Clinical relationships and ethical problems in primary care, Sao Paulo, SP, Brazil

Objectives: Main Objective: to identify ethical problems in primary care according to nurses` and doctors` perceptions. Secondary Objective: to know ethical issues of patient-professional relationships in primary care. Design: Synthesis to integrate and reinterpret primary results of qualitative studies. Setting: Primary healthcare centers, Sao Paulo, SP, Brazil. Participants and/or context: Incidental sample of 34 nurses and 36 medical doctors working in primary healthcare centers selected by convenience. Methods: Individual, semi-structured interviews to identity situations considered as sources of ethical problems. The sample is socially representative of primary care health centers and professionals. Data collection assured discourse saturation. Hermeneutic-dialectical discourse analysis was used to study the results. Results: Patient-professional relationships and team work were the main sources of ethical problems. The most important problems were patient information, privacy, confidentiality, interpersonal relationship, linkage and patient autonomy. These issues reflect the recent changes in clinical relation ships and show the peculiarities of primary care with its continuous care which lasts a long time. Healthcare involves multiprofessional team work in the midst of the patient claims for autonomy. Good care of patients needs requires a relationship based on communication and cooperation, and includes feelings and values, with communication skills. Conclusions: Ethical problems in primary care are common situations. For quality and humane primary care the relationship should consist of dialogue, trust and cooperation. (C) 2009 Elsevier Espana, S.L. All rights reserved.

Correlation of habitual physical activity levels with flow mediated dilation of the brachial artery in 5-10 year old children

Endothelial dysfunction is an early key event of atherogenesis. Both fitness level and exercise intervention have been shown to positively influence endothelial function. In a cross-sectional study of 47 children, the relationship between habitual physical activity and flow-mediated dilation (FMD) of the brachial artery was explored. Habitual physical activity levels (PALs) were assessed using a validated stable isotope technique, and FMD of the brachial artery was measured via high-resolution ultrasound. The results showed that habitual physical activity significantly correlated with FMD (r=0.39, P=0.007), and remained the most influential variable on dilation in multivariate analysis. Although both fitness level and exercise intervention have previously been shown to positively influence FMD, this is the first time that a relationship with normal PALs has been investigated, especially, at such a young age. These data support the concept that physical activity exerts its protective effect on cardiovascular health via the endothelium and add further emphasis to the importance of physical activity in childhood.

Assessing flow in physical activity: The Flow State Scale-2 and Dispositional Flow Scale-2

The Flow State Scale-2 (FSS-2) and Dispositional Flow Scale-2 (DFS-2) are presented as two self-report instruments designed to assess flow experiences in physical activity. Item modifications were made to the original versions of these scales in order to improve the measurement of some of the flow dimensions. Confirmatory factor analyses of an item identification and a cross-validation sample demonstrated a good fit of the new scales. There was support for both a 9-first-order factor model and a higher order model with a global flow factor. The item identification sample yielded mean item loadings on the first-order factor of .78 for the FSS-2 and .77 for the DFS-2. Reliability estimates ranged from .80 to .90 for the FSS-2, and .81 to .90 for the DFS-2. In the cross-validation sample, mean item loadings on the first-order factor were .80 for the FSS-2, and .73 for the DFS-2. Reliability estimates ranged between .80 to .92 for the FSS-2 and .78 to .86 for the DFS-2. The scales are presented as ways of assessing flow experienced within a particular event (FSS-2) or the frequency of flow experiences in chosen physical activity in general (DFS-2).

Breastfeeding and the responsibilities of GPs: a qualitative study of general practice registrars

The most recent National Health Survey reports that more than 80% of women initiate breastfeeding, while recent studies describe initiation rates of more than 90%. Yet fewer than 50% of women continue to breastfeed for 6 months or longer. This is at odds with National Health and Medical Research Council recommendations that 80% of infants be exclusively breastfed for the first 6 months of life. Women are more likely to initiate and continue to breastfeed if their doctor supports and encourages them to do so. Conversely, women perceive a neutral attitude by doctors toward breastfeeding to be similar to a negative attitude. Therefore, while doctors may not perceive their support or encouragement to be a determining factor in a woman’s breastfeeding decisions, women often place great emphasis on their GP's attitude to breastfeeding and are much more likely to think that information provided by a doctor is important. No previous research in Australia has addressed the issue of how GPs perceive their roles and responsibilities regarding breastfeeding. As part of a larger research project investigating the breastfeeding skills and knowledge of general practice registrars, this article reports the results of qualitative interviews with eight general practice registrars and their views and beliefs about GPs’ responsibilities to breastfeeding women.

