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Recorded patient and therapist goal-setting sessions. The relationship between patients' participation in these sessions and their later involvement with their therapy goals was studied (N = 29). How much patients participated and how much influence they had over the goals set were found to be related significantly to later goal involvement.
Why do some implementations in human service settings of goal attainment scaling (GAS), an innovative program evaluation technique, last over time, whereas others die out despite an initially successful period of operation? To provide some tentative answers to this question and to help shed more light generally on differences between sustained and nonsustained innovative programs in service delivery organizations, 10 intensive case studies were conducted. Four were goal attainment scaling programs that have proved durable over time in their host organizations versus six other programs in which goal attainment scaling did not survive despite some initial success. These case studies were analyzed both clinically and by means of expert judges' ratings to identify some of the critical variables that seem to be associated with durability of the goal attainment scaling programs.
Individual treatment decisions for patients with Alzheimer dementia are often characterized by uncertainty about the actual benefit that specific treatments or procedures may bring about. It often even remains unclear how the benefit of a treatment may be determined. In this paper, three criteria for determining the benefit of a treatment measure are developed: An intervention (1) must be effective and (2) able to achieve a clinically relevant goal, which is (3) desirable for the individual patient. By using example of anti-dementia drug treatment, it will by shown that even if standard goals of dementia care are achieved, the benefit for the patient may still be questionable. A cognitive improvement or a delay of cognitive decay may even harm the patient. Therefore it is not sufficient to focus on the efficacy of a drug and on general goals of care when making decisions about individual dementia treatments. Rather it is necessary to reflect and discuss explicitly the goals of the individual patient. As shown by various examples, this will facilitate coherent, patient-orientated treatment decisions.
Since the realization that hypertension was a risk factor for cardiovascular disease, methods of lowering elevated blood pressure have been developed. The main goal of antihypertensive treatment is to prevent or to arrest cardiovascular damage. Based on the successes and failures encountered for over 30 years or more of therapeutic experience in hypertension, several treatment goals have been established. Previously, it was claimed that the advantages of lowering blood pressure were not dependent on the antihypertensive drug used. Now, this is being questioned. For instance, fatigue is often observed in hypertensive patients treated with drugs that reduce cardiac output and limit peripheral blood flow. Is it therefore more rational to reduce blood pressure by returning increased vascular resistance to normal? Since antihypertensive therapy is life-long, we are becoming increasingly aware of the long-term effects (both beneficial and adverse) of antihypertensive drugs. The metabolic changes caused by current antihypertensive drugs are now being studied in detail. The potassium-depleting action of diuretics is well-known, and the significance of such an effect is being re-examined. The effects of various antihypertensive agents on serum lipids are relatively recent observations, the clinical importance of which is worthy of wider discussion and investigation. The abolition or reduction of all vascular complications of hypertension is the goal for which current antihypertensive treatment has most often failed. Whereas prevention of cerebrovascular accidents, renal failure, and heart failure has indeed been successfully achieved, coronary complications (the most frequent adjunct of hypertension) have been little influenced by antihypertensive therapy. Is this because coronary heart disease may be simply an associated disease, rather than a consequence of hypertension? Or is this because the beneficial action of the most widely used antihypertensive drugs on vascular disease is largely counteracted by unfavorable metabolic effects? These and similar questions have to be debated and resolved before we can define treatment goals more precisely and develop the most appropriate means to achieve them.
Choice of drinking goals were studied in a two-year out-patient alcoholic treatment program with a low attrition rate. Eighty-four percent of the alcoholics (N = 50) preferred abstinence during the first 3-month period and 64% during the last 3-month period. Forty-four percent changed drinking goals (abstinence or controlled drinking) during the 2-year period. Women had a more stable choice than men (p less than .1). Patients with an abstinence drinking goal during the total 2-year period were more often physically dependent on alcohol and had more drinks during abuse days than the other patients. Patients did not differ in number of abuse days during the 2-year program as a function of goal choice.
Evaluation of alcoholism treatment effectiveness needs to be based on the healthy goals that alcoholics themselves identify as important. This research uses ethnography and grounded-theory methods to develop a model of recovering alcoholics' goal progression. The author spent 28 days in a treatment center, engaging in all patient activities, and observed and interviewed 42 participants to determine what they wanted from treatment. The research indicates that recovering alcoholics' goals develop through four stages. Certain kinds of behavior must be accomplished for an alcoholic to move from one stage to another. Behavior that facilitates and inhibits goal progression is identified.
