Jennifer B. McClure

Predictors of outpatient medical appointment attendance among persons with HIV.

Non-adherence to medical regimens is a critical threat to the health of HIV-infected individuals. Patients who do not adhere to routine medical care cannot fully benefit from the increasingly efficacious treatments available to them. Consistent attendance at medical appointments plays a central role in both prolonging life and enhancing quality of life for persons living with HIV/AIDS. By identifying why many patients do not reliably attend medical services, interventions can be undertaken to improve appointment-keeping. The primary purpose of the present study was to identify factors predictive of HIV-related medical appointment attendance. One-hundred-and-forty-four outpatients in a public hospital ambulatory care HIV clinic were followed for seven months. Demographic, medical care and psychosocial factors were measured in order to prospectively predict the percentage of missed clinic appointments by persons with HIV disease. Greater outpatient appointment non-attendance was associated with younger age, minority status, less severe illness and lower perceived social support. Treatment duration, provider consistency, hopelessness and religious coping did not emerge as significant predictors of outpatient appointment-keeping in this sample. Practical and theoretical implications of these findings are discussed in light of recent medical advances in HIV/AIDS care.

Gender differences in response to nicotine replacement therapy: objective and subjective indexes of tobacco withdrawal.

K. A. Perkins (1996) recently proposed that nicotine reinforcement controls smoking to a greater degree among men than women and that consequently, nicotine replacement therapy (NRT) during smoking cessation should benefit men more than women. The authors tested this hypothesis. Polysomnographic measures of sleep and self-report indexes of tobacco withdrawal were collected pre- and postcessation from an active nicotine patch group and a placebo patch group in a randomized, double-blind clinical trial (N = 34). Objective sleep parameters supported Perkinss hypothesis and indicated that among women, NRT may be less effective at suppressing certain withdrawal responses compared with men and may produce some iatrogenic effects. Valid and reliable self-report measures of withdrawal did not reveal gender differences in response to NRT.

Scheduled reduced smoking: Effects on smoking abstinence and potential mechanisms of action

Although most smokers in our society report that they would like to quit, smoking prevalence rates have remained relatively unchanged during most of the 1990s. This is in contrast to a nearly 50% reduction in prevalence observed over the past 3 decades. Presently, an estimated 25.5% of adults (48 million people) continue to smoke, although most smokers would like to quit. Recent research on the treatment of nicotine dependence has focused primarily on events that occur after the initial cessation period (i.e., the prevention of relapse with behavioral counseling and/or the management of withdrawal symptoms with nicotine replacement therapy). Although these methods are effective, there is evidence that cessation rates may also be enhanced by manipulating smoking behavior prior to quitting. One promising approach is scheduled reduced smoking. Early work with this approach has yielded superior abstinence rates compared to gradual reduction and abrupt cold turkey quitting techniques. In this article, we present an overview of research on scheduled reduced smoking and discuss the effects of the treatment on smoking urges, negative affect, and self-efficacy.

Smoking Cessation 1: An Overview of Research

Although tobacco smoking has long been recognized as having negative health consequences, more than one quarter of the US adult population smokes. This article presents (a) national trends in the prevalence of tobacco smoking, (b) health consequences associated with tobacco smoking and tobaccos mode of action (how tobacco/nicotine cause the problems), and (c) a brief overview of the smoking cessation treatment literature and several recommendations based on the review of research.

Smoking cessation 2: Components of effective intervention

Smoking cessation treatment is an essential component of comprehensive healthcare, but many healthcare providers lack formal training and are hesitant to provide such intervention. The recently published US Agency for Health Care Policy and Research (AHCPR) Smoking Cessation Clinical Practice Guideline provided empirically based recommendations to address these issues. The most effective components of smoking cessation include the use of nicotine replacement therapy, provider support and encouragement, and training in such skills as problem solving and coping. Methods of using these recommendations are illustrated, and sample scripts are offered to serve as references for providers from various disciplines who conduct smoking cessation interventions.

An evaluation of videotaped vignettes for smoking cessation and relapse prevention during pregnancy: the Very Important Pregnant Smokers (VIPS) program

1This may be a particularly important time to focus on innovations in self help technology for pregnant smokers. Printed materials are the major media by which current self help interventions are delivered, and in the general population their overall eVectiveness has been shown to be similar to no treatment control conditions. 1 Moreover, currently available treatments for pregnant smokers have often emphasised provider delivered counselling but have typically failed to incorporate treatment components that address some of the major