Enhancing delivery of health behaviour change interventions in primary care: a meta-synthesis of views and experiences of primary care nurses

Objective To systematically find and synthesise qualitative studies that elicited views and experiences of nurses involved in the delivery of health behaviour change (HBC) interventions in primary care, with a focus on how this can inform enhanced delivery and adherence to a structured approach for HBC interventions. Methods Systematic search of five electronic databases and additional strategies to maximise identification of studies, appraisal of studies and use of meta-synthesis to develop an inductive and interpretative form of knowledge synthesis. Results Nine studies met the inclusion criteria. Synthesis resulted in the development of four inter-linking themes; (a) actively engaging nurses in the process of delivering HBC interventions, (b) clarifying roles and responsibilities of those involved, (c) engaging practice colleagues, (d) communication of aims and potential outcomes of the intervention. Conclusion The synthesis of qualitative evidence resulted in the development of a conceptual framework that remained true to the findings of primary studies. This framework describes factors that should be actively promoted to enhance delivery of and adherence to HBC interventions by nurses working in primary care. Practice implications The findings can be used to inform strategies for researchers, policymakers and healthcare providers to enhance fidelity and support delivery of HBC interventions.

Intern pharmacists as change agents to improve the practice of nonprescription medication supply: provision of salbutamol to patients with asthma

BACKGROUND: Earlier work established an evidence practice gap during provision of nonprescription salbutamol (albuterol). Pharmacist interns are hypothesized to be in a position to improve professional practice in the community pharmacy setting. OBJECTIVE: To explore the potential of intern pharmacists to improve the professional practice of community pharmacy staff in the provision of nonprescription salbutamol. METHODS: Intern pharmacists (n = 157) delivered an asthma intervention in 136 pharmacies consisting of an educational activity to pharmacy staff and a health promotion campaign to consumers. Post-intervention, simulated patients presented to 100 intervention and 100 control community pharmacies with a request for salbutamol. The appropriate outcome was medical referral for poor asthma control and correction of poor inhaler technique. Incidence and quantity of patient assessment and counseling provided during the visit were also assessed. Logistic regression was used to determine the predictors of medical referral. RESULTS: A doubling in the rate of medical referral was seen in the intervention group (19% vs 40%; p = 0.001). Assessment of reliever use frequency was the main predictor of medical referral (OR = 22.7; 95% CI 9.06 to 56.9). Correction of poor inhaler technique did not improve; however, a reduction in salbutamol supplied without patient assessment (23% vs 8%; p = 0.009) or counseling (75% vs 48%; p < 0.001) was noted. CONCLUSIONS: A doubling in the rate of medical referral showed a clear improvement in professional practice during the provision of nonprescription salbutamol. The improved patient outcome in the intervention group was due to increased assessment of reliever use frequency. Identification of poor inhaler technique remained near zero in both groups, which suggests that intern pharmacists were able to improve the current practice of community pharmacies yet were unable to establish a new practice behavior. This study provides evidence that intern pharmacists can act as change agents to improve pharmacy practice.

Measuring the assessment and counselling provided with the supply of non-prescription asthma reliever medication: a simulated patient study

BACKGROUND: Over one quarter of asthma reliever medications are provided without prescription by community pharmacies in Australia. Evidence that community pharmacies provide these medications with sufficient patient assessment and medication counseling to ensure compliance with the government's Quality Use of Medicines principles is currently lacking. OBJECTIVE: To assess current practice when asthma reliever medication is provided in the community pharmacy setting and to identify factors that correlate with assessment of asthma control. METHODS: Researchers posing as patients visited a sample of Perth metropolitan community pharmacies in May 2007. During the visit, the simulated patient enacted a standardized scenario of someone with moderately controlled asthma who wished to purchase a salbutamol (albuterol) inhaler without prescription. Results of the encounter were recorded immediately after the visit. Regression analysis was performed, with medication use frequency (a marker of asthma control) as the dependent variable. RESULTS: One hundred sixty community pharmacies in the Perth metropolitan area were visited in May 2007. Pharmacists and/or pharmacy assistants provided some form of assessment in 84% of the visits. Counseling was provided to the simulated patients in 24% of the visits. Only 4 pharmacy staff members asked whether the simulated patient knew how to use the inhaler. Significant correlation was found between assessment and/or counseling of reliever use frequency and 3 independent variables: visit length (p < 0.001), number of assessment questions asked (p < 0.001), and the simulated patient who conducted the visit (p < 0.02). CONCLUSIONS: Both patient assessment and medication counseling were suboptimal compared with recommended practice when nonprescription asthma reliever medication was supplied in the community pharmacy setting. Pharmacy and pharmacist demographic variables do not appear to affect assessment of asthma control. This research indicates the need for substantial improvements in practice in order to provide reliever medication in line with Quality Use of Medication principles of ensuring safe and effective use of medication.

