World Conference on Local Initiatives for Sustainable Cities, November 2-4 1995, Yokohama, Japan. Conference report.
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[Programmed stimulation in patients with malignant ventricular arrhythmia. II: Individual optimization of anti-arrhythmia therapy].
The major purpose of programmed ventricular stimulation in patients with malignant ventricular arrhythmias (sustained ventricular tachycardia/ventricular fibrillation) is not the diagnostic or prognostic evaluation but the individual optimization of antiarrhythmic therapy. For successful antiarrhythmic treatment, the choice of an adequate parameter of efficacy is of outstanding relevance: in patients with frequent daily episodes of malignant ventricular arrhythmias, proper treatment can be based on Holter monitoring; however, in patients with infrequent but life-threatening attacks, Holter monitory appears to be inadequate and programmed stimulation is the method of choice for proper treatment decisions. A total of 394 serial pharmaco-electrophysiological studies was performed in 82 patients with inducible sustained ventricular tachycardia or ventricular fibrillation. During the acute serial studies, one drug was tested each subsequent day using short-term intravenous infusions. The only criterion for drug efficacy was prevention of inducible sustained ventricular tachycardia or ventricular fibrillation that had been reproducibly initiated under control conditions before antiarrhythmic treatment. At least one preventive drug was found in approximately 2/3rd of the patients. Following serial acute studies using intravenous administration, an effective agent was selected and given orally. Programmed stimulation was repeated usually after three days demonstrating reproducibility of preventive efficacy in 90% of the trials. During a subsequent follow-up period of an average of 15 months, the number of acute events (9%) including sudden death or life-threatening recurrences of malignant ventricular arrhythmias was significantly reduced as compared to patients with non-optimized therapy (54%; p less than 0.05). The number of cardiac deaths due to progressive heart failures was not significantly different in patients placed on optimized or non-optimized antiarrhythmic treatment.
Administration, Oral↗
Diet and obesity.
PURPOSE OF REVIEW: Obesity continues to increase in the United States and worldwide. There is controversy surrounding different dietary patterns used to promote weight loss, and none has emerged as clearly more effective. This paper briefly reviews the factors that influence energy intake and dietary treatments used to promote weight loss. RECENT FINDINGS: Increasing portion size, eating away from home, and consuming a variety of high-energy dense foods appear to increase energy intake. Hormonal influences on diet continue to be explored. Very-low-calorie diets and low-carbohydrate diets lead to greater initial weight loss, but long-term results are no better than more moderate calorie-restricted diets. A program using meal replacements appears to lead to weight loss slightly greater than calorie-restricted diets and offers one option to treat obesity. Dietary patterns low in energy density and glycemic index have potential in treating obesity and should be studied further. SUMMARY: Clearly, a dietary pattern that prescribes a lower total energy intake is necessary for weight loss, and this pattern should be sustainable to maintain weight loss. Although many dietary programs can achieve short-term loss of weight, dietary treatment should be recommended that emphasizes lifestyle changes and is consistent with other dietary guidelines to promote long-term health. Features consistent with this are a dietary pattern low in total calories, saturated fat, and refined carbohydrate; moderate in whole grains; and high in low-energy dense vegetables and fruits. Future studies should explore dietary strategies and combination therapies that contribute to weight loss, long-term weight maintenance, and improved health.
Journal Article↗
Relation between repolarization and refractoriness during programmed electrical stimulation in the human right ventricle. Implications for ventricular tachycardia induction.
