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Heart Partners: a strategy for promoting effective diffusion of school health promotion programs.

Heart Partners uses a straightforward, interpersonal approach to increase acceptance and use of innovations in school health promotion. In accord with the linkage model of innovation diffusion, developers of a new program or technology (i.e., resource system) simply designate and train selected members to be recruiters and allies of individual advocates at the campus-level (i.e., user system). Linkage is supported by supplying advocates and allies with guidelines and materials that encourage ongoing, interactive, interpersonal partnerships to promote effective implementation of the new technology at the school. Empirical assessment of this simple strategy implemented by the Texas Affiliate of the American Heart Association showed a twofold to fourfold increase in actual use and reach of school health promotion packages, with an average reported volunteer time of less than three hours per month.

American Heart Association↗

Approaching a consensus: psychosocial support services for solid organ transplantation programs.

BACKGROUND: Solid organ transplantation has become an accepted treatment for individuals with end-stage organ dysfunction. Criteria are being developed in the United States to determine medical eligibility for transplant candidates and competencies for transplant centers and physicians. To date, similar criteria for psychosocial services have not been developed. DESIGN AND SETTING: We queried participants in a specialty psychosocial transplant meeting to determine their views of which psychosocial services are essential to the comprehensive care of transplant patients in the United States. RESULTS: There was broad based multidisciplinary support for proactive pretransplant screening to discern individual psychosocial needs; focused pretransplant interventions to improve candidacy and future compliance; and posttransplant programs that address psychosocial, rehabilitation, and financial issues. CONCLUSION: Among psychosocial providers of solid organ transplantation services, there is support for expanding routine screening and support services to individuals who are candidates for and undergo solid organ transplantation.

Community Health Services↗

A company-instituted program to improve blood pressure control in primary care.

An occupation-based effort to improve the outcome of antihypertensive therapy provided in the community was instituted by the Massachusetts Mutual Life Insurance Company in 1977. The goal of the program was to utilize the administrative and organizational resources of the company to enhance employee/patient adherence to treatment provided in conventional primary care settings. Key elements of the program were: companywide education and on-site screening, referral to community physicians and company assumption of all patient costs, linked to a monitoring system to permit oversight of care. Initially, 98% of employees were screened, 70% accepted referral for care and 59% fully adhered to program performance criteria. Blood pressure control has risen from 36% at the beginning to 69% at the end of the second year. Fully compliant patients have achieved the greatest lowering of blood pressure and compiled the best work attendance record. Program costs are modest and acceptance by employees and physicians supports the concept that occupation-based, systematic efforts can enhance the impact of primary care.

Adult↗

Foods, health claims, and the law: comparisons of the United States and Europe.

Government, academia, and the food industry can play a significant role in the identification of healthy foods and ingredients important for weight management and health. The U.S. Food and Drug Administration developed regulations that define specific food categories for weight management and health. These categories include foods for special dietary uses and medical foods. Medical foods are classified for use in specific disease states and require a physician's recommendation and continuous monitoring. The European regulations specify energy-restricted foods as a subcategory of food for particular nutritional uses, which includes infant formula, medical foods, and foods for sports. European standards for energy-restricted diets have been established, leaving little flexibility for change. Three categories exist (i.e., very-low-calorie diets [450 to 800 kcal], low-calorie diets [800 to 1200 kcal], and meal replacements [200 to 400 kcal]). No claims on anticipated weight loss can be made even where significant clinical research has demonstrated long-term efficacy, thereby preventing informed choice management. Dramatic changes in lifestyle (e.g., disruption of the family unit, altered eating occasions, fast foods, and food grazing) have resulted in an epidemic of obesity and chronic disease. Regulating food selection or dietary patterns to limit the epidemic is not realistic. However, stimulating government health agencies and the food industry to increase public awareness through educational programs and regulating the definition of acceptable methods and products can provide an environment for change. A consensus is needed among academia, government, and industry for appropriate food labeling and claims. These actions are needed to help individuals make healthy food selections and maintain a healthy weight. Public health initiatives should change consumer attitudes with programs that are simple, affordable, effective, and accessible.

Diet, Reducing↗

Improving pneumococcal vaccination rates in an elderly population by patient education in an outpatient clinic.

