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Background: Despite the availability of multiple effective screening tests for colorectal cancer, screening rates remain suboptimal. The literature documents patient preferences for different test types and recommends a shared decision-making approach for physician-patient colorectal cancer screening (CRCS) discussions, but it is unknown whether such communication about CRCS preferences and options actually occurs in busy primary-care settings., Objective: Describe physician-patient CRCS discussions during a wellness visit., Design: Cross-sectional; patients audio-recorded with physicians., Participants: A subset of patients (N = 64) participating in a behavioral intervention trial designed to increase CRCS who completed a wellness visit during the trial with a participating physician (N = 8)., Approach: Transcripts were analyzed using qualitative methods., Results: Physicians in this sample consistently recommended CRCS, but focused on colonoscopy. Physicians did not offer a fecal occult blood test alone as a screening choice, which may have created missed opportunities for some patients to get screened. In this single visit, physicians' communication processes generally precluded discussion of patients' test preferences and did not facilitate shared decision-making. Patients' questions indicated their interest in different CRCS test types and appeared to elicit more information from physicians. Some patients remained resistant to CRCS after discussing it with a physician., Conclusion: If a preference for colonoscopy is widespread among primary-care physicians, the implications for intervention are either to prepare patients for this preference or to train physicians to offer options when recommending screening to patients.

The "Partners in School Asthma Management" program for inner-city elementary school children comprises (1) case finding; (2) linkage of school nurses, parents, and clinicians; (3) a computer-based tailored educational program; and (4) school environmental assessment and intervention. Case finding identified 1730 children in 60 elementary schools with probable asthma; 835 (96% Hispanic or African American) joined the study. Baseline, posttest, and follow-up measures of asthma knowledge, self-efficacy, and self-management behavior were obtained from the children, and data on symptoms, emergency department visits, and hospitalizations were obtained from their parents. The schools provided data on grades and absences. Each school had a baseline and follow-up environmental assessment. The children in the intervention group showed greater increases in knowledge, self-efficacy, and some aspects of self-management. No differences between groups were found in health status variables, school performance, attendance, or levels of environmental allergens in schools. In 15 schools, an enhanced intervention allowed children and their parents to meet with a project physician, develop an asthma action plan, and receive a 1-month supply of medication; the project physician then followed up with the child's community physician. Children participating in this enhanced intervention had better school performance and fewer absences than the comparison group. Overall, the program was effective in improving children's asthma self-management but not in improving their health status. While the case-finding, computer-based self-management training program and linkage system were successfully implemented, the program failed in creating needed changes in the medical (action plans by community physicians) and physical environments (reduced school allergen levels) of the children.

Background and Purpose: Only a small minority of acute stroke patients receive approved acute stroke therapy. We performed a community and professional behavioral intervention project to increase the proportion of stroke patients treated with approved acute stroke therapy., Methods: This study used a quasi-experimental design. Intervention and comparison communities were compared at baseline and during educational intervention. The communities were based in 5 nonurban East Texas counties. The multilevel intervention worked with hospitals and community physicians while changing the stroke identification skills, outcome expectations, and social norms of community residents. The primary goal was to increase the proportion of patients treated with intravenous recombinant tissue plasminogen activator (rTPA) from 1% to 6% of all cerebrovascular events in the intervention community., Results: We prospectively evaluated 1733 patients and validated 1189 cerebrovascular events. Intravenous rTPA treatment increased from 1.38% to 5.75% among all cerebrovascular event patients in the intervention community (P=0.01) compared with a change from 0.49% to 0.55% in the comparison community (P=1.00). Among the ischemic stroke patients, an increase from 2.21% to 8.65% was noted in the intervention community (P=0.02). The comparison group did not appreciably change (0.71% to 0.86%, P=1.00). Of eligible intravenous rTPA candidates, treatment increased in the intervention community from 14% to 52% (P=0.003) and was unchanged in the comparison community (7% to 6%, P=1.00)., Conclusions: An aggressive, multilevel stroke educational intervention program can increase delivery of acute stroke therapy. This may have important public health implications for reducing disability on a national level.

Objective: To evaluate Watch, Discover, Think and Act (WDTA), a theory-based application of CD-ROM educational technology for pediatric asthma self-management education., Design: A prospective pretest posttest randomized intervention trial was used to assess the motivational appeal of the computer-assisted instructional program and evaluate the impact of the program in eliciting change in knowledge, self-efficacy, and attributions of children with asthma. Subjects were recruited from large urban asthma clinics, community clinics, and schools. Seventy-six children 9 to 13 years old were recruited for the evaluation., Results: Repeated-measures analysis of covariance showed that knowledge scores increased significantly for both groups, but no between-group differences were found (P: = 0.55); children using the program scored significantly higher (P: < 0.01) on questions about steps of self-regulation, prevention strategies, and treatment strategies. These children also demonstrated greater self-efficacy (P: < 0.05) and more efficacy building attribution classification of asthma self-management behaviors (P: < 0.05) than those children who did not use the program., Conclusion: The WDTA is an intrinsically motivating educational program that has the ability to effect determinants of asthma self-management behavior in 9- to 13-year-old children with asthma. This, coupled with its reported effectiveness in enhancing patient outcomes in clinical settings, indicates that this program has application in pediatric asthma education.