BACKGROUND: Although programmed electrical stimulation is widely used for provoking sustained ventricular tachycardia (VT), the mechanism by which repetitive extrastimulation evokes VT is still little understood. Specifically, it is not clear why several closely coupled extrastimuli are frequently required to induce VT. Although regularly paced human ventricular myocardium exhibits a near constant relation between myocardial repolarization and refractoriness, the effect of repetitive extrastimulation on the relation between repolarization and excitability in the human heart and its relevance for arrhythmia induction by programmed stimulation are unknown. We hypothesized that the induction of VT by repetitive extrastimulation is facilitated by an altered relation between repolarization and refractoriness, and this leads to disturbances in ventricular impulse propagation, which trigger the onset of VT. METHODS AND RESULTS: Twenty-one patients undergoing routine electrophysiological study were paced from the right ventricular apex and outflow tract endocardium with monophasic action potential-pacing catheters placed at both sites simultaneously Monophasic action potential durations (APDs) and effective refractory periods (ERPs) were measured simultaneously at each site, during regular stimulation (S1-S1) at 400-ms cycle length and during three consecutive extrastimuli (S2 through S4) at the closest coupling intervals at which all three extrastimuli still resulted in capture. Measurements further included the repolarization level at which the earliest capture occurred, the ratio between ERP and APD, and the propagation time between the pacing and distant recording site. APD and ERP both shortened progressively with each extrastimulus. APD at 90% repolarization decreased from a baseline (S1) of 238.1 +/- 19.7 ms by 14.9% at S2, 18.9% at S3, and 22.9% at S4 (P < .0001, S1 versus S4). ERP decreased from 233.1 +/- 19.7 ms (S1) to 180.0 +/- 41.9 ms (S3) (P < .0001, S1 versus S3). While ERP shortening occurred mainly on the basis of APD shortening, there was an additional factor that contributed to ERP shortening independent of APD shortening. Each consecutive extrastimulus was able to elicit a propagated response at earlier repolarization levels than the previous one: the earliest capture for S2 occurred at 85.5 +/- 10.2% of complete repolarization, for S3 at 83.9 +/- 10.5%, and for S4 at 78.4 +/- 11.2% (P < .05 for S2 versus S3; P < .05 for S3 versus S4; P < .01 for S2 versus S4). This progressive "encroachment" of the earliest capture stimulus onto the preceding repolarization phase (at progressively less repolarized levels) correlated with a progressive delay of impulse propagation between the pacing site and the second recording site: propagation time increased from baseline (S1) by 10.5 +/- 1.3% with S2 to 19.0 +/- 1.6% with S3 and to 22.5 +/- 2.8% with S4 (P < .05, S4 versus S1). VT was induced in 11 of 21 patients. Nine of these had VT induced only when significant encroachment of extrastimuli on the preceding repolarization phase (< 81.3 +/- 7.0%) and associated conduction slowing (> 16.6 +/- 1.8%) were present. CONCLUSIONS: Repetitive extrastimulation not only shortens APD and subsequently ERP but also alters the ERP/APD relation by allowing capture to occur at progressively less complete repolarization levels. This progressive encroachment onto the preceding repolarization phase is associated with impaired impulse propagation and a high incidence of VT induction. This may help explain how repetitive, closely coupled extrastimulation induces ventricular tachycardia in the human heart.
Aged↗
The signal-averaged electrocardiogram as a screening test for inducibility of sustained ventricular tachycardia in high risk patients: a prospective study.
The role of the signal-averaged electrocardiogram in predicting the induction of sustained monomorphic ventricular tachycardia in high risk patients was assessed prospectively in 100 consecutive patients. Presenting diagnoses were syncope (38 patients), nonsustained ventricular tachycardia (24 patients), sustained ventricular tachycardia (25 patients) and sudden cardiac arrest (13 patients). Using programmed ventricular stimulation, 71 patients (group I) did not have and 29 patients (group II) did have inducible sustained monomorphic ventricular tachycardia. Using the signal-averaged electrocardiogram with filtering (6 dB/octave) at high pass corner frequencies of 67 and 100 Hz, the two groups were compared. The signal-averaged electrocardiogram was considered abnormal if all of the following criteria were satisfied: 1) the total filtered QRS complex duration was greater than 120 ms, 2) the duration of the terminal QRS complex of less than or equal to 20 microV was greater than or equal to 30 ms, and 3) at least one deflection (late potential) was present in this region. Differences between groups I and II in these three measures were highly significant (p less than or equal to 0.001). The sensitivity and specificity of signal averaging for predicting the induction of sustained ventricular tachycardia were 93 and 94%, respectively. Stepwise logistic regression analysis identified the signal-averaged electrocardiogram as the best predictor of induction of sustained monomorphic ventricular tachycardia, independent of left ventricular ejection fraction, presence of ventricular aneurysm, myocardial infarction and other clinical variables (chi-square = 93.2, p less than 0.0001). The signal-averaged electrocardiogram is a sensitive and specific test for the induction of sustained monomorphic ventricular tachycardia, having independent predictive value.