BACKGROUND: Invasive pneumococcal disease is a major cause of morbidity and mortality in elderly patients. This study investigated the impact of a patient education intervention on the pneumococcal vaccination rate in elders. METHODS: Charts of all patients aged 65 years or older who visited a university ambulatory care clinic during a 3-month period were reviewed for pneumococcal vaccination status before the patients' arrival for an office visit. Those who did not have the vaccination were provided patient education in the waiting room. Data were collected on age, sex, race, and immunization status. The reasons for refusing the vaccination before or during this intervention also were obtained. The charts of patients who consented were flagged for the attending physician to order the vaccination if appropriate. RESULTS: Charts of 535 patients were reviewed for pneumococcal vaccination status. Of these patients, 291 had had a pneumococcal vaccination before the study. The cumulative vaccination rate increased significantly from 54 percent to 79 percent after the study intervention. The rate of pneumococcal vaccination was significantly lower among African-Americans than whites both before and after the patient education intervention. CONCLUSION: This study reports a substantial impact of patient education on improving pneumococcal vaccination rates in an elderly population. Most elders accept vaccination, and it can be delivered effectively without an additional visit.

Black or African American↗

Medically appropriate use of helicopter EMS: the mission acceptance/triage process.

INTRODUCTION: Appropriate use of helicopter emergency medical services (HEMS) ensures the maximum impact of a limited resource on improved health outcomes. Overtriage increases real and opportunity costs and may unjustifiably expose the program to small but inherent safety risks. The purpose of this study is to describe the mission acceptance process for an integrated, provincially based HEMS program and determine its utilization patterns. METHODS: This is a retrospective review of patient care and administrative databases. All missions were reviewed to determine whether they were medically appropriate. "Appropriateness" was defined a priori as requiring admission to a critical care unit, death during transportation or in first 24 hours, or in the case of trauma, an injury severity scale (ISS) score > or = 12. Overtriage was defined as not meeting these a priori definitions. RESULTS: Five hundred eighty-four missions were reviewed from March 31, 2003 through December 31, 2004. Our mission acceptance process consists of three distinct but complementary phases: ongoing outreach education, scanning by dispatchers in an integrated dispatch center, and a clinician to online physician discussion about each case. The overall overtriage rate was 13.1%. CONCLUSION: The rate of medically appropriate missions in this system is relatively high. Prospective research is required to improve HEMS triage systems.

Air Ambulances↗

Parental perspectives on vaccinating children against sexually transmitted infections.

Several vaccines for sexually transmitted infections (STI) are presently in development and the eventual availability of such vaccines is expected to result in the prevention of a significant number of burdensome conditions. Young adolescents are presumed to be likely targets for these vaccines since adolescents' risk for STI increases as they age and become sexually active. It is unclear, however, to what extent parents will agree to having adolescents receive STI vaccines. Inasmuch as acceptance is the foundation for effective immunization programs, an understanding of parental perspectives about this issue is required to inform future STI vaccine program strategies. This paper presents findings from a qualitative study that used in-depth interviews to elicit attitudes from 34 parents about accepting vaccines for genital herpes, human immunodeficiency virus, human papillomavirus and gonorrhea for their children (aged 8-17). Data were collected from parents bringing their children for care at an urban clinic and a suburban private office. Content analysis of the responses revealed that most parents (>70%) approved the administration of all four of the STI vaccines proposed. Parents' reasons for acceptance included wanting to protect their children, being concerned about specific disease characteristics, and previous experience with the infections. Parents who declined the vaccines did so primarily because they perceived their children to be at low risk for the infections or they had low concern about features of the diseases. Most parents thought they should be the decision-maker regarding children receiving an STI vaccine. Results from this study will be used to plan subsequent investigations of the determinants of STI vaccine acceptance by parents.

Adolescent↗

Beliefs and attitudes associated with the intention to not accept the diagnosis of depression among young adults.