Humans show a strong and early inclination to interpret observed behaviours of others as goal-directed actions. We identify two main epistemic functions that this 'teleological obsession' serves: on-line prediction and social learning. We show how teleological action interpretations can serve these functions by drawing on two kinds of inference ('action-to-goal' or 'goal-to-action'), and argue that both types of teleological inference constitute inverse problems that can only be solved by further assumptions. We pinpoint the assumptions that the three currently proposed mechanisms of goal attribution (action-effect associations, simulation procedures, and teleological reasoning) imply, and contrast them with the functions they are supposed to fulfil. We argue that while action-effect associations and simulation procedures are generally well suited to serve on-line action monitoring and prediction, social learning of new means actions and artefact functions requires the inferential productivity of teleological reasoning.
BACKGROUND: Studies indicate that, overall, African Americans are less likely to achieve control of hyperlipidemia compared with whites. No population-based studies have examined the effect of race on achieving target low-density lipoprotein (LDL) goals among treated individuals. METHODS: Using computerized encounter and laboratory result data, we identified all African American and white patients in a Midwestern health system filling a statin prescription from January 1, 1997, through June 30, 2001 (index prescription), with no prescriptions filled 1 year before index prescription. We followed LDL results for 1 year after index prescription. RESULTS: A total of 16052 new statin users (32.5% African American) were identified. Mean baseline LDL was higher for African Americans (170.2 +/- 36.6) than for whites (161.8 +/- 37.2) (P < .001). Whites were more adherent to therapy, with 48.6% of white patients exposed to statins >80% of follow-up time (31.2% of African Americans) (P < .001). By the end of follow-up, 49.5% of African Americans and 71.1% of whites reached LDL goal. A proportional hazards model adjusting for age, sex, median household income, physician specialty, clinic site, baseline LDL, starting dose, and target LDL indicated that African Americans were less likely to reach goal compared with whites (hazard ratio 0.64, 95% CI 0.61-0.68). Results persisted after controlling for racial differences in statin adherence and LDL testing (hazard ratio 0.60, 95% CI 0.57-0.63). CONCLUSIONS: African American patients initiating statin therapy are less likely to achieve LDL goal, even after controlling for adherence differences and other factors, suggesting that African Americans may require different pharmacologic management.
OBJECTIVE: The purpose of this study was to assess factors that influence patient satisfaction 1 year after pelvic reconstructive surgery. STUDY DESIGN: We previously reported the objective success, goals, and expectations of a cohort of 78 patients 3 months after surgery. A second blinded independent physician investigator contacted the same patients by phone to reassess these items 1 year after surgery. Data were analyzed with the Spearman correlation, the Mann-Whitney test, the chi-squared test of association, and the Friedman test. RESULTS: Seventy patients (89%) of the original cohort completed the second assessment. Although group satisfaction and goal achievement were stable (P < .01), 70% of patients reported a change in their satisfaction ratings between 3 months and 1 year (rho = 0.3). Reduced satisfaction between 3 and 12 months after surgery was strongly associated with decreased goal achievement (rho = 0.47; P = .006). Fifty-six percent of patients reported urge incontinence symptoms after surgery (44% de novo and 12% persistent). Urge incontinence was the most common reason for patient dissatisfaction after surgery (P = .04). CONCLUSION: Symptoms of urge incontinence and reduced achievement of subjective surgical goals are associated with decreased long-term patient satisfaction after reconstructive pelvic surgery.
Participation in leisure-time activities, self-concept perceptions and individual dispositional goal orientations were examined as mediators of relationships between physical coordination and self-evaluations of life satisfaction and general self-concept for 173 boys aged 10-13 years. Participants completed seven-day activity diaries and 12-month retrospective recall questionnaires recording participation in leisure-time activities. Self-report measures of self-concept, global life satisfaction and dispositional goal orientations were also completed. Results showed that boys with moderate to severe physical coordination difficulties had significantly lower self-concept perceptions of physical ability and appearance, peer and parent relations and general self-concept, as well as lower life satisfaction than boys with medium to high levels of physical coordination. The relationships between boys' physical coordination and their self-perceptions of life satisfaction and general self-concept were significantly influenced by individual self-concept appraisals of physical ability and appearance, peer and parent relations. Adopting task-oriented goals was found to positively change the relationship between physical coordination and both general self-concept and life satisfaction. Team sport participation positively mediated the relationship between physical coordination and life satisfaction. The potential for team sport participation and adoption of task-oriented goals to influence life satisfaction for boys with differing levels of physical coordination was discussed.
