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Chronic low back pain is experienced by many. Pain management programs have been developed to help patients cope with their condition and learn ways to modify their lifestyle to reduce discomfort. This article describes the development, implementation, and evaluation of a chronic pain management program at one facility.
Controlled trials in a number of countries have documented benefits from different types of in-home assessment and treatment programs for various subgroups of elderly persons. We have developed a program to test, using a randomized controlled design, the concepts of in-home comprehensive geriatric assessment (CGA) coupled with follow-up, health education, and preventive care in an urban United States community. The intervention includes yearly in-home CGA by geriatric nurse practitioners (GNPs), who provide, following discussions with physician geriatricians, lists of specific recommendations for health and well-being enhancement. The GNPs provide follow-up visits quarterly and regular telephone contacts to improve compliance. We recruited for our trial 414 home-living subjects aged 75 years and over, 215 randomized to the intervention group and 199 to the control group. Subjects were generally representative of the overall elderly population of the city of Santa Monica, a seaside suburb of Los Angeles. Extensive baseline data (medical, functional, psychosocial and environmental) were collected from subjects prior to randomization, using validated instruments whenever possible. Follow-up data were collected from each subject every 4 months by trained research assistants throughout the 3-year intervention follow-up period. Our study was designed to assess effects of the intervention on the hypothesized outcomes of health status, functional status, psychosocial parameters, and service utilization. Careful documentation of the intervention will enhance our ability to make process-outcome comparisons. Preliminary analysis reveals that the in-home CGA uncovered many important health deficits for most subjects resulting in a number of substantial recommendations. We are confident that when it is completed, this study will succeed in answering important remaining questions about the feasibility and effectiveness of establishing a geriatric in-home prevention and health promotion program in the United States based on principles of CGA.
The following article looks at social controls on the behavior of rural women in Bangladesh that need to be considered in project designs if women are to be able to respond to development programs. Rural women in many countries are constrained by analogous social pressures, which usually have an economic basis favoring the more powerful and therefore are resistant to change. Since these pressures on rural women often have a negative effect on the goals of rural development, they need to be understood and addressed.
The Diabetes Prevention Program is a randomized clinical trial testing strategies to prevent or delay the development of type 2 diabetes in high-risk individuals with elevated fasting plasma glucose concentrations and impaired glucose tolerance. The 27 clinical centers in the U.S. are recruiting at least 3,000 participants of both sexes, approximately 50% of whom are minority patients and 20% of whom are > or = 65 years old, to be assigned at random to one of three intervention groups: an intensive lifestyle intervention focusing on a healthy diet and exercise and two masked medication treatment groups--metformin or placebo--combined with standard diet and exercise recommendations. Participants are being recruited during a 2 2/3-year period, and all will be followed for an additional 3 1/3 to 5 years after the close of recruitment to a common closing date in 2002. The primary outcome is the development of diabetes, diagnosed by fasting or post-challenge plasma glucose concentrations meeting the 1997 American Diabetes Association criteria. The 3,000 participants will provide 90% power to detect a 33% reduction in an expected diabetes incidence rate of at least 6.5% per year in the placebo group. Secondary outcomes include cardiovascular disease and its risk factors; changes in glycemia, beta-cell function, insulin sensitivity, obesity, diet, physical activity, and health-related quality of life; and occurrence of adverse events. A fourth treatment group--troglitazone combined with standard diet and exercise recommendations--was included initially but discontinued because of the liver toxicity of the drug. This randomized clinical trial will test the possibility of preventing or delaying the onset of type 2 diabetes in individuals at high risk.
The Management Academy for Public Health is a team-based training program jointly offered by the School of Public Health and the Kenan-Flagler Business School at the University of North Carolina at Chapel Hill. This 9-month program teaches public health managers how to better manage people, information, and finances. Participants learn how to work in teams with community partners, and how to think and behave as social entrepreneurs. To practice and blend their new skills, teams develop a business plan that addresses a local public health issue. This article describes the program and explains the findings of the process evaluation, which has examined how best to structure and deploy a team-based method to create more effective, more entrepreneurial public health managers. Findings indicate that recruitment and retention are strong, program elements are relevant to learners' needs, and learners are satisfied with and value the program. Several specific benefits of the program model are identified, as well as several elements that support business plan success and skills' application on the job. On the basis of these findings, four success factors critical for developing similar programs are identified.
The State University of New York, Stony Brook (SUNY-SB) Pathways to Midwifery Program offers a distributed learning curriculum that is unique among American nurse-midwifery education programs. The Pathways to Midwifery Program provides asynchronic, computer-mediated instruction. Community-based faculty coordinate, supervise, and evaluate the clinical education of students. The SUNY-SB model offers an opportunity to increase dramatically the number of students who can receive the curriculum. It also provides distinct advantages in maintaining a curriculum database that reflects rapidly changing clinical science and that takes advantage of vast educational resources available through related computer networks. By creating a classroom without walls, the program is cost-effective.
The data collected during the evaluation of the natural science program at Roswell Park revealed a high rate of success in preparing students to enter health and science related careers. An average of 50 percent of the entering students each year had been unsuccessful medical school applicants or students preparing to enter Ph.D. programs following an initial research experience. The program assists students in admission to medical and research programs and encourages research participation. Many graduate programs will not accept or find difficulty dealing with students who have career goals in medicine and are not necessarily in research. This is understandable, especially in Ph.D. granting programs with substantial investments of faculty time and funding. The philosophy of the program reported here is to assist the students to enter the career of their choice; however, at the same time, the faculty members insist on a high level of scholarship in course work and research during the program. With this philosophy, the program continues to be successful in attracting students of high quality.