PURPOSE: Negative attitudes and beliefs about depression treatment may prevent many young adults from accepting a diagnosis and treatment for depression. We undertook a study to determine the association between depressive symptom severity, beliefs about and attitudes toward treatment, subjective social norms, and past behavior on the intent not to accept a physician's diagnosis of depression. METHODS: We conducted a cross-sectional study of 10,962 persons aged 16 to 29 years who participated and had positive screening results on the Center for Epidemiologic Studies Depression (CES-D) score in an Internet-based public health depression screening program. Participants reported whether they would accept their physician's diagnosis of depression. Based on the theory of reasoned action, we developed a multivariate model of the factors that predict intent not to accept a diagnosis of depression. RESULTS: Twenty-six percent of the participants stated their intent not to accept their physician's diagnosis of depression. Disagreeing that medications are effective in treating depression (strongly disagree, odds ratio ( OR ) = 6.5, 95% confidence interval (CI), 4.6-9.3), that there is a biological cause for depression (strongly disagree, OR = 1.9, 95% CI, 1.3-2.7), and agreeing that you would be embarrassed if your friends knew you had depression were associated with the intent not to accept a diagnosis of depression (strongly agree, OR = 2.3, 95% CI, 1.8-2.9). Beliefs and attitudes, subjective social norms, and past behavior explained most of the variance in this model (84%). CONCLUSIONS: Negative beliefs and attitudes, subjective social norms, and lack of past helpful treatment experiences are associated with the intent to not accept the diagnosis of depression and may contribute to low rates of treatment among young adults.

Adolescent↗

Evaluation of a model for the treatment of combined mental illness and substance abuse: the Bellevue model for peer-led treatment in systems change.

The present study evaluated a model program at Bellevue Hospital Center incorporating a peer-led self-help (PLSH) approach which can be applied to bring about systems-level change in a variety of settings where persons with dual diagnosis are encountered. A total of 461 consecutive MICA inpatient admissions were evaluated to compare the PLSH unit with two standard psychiatric units. The PLSH program was associated with a higher rate of acceptance of aftercare referral (93% vs. 74%) and aftercare attendance (52% vs. 30%) among patients with no prior psychiatric hospitalizations (N = 111). In addition, the PLSH program appeared to benefit chronically impaired MICA patients (N = 350) or those with a history of prior psychiatric hospitalizations, as they were more likely to accept referral to aftercare treatment than were chronic patients discharged from the standard psychiatric units (96% vs. 81%). Such a program, when more widely applied, could yield decreased recidivism and considerably lower medical, psychiatric, and economic cost.

Adolescent↗

The feasibility of a bed net impregnation program to enhance control of Malayan filariasis along a swamp forest in southern Thailand.

The purpose of this study is to document the potential feasibility of using a bed net impregnation program to enhance the control of Malayan filariasis in southern Thailand. A survey was conducted in one Muslim and one Buddhist village along the swamp forest in Narathiwat Province. Face-to-face interview was employed to collect data on practice of bed net use, knowledge and attitudes on filarial control and acceptance if a bed net impregnation program were to be introduced. Bed nets were used by 98.5% of the study households. Both Muslims and Buddhists were all in bed by 23.00 hrs. By 03.00 hrs, more than 20% of Buddhists were out of bed for rubber tapping, whereas more than 90% of the Muslim were still in bed until 04.30 hrs. Combining our data with biting rate from a previous study, approximately one-third of Mansonia bites were protected by the current bed net practice. The impregnation program was potentially welcome by both groups of villagers. From this study, we conclude that a bed net impregnation program in this area is feasible.

Adolescent↗

Gay and lesbian physicians in training: family practice program directors' attitudes and students' perceptions of bias.

BACKGROUND: Disclosure of homosexual orientation by medical students or physicians has generally been regarded as having dire professional consequences. We surveyed family practice residency directors to determine how knowledge of homosexual orientation might affect a residency applicant's ranking. We then surveyed gay and lesbian medical students to better understand their attitudes and beliefs about disclosure of orientation during residency application. METHODS: A survey was mailed to all family practice residency directors and a convenience sample of third- and fourth-year gay and lesbian medical students. RESULTS: The program director response rate was 73%. Of these respondents, 67% showed accepting attitudes toward homosexuality, 25% were neutral, and 8% had negative views. One of four directors admitted they "might rank" or "most certainly" would rank an applicant known to be gay lower than a heterosexual one. The medical student response rate was 81%. When choosing a specialty, 42 students (71%) considered how other physicians might accept them as a lesbian or gay provider. Psychiatry and family practice were perceived as the most accepting specialties. Thirty-one student respondents (52%) agreed that at most residency programs, an applicant known to be gay or lesbian would be ranked lower than an applicant assumed to be heterosexual. CONCLUSIONS: Most family practice residency directors have accepting attitudes toward gays and lesbians in general, but 25% of directors express hesitation in matching openly gay residents. Gay and lesbian medical students want to match in residency programs where they will be welcomed and respected but fear discrimination if they disclose their orientation.

