence-based investigations of the derived hypotheses require both well-designed qualitative and quantitative studies as well as an interdisciplinary research approach. [Copyright &y& Elsevier]

Objectives: Research and education of medical communication different perspective, making the extraction of clear recommendations from research that can be applied in education not always possible. In education, medical communication is encountered from a goal-oriented perspective, which is often lacking in quantitative research where the relationship between process variables and the content of medical practice is often ignored. The aim of this paper is to bring the worlds of research and education together by presenting a comprehensive model of determinants explaining the behavior of physicians in daily practice. A basic notion in this model is that medical communication is goal-oriented, problem-solving behavior. Goals in communication are not fixed, but permanently changing over time. Hence, communication abilities do not rely on behavioral skills only but also on perceptual skills in identifying goals. A number of determinants affect the cognitive processes of goal appraisal and response formation: knowledge, attitudes, social norms, self-efficacy, stressors and interfering goals. Conclusion: Modeling medical communication as goal-oriented problem-solving behavior, and recognizing the complexity of goal appraisal and other key determinants of response formation may provide a common focus for both research and education in measuring, explaining and improving the HCP's behavior. Practice implications: In education not only skill practicing but also reflection on the process and outcomes is important to understand how one acts in practice situations and should act in future situations. In research measurements should be expanded to take contextual and goal-oriented dimensions of the process of communication into account to make findings more relevant for education and practice. [Copyright &y& Elsevier]

Objective: The evidence base of medical communication has been underdeveloped and the field was felt to be in need for thorough empirical investigation. Studying medical communication can help to clarify what happens during medical encounters and, subsequently, whether the behavior displayed is effective. However, before effectiveness can be established, one should argue what functions or goals the communication has and what outcomes are relevant in medical communication research. Results and conclusions: In the present paper, we first suggest the six function model of medical communication based on the integration of earlier models. The model distinguishes (1) fostering the relationship, (2) gathering information, (3) information provision, (4) decision making, (5) enabling disease and treatment-related behavior, and (6) responding to emotions. Secondly, a framework for endpoints in such research is presented. Immediate, intermediate and long-term outcomes are distinguished on the one hand and patient-, provider- and process- or context-related outcomes on the other. Based on this framework priorities can be defined and a tentative hierarchy proposed. Health is suggested to be the primary goal of medical communication as are patient-related outcomes. Dilemmas are described. Finally, in medical communication research, theory is advocated to link health care provider behavior or skills to outcomes and to connect intermediate outcomes to long-term ones. Practice implications: By linking specific communication elements to concrete endpoints within the six function model of medical communication, communication will become better integrated within the process of medical care. This is helpful to medical teachers and motivational to medical students. This approach can provide the place to medical communication it deserves in the center of medical care. [Copyright &y& Elsevier]

OBJECTIVE: UK medical schools find it challenging to provide standardised teaching to expanding year intakes. In addition, developing and implementing diversity training can cause difficulties. This paper describes the evaluation of an interactive e-learning programme to raise awareness and understanding of communication difficulties in diversity consultations. METHODS: The programme was part of an undergraduate portfolio-based community module. Three hundred and two students were assigned to one of three delivery methods-a large group setting, small groups with a facilitator, and as part of distance learning while on community placement. The evaluation included analysis of their coursework marks, a self-completed evaluation questionnaire, and small group discussions. RESULTS: Two hundred and twenty-three students took part in the evaluation. They were able to apply the concepts they learnt to clinical examples from their own experiences. Type of delivery did not affect coursework marks, but students tended to prefer the e-learning as part of a distance learning package. They offered helpful suggestions to improve its complexity and range. CONCLUSION: The acceptability and utility of this e-learning module both in face to face teaching and remote placement has been demonstrated, and evaluation by the students has provided valuable information for its further development. PRACTICE IMPLICATIONS: All medical schools should include some diversity training, and further research should concentrate on the effects of this type of learning on longer term outcomes such as attitude and performance tests. Such tools could reduce demands on staff time in facilitation of small groupwork, and their cost effectiveness could be increased by making them available to other medical schools. [ABSTRACT FROM AUTHOR]

Abstract: Objective: UK medical schools find it challenging to provide standardised teaching to expanding year intakes. In addition, developing and implementing diversity training can cause difficulties. This paper describes the evaluation of an interactive e-learning programme to raise awareness and understanding of communication difficulties in diversity consultations. Methods: The programme was part of an undergraduate portfolio-based community module. Three hundred and two students were assigned to one of three delivery methods—a large group setting, small groups with a facilitator, and as part of distance learning while on community placement. The evaluation included analysis of their coursework marks, a self-completed evaluation questionnaire, and small group discussions. Results: Two hundred and twenty-three students took part in the evaluation. They were able to apply the concepts they learnt to clinical examples from their own experiences. Type of delivery did not affect coursework marks, but students tended to prefer the e-learning as part of a distance learning package. They offered helpful suggestions to improve its complexity and range. Conclusion: The acceptability and utility of this e-learning module both in face to face teaching and remote placement has been demonstrated, and evaluation by the students has provided valuable information for its further development. Practice implications: All medical schools should include some diversity training, and further research should concentrate on the effects of this type of learning on longer term outcomes such as attitude and performance tests. Such tools could reduce demands on staff time in facilitation of small groupwork, and their cost effectiveness could be increased by making them available to other medical schools. [Copyright &y& Elsevier]