Patients’ and health professionals’ views and experiences of atrial fibrillation and oral-anticoagulant therapy:a qualitative meta-synthesis

Objective - Atrial fibrillation (AF) patients are prescribed oral-anticoagulant (OAC) therapy, often warfarin, to reduce stroke risk. We explored existing qualitative evidence about patients’ and health professionals’ experiences of OAC therapy. Methods - Systematic searches of eight bibliographic databases were conducted. Quality was appraised using the Critical Appraisal Skills Programme tool and data from ten studies were synthesised qualitatively. Results - Four third-order constructs, emerged from the final step in the analysis process: (1) diagnosing AF and the communication of information, (2) deciding on OAC therapy, (3) challenges revolving around patient issues, and (4) healthcare challenges. Synthesis uncovered perspectives that could not be achieved through individual studies. Conclusion - Physicians’ and patients’ experiences present a dichotomy of opinion on decision-making, which requires further exploration and changes in practice. Outcomes of workload pressure on both health professionals and patients should be investigated. The need for on-going support and education to patients and physicians is critical to achieve best practice and treatment adherence. Practice implications - Such research could encourage health professionals to understand and attend better to the needs and concerns of the patient. Additionally these findings can be used to inform researchers and healthcare providers in developing educational interventions with both patients and health professionals.

The mediating role of discrete emotions in the relationship between injustice and counterproductive work behaviors:a study in Pakistan

Purpose: Our study explores the mediating role of discrete emotions in the relationships between employee perceptions of distributive and procedural injustice, regarding an annual salary raise, and counterproductive work behaviors (CWBs). Design/Methodology/Approach: Survey data were provided by 508 individuals from telecom and IT companies in Pakistan. Confirmatory factor analysis, structural equation modeling, and bootstrapping were used to test our hypothesized model. Findings: We found a good fit between the data and our tested model. As predicted, anger (and not sadness) was positively related to aggressive CWBs (abuse against others and production deviance) and fully mediated the relationship between perceived distributive injustice and these CWBs. Against predictions, however, neither sadness nor anger was significantly related to employee withdrawal. Implications: Our findings provide organizations with an insight into the emotional consequences of unfair HR policies, and the potential implications for CWBs. Such knowledge may help employers to develop training and counseling interventions that support the effective management of emotions at work. Our findings are particularly salient for national and multinational organizations in Pakistan. Originality/Value: This is one of the first studies to provide empirical support for the relationships between in/justice, discrete emotions and CWBs in a non-Western (Pakistani) context. Our study also provides new evidence for the differential effects of outward/inward emotions on aggressive/passive CWBs. © 2012 Springer Science+Business Media, LLC.

A preliminary investigation of 4 to 11-year-old children's knowledge and understanding of stress

Objective. To examine children's knowledge, understanding and experience of stress from 4 to 11 years of age across four age groups (4–5, 6–7, 8–9, and 10–11 years old). Methods. A semi-structured interview format was used to elicit information from 50 children about their understanding and experience of stress. Results. Most children were able to define stress, with older children providing more complex responses. Many children had indirect and/or personal experience of stress. Younger children were more likely than older children to report that there was nothing people could do to stop stress; children reported using both adaptive and maladaptive coping strategies to deal with stress. Conclusion. Some young children have a basic understanding of stress and many have experience of stress; both understanding and experience develop with age. Practice Implications. The research has potential implications for provider-patient communication, particularly within preventative health education and clinically within the field of childhood post-traumatic stress disorder (PTSD).