Administrative Personnel↗

[Relapse prevention group therapy for paedophiles: French adaptation].

Psychotherapy for sex offenders has only very recently started to develop in France. The French law on compulsory treatment for sex offenders was voted in 1998, and many mental health practitioners are not trained to treat such patients yet. In our ambulatory forensic consultation, sex offenders have been treated since 1992 and group psychotherapy has been offered to them since 1994. Our first therapeutic models were the North-American behavioural-cognitive therapy and Pithers' relapse prevention model. Behavioural-cognitive theory describes paedophilia as an acquired sexual preference maintained by positive reinforcement. Pithers (1990) considered that relapse only occurs in high-risk situations, and that high-risk situations always come after offence precursors. In North America, relapse prevention consists in helping paedophiles spot their high-risk situations and offence precursors, and enhance their skills to cope with such situations or to prevent them. Therapy programs were developed according to these models, aiming to help offenders develop such skills, ie empathy, social skills, cognitive restructuring, self-esteem, etc. Trying to apply these therapy programs in France, our team quickly realised that we would have to adapt them to French culture. On the one hand, behavioural-cognitive theory did not seem satisfactory enough in explaining paedophilic behaviour and paedophilic preference. On the other hand, behavioural-cognitive therapy made patients into children too much and increased resistance. Therapy based on programs seemed too rigid for French patients and therapists, and we often felt we were working on an issue that would have been much more accurate to work on a few sessions earlier, when this issue was spontaneously brought up by a patient. We believe change occurs all the more as issues are worked on at the right moment for the patient. Moreover, on a cultural point of view, we also realised the use of programs in psychotherapy was difficult to accept in France both by patients and therapists, as our culture is strongly influenced by psychoanalysis, especially free association. The use of a plethysmograph was also impossible in our country. We thus decided to use Pithers' relapse prevention model but to let our patients free to speak, so our therapy was not a program. Offences were analysed according to Pithers' ideas about high-risk situations and offence precursors. Most of the sessions were non-directive, but therapists offered each patient to work on his offence when they believed it was the right moment. Important issues (such as empathy, cognitive distortions, emotional control, etc.), were tackled as they came up, which seemed easier and less rigid as sessions were linked to patients' current pre- occupations. Post-group meetings enabled therapists to draw themes that seemed important to work on with each patient (empathy, consequences on victims, anger, cognitive distortions, emotional expression, relational issues, self-esteem, intimacy...). These issues were discussed the next time they were raised by the group. We were interested to notice that all important issues came up spontaneously from the group during the sessions as long as patients were free to share their concerns, without therapists having to set issues beforehand. Two case studies illustrate our method. Bernard was 40 when he first came to our consultation. Originally a teacher, he was dismissed and became a marketing man after being sentenced to five years of prison for sex offences on two 6-year-old girls. Bernard relapsed a few years after he got out of prison by sexually offending two girls, aged 10 and 13. At our first interview, Bernard had cognitive distortions about sexual education and always avoided sexually explicit words to describe the offences. He did not realise the consequences of his acts on the victims, but said he wanted to be treated because he felt lonely. He first described a sexual preference for adult women, but progressively aknoledged feeling attracted to female teenagers. He did not know why the offences occurred at such a moment in his life, and had no idea of his high-risk situations nor of his offence precursors. Bernard often confused his need for sex and his need for affection. After four years' participation to our relapse prevention group therapy, Bernard has clarified his sexual preferences : he has always been mostly attracted to girls from 6 to 10 years old. He has also always been attracted to women younger than him, and now seems to be mostly aroused by female teenagers. Working on his offences has helped him identify his high-risk situations and the strategies he used to get close to his victims and to be trusted by them and their single mothers. Bernard often offended when he was feeling lonely and rejected, after a break-up with a partner. Twice during these four years, Bernard found himself in such high-risk situations, but managed to stop before relapsing. However, empathy towards victims is still difficult to develop for Bernard. Neither has he yet managed to build a new relationship with a woman, as he still seems to suffer from an unhappy love affair he went through several years ago. This case study shows one of the limits of Pithers' relapse prevention model, if it is used mechanically. Indeed, we should logically have spotted as high-risk situations for Bernard interactions with 6 to 10 year-old girls. Helping him face his past and present sexual fantasies led Bernard realise his high-risk situations were now mainly about teenage girls, even if he had mostly been attracted to younger girls earlier in his life. After 2 to 3 years of therapy, we have quite often noticed this kind of evolution in sexual preferences in paedophiles, their preferences changing towards teenagers or young adults. In France, mental health professionals are often reluctant to follow sex offenders because of negative counter-transference and lack of specific training. However, first changes often occur quite quickly in paedophiles when they are offered group therapy. The group makes it easier to confront paedophiles to the reality of their offence and of their sexual fantasies. These patients often express being very relieved after the first sessions, as the group therapy is generally their first opportunity to express their feelings, sexual fantasies and thoughts about paedophilia. Pithers' model, used within a group were patients are free to speak in a human, warm and confronting atmosphere, seems clinically accurate and effective in helping paedophiles in France. We now need studies to check therapy effectiveness on relapse and to understand which therapy factors are efficient on sex offenders.