Eighty-three subjects were asked to solve a series of 15 mathematical problems after having been randomly assigned to an easy (5 problems) or to a difficult (9 problems) performance challenge. In addition to this, in order to create a sense of threat, subjects were told that a loud noise would be contingent upon failing to attain the performance challenge. Goal self-efficacy was computed from calculating the difference between self-efficacy level and the performance challenge. Intrinsic incentive value was derived from a six-item scale measuring the intensity of negative affects expected by the subject to be contingent upon a hypothetical failure to attain the goal. Systolic and diastolic blood pressure, and heart rate were collected during both the task performance and a prior rest phase. Anxiety-state was measured during the task performance as well. Statistical analyses revealed that interaction of goal self-efficacy and intrinsic incentive value partially predicted systolic blood pressure and heart rate reactivity. A main effect of self-efficacy was found on diastolic blood pressure. Overall, data best fitted to non-linear, quadratic functions in which either very low or very high self-efficacy, jointly with high incentive value, led to an enhanced cardiovascular reactivity. These findings are partially consistent with those previously obtained, and point to a complex model in which self-efficacy exerts specific effects on each cardiovascular parameter, usually in a non-monotonical way. Again, incentive value appeared as a moderator, but anxiety-state did not appear as a mediator of the relationship between goal self-efficacy and cardiovascular reactivity.
The behavioral problems and cognitive deficits resulting from even small amounts of prenatal alcohol exposure can be significant and enduring but completely preventable. The purpose of this study was to examine the impact of a prenatal drinking goal selected during a brief intervention for 115 pregnant women and their partners on subsequent consumption. Higher proportions of women having their first pregnancy chose abstinence as a goal over drinking reduction. Goal selection was highly predictive of subsequent drinking behavior. Interestingly, the participants who were abstinent at enrollment and who chose to remain abstinent had the highest rates of abstinence. In contrast, the women who chose cutting down on drinking were the least likely to drink less subsequently, despite recognizing more situations putting them at risk for drinking and identifying more alternatives to consumption. We conclude that goal choice in behavioral self-management of alcohol use by pregnant women is critical.
A model of intentional actions is presented through the operation of two connected neural networks. A deterministic causal recurrent network relates a random initial state to an ordered final state. A perceptron-like, feed-forward network provides a memory mechanism that links the final states to the original initial states. A non-supervised learning mechanism that selects which final states are defined as goals to be retrieved together with initial states leading to them. Causal sequences of states are transformed into procedures directed towards the achievements of goals. We propose a mechanism through which goals and their achievement in goal-directed actions can be emerging properties of self-organizing networks, not initially endowed with intentionality. This allows for a monist, non-mentalist description which does not need to resort to intentional mental states as causes of intentional actions. Cognitive, neurophysiological and philosophical implications are discussed.
The ability to dynamically modulate the intensity of sustained attention (i.e., alertness) is an essential component of the human executive control system, allowing us to function purposefully in accordance with our goals. In this study we examine high-density ERP markers of alert responding during the fixed sequence sustained attention to response task (SART(fixed)). This paradigm has proven to be a sensitive clinical metric in patient populations with deficits in their ability to sustain attention (e.g., attention deficit hyperactivity disorder). In this task subjects withhold a button press to an infrequent no-go target ('3') embedded within a predictable sequence of numbers ('1' to '9'). Our data reveal a complex pattern of effects across the trial sequence of the SART, with clear contributions from frontal and parietal cortices to sustained attentional performance. Over occipito-parietal regions, early visual attention processes were increased during trial 2 (i.e., trial in which the digit '2' was presented) and trial 3, giving rise to the so-called selection negativity (SN). Two prominent late components were manifest during trial 2: LP1 (550-800 ms) and LP2 (850-1150 ms) over occipito-parietal and central sites. We interpret the LP1 component on trial 2 as reflecting retrieval of the task goal and the subsequent LP2 as reflecting competition between the currently relevant go response and the subsequent no-go response. On trial 3, an enhanced "no-go N2" (250-450 ms) was seen fronto-centrally in the absence of the "no-go P3" that typically follows. Fronto-polar activity was also seen across all trials and may be indicative of subgoal processes to integrate the association between stimulus and goal. Prior to a lapse of attention (i.e., failure to inhibit a response to "3") the LP1 was significantly attenuated on the preceding trial 2 indicating a failure of anticipatory goal-directed processing. The results are discussed in terms of models of sustained attention involving frontal and parietal cortices.
