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Care remains suboptimal for many patients with hypertension.

Our objective was to determine the factors that influence women's decision making about hormone replacement therapy, particularly with respect to coronary heart disease and breast cancer risk. We mailed questionnaires to a random sample of women ages 45–55 years. We requested information on demographics; menopausal state; current, past, and intended hormone replacement therapy use; beliefs and attitudes about the efficacy of hormone replacement therapy; and the relationship of hormone replacement therapy to the risks of osteoporosis, heart disease, and breast and endometrial cancer. One hundred twenty-six women (42 response rate) returned the questionnaire. Although the majority of women (81) knew that the risk of osteoporosis increased after menopause, only about half knew that the risk of heart disease (53) and breast cancer (45) increased as well. Although 69 of women knew that hormone replacement therapy decreased osteoporosis risk, only 48 knew about the association between hormone replacement therapy and heart disease risk. Bivariate and multivariate logistic regression models were used to assess the predictors of ever using hormone replacement therapy. The most important predictor was health care provider recommendation of (odds ratio 22.8: 95 confidence interval 4.2,124.5) hormone replacement therapy. Other factors that remained important predictors in a multivariate model included concern for developing osteoporosis (odds ratio 1.8: 95 confidence interval 1.2,2.7), feeling that taking estrogen is too much trouble (OR 0.5: 95 confidence interval 0.3,0.7), and family history of breast cancer (OR 0.2: 95 confidence interval 0.04,0.9). Although most women were aware of the associations between menopause, hormone replacement therapy, and osteoporosis, fewer women were aware of the associations with coronary heart disease or breast cancer. No aspects of heart disease risk were associated with a woman's decision to take hormone replacement therapy. Physicians should include coronary heart disease and breast cancer in their discussions with patients considering hormone replacement therapy.

An ideal model for clinical preventive care must consider the physician, the patient and the many factors which influence each of them. In this paper, we review existing models, examining their strengths and weaknesses. We then propose a new model, the Systems Model of Clinical Preventive Care. This model is unique in its focus on the patient-physician interaction and details the factors impinging on each that promote or inhibit the completion of preventive care activities. These factors include patient and physician predisposing factors, such as health beliefs and attitudes; enabling factors, such as skills and resources; and reinforcing factors, such as social support. Additional factors include health care system organizational factors, such as access or availability; characteristics of the preventive activity, such as cost; and cues to action, such as symptoms or reminders. The proposed model contains components of behavioral, communication, health education and psychosocial theories. We then apply our model to mammography as an example of a screening activity. Finally, we describe the strengths and weaknesses of the proposed model, and identify areas for future research.