Coronary Disease↗
Dissociation of termination and prevention of inducibility of sustained ventricular tachycardia with infusion of procainamide: evidence for distinct mechanisms.
To determine if termination of hemodynamically tolerated, sustained ventricular tachycardia during intravenous infusion of procainamide predicts the success of procainamide therapy in preventing induction of tachycardia, 15 patients with inducible, sustained ventricular tachycardia in the setting of chronic coronary artery disease were studied. Procainamide was infused at a rate of 50 mg/min during ventricular tachycardia until the arrhythmia terminated spontaneously or a total dose of 15 mg/kg was administered. An infusion (2 to 10 mg/min) was given after the loading dose to maintain constant serum drug concentrations after termination of the tachycardia. The infusion of procainamide was well tolerated and resulted in termination of ventricular tachycardia in 14 (93%) of 15 patients after administration of 100 to 1,080 mg (median dose 600 mg). In all patients, programmed ventricular stimulation was repeated immediately after termination of the arrhythmia until ventricular tachycardia was reinitiated or until the stimulation protocol was completed. Of the 14 patients whose ventricular tachycardia terminated during the infusion of procainamide, 1 patient had no inducible sustained tachycardia with repeated programmed stimulation. In the remaining 13 patients, programmed stimulation resulted in initiation of sustained ventricular tachycardia of the same configuration in 7 patients and of a different configuration in 6. In the former 7 patients, the serum procainamide concentration (7.7 +/- 4 vs. 7.4 +/- 3.3 mg/liter, p = NS) and the observed drug effects on the tachycardia cycle length (449 +/- 78 vs. 450 +/- 81 ms, p = NS) and QRS duration (184 +/- 38 vs. 185 +/- 38 ms, p = NS) were similar at the times of termination and reinitiation of ventricular tachycardia.(ABSTRACT TRUNCATED AT 250 WORDS)
Cardiac Pacing, Artificial↗
Programmed ventricular stimulation in patients without spontaneous ventricular tachycardia.
Programmed ventricular stimulation was performed in 52 patients who had not had a documented or suspected episode of spontaneous ventricular tachycardia (VT) or ventricular fibrillation (VF). Programmed stimulation with up to three extrastimuli was performed from the right ventricular (RV) apex in all patients and from the left ventricular (LV) apex in 14 patients. A maximum response of one to five intraventricular reentry beats was induced in 52% of patients. Nonsustained VT (six or more repetitive beats terminating spontaneously within 30 seconds) was never induced in the 16 patients without structural heart disease but was induced (usually with triple extrastimuli) in 45% of nine patients with mitral valve prolapse and in 37% of 27 patients with other types of heart disease. Sustained VT was never induced; however, sustained VF was induced in two patients. During programmed RV and LV stimulation with up to three extrastimuli (with 2 msec pulses, 5 mA in intensity), (1) a maximum response of one to five repetitive beats is a nonspecific finding of no predictive value; (2) nonsustained VT was not induced in patients without structural heart disease who had not had spontaneous VT; (3) nonsustained VT was frequently induced in patients with structural heart disease who had not previously been known to have had VT; (4) the induction of sustained VT appears to be a response specific to patients who have had spontaneous VT or VF; and (5) sustained VF can be induced infrequently in patients who have never had spontaneous VT or VF.
Aged↗
Reengineering outcomes management: an integrated approach to managing data, systems, and processes.
