Toward a better understanding of the influences on physical activity: The role of determinants, correlates, causal variables, mediators, moderators, and confounders

Background: For research on physical activity interventions to progress systematically, the mechanisms of action must be studied. In doing so, the research methods and their associated concepts and terminology become more complex. It is particularly important to clearly distinguish among determinants, correlates, mediators, moderators, and confounder variables used in physical activity research. This article examines the factors that are correlated with and that may have a causal relationship to physical activity. Methods and Results: We propose that the term correlate be used, instead of determinant, to describe statistical associations or correlations between measured variables and physical activity. Studies of the correlates of physical activity are reviewed. The findings of these studies can help to critique existing theories of health behavior change and can provide hypotheses to be tested in intervention studies from which it is possible to draw causal inferences. Mediator, moderator, and confounder variables can act to influence measured changes in physical activity. Intervening causal variables that are necessary to complete a cause-effect pathway between an intervention and physical activity are termed mediators. The relationship between an intervention and physical activity behaviors may vary for different groups; the strata by which they vary are levels of moderators of the relationship. Other factors may distort or affect the observed relationships between program exposure and physical activity, and are known as confounders. Conclusions: Consistent use of terms and additional research on mediators and moderators of intervention effects will improve our ability to understand and influence physical activity.

Some new killing trick: Welfare reform and drug markets in a U.S. urban ghetto

Ethnographic data collected over a 5-year period is analyzed to determine how the Personal Responsibility & Work Opportunity Reconciliation Act of 1996 (PRWORA) has affected the lives of young male drug dealers from AIDS-afflicted families residing in Detroit. The data analysis indicated that the participants perceived drug dealing as the only viable employment opportunity for meeting the quotidian & health care needs of their families. The findings also revealed that the participants were highly aware of local political processes & the necessities of caring for relatives living with AIDS. Additional attention is dedicated to exploring the state of MI's rationale for ending the General Assistance Program, the sociocultural foundations of the PRWORA, various stipulations of the PRWORA, & how the PRWORA has augmented the legal vulnerability of welfare recipients. It is concluded that the PRWORA will force many welfare recipients to engage in illicit activities & will generally decrease recipients' health. 59 References. J. W. Parker

Attitudes and practices of general practitioners in the diagnosis and management of attention-deficit/hyperactivity disorder

Objective: To assess understanding of, and actual and potential roles in management of attention-deficit/hyperactivity disorder (ADHD) among GPs. Methods: A cross-sectional questionnaire survey of Queensland GPs selected randomly from the Royal Australian College of General Practitioners directory of members was carried out. Main outcome measures were knowledge levels of ADHD, current management practices, referral patterns and self-perceived information and training needs. Results: Three hundred and ninety-nine GPs returned a completed questionnaire (response rate 76%). Roles identified by GPs were: the provisional diagnosis of ADHD and referral to specialist services for confirmation of the diagnosis and initiation of management; assistance with monitoring progress once a management plan was in place; education of the child and their family regarding the disorder; and liaison with the school where necessary. Perceived barriers to increased involvement of GPs were: time and resource constraints of general practice; concerns regarding abuse and addiction liability of prescription stimulants; complex diagnostic issues associated with childhood behavioural problems; and lack of training and education regarding ADHD. Conclusions: General practitioners identify a role for themselves in ADHD care that is largely supportive in nature and involves close liaison with specialist services.

Levene tests of homogeneity of variance for general block and treatment designs

This article develops a weighted least squares version of Levene's test of homogeneity of variance for a general design, available both for univariate and multivariate situations. When the design is balanced, the univariate and two common multivariate test statistics turn out to be proportional to the corresponding ordinary least squares test statistics obtained from an analysis of variance of the absolute values of the standardized mean-based residuals from the original analysis of the data. The constant of proportionality is simply a design-dependent multiplier (which does not necessarily tend to unity). Explicit results are presented for randomized block and Latin square designs and are illustrated for factorial treatment designs and split-plot experiments. The distribution of the univariate test statistic is close to a standard F-distribution, although it can be slightly underdispersed. For a complex design, the test assesses homogeneity of variance across blocks, treatments, or treatment factors and offers an objective interpretation of residual plot.

General practitioner attitudes to case conferences: how can we increase participation and effectiveness?

Objectives: To identify general practitioners' views on the barriers to using case conferencing (as outlined in the Medical Benefits Schedule (MBS) Enhanced Primary Care package) and to develop a set of principles to encourage greater GP participation in case conferences. Design: Qualitative study, involving semistructured questions administered to focus groups of GPs, conducted between April and July 2001 as part of a broader study of case coordination in palliative care. Participants: 29 GPs from urban, regional, and rural areas of Queensland. Principal findings: Many of the GPs' work practices militated against participation in traditionally structured case conferences. GPs thought the range of MBS item numbers should be expanded to cover alternative methods of liaison (eg, phone consultations with other service providers). The onerous bureaucratic processes required to claim reimbursement were an additional disincentive. Conclusions: GPs would probably be more likely to participate in case conferences if they were initiated by specialist services and arranged more flexibly to suit GP work schedules.

How well do general practitioners deliver palliative care? A systematic review

General practitioners (GPs) deliver the majority of palliative care to patients in the last year of life. This article seeks to examine the nature of GP care, perceptions of the GPs themselves and others of that care, the adequacy of palliative care training, issues relating to accessibility of GPs to palliative care patients, and strategies that may be of use in encouraging more effective delivery of palliative care by GPs. Medline and PubMed databases from 1966 to 2000 were searched, and 135 references identified. Sixty-six of these described studies relevant to GP palliative care. GPs value this part of their work. Most of the time, patients appreciate the contribution the GP makes to palliative care particularly if the GP is accessible, takes time to listen, allows patient and carer to ventilate their feelings, and is seen to be making efforts made regarding symptom relief. However, reports from bereaved relatives suggest that palliative care is performed less well in the community than in other settings. GPs express discomfort about their competence to perform palliative care adequately. They tend to miss symptoms which are not treatable by them, or which are less common. However, with appropriate specialist support and facilities, GPs have been shown to deliver sound and effective care. GP comfort working with specialist teams increases with exposure to this form of patient management, as does the understanding of the potential other team members have in contributing to the care of the patient. Formal arrangements engaging GPs to work with specialist teams have been shown to improve functional outcomes, patient satisfaction, improve effective use of resources and improve effective physician behaviour in other areas of medicine. Efforts by specialist services to develop formal involvement of GPs in the care of individual patients, may be an effective method of improving GP palliative care skills and appreciation of the roles specialist services can play.