BACKGROUND AND PURPOSE: We evaluated the physical-examination section of a multimedia program developed to teach infant history and physical-examination skills. METHODS: A total of 71 students participated: one group viewed only the physical-examination section (PX), one the history section (HX), one none of the program (CX). We assessed physical-examination skills by direct observation of medical students performing an abdominal exam and scored using a checklist at baseline, immediately after intervention, and at the end of the pediatric clerkship. We analyzed results using analysis of variance with repeated measures. RESULTS: Baseline scores were PX = 2.5, HX = 2.8. The PX group scored significantly higher immediately postintervention at 6.8 compared to the HX group (3.1). At the end of the clerkship, significant differences between the groups remained. Final group mean scores were PX = 5.5, HX = 4.4, and CX = 2.7. CONCLUSION: The program improved examination skills with attenuation over 6 weeks.
Staff members at Baylor University Medical Center, Dallas, were dissatisfied with the existing clinical ladder program, so a committee of perioperative staff nurses was appointed to create a new program. The new program was based on a literature review and RN and management survey data. Under the new program, nurses must accumulate points to quality for or maintain clinical nurse levels I, II, or III. The point system recognizes many professional contributions that were ignored by the previous program.
This paper presents an evaluation of the implementation and impact of a program promoting social competence among kindergarten children. This program was conducted experimentally in 8 schools (10 classrooms, n = 165) in Montreal; 5 classrooms (n = 74) from 5 other schools formed the control group. Analysis of the impact reveals significant gains in self-esteem and conflict resolution skills in the experimental group compared to the control group. However, there was no significant change in pro-sociality and social withdrawal. Finally, an unexpected result was found in the area of boys' aggression. Analysis of the implementation indicates that teachers found the program's activities easy to use and adapt. In addition, great diversity in the utilization of these activities was observed. These results lead to areas of discussion concerning: (a) the links between gains realized by children and the emphasis teachers place on some aspects of the program; (b) the development of social competence among preschoolers; (c) the evaluation of the this type of program.
BACKGROUND: Healthy Steps (HS) for Young Children strengthens the healthcare system as a source of developmental and behavioral support for parents. This series of papers presents a study of HS as implemented within a large health maintenance organization that tested the benefit of beginning intervention services during pregnancy with an extension program called "PrePare" (PP). METHODS: The design was a quasi-experimental comparison of intervention families with families receiving usual care. Within the intervention, families were assigned randomly to begin receiving Healthy Steps services prenatally (PP+HS) or shortly after birth (HS). We used a systems model, PRECEDE/PROCEED, for planning, implementation, and process evaluation. Outcomes examined when the infants were aged 3 months included changes in family social support and capacity for parenting, parenting behaviors, and satisfaction and loyalty to the health plan. RESULTS: The sample of 439 families was distributed as follows: usual care (n=136), prenatal initiation of services (PP+HS; n=151), and postnatal Healthy Steps (HS; n=152). Information about program implementation, including provider satisfaction, is provided for the early phases of the study (through age 3 months). The intervention was delivered with fidelity and with minimal disruption to the practice styles of pregnancy providers, most of whom considered the program valuable to their patients. Relative to families in the comparison group, families in the intervention group received more usual care services and more intervention-specific services. CONCLUSIONS: The pregnancy and newborn phases of the intervention were embedded successfully within the existing healthcare delivery system. The program was considered valuable for parents by providers and parents. Participating families received more services and a greater variety of services than families in usual care. Whether these differences result in beneficial outcomes for families or the health plan are topics of the subsequent papers.
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In 1992, the Johns Hopkins Hospital and University initiated a program aimed at the early diagnosis and treatment of potential upper extremity work related musculoskeletal disorders (UEWMSDs), ergonomic assessment and abatement of work areas where individuals with UEWMSDs are employed, as well as the identification and correction of areas throughout the hospital and university where UEWMSDs could possibly occur. The program resulted in an initial increase in the number and cost for the treatment of UEWMSDs. Subsequently, there was a significant decrease in the number of UEWMSDs reported and virtual elimination of the need to use surgical procedures to correct these conditions. This article suggests that a coordinated program of medical care, ergonomic assessment, and intervention can be efficacious in the primary, secondary, and tertiary prevention of UEWMSD.
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BACKGROUND: Most heart failure care is provided by primary care providers. Although heart failure disease management programs improve outcomes, most have been hospital-based with little integration with primary care providers. To address this issue, a heart failure clinic disease management model was adapted for use in the primary care setting. METHODS AND RESULTS: A heart failure clinic staffed by 2 internists and their nurses was established in a large primary care practice. Medical care and pharmacotherapy were based on national guidelines. Nurses assisted with disease management. Primary outcomes included quality of life, functional class, and all-cause hospital and emergency room admissions 12 months before compared with 12 months after enrollment; a secondary endpoint was patient satisfaction. Of 165 patients sent to the heart failure clinic, 54 were referred back because of no active heart failure, and 18 had only 1 clinic visit. The 93 patients seen 2 or more times had a median age of 75 years. Anti-angiotensin II therapy was present in 84% and did not change over time, but doses of angiotensin-converting enzyme inhibitor increased by >50%. beta-blocker use increased from 40% at baseline to 63% at 6 months. Emergency room visits or all-cause hospitalizations were reduced (0.86 +/- 1.5 to 0.52 +/- 0.86, P < .001) or trended to be reduced (0.56 +/- 0.98 to 0.35 +/- 0.62, P = .07), respectively, by approximately 40%. Quality of life improved significantly at all time points, and patients were highly satisfied. CONCLUSION: This heart failure disease management model, designed for patients and providers in an primary care setting, was feasible and successful.
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