An interactive multimedia computer game to enhance self-management skills and thereby improve asthma outcomes in inner city children with asthma was evaluated. Subjects aged 6-17 were recruited from four pediatric practices and randomly assigned to the computer intervention condition or to the usual-care comparison. The main character in the game could match the subject on gender and ethnicity. Characteristics of the protagonist's asthma were tailored to be like those of the subject. Subjects played the computer game as part of regular asthma visits. Time between pre- and post-test varied from 4 to 15.6 months (mean, 7.6 months). Analysis of covariance, with pre-test scores, age, and asthma severity as covariates, found that the intervention was associated with fewer hospitalizations, better symptom scores, increased functional status, greater knowledge of asthma management, and better child self-management behavior for those in the intervention condition. Interactions with covariates were found and discussed in terms of variable efficacy of the intervention.

In this report we describe the development of the Watch, Discover, Think and Act asthma self-management computer program for inner-city children with asthma. The intervention focused on teaching two categories of behaviors--asthma specific behaviors such as taking preventive medication and self-regulatory processes such as monitoring symptoms and solving asthma problems. These asthma self-management behaviors were then linked with empirical and theoretical determinants such as skills and self-efficacy. We then further used behavioral science theory to develop methods such as role modeling and skill training linked to the determinants. We matched these theoretical methods to practical strategies within the computer simulation and created a culturally competent program for inner-city minority youth. Finally, we planned a program evaluation that linked program impact and outcomes to the theoretical assumptions on which the intervention was based.

This study tested the efficacy of the Cystic Fibrosis Family Education Program, a cystic fibrosis self-management program, on improving participants' knowledge, self-efficacy, self-management behavior, health, and quality of life. A quasi-experimental pretest-posttest nonequivalent comparison group design was employed. Participants made up 104 patient-primary caregiver dyads from the intervention site cystic fibrosis center and 95 from the usual care comparison center. The intervention, a self-paced print curriculum based on social cognitive theory, targeted behavioral capability, self-efficacy, and outcome expectations and was implemented as an integral part of medical care. Parents, early childhood, middle childhood, and adolescents received separate materials on respiratory, nutrition and malabsorption, communication, and coping issues. Significant intervention effects were found on the knowledge scores for caregivers, adolescents, and children; caregiver and adolescent total self-management scores; Child Behavior Checklist total score; one parent coping scale score; the modified NIH score; NIH pulmonary factor 1; and the Brasfield total score. Significant interaction effects were evident in the self-efficacy scores for caregivers and children.

Investigated the behaviors of pediatric rheumatology health care providers that were expected to be related to patient or parent adherence. Medical charts of 108 patients ages 1 to 20 years diagnosed with Juvenile Rheumatoid Arthritis were examined. The 473 outpatient visits over 15 months yielded a total of 2,578 treatment recommendations, but only 1,390 adherence-facilitating behaviors by medical staff were documented. Providing information about how often to perform the recommendation was the most common staff behavior. In contrast, care providers rarely indicated that they addressed their patients' concerns and barriers to implementing the recommendations, or employed behavior modification strategies to increase adherence. Implications of these findings for development of programs designed to increase treatment adherence in children with chronic diseases requiring time-consuming, intrusive medical regimens are discussed.

Objective: Our objective is to describe the use of the PRECEDE model (predisposing, reinforcing, and enabling causes in educational diagnosis and evaluation) to organize needs assessment data in order to define self-management behaviors and plan an educational intervention for children with juvenile rheumatoid arthritis (JRA) and their families., Methods: Analysis was done of needs assessment data collected from several sources: 1) literature review, 2) survey of parents of 51 children with JRA, 3) group interview of seven parents of children with JRA, 4) results of pilot programs, and 5) clinical experience of an interdisciplinary pediatric rheumatology team., Results: Two sets of interrelated behavioral factors were identified through the needs assessment: 1) those related to managing the school environment to facilitate optimal participation and to minimize school-related disability, and 2) those related to treating pain and stiffness, intervening in the disease process, and preserving joint function., Conclusion: Both of these sets of behavioral factors may be related to the optimization of children's mobility, joint function, and autonomy of activities of daily living and should be targets of an educational intervention.

One hundred and ninety-nine patients and their primary caregivers at two metropolitan cystic fibrosis centers participated in a clinical trial to evaluate the effectiveness of a health education program designed to help improve self-management skills for the care of CF. The baseline data from the study was used to test a structural model that hypothesized the relationship between educational, behavioral, and health status variables. Controlling for the effects of all other variables, including demographic, self-efficacy (confidence in being able to perform a behavior) was the most important educational factor predicting self-management behavior for monitoring and treating respiratory problems. Knowledge about the management of CF was only related to the ability of caretakers to apply coping skills to problems associated with CF. The more caretakers reported performing monitoring behaviors the more likely they were to report performing self-management treatment behaviors. The findings suggest that educational interventions that focus on increased knowledge alone are not likely to be effective in improving self-management behavior for CF. Based on the structural model analyses, it is recommended that educational programs for CF patients and families address increased self-efficacy and improved monitoring skills to influence the improvement of self-management treatment for CF.

The creative challenge of health education for chronic illnesses is the translation of theory-based intervention methods into practical strategies that can be organized into a logical series of learning activities to influence changes in environmental, cognitive, or behavioral factors. A case example describing the development and implementation of a comprehensive health-education intervention for the self-management of cystic fibrosis (CF) is presented. The design of intervention strategies began with an assessment of the educational needs for self-management of CF, followed by specification and validation of particular self-management behaviors. Behavioral and learning objectives then were formulated for each of the self-management behaviors. Constructs from social learning theory considered to be important influences on specified self-management behaviors in CF were identified. Taking into consideration the learning needs of the target population and the practical constraints of the system for providing health care, various intervention methods then were devised based on social learning theory. Lastly, the intervention methods chosen were translated into strategies organized into a series of practical learning activities for CF patients and their families. The process described here should prove useful to others who are planning and developing comprehensive health education programs for self-management of chronic illnesses.