Faculty Bibliography

Treatment fidelity refers to the methodological strategies used to monitor and enhance the reliability and validity of behavioral interventions. This article describes a multisite effort by the Treatment Fidelity Workgroup of the National Institutes of Health Behavior Change Consortium (BCC) to identify treatment fidelity concepts and strategies in health behavior intervention research. The work group reviewed treatment fidelity practices in the research literature, identified techniques used within the BCC, and developed recommendations for incorporating these practices more consistently. The recommendations cover study design, provider training, treatment delivery, treatment receipt, and enactment of treatment skills. Funding agencies, reviewers, and journal editors are encouraged to make treatment fidelity a standard part of the conduct and evaluation of health behavior intervention research

In patients with chronic diseases, expectations of care are associated with clinical outcomes. Using open-ended interviews, we elicited the expectations of treatment in 93 hypertensive African-American patients. During routine clinic visits, patients were asked, 'What are your expectations of the treatment your doctor prescribed for your high blood pressure?' Their responses were explored with the probes: Do you expect to take your blood pressure medications for the rest of your life? Do you expect to take your medications daily regardless of symptoms? Do you expect a cure for your high blood pressure? Using standard qualitative techniques, patients' responses were grouped into a taxonomy of three categories of expectations reflecting patients' role, physicians' role, and medication effects. They expected to take active role in their treatment, especially as it relates to adoption of healthy behaviors. They expected their physicians to educate them about blood pressure treatment, and they expected medications to lower their blood pressure and prevent heart attack, stroke, and kidney failure. Despite such appropriate expectations, a considerable proportion of patients had nonbiomedical expectations of their treatment-38% expected a cure, 38% did not expect to take their medications for life and 23% take medications only with symptoms. The taxonomy of patient expectations outlined in this study may serve as a useful framework for patient education and counseling about hypertension and its management in this patient population

BACKGROUND: We sought to study the clinicopathologic characteristics of colorectal cancer in young female patients. We also wanted to determine the association of colorectal cancer with anemia in these female patients and, finally, to determine the effect of gender on prognosis in young patients with colorectal cancer. METHODS: We performed a retrospective analysis of all young patients diagnosed with colorectal cancer between 1982 and 1999 in two teaching hospitals in New York City. RESULTS: A total of 3,546 cases of colorectal cancer were diagnosed. Sixty-one (1.63%) of these patients were young patients and 32 (0.85%) were female. Young refers to all patients in the study who were younger than 40 years of age. The clinical presentation and mean age at presentation were very similar in both male and female patients. At presentation, 87.5% of female patients had anemia compared with only 69% of male patients. Males had a statistically significant higher mean hemoglobin level compared with females (12.87 versus 10.29 g) at P = 0.0001. Seventy-nine percent of female patients compared with 86% of male patients presented with left-sided tumors. Fifty-five percent of males presented with late stage disease compared with 68% of females (P = 0.27). Female sex seemed to adversely affect the prognosis, although this did not reach statistical significance (P = 0.08). Stage of disease was associated with worse prognosis and this was independent of sex. Age and hemoglobin were not independent predictors of mortality. CONCLUSION: Colorectal cancer does occur in females of childbearing age who might have a tendency to present with late stage disease as evidence from this study. Young female patients with anemia should be questioned about gastrointestinal symptoms, and colorectal cancer should definitely be in the differential diagnoses. This might conceivably allow for earlier diagnosis and potential for cure in this patient group

OBJECTIVE: This study explored the perspectives of hypertensive African-American patients, in 2 primary care practices, regarding the factors they perceived as barriers or facilitators of adherence to prescribed antihypertensive medications. DESIGN: This qualitative study used a grounded theory methodology with data collection occurring through in-depth individual patient interviews. SETTING AND PARTICIPANTS: One hundred and six hypertensive African-American patients followed at 2 urban primary care practices participated in the open-ended interviews. METHODS: During interviews, patients' experiences taking antihypertensive medications and their perceptions of the challenges they face in adhering to their medications as prescribed were explored. Patients were also asked about the situations that make it easy or difficult for them to take their antihypertensive medications as prescribed and the skills they thought were necessary for patients to adhere to their medications as prescribed. All responses were recorded verbatim and analyzed using grounded theory methodology. RESULTS: Fifty-eight percent of participants were women, mean age was 56 years, and 60% had uncontrolled hypertension. Four categories of barriers and 5 categories of facilitators were identified. The barriers included patient-specific, medication-specific, logistic, and disease-specific barriers. The facilitators included use of reminders, having a routine, knowledge about hypertension, its treatment and complications, having social support and good doctor-patient communication. CONCLUSION: This study provides a framework for investigating issues of medication adherence in hypertensive African Americans by describing a taxonomy of barriers and facilitators of adherence identified by patients

Self-efficacy, a known predictor of a wide range of health behaviors, has not been investigated in studies of adherence to antihypertensive medications. A medication adherence self-efficacy scale was developed and evaluated in ambulatory hypertensive African-American patients in two sequential phases. For the item-generation phase, open-ended interviews with 106 patients were used to elicit their experiences with taking antihypertensive medications. Using qualitative techniques, responses were recorded verbatim, coded, and sorted into nine categories of barriers and facilitators of medication adherence. Concepts from categories were formatted into an initial 43-item self-efficacy questionnaire, which was administered to another group of 72 patients for the item analyses phase. Twenty-six items were retained for the final self-efficacy scale based on item-to-total correlation coefficient >0.5, kappa >0.4, and clinical relevance of individual items. Clinicians and researchers can use this scale to identify situations in which patients have low self-efficacy in adhering to prescribed medications

Patients who have been relieved of cardiac symptoms following angioplasty may not be sufficiently motivated to initiate behavior changes that can reduce risk of subsequent cardiac events. Finding an effective means to help patients modify their behavior thus presents a unique challenge. This paper describes an innovative behavioral intervention whose theoretical underpinning is net-present value economic theory. This intervention is being evaluated in a randomized controlled trial in which all patients complete a computerized baseline health assessment of 14 cardiovascular risk factors. Each patient is presented with an individualized risk-factor profile and asked to choose risk factors for modification. In the experimental group, each risk factor is presented with a corresponding numerical biologic age value that represents the relative potential to benefit from modifying each risk factor. Risk reduction for these patients is framed as the opportunity to reduce present biologic age (the net-present value), and improve current health status and quality of life. In the control group, risk reduction is framed in the standard risk-factor approach as the value of preventing future health problems. We hope to demonstrate that economic theory is a plausible perspective from which to design interventions aimed at communicating risk and facilitating change in health behaviors