The integration of outcomes management into organizational reengineering projects is often overlooked or marginalized in proportion to the entire project. Incorporation of an integrated outcomes management program strengthens the overall quality of reengineering projects and enhances their sustainability. This article presents a case study in which data, systems, and processes were reengineered to form an effective Outcomes Management program as a component of the organization's overall project. The authors describe eight steps to develop and monitor an integrated outcomes management program. An example of an integrated report format is included.
Attitude of Health Personnel↗
Benefit of selective respiratory muscle training on exercise capacity in patients with chronic congestive heart failure.
BACKGROUND: Diminished respiratory muscle strength and endurance have been demonstrated in patients with heart failure. This may contribute to exertional dyspnea and reduced exercise capacity in these patients. The purpose of this study was to investigate whether selective respiratory muscle training could alleviate dyspnea and improve exercise performance in patients with chronic congestive heart failure. METHODS AND RESULTS: Fourteen patients with chronic heart failure (left ventricular ejection fraction, 22 +/- 9%) were enrolled in a supervised respiratory muscle training program. This consisted of three weekly sessions of isocapnic hyperpnea at maximal sustainable ventilatory capacity, resistive breathing, and strength training. Maximum sustainable ventilatory capacity, maximum voluntary ventilation, maximal inspiratory and expiratory pressures, peak VO2, and the 6-minute walk test were measured before (pre) and after (post) 3 months of training. Eight patients completed the training program. Respiratory muscle endurance was improved with training, as evidenced by increases in maximal sustainable ventilatory capacity (pre, 48.6 +/- 10.7 versus post, 76.9 +/- 14.5 L/min; P < .05) and in maximal voluntary ventilation (pre, 100 +/- 36 versus post, 115 +/- 39 L/min; P < .05). Respiratory muscle strength was also increased with training as maximal inspiratory (pre, 64 +/- 31 versus post, 78 +/- 33 cm, H2O; P < .01) and expiratory (pre, 94 +/- 30 versus post, 133 +/- 53 cm H2O; P < .001) pressures rose. Submaximal and maximal exercise capacity were significantly improved with selective respiratory muscle training as the 6-minute walk (pre, 1101 +/- 351 versus post, 1421 +/- 328 ft; P < .001) and peak exercise VO2 (pre, 11.4 +/- 3.3 versus post, 13.3 +/- 2.7 mL.kg-1.min-1; P < .05) both significantly increased. Dyspnea during activities of daily living was subjectively improved in the majority of trained patients. Dyspnea quantified by the Borg scale was significantly reduced during progressive isocapnic hypernea but not during bicycle exercise. No statistically significant improvement in maximal sustainable ventilatory capacity, maximum voluntary ventilation, maximal inspiratory or expiratory mouth pressures, 6-minute walk, or peak VO2 was observed in the 6 patients who did not complete the training program. CONCLUSIONS: Selective respiratory muscle training improves respiratory muscle endurance and strength, with an enhancement of submaximal and maximal exercise capacity in patients with heart failure. Dyspnea during activities of daily living was subjectively improved in the majority of trained patients.
Adult↗
Chagas' heart disease in the United States.