Occupation, hours worked, and leisure-time physical activity

Background. International research indicates that blue-collar employees typically exhibit lower rates of leisure-time physical activity. While lack of time and work demands are commonly reported barriers to activity, the extent to which time-at-work mediates the relationship between occupation and leisure-time physical activity is unclear. This study investigated the association between occupation, time spent in paid employment, and participation in leisure-time physical activity. Methods. This was a secondary analysis of cross-sectional data from the 1995 Australian Health Survey, focusing on employed persons ages 18-64 years (n = 24,454), Occupation was coded as per the Australian Standard Classification of Occupations and collapsed into three categories (professional, white-collar, blue-collar). Hours worked was categorized into eight levels, ranging from 1-14 to more than 50 h per week. Participation in leisure-time physical activity was categorized as either insufficient or sufficient for health, consistent with recommended levels of energy expenditure (1600 METS-min/fortnight). The relationship between occupation, hours worked, and leisure-time physical activity was examined using logistic regression. Analyses were conducted separately for male and female, and the results are presented as a series of models that successively adjust for a range of potential covariates: age, living arrangement, smoking status, body mass index, and self-reported health. Results. Individuals in blue-collar occupations were approximately 50% more likely to be classified as insufficiently active. This occupational variability in leisure-time physical activity was not explained by hours worked. There was a suggested relationship between hours worked and leisure-time physical activity; however, this differed between men and women, and was difficult to interpret. Conclusions. Occupational variability in leisure-time physical activity cannot be explained by hours worked. Therefore, reports that work constitutes a barrier to participation should be explored further. Identification of the factors contributing to occupational variability in leisure-time physical activity will add to our understanding of why population subgroups differ in their health risk profiles, and assist in the development of health promotion strategies to reduce rates of sedentariness and health inequalities. (C) 2000 American Health Foundation and Academic Press.

Developing a reliable audit instrument to measure the physical environment for physical activity

Background: The physical environment plays an important role in influencing participation in physical activity, although which factors of the physical environment have the greatest effect on patterns of activity remain to be determined. We describe the development of a comprehensive instrument to measure the physical environmental factors that may influence walking and cycling in local neighborhoods and report on its reliability. Methods: Following consultation with experts from a variety of fields and a literature search, we developed a Systematic Pedestrian and Cycling Environmental Scan (SPACES) instrument and used it to collect data over a total of 1987 kilometers of roads in metropolitan Perth, Western Australia. The audit instrument is available from the first author on request. Additional environmental information was collected using desktop methods and geographic information systems (GIS) technology. We assessed inter- and intra-rater reliability of the instrument among the 16 observers who collected the data. Results: The observers reported that the audit instrument was easy to use. Both inter- and intra-rater reliability of the environmental scan instrument were generally high. Conclusions: Our instrument provides a reliable, practical, and easy to-use method for collecting detailed street-level data on physical environmental factors that are potential influences on walking in local neighborhoods.

Participation in recreational physical activity: Why do socioeconomic groups differ?

This qualitative study explored how influences on recreational physical activity (RPA) were patterned by socioeconomic position. Face-to-face interviews were conducted with 10 males and 10 females in three socioeconomic groups (N = 60). Influences salient across all groups included previous opportunities, physical health, social assistance, safety, environmental aesthetics and urban design, physical and health benefits, and barriers of self-consciousness, low skill, and weather/time of year. Influences more salient to the high socioeconomic group included social benefits, achieving a balanced lifestyle, and the barrier of an unpredictable lifestyle. Influences more salient to the high and mid socioeconomic groups included efficacy, perceived need, activity demands, affiliation, emotional benefits, and the barrier of competing demands. Influences more salient to the low socioeconomic group included poor health and barriers of inconvenient access and low personal functioning. Data suggest that efforts to increase RPA in the population should include both general and socioeconomically targeted strategies.

Physical activity profile in heart failure patients from a Brazilian tertiary cardiology hospital

Background: Physical activity (PA) has proven benefits in the primary prevention of heart diseases such as heart failure (HF). Although it is well known, HF PA habits and physicians` advice have been poorly described. The aim of this study was to investigate if physicians were advising HF patients to exercise and to quantify patients` exercise profiles in a complex cardiology hospital. Methods: All 131 HF patients (80 male, average age 53 +/- 10 years, NYHA class I-V, left ventricular ejection fraction 35 +/- 11%, 35 ischemic, 35 idiopatic , 32 hypertensive and 29 with Chagas disease) went to the hospital for a HF routine check-up. On this occasion, after seeing the physician, we asked the patients if the physician had advised them about PA. Then, we asked them to fill in the international physical activity questionnaire (IPQA) Short Form to classify their PA level. Results: Our data showed a significant difference between patients who had received any kind of PA advice from physicians (36%) and those who had not (64%, p<0.0001). Using the IPAQ criteria, of the 36% of patients who had received advice, 12.4% were classified as low and 23.6% as moderate. Of the 64% of patients who did not receive advice, 26.8% were classified as lowand 37.2% as moderate. Etiology (except Chagas), functional class, ejection fraction, sex and age did not influence the PA profile. Conclusions: Physicians at a tertiary cardiology hospital were not giving patients satisfactory advice as to PA. Our data supports the need to strengthen exercise encouragement by physicians and for complementary studies on this area. (Cardiol J 2010; 17, 2: 143-148)