Talking about depression:an analogue study of physician gender and communication style on patient disclosures

Objectives: To disentangle the effects of physician gender and patient-centered communication style on patients' oral engagement in depression care. Methods: Physician gender, physician race and communication style (high patient-centered (HPC) and low patient-centered (LPC)) were manipulated and presented as videotaped actors within a computer simulated medical visit to assess effects on analogue patient (AP) verbal responsiveness and care ratings. 307 APs (56% female; 70% African American) were randomly assigned to conditions and instructed to verbally respond to depression-related questions and indicate willingness to continue care. Disclosures were coded using Roter Interaction Analysis System (RIAS). Results: Both male and female APs talked more overall and conveyed more psychosocial and emotional talk to HPC gender discordant doctors (all p <.05). APs were more willing to continue treatment with gender-discordant HPC physicians (p <.05). No effects were evident in the LPC condition. Conclusions: Findings highlight a role for physician gender when considering active patient engagement in patient-centered depression care. This pattern suggests that there may be largely under-appreciated and consequential effects associated with patient expectations in regard to physician gender that these differ by patient gender. Practice implications: High patient-centeredness increases active patient engagement in depression care especially in gender discordant dyads. © 2014.

The role of volunteer support in the community for adults with hearing loss and hearing aids

Objectives: To explore interactions between audiology patients and volunteers, to describe encounters and define the role of volunteers. Methods: Qualitative ethnographic and interview study of volunteer-patient interactions. Ten volunteer participants from two volunteer schemes in South West England were observed and interviewed. Three patient participants were interviewed. Results: Analysis of observational data showed that volunteers provided support relating to local services and hearing aids, but did not engage in discussions about hearing loss. Interviews with volunteers identified gaps in audiology provision, including accessible services and clear information and highlighted a need for more support from audiology services to enable them to fulfil their role. Volunteer interactions with patients mimicked a clinician-patient encounter and volunteers employed strategies and behaviours used by professional audiologists. Conclusions: Audiology volunteers could provide an accessible bridge between health services and the community but their care is limited to focus on hearing aids. Practice implications: Volunteers enable patients to use hearing aids appropriately and are a core element of current care arrangements. However, volunteers express a need for adequate support from audiology services. Volunteers have the potential to increase service capacity and to bridge the gaps between community and audiology healthcare services.

How doctors' communication style and race concordance influence African-Caribbean patients when disclosing depression

Objective: To determine the impact of doctors' communication style and doctor-patient race concordance on UK African-Caribbeans' comfort in disclosing depression. Methods: 160 African-Caribbean and 160 white British subjects, stratified by gender and history of depression, participated in simulated depression consultations with video-recorded doctors. Doctors were stratified by black or white race, gender and a high (HPC) or low patient-centred (LPC) communication style, giving a full 2. ×. 2. ×. 2 factorial design. Afterwards, participants rated aspects of doctors' communication style, their comfort in disclosing depression and treatment preferences. Results: Race concordance had no impact on African-Caribbeans' comfort in disclosing depression. However a HPC versus LPC communication style made them significantly more positive about their interactions with doctors (p = 0.000), their overall comfort (p = 0.003), their comfort in disclosing their emotional state (p = 0.001), and about considering talking therapy (p = 0.01); but less positive about considering antidepressant medication (p =0.01). Conclusion: Doctors' communication style was shown to be more important than patient race or race concordance in influencing African Caribbeans' depression consultation experiences. Changing doctors' communication style may help reduce disparities in depression care. Practice Implications: Practitioners should cultivate a HPC style to make African-Caribbeans more comfortable when disclosing depression, so that it is less likely to be missed.

Integrating service user and practitioner expertise within a web-based system for collaborative mental-health risk and safety management

Objectives: To develop a decision support system (DSS), myGRaCE, that integrates service user (SU) and practitioner expertise about mental health and associated risks of suicide, self-harm, harm to others, self-neglect, and vulnerability. The intention is to help SUs assess and manage their own mental health collaboratively with practitioners. Methods: An iterative process involving interviews, focus groups, and agile software development with 115 SUs, to elicit and implement myGRaCE requirements. Results: Findings highlight shared understanding of mental health risk between SUs and practitioners that can be integrated within a single model. However, important differences were revealed in SUs' preferred process of assessing risks and safety, which are reflected in the distinctive interface, navigation, tool functionality and language developed for myGRaCE. A challenge was how to provide flexible access without overwhelming and confusing users. Conclusion: The methods show that practitioner expertise can be reformulated in a format that simultaneously captures SU expertise, to provide a tool highly valued by SUs. A stepped process adds necessary structure to the assessment, each step with its own feedback and guidance. Practice Implications: The GRiST web-based DSS (www.egrist.org) links and integrates myGRaCE self-assessments with GRiST practitioner assessments for supporting collaborative and self-managed healthcare.