BACKGROUND AND METHODS: Chagas' heart disease is believed to be rare in the United States, although many persons from countries where the disease is endemic reside here. We performed a retrospective case review and prospective follow-up of 25 patients with Chagas' heart disease and no obstructive coronary artery disease on angiography. RESULTS: The patients mainly presented with symptomatic atrioventricular block, congestive heart failure, anginal chest pain, sudden death averted by resuscitation, or sustained ventricular tachycardia. Of the 25 patients, 18 had been treated for coronary artery disease or idiopathic dilated cardiomyopathy for up to 108 months before the diagnosis of Chagas' disease was considered. The electrocardiograms frequently suggested coronary artery disease. Six of the seven patients who had exercise thallium-perfusion scans had abnormalities suggesting ischemia or infarction. A left ventricular aneurysm was found in 14 of the 25 patients, segmental akinesia or hypokinesia in 5, and diffuse hypokinesia in 3. Programmed ventricular stimulation performed in 13 patients induced sustained ventricular tachycardia in 9 and nonsustained ventricular tachycardia in 2. Actuarial survival (mean +/- SE) after four years for the entire group was 56 +/- 12 percent; it was 32 +/- 16 percent among those with global left ventricular dysfunction, and 78 +/- 14 percent among those without such dysfunction (P = 0.03). Only patients with left ventricular dysfunction or an aneurysm died (four-year survival, 45 +/- 14 percent, as compared with 100 percent for the remaining patients; P = 0.0002). Heart failure and left ventricular aneurysm or dysfunction were the only independent predictors of death. Nine patients required permanent pacemakers. CONCLUSIONS: In the United States, Chagas' heart disease commonly mimics coronary artery disease or idiopathic dilated cardiomyopathy. The prognosis is poor for patients with heart failure or left ventricular aneurysm or dysfunction. The disease may be underdiagnosed in the United States.
Chagas Cardiomyopathy↗
Training pre-hospital trauma care in low-income countries: the 'Village University' experience.
A prospective study was carried out of the health effects and sustainability of a low-cost trauma training program for non-graduate village healthcare workers. From 1996 to 1999, a core group of 44 health workers from mine-infested rural communities in Cambodia and Northern Iraq were trained and equipped to deliver low-cost life support to trauma victims. They in turn trained a network of 2800 layman village first responders. Training was done in makeshift camps at village level ('Village Universities'). A total of 813 patients were managed by the rural rescue system from 1997 to 1999. The mortality rate for trauma victims decreased from 22.6% in 1997 to 13.7% in 1999 (95% CI for difference 1.8% to 16.0%). Management by village first responders had a significant impact on in-field response times and trauma mortality. The rescue system replicated itself during the study period as an indicator of sustainability. The study showed that after trauma care training at rural makeshift training centers, non-graduate health workers can build efficient and sustainable rural rescue systems.
Allied Health Personnel↗
[Shock-induced, but not terminated ventricular tachycardia in a patient with implantable defibrillator].
A 62-year-old male patient with coronary artery disease and drug refractory sustained ventricular tachycardia received an implantable cardioverter defibrillator (PRX III, model 1720, CPI) with a transvenous lead system (Endotak, model 0115, CPI) in combination with a subcutaneous array electrode (SQ array, model 049, CPI). The intraoperative defibrillation threshold was 15 J and was confirmed 1 week later at the hospital discharge test. Three months after discharge from hospital the patient reported 5 shocks during moderate physical exertion followed by a tachycardia associated with dizziness which terminated spontaneously. The print out of the stored electrogram showed a supraventricular tachycardia (probably sinus tachycardia) with a heart rate of 154/min which activated the device. Antitachycardia pacing did not terminate the supraventricular tachycardia, and hence shock therapy was delivered. The first shock (34 J) converted the supraventricular tachycardia to a ventricular tachycardia with a heart rate of 178/min, which was not terminated by four consecutive 34 J DC shocks. There was no hint of a device or lead failure. Determination of the defibrillation threshold reconfirmed the 15 J value for termination of ventricular fibrillation. However, neither a 1 J shock nor a 34 J shock terminated a monomorphic sustained ventricular tachycardia (cycle length 340 ms) induced by noninvasive programmed electrical stimulation. The ventricular tachycardia was, however, reproducibly terminate by antitachycardia pacing. It is concluded that an inappropriate high-energy DC shock might induce a sustained ventricular tachycardia. However, a sufficient defibrillation threshold for the termination of ventricular fibrillation does not necessarily mean that a sustained ventricular tachycardia will be terminated by a high-energy DC shock.
Coronary Disease↗
Harstad injury prevention study: prevention of burns in young children by community based intervention.