Evidence Based Medicine (EBM) and Shared Medical Decision Making (SDM) are changing the nature of health care decisions. It is broadly accepted that health care decisions require the integration of research evidence and individual preferences. These approaches are justified on both efficacy grounds (that evidence based practice and Shared Decision Making should lead to better health outcomes and may lead to a more cost-effective use of health care resources) and ethical grounds (patients' autonomy should be respected in health care). However, despite endorsement by physicians and consumers of these approaches, implementation remains limited in practice, particularly outside academic and tertiary health care centres. There are practical problems of implementation, which include training, access to research, and development of and access to tools to display evidence and support decision making. There may also be philosophical difficulties, and some have even suggested that the two approaches (evidence based practice and Shared Decision Making) are fundamentally incompatible. This paper look at the achievements of EBM and SDM so far, the potential tensions between them, and how things might progress in the future. [ABSTRACT FROM AUTHOR]

Evidence Based Medicine (EBM) and Shared Medical Decision Making (SDM) are changing the nature of health care decisions. It is broadly accepted that health care decisions require the integration of research evidence and individual preferences. These approaches are justified on both efficacy grounds (that evidence based practice and Shared Decision Making should lead to better health outcomes and may lead to a more cost-effective use of health care resources) and ethical grounds (patients’ autonomy should be respected in health care). However, despite endorsement by physicians and consumers of these approaches, implementation remains limited in practice, particularly outside academic and tertiary health care centres. There are practical problems of implementation, which include training, access to research, and development of and access to tools to display evidence and support decision making. There may also be philosophical difficulties, and some have even suggested that the two approaches (evidence based practice and Shared Decision Making) are fundamentally incompatible. This paper look at the achievements of EBM and SDM so far, the potential tensions between them, and how things might progress in the future. [Copyright &y& Elsevier]

Objective: The PREPARE programme study is a randomized controlled trial which aims to determine whether structured education can be used to increase physical activity and improve glucose tolerance in individuals with impaired glucose tolerance (IGT). This paper outlines the rationale, design and baseline data from the PREPARE programme study. Methods: Individuals with IGT were recruited from ongoing diabetes screening programmes. Outcomes included an oral glucose tolerance test, physical activity (piezoelectric pedometer) and psychological determinants. Results: 103 individuals (male n = 65; female n = 38) were recruited, 28% of whom were from a South Asian ethnic background. At baseline the participants' mean age and BMI were 64 +/- 9 years and 29.4 +/- 4.5 kg/m2 respectively. Steps per day were associated with 2-h glucose (p = -0.22, p = 0.03), fasting glucose (p = 0.22, p = 0.04), HDL-cholesterol (p = 0.23, p = 0.02), triglycerides (p = -0.22, p = 0.03) and body fat percentage (p = -0.26, p = 0.01). Mean self-efficacy scores were significantly (p < 0.01) higher for walking than for any other form of exercise. Participants reported high levels of concern about their IGT status but were confident that exercise would help treat/control IGT. Conclusion: This study demonstrates the importance of developing effective physical activity and self-management programmes for individuals with IGT. Practice Implications: This study provides a detailed framework for the promotion of physical activity in a population identified with an increased risk of developing type 2 diabetes which, if successful, could feasibly be implemented in a primary health care or community setting. [ABSTRACT FROM AUTHOR]

Objective: Randomized controlled trials in patient education often have difficulty enrolling vulnerable populations-specifically, older, poorer, and less educated individuals. We undertook a randomized controlled trial (RCT) of an educational intervention for arthritis management, which included strategies to remove literacy-related barriers to participation. This paper reports on the multi-stage recruitment process and assesses whether refusal to participate was related to education, age, gender, working status, or insurance status.Methods: The recruitment protocol was designed to eliminate literacy-related barriers to participation. Patients were never asked to read or fill out forms. Interactions were oral, using everyday terms and short, clear sentences. Patients who declined during a screening call were considered Stage 1 Refusers. Patients who initially expressed interest but neither completed a baseline questionnaire nor provided consent were considered Stage 2 Refusers. Patients who consented were considered Enrollees. Age, gender, and insurance status were compared between Stage 1 Refusers and Enrollees. A second analysis compared these variables, plus educational attainment and working status, between Stage 2 Refusers, and Enrollees.Results: Of 408 eligible patients, there were 193 (47.3%) Stage 1 Refusers, 81 (19.9%) Stage 2 Refusers and 134 (32.8%) Enrollees. A higher proportion of Stage 1 Refusers than Enrollees were > or = 65 years old (58% vs. 37%, p = .0003). Multivariate analysis, adjusting for gender and insurance status, confirmed the effect of older age on refusal (OR = 2.3 (1.4, 3.6)). There were no significant differences between Stage 2 Refusers and Enrollees.Conclusion: We found no evidence of refusal to participate due to educational attainment, working status, insurance status, or gender. Older patients were more likely to refuse participation at the first stage of recruitment.Practice Implications: Researchers should continue efforts to increase participation among older patients, particularly when studies are designed to be generalized to an elderly population as is the case with arthritis research. Strategies used in this recruitment protocol designed to remove literacy-related barriers to recruitment may be responsible for the observation that subjects with lower education did not have a higher rate of refusal. Such strategies deserve further study. [ABSTRACT FROM AUTHOR]