Ways of using evidence-based medicine in general practice

General practitioners wanting to practise evidence-based medicine (EBM) are constrained by time factors and the great diversity of clinical problems they deal with. They need experience in knowing what questions to ask, in locating and evaluating the evidence, and in applying it. Conventional searching for the best evidence can be achieved in daily general practice. Sometimes the search can be performed during the consultation, but more often it can be done later and the patient can return for the result. Case-based journal clubs provide a supportive environment for GPs to work together to find the best evidence at regular meetings. An evidence-based literature search service is being piloted to enhance decision-making for individual patients. A central facility provides the search and interprets the evidence in relation to individual cases. A request form and a results format make the service akin to pathology testing or imaging. Using EBM in general practice appears feasible. Major difficulties still exist before it can be practised by all GPs, but it has the potential to change the way doctors update their knowledge.

Environmental factors associated with adults' participation in physical activity : A review

Background: Promoting physical activity is a public health priority, and changes in the environmental Contexts of adults' activity choices are believed to be crucial. However, of the factors associated with physical activity, environmental influences are among the least understood. Method: Using journal scans and computerized literature database searches, we identified 19 quantitative studies that assessed the relationships With physical activity behavior of perceived and objectively determined physical environment attributes. Findings were categorized into those examining five categories: accessibility of facilities, opportunities for activity, weather, safety, and aesthetic attributes. Results: Accessibility, opportunities, and aesthetic attributes had significant associations with physical activity, Weather and safety showed less-strong relationships. Where Studies pooled different categories to create composite variables, the associations were less likely to be statistically significant. Conclusions: Physical environment factors have consistent associations with physical activity behavior. Further development of ecologic and environmental models, together with behavior-specific and context-specific measurement strategies, should help in further understanding of these associations. Prospective Studies are required to identify possible causal relationships.

Life transitions and changing physical activity patterns in young women

Background: Physical activity (PA) patterns are likely to change in young adulthood in line with changes in lifestyle that occur in the transition from adolescence to adulthood. The aim of this study was to ascertain whether key life events experienced by young women in their early twenties are associated with increasing levels of inactivity. Methods: This was a 4-year follow-up of 7281 participants (aged 18 to 23 years at baseline) in the Australian Longitudinal Study of Women's Health, with self-reported measures of PA, life events, body mass index (BMI), and sociodemographic variables. Results: The cross-sectional data indicated no change in PA between baseline (57% active) and follow-up (56% active). However, for almost 40% of the sample, PA category changed between baseline and follow-up, with approximately 20% of the women changing from being active to inactive, and another 20% changing from being inactive to active. After adjustment for age, other sociodemographic variables, BMI, and PA at baseline, women who reported getting married, having a first or subsequent child, or beginning paid work were more likely to be inactive at follow-up than those who did not report these events. Conclusions: The results suggest that life events such as getting married, having children, and starting work are associated with decreased levels of PA in young adult women. Strategies are needed to promote maintenance of activity at the time when most women experience these key life-stage transitions.

Physical activity and sedentary behavior: A population-based study of barriers, enjoyment, and preference

The associations of physical activity and sedentary behavior with barriers, enjoyment, and preferences were examined in a population-based mail survey of 1,332 adults. Respondents reporting high enjoyment and preference for physical activity were more likely to report high levels of activity. Those reporting cost, the weather, and personal barriers to physical activity were less likely to be physically active. Preference for sedentary behavior was associated with the decreased likelihood of being physically active, and the weather as a barrier to physical activity was associated with the increased likelihood of sedentary behavior. These constructs can be used to examine individual and environmental influences on physical activity and sedentary behavior in specific populations and could inform the development of targeted interventions.

Reliability of moderate-intensity and vigorous physical activity stage of change measures for young adults

Background. The purpose of this study was to examine the reliability of stage of change (SOC) measures for moderate-intensity and vigorous physical activity in two separate samples of young adults. Staging measures have focused on vigorous exercise, but current public health guidelines emphasize moderate-intensity activity. Method. For college students in the USA (n = 105) and in Australia (n = 123), SOC was assessed separately on two occasions for moderate-intensity activity and for vigorous activity. Test-retest repeatability was determined, using Cohen's kappa coefficient. Results. In both samples, the reliability scores for the moderate-intensity physical activity staging measure were lower than the scores for the vigorous exercise staging measure. Weighted kappa values for the moderate-intensity staging measure were in the fair to good range for both studies (0.50 and 0.45); for the vigorous staging measure kappa values were excellent and fair to good (0.76 and 0.72). Conclusions. There is a need to standardize and improve methods for staging moderate-intensity activity, given that such measures are used in public health interventions targeting HEPA (health-enhancing physical activity). (C) 2003 American Health Foundation and Elsevier Science (USA). All rights reserved.