OBJECTIVE: To describe the long term effectiveness of a community based program targeting prevention of burns in young children. DESIGN: Quasiexperimental. SETTING: The Norwegian city of Harstad (main intervention), six surrounding municipalities (intervention diffusion), and Trondheim (reference). PARTICIPANTS: Children under age 5 years in the three study populations. METHODS: Outpatient and inpatient hospital data were coded according to the Nordic system, and collected as part of a national injury surveillance system. Burn data collection started in May 1985. The first 19.5 months of the study provided baseline data, while the last 10 years involved community based intervention, using a mix of passive and active interventions. RESULTS: The mean burn injury rate decreased by 51.5% after the implementation of the intervention in Harstad (p < 0.05) and by 40.1% in the six municipalities (not significant). Rates in the reference city, Trondheim, increased 18.1% (not significant). In Harstad and the six surrounding municipalities there was a considerable reduction in hospital admissions, operations, and bed days. Interventions with passive strategies were more effective, stove and tap water burns being eliminated in the last four years, while active strategies were less effective. CONCLUSIONS: A program targeting burns in children can be effective and sustainable. Local injury data provided the stimulus for community action.
Burns↗
The impact of supervised exercise intervention on short-term postprogram leisure time physical activity level in cancer patients undergoing chemotherapy: 1- and 3-month follow-up on the body & cancer project.
BACKGROUND: Exercise is becoming an important component of cancer rehabilitation programs. A consistent finding across studies is that patients experience improved physical fitness and reduced fatigue. However, sustained physical activity is essential if the benefits are to be preserved over the course of cancer survivorship. OBJECTIVE: This study examined self-reported short-term exercise adherence following a 6-week, supervised exercise program (muscle strength, cardiovascular fitness, relaxation, body awareness, and massage) in a heterogeneous group of 61 cancer patients (mean age 42.9 years, 82% oncological and 18% haematological) from the Body & Cancer Project. METHODS: Semistructured interviews were used to quantitatively assess leisure time physical activity level 1 and 3 months after completion of the program. The study furthermore included 3-month follow-up assessment of psychological distress (Hospital Anxiety and Depression Scale-HADS). Patient statements were selected that best illustrated trends found in the statistical material. RESULTS: There was a significant postprogram reduction in physical activity from 6 to 10 weeks and from 6 to 18 weeks. However, the patients (half of whom were still undergoing treatment at the time of follow-up) reported a higher physical activity level postprogram compared to their baseline levels. The analyses showed a positive association between the 3-month postprogram physical activity level and pre-illness physical activity level, treatment, and postprogram changes in depression. SIGNIFICANCE OF RESEARCH: Given the significant decrease in postprogram PA level, especially in subjects still undergoing cancer treatment, the study suggests that continuous supervised programs may be required in order to encourage and support exercise adherence in this population. However, randomized clinical controlled trials and more follow-up studies are needed to establish the optimal program length and content for sustained exercise adherence in cancer patients.
Adult↗
From randomized trial to community-focused practice.
PURPOSE: To describe the use of findings from a randomized trial--a nursing intervention using telephone contacts to reduce the incidence of low-birth-weight and preterm births--in four community settings in North Carolina, to show that implementing research into practice is important. Low-birth-weight and preterm births are the major cause of high infant mortality in the United States. Rates are highest among African-American women. Telephone intervention as a strategy for preventive health care can be cost effective, reduce low-birth-weight and preterm births in African-American women, and provide a means of health consultation for parents of children age five and under. ORGANIZING FRAMEWORK: Four community programs are discussed in relation to five phases of implementing and sustaining research in communities: research, transfer, transition, regeneration, and empowerment. Modification from the original research, bonuses, and barriers are described for each program. METHODS: The randomized trial was conducted from 1990-1995. Randomized trial data and data for subsequent projects were collected from telephone interviews and health care records from 1994-1998. A successful adaptation was made from the original randomized trial to the four programs by (a) educating the staff for each program about the methods and findings in the original research, and (b) working with program staff to make appropriate modifications for each site. CONCLUSIONS: Findings from a randomized trial can be used in a variety of settings. By working together, researchers and community-health nurses can integrate research findings into community-health nursing practice.