The PREPARE programme study is a randomized controlled trial which aims to determine whether structured education can be used to increase physical activity and improve glucose tolerance in individuals with impaired glucose tolerance (IGT). This paper outlines the rationale, design and baseline data from the PREPARE programme study. Methods: Individuals with IGT were recruited from ongoing diabetes screening programmes. Outcomes included an oral glucose tolerance test, physical activity (piezoelectric pedometer) and psychological determinants. Results: 103 individuals (male n =65; female n =38) were recruited, 28% of whom were from a South Asian ethnic background. At baseline the participants’ mean age and BMI were 64±9 years and 29.4±4.5kg/m2 respectively. Steps per day were associated with 2-h glucose (ρ =−0.22, p =0.03), fasting glucose (ρ =−0.22, p =0.04), HDL-cholesterol (ρ =0.23, p =0.02), triglycerides (ρ =−0.22, p =0.03) and body fat percentage (ρ =−0.26, p =0.01). Mean self-efficacy scores were significantly (p <0.01) higher for walking than for any other form of exercise. Participants reported high levels of concern about their IGT status but were confident that exercise would help treat/control IGT. Conclusion: This study demonstrates the importance of developing effective physical activity and self-management programmes for individuals with IGT. Practice implications: This study provides a detailed framework for the promotion of physical activity in a population identified with an increased risk of developing type 2 diabetes which, if successful, could feasibly be implemented in a primary health care or community setting. [Copyright &y& Elsevier]

Objective: Randomized controlled trials in patient education often have difficulty enrolling vulnerable populations—specifically, older, poorer, and less educated individuals. We undertook a randomized controlled trial (RCT) of an educational intervention for arthritis management, which included strategies to remove literacy-related barriers to participation. This paper reports on the multi-stage recruitment process and assesses whether refusal to participate was related to education, age, gender, working status, or insurance status. Methods: The recruitment protocol was designed to eliminate literacy-related barriers to participation. Patients were never asked to read or fill out forms. Interactions were oral, using everyday terms and short, clear sentences. Patients who declined during a screening call were considered Stage 1 Refusers. Patients who initially expressed interest but neither completed a baseline questionnaire nor provided consent were considered Stage 2 Refusers. Patients who consented were considered Enrollees. Age, gender, and insurance status were compared between Stage 1 Refusers and Enrollees. A second analysis compared these variables, plus educational attainment and working status, between Stage 2 Refusers, and Enrollees. Results: Of 408 eligible patients, there were 193 (47.3%) Stage 1 Refusers, 81 (19.9%) Stage 2 Refusers and 134 (32.8%) Enrollees. A higher proportion of Stage 1 Refusers than Enrollees were ≥65 years old (58% vs. 37%, p =.0003). Multivariate analysis, adjusting for gender and insurance status, confirmed the effect of older age on refusal (OR=2.3 (1.4, 3.6)). There were no significant differences between Stage 2 Refusers and Enrollees. Conclusion: We found no evidence of refusal to participate due to educational attainment, working status, insurance status, or gender. Older patients were more likely to refuse participation at the first stage of recruitment. Practice implications: Researchers should continue efforts to increase participation among older patients, particularly when studies are designed to be generalized to an elderly population as is the case with arthritis research. Strategies used in this recruitment protocol designed to remove literacy-related barriers to recruitment may be responsible for the observation that subjects with lower education did not have a higher rate of refusal. Such strategies deserve further study. [Copyright &y& Elsevier]

OBJECTIVE: This paper describes a translational project that explored the feasibility and effect of introducing a coordinated approach to emotional care. METHODS: The project was undertaken using Action Research on one ward at St John of God Hospital Subiaco, Western Australia. A senior Registered Nurse was appointed to provide the leadership and direction to staff regarding emotional care and an education program for staff was provided. The project was evaluated using both quantitative and qualitative data. RESULTS: Data demonstrated an increase in the patient's evaluation of emotional care, although levels were found to fluctuate throughout the project. Factors such as the emotional distress of the staff were hypothesised as impacting on the delivery of emotional care. CONCLUSION: The approach used in this project was found to be a useful method of improving emotional care. However, the data collected in this study revealed the complexity of emotional care delivery and the possible impact of a number of factors within the environment. PRACTICE IMPLICATIONS: Emotional care delivery can be improved by using a coordinated research-based educational approach led by a clinical champion. However, the impact of other factors within the hospital environment needs to be considered and more research is required. [ABSTRACT FROM AUTHOR]