BACKGROUND: The effect of dieting and weight-control perceptions, goals, and behaviors on food intake, including fruit and vegetable (F&V) consumption, is not completely understood. We examined these associations in 1,755 young adolescents. METHODS: Data from the Teens Eating for Energy and Nutrition at School (TEENS) study were analyzed separately by gender using mixed linear modeling. Surveys completed at the beginning and end of 7th grade asked students to self-report fruit and vegetable consumption, weight-related perceptions, goals, and behaviors, and demographic variables. RESULTS: Underweight boys reported 0.8 fewer F&V servings per day than boys who reported their weight to be 'about right' (P = 0.002), while overweight girls reported 0.7 fewer F&V than girls who reported their weight to be 'about right' (P = 0.005). Boys with weight-related goals consumed significantly more F&V than did boys not wanting to do anything about their weight (P < 0.05). Girls engaging in weight-related behaviors reported 0.7 more F&V than girls who did not engage in weight-related behaviors (P = 0.006). CONCLUSIONS: Because F&V intake is low among all adolescents, population interventions should take place to increase F&V intake. These data support the inclusion of gender-specific intervention components related to weight-related perceptions, goals, and behaviors.
This research investigates the sunk-cost effect or escalation defined as the irrational tendency to choose to continue to invest money, time, or effort following unsuccessful investments. Building on previous research demonstrating a loss-sensitivity principle in sequential decision making, the hypothesis was proposed that a loss-minimization goal would lead to stronger effects of sunk outcomes (prior gains and losses) than would a gain-maximizing goal. The hypothesis was investigated in three experiments with undergraduates responding to investment decision scenarios. Although the tendency to continue investments was always larger for gain-maximizing than for loss-minimizing goal instructions, the sunk-outcome effect was stronger in the former case. However, when the decisions were personal and concerned lower stakes rather than business investments involving large amounts of money, the expected stronger effect of sunk outcomes was found for loss-minimizing goal instructions. Another finding was that the expected value was never ignored, thus suggesting that future research should focus on the joint effects of the expected value and sunk outcomes.
Social health insurance, with contributions based on incomes and access to services on need is being considered as an option for health care finance in many countries. The argument in this paper starts from the premise that the choice of health care financing mechanisms should start with a clear focus on policy goals, with different options judged against the extent to which these are met. These are likely to include objectives of access to care for those in need, quality of care, incentives for efficient provision and cost control. Different systems will meet the objectives of mobilising resources, providing insurance against risk and redistribution resources to differing extents. It is argued that a particular problem in health care finance is shifting rights to resources over time. It is also important to be clear about the distinction between affordability of and payment mechanisms for health care. The choice of funding mechanisms may have little effect on other policy goals, such as economic development. However, they may differ in the degree to which they allow specific health policy goals to be met. Different mechanisms for collecting and managing funds, and for paying for services are discussed. The paper concludes with concerns that too much emphasis is placed on structures and not how they work, that a lack of cost control may be a serious risk in developing social health insurance and that it is important to have clear mechanisms for setting priorities if policy goals are to be met.
The Niagara District Health Council has embarked on a strategic planning exercise to develop health goals, objectives and preliminary targets for action. This process was approached in three phases: establishment of a Health Goals Task Force and adoption of the five goals developed by the Premier's Council on Health Strategy; planning and implementation of a Health Goals Consultation Day to involve community members in the identification and priority ranking of objectives; and development of measurable and realistic preliminary targets through consultations with expert groups and individuals. This process is a practical planning tool applicable across sectors and communities.