Black People↗
The role of intracavernous injection of vasoactive medications for the restoration of erection in spinal cord injured males: a three year follow up.
Fifty-eight spinal cord injured men entered our self injection program for restoration of erections since the program began in September 1985. Early complications included sustained erection (greater than 8 hours) in 4 patients on 6 occasions requiring aspiration of the corpora cavernosa and injection of a dilute epinephrine solution (1/100,000). Bruising at the site of injection was reported at least once by 10 patients. Blood draining from the urethra was noted in 3 patients when the urethra was inadvertently injected. Rigid erections were obtained in all but 5 patients that injected (90%). Late complications included penile plaque in 3 patients (15%). There were no abnormal liver function tests. Average time on the injection program was 2 years (range of 0.5 to 4.5 years). Thirty-one (53%) of the patients have dropped out of the program, most doing so prior to the first injection or during the titration period. The average frequency of injection was twice a month. Injection therapy remains an effective and relatively safe alternative for selective patients with spinal cord injury.
Adult↗
The diabetes network internet-based physical activity intervention: a randomized pilot study.
OBJECTIVE: Because of other competing priorities, physical activity (PA) is seldom addressed in a consistent way in either primary care or diabetes education. This 8-week pilot study evaluated the short-term benefits of an Internet-based supplement to usual care that focused on providing support for sedentary patients with type 2 diabetes to increase their PA levels. RESEARCH DESIGN AND METHODS: A total of 78 type 2 diabetic patients (53% female, average age 52.3 years) were randomized to the Diabetes Network (D-Net) Active Lives PA Intervention or an Internet information-only condition. The intervention condition received goal-setting and personalized feedback, identified and developed strategies to overcome barriers, received and could post messages to an on-line "personal coach," and were invited to participate in peer group support areas. Key outcomes included minutes of PA per week and depressive symptomatology. RESULTS: There was an overall moderate improvement in PA levels within both intervention and control conditions, but there was no significant improvement in regard to condition effects. There was substantial variability in both site use and outcomes within the intervention and control conditions. Internal analyses revealed that among intervention participants, those who used the site more regularly derived significantly greater benefits, whereas those in the control condition derived no similar benefits with increased program use. CONCLUSIONS: Internet-based self-management interventions for PA and other regimen areas have great potential to enhance the care of diabetes and other chronic conditions. We conclude that greater attention should be focused on methods to sustain involvement with Internet-based intervention health promotion programs over time.
Computer Communication Networks↗
Implementing the WISEWOMAN program in local health departments: staff attitudes, beliefs, and perceived barriers.
BACKGROUND: Although most health departments recognize the need for programs to reduce the risk of cardiovascular disease (CVD) among older, low-income women, they face numerous barriers to successfully implementing such programs. This paper explores counselors' attitudes and beliefs about patients and perceived barriers to implementing the North Carolina Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program. METHODS: Health departments were assigned to provide patients with either an enhanced intervention (EI) or a minimum intervention (MI). Cross-sectional baseline and 12-month follow-up surveys were completed by health department counselors designated to deliver the MI or EI. Both surveys addressed counselors' beliefs about patients' motivation and attitudes, their counseling practices, and their personal diet and physical activity behaviors and attitudes. The follow-up survey also addressed opinions about the feasibility of long-term WISEWOMAN implementation. RESULTS: Counselors were skeptical about patients' motivation to improve their lifestyle, citing high perceived cost and burden. At follow-up, EI counselors reported having higher self-efficacy for counseling, incorporating more behavioral change strategies, and spending more time counseling than did counselors at MI sites. They were also more likely to report making healthful personal lifestyle choices. All counselors identified lack of time as a major barrier to counseling, and most cited obtaining low-cost medications for patients, ensuring that patients made follow-up visits, and implementing the program with existing staff as key challenges to the long-term sustainability of WISEWOMAN. CONCLUSIONS: Our findings provide insight into the organizational challenges of implementing a CVD risk-reduction program for low-income women. We discuss ways in which intervention and training programs can be improved.
Adult↗