Parenting a child with chronic illness as they transition into adulthood:a systematic review and thematic synthesis of parents’ experiences

Objective - To understand how parents view and experience their role as their child with a long-term physical health condition transitions to adulthood and adult healthcare services. Methods - Five databases were systematically searched for qualitative articles examining parents’ views and experiences of their child’s healthcare transition. Papers were quality assessed and thematically synthesised. Results - Thirty-two papers from six countries, spanning a 17-year period were included. Long-term conditions were diverse. Findings indicated that parents view their child’s progression toward self-care as an incremental process which they seek to facilitate through up-skilling them in self-management practices. Parental perceptions of their child’s readiness, wellness, competence and long-term condition impacted on the child’ progression to healthcare autonomy. A lack of transitional healthcare and differences between paediatric and adult services served as barriers to effective transition. Parents were required to adjust their role, responsibilities and behaviour to support their child’s growing independence. Conclusion - Parents can be key facilitators of their child’s healthcare transition, supporting them to become experts in their own condition and care. To do so, they require clarification on their role and support from service providers. Practice Implications - Interventions are needed which address the transitional care needs of parents as well as young people.

A longitudinal study of Project Trio: A dropout prevention program in a large urban environment

The subject of dropout prevention/reduction is deservedly receiving attention as a problem that, if not resolved, could threaten our national future.^ This study investigates a small segment of the overall dropout problem, which has apparently unique features of program design and population selection. The evidence presented here should add to the knowledge bank of this complicated problem.^ Project Trio was one of a number of dropout prevention programs and activities which were conducted in Dade County school years 1984-85 and 1985-86, and it is here investigated longitudinally through the end of the 1987-88 school year. It involved 17 junior and senior high schools, and 27 programs, 10 the first year and 17 the second, with over 1,000 total students, who had been selected by the schools from a list of the "at risk" students provided by the district, and were divided approximately evenly into the classical research design of an experimental group and the control group, which following standard procedure was to take the regular school curriculum. No school had more than 25 students in either group.^ Each school modified the basic design of the project to accommodate the individual school characteristics and the perceived needs of their students; however all schools projects were to include some form of academic enhancement, counseling and career awareness study.^ The conclusion of this study was that the control group had a significantly lower dropout rate than the experimental group. Though impossible to make a certain determination of the reasons for this unexpected result, it appears from evidence presented that one cause may have been inadequate administration at the local level.^ This study was also a longitudinal investigation of the "at risk" population as a whole for the three and four year period, to determine if academic factors were present in records may be used to identify dropout proneness.^ A significant correlation was found between dropping out and various measures including scores on the Quality of School Life Instrument, attendance, grade point averages, mathematics grades, and overage in grade, important identifiers in selection for dropout prevention programs. ^

Effects of two intervention strategies on the behavior of nurses and nurse students related to advance directives

Advance directives are one mechanism for preserving the rights of individuals to exercise some control over their health care when serious illness may prevent them from direct participation. Nurses, as the health care providers with the closest and most sustained contact with critically ill and dying patients, are positioned to assist patients to plan for future health care needs. Although a majority of nurses favor the concept of advance directives for their patients and for themselves, they have not played a significant role in facilitating advance health care planning with their patients nor implemented advance health care planning for themselves.^ Research has also shown that differing forms of education and counseling increase the completion rates for advance directives in selected populations, mostly the elderly and seriously ill. Not yet developed are effective educational strategies to assist nurses and nurse students to make optimal contributions in assisting their clients' plans for future health care decision-making. This study sought to determine whether specific learning strategies (a) increased the involvement of nurses and nurse students in facilitating advance care planning with patients and (b) increased the percentage of the nurses' and nurse students' own personal advance care planning activities.^ The study compared two learning interventions and two populations, nurses and nurse students. The participants were randomly assigned to one of the two learning interventions, L1 or L2. Participants in L1 received a lecture, discussion and exploration of the forces impacting on advance directive behavior. Participants in L2 received the same intervention components with the additional component of group practice completing advance directives.^ Analysis of the data by chi-square and logistic regression did not support the hypotheses that the practice component would make a difference in the participants' facilitation of advance care planning with patients or in their own personal advance care planning activities. There were significant differences in post-intervention behavior between the nurse and nurse student groups. The nurses in the study did significantly more facilitation of advance care planning with patients and completed significantly more advance care documents than the nurse students post-intervention. However, the nurse students held more post-intervention family discussions than did the nurses. ^