Adult↗

Consumer acceptability versus trained sensory panel scores of powdered milk shelf-life defects.

The objective of the present work was to correlate consumer panel acceptability versus trained sensory panel scores for appearance and flavor defects likely to appear during storage of whole milk powder. Descriptors selected for the study were: acid, caramel, cooked, dark color, lipolysis, and oxidized. For each descriptor a set of nine samples with different intensities were measured for acceptability and likelihood to consume by a 50-member consumer panel and for sensory intensity by a trained panel. Linear correlations between sensory acceptability and trained sensory panel scores were used to determine the sensory failure cut-off point for each descriptor, except caramel and cooked, which were not critical from the consumer's point of view. Differences in acceptability were found between Argentine and Uruguayan consumers for oxidized samples, while for lipolysis flavor, Argentine and Costa Rican consumers behaved similarly. For the color descriptor, significant changes in acceptability measured on a hedonic scale did not mean that consumers refused to consume the product. In contrast, for flavor descriptors, as soon as a significant decrease in acceptability occurred approximately 30% of the consumers said they would not consume the product. The sensory failure cut-off points presented in this paper can be used as a guide in future studies on the shelf life of MP and can also be of value in establishing sensory specifications for quality control programs. The methodology of correlating consumer acceptability to sensory panel scores and, thus, defining sensory failure is an improvement over more arbitrary criteria presented in most shelf-life studies.

Animals↗

Data verification in the residue laboratory.

Residue analysis frequently presents a challenge to the quality assurance (QA) auditor due to the sheer volume of data to be audited. In the face of multiple boxes of raw data, some process must be defined that assures the scientist and the QA auditor of the quality and integrity of the data. A program that ensures that complete and appropriate verification of data before it reaches the Quality Assurance Unit (QAU) is presented. The "Guidelines for Peer Review of Data" were formulated by the Residue Analysis Business Center at Ricerca, Inc. to accommodate efficient use of review time and to define any uncertainties concerning what are acceptable data. The core of this program centers around five elements: Study initiation (definitional) meetings, calculations, verification, approval, and the use of a verification checklist.

Chemistry Techniques, Analytical↗

A comparison of the effects of dialysis and renal transplantation on the survival of older uremic patients.