Perceptions of family environment, body image and self-esteem of eating disordered and non-eating disordered women

This study explored the perceptions of family environment, body image and self esteem of women who suffer from anorexia nervosa, bulimia nervosa, and depression. Using a nonequivalent control group design, one hundred and fifty women with anorexia nervosa (n = 50), bulimia nervosa (n = 50), and depression (n = 50) were given the Family Environment Scale (FES) and the Eating Disorders Inventory-2 (EDI-2). The objectives of this study were to: (1) study how women with anorexia nervosa and bulimia nervosa perceive their family environment as measured by the FES; (2) compare and contrast perceptions of family environment of women with anorexia nervosa and bulimia nervosa with the control group; (3) compare and contrast perceived levels of self esteem and body image as measured by the EDI-2 of women with anorexia nervosa and bulimia nervosa with the control group; and (4) examine the perceived family environments of eating disordered and non-eating disordered women with regard to body image and self esteem. Results suggested, women who suffered from anorexia nervosa or bulimia nervosa scored significantly lower (p $<$.021) on the Expressiveness, Intellectual-Cultural Orientation, and Active-Recreational subscales of the FES. The results also indicated that women who suffered from bulimia nervosa scored significantly higher (p $<$.015) than women who suffered from anorexia nervosa on the Conflict and Independence subscales of the FES. The results of studying these three populations reflected that women who suffered from anorexia nervosa scored significantly different (p $<$.000) than women who suffered from bulimia nervosa on many of the subscales of the EDI-2. The findings of the study confirmed that women who suffered from anorexia nervosa or bulimia nervosa scored significantly different (p $<$.000) on the subscales of the EDI-2 compared to women who suffered from depression. It was also confirmed that a relationship does exist between perceptions of body image and self esteem and perceptions of family environment amongst women with anorexia nervosa and bulimia nervosa as compared to depressed women. The findings of the study indicated that women who suffered from anorexia nervosa tended to: be less expressive and independent; handle conflict less openly; have a greater drive for thinness; have greater body dissatisfaction; be more perfectionistic; and struggle more intensely with fears around maturity and social insecurity than did women who suffered from bulimia nervosa or depression. In addition, the findings of the study also suggested that women who suffered from bulimia nervosa tended to: be raised in homes where openly expressed anger is permitted amongst family members; have a lesser drive for thinness; have less body dissatisfaction; be less perfectionistic; and not struggle as intensely with fears around maturity and social insecurity as do women who suffered from anorexia nervosa, but more than women who suffer from depression. Treatment implications that may assist community college professors and counselors in meeting the special needs of this special group of women were also discussed. (Abstract shortened by UMI.) ^

A comparative analysis of school satisfaction and dropout risk of middle school students attending programs for students with emotional handicaps, severe emotional disturbance and general education students attending center schools and satellite schools

This study evaluated school satisfaction as an indicator of dropout risk of students with Emotional Handicaps (EH) and students with Severe Emotional Disturbance (SED). The students attended two different kinds of middle schools in a largely urban school district in South Florida. One hundred eight students in grade 8 (ages 13-16) participated in this study. Participants were administered the National Dropout Prevention Assessment (NDPA). Forty participants with EH and SED attended a special center school. Thirty-one participants with EH and SED attended satellite programs in a regular middle school. Thirty-seven general education participants attended the same regular middle school. Overall school satisfaction scores were generated, as well as three primary factors (school, environment and personal) and 16 subscales (school atmosphere, future income, difficulty level of classwork, teacher relationships, peer relationships, intrinsic interest in classwork, school hours, classwork stress, general attitude towards school, family influence, perceived opportunity for career, future goals, travel distance, leisure time, self-appraisal of performance, and self-esteem).^ Comparison of students with EH and SED revealed that both groups of students were rated at "low risk" of becoming dropouts on the Environmental factor and the Difficulty of Schoolwork subscale. Students with EH were rated at "caution risk" risk on the Travel Distance subscale. Students with SED were rated at "high risk" on this subscale.^ There were no significant differences in school satisfaction and dropout risk between different program delivery models. There were also no significant differences for category of students (EH, SED) by school type (center school, satellite program). All students were rated at "low risk" of dropping out of school.^ There were significant differences between general education students and students with EH and SED attending satellite programs. Students with EH and SED were rated at "caution risk" for dropping out on the Travel Distance and the Leisure Time subscales. Discussion of results, implications for practice and recommendations for further research are included. ^