BACKGROUND: Patients over age 60 constitute half of all new patients accepted into the renal replacement therapy programs in Australia. However, the optimal treatment of their end-stage renal disease remains controversial. The aim of the present study was to compare survival for dialysis and renal transplantation in older patients who were rigorously screened and considered eligible for transplantation. METHODS: The study cohort consisted of 174 consecutive patients over 60 who were accepted on to the Queensland cadaveric renal transplant waiting list between January 1, 1993 and December 31, 1997. Follow-up was terminated on October 1, 1998. Data were analyzed on an intention-to-transplant basis using a Cox regression model with time-varying explanatory variables. An alternative survival analysis was also performed, in which patients no longer considered suitable for transplantation were censored at the time of their removal from the waiting list. RESULTS: There were 67 patients receiving a renal transplant, whereas the other 107 continued to undergo dialysis. These two groups were well matched at baseline with respect to age, gender, body mass index, renal disease etiology, comorbid illnesses, and dialysis duration and modality. The overall mortality rate was 0.096 per patient-year (0.131 for dialysis and 0.029 for transplant, P<0.001). Respective 1-, 3- and 5-year survivals were 92%, 62%, and 27% for the dialysis group and 98%, 95%, and 90% (P<0.01) for the transplant group. Patients in the transplant group had an adjusted hazard ratio 0.16 times that of the dialysis group (95% confidence interval 0.06-0.42). If patients were censored at the time of their withdrawal from the transplant waiting list, the adjusted hazard ratio was 0.24 (95% confidence interval 0.09-0.69). CONCLUSIONS: Renal transplantation seems to confer a substantial survival advantage over dialysis in patients with end-stage renal failure who are rigorously screened and considered suitable for renal transplantation.

Aged↗

Options for small employers.

Although offering health benefits is very expensive, many employers (small, medium, and large) make health care purchasing decisions based on very little information. This is largely because employers have not taken the time to learn how to be knowledgeable health care purchasers. Higher health care costs result when employers: purchase programs and services that employees and their dependents do not need and seldom use; pay (unknowingly) for services not offered in their benefit plan; accept and pay for ineffective cost containment programs that increase (not decrease) health care costs (remember that cost containment is a business in itself); make standard recommended changes (e.g., increased copays or deductibles) to their benefit plans, hoping to reduce costs (the result has been higher costs for too many employees); fail to assess whether health plans and insurance companies have effective internal quality and cost management programs; use financial incentives to encourage employees and dependents to enroll in managed care plans without examining whether the health plan or insurer used quality criteria, high standards, and capable processes in developing provider networks. (Capable processes consistently deliver quality products or services.) Most health plans and insurance companies have chosen providers based on their willingness to discount their charges, which places all parties (health plans or insurance companies, employers, and patients) at risk. Most of the problems listed above could be avoided if small employers based their health care purchasing decisions on information obtained from a careful analysis of needs and expectations.(ABSTRACT TRUNCATED AT 250 WORDS)

Administrative Personnel↗

Incentives and disincentives in the Indian family welfare program.

The Indian family welfare program has offered financial incentives since the early 1960s to both family planning motivators and acceptors of sterilization and the IUD. This article reviews the available evidence regarding the impact of incentives on the quality and quantity of family planning services in India. Administrative concerns related to the implementation of incentive programs are discussed, and the current debate on disincentives, as well as the brief period when disincentives were used, is summarized. The studies reviewed, though few in number and varying in quality and methodology, indicate that incentives to acceptors help to increase the level of contraceptive acceptance, especially when they are part of a well designed strategy of service delivery and client motivation. Incentives do not appear to have an adverse effect on quality of services and acceptors, and they do not seem to influence method choice. Disincentives, if they are used, should not impinge on fundamental individual rights of either the parents or the child.

Birth Intervals↗

A computer program for predicting possible cytotoxic T lymphocyte epitopes based on HLA class I peptide-binding motifs.

Vaccination with peptides recognized by antigen-specific CTLs can prevent lethal virus infections and tumor growth. In order to avoid the synthesis and testing of the numerous overlapping peptide of long AA sequences of proteins of interest, we developed a computer program which utilizes the rules, "motifs" which govern how peptides bind to HLA class I molecules, to derive a predicted binding score for each overlapping peptide. Correlations between the predicted and actual binding results to HLA-A*0201 for 100 peptides selected from six early and two late protein sequences of human papillomavirus type 1a revealed an acceptable level (61%) of concordance. The program is very flexible with regard to the input of protein sequences and motif definitions and is able to handle various motif and peptide lengths.

Amino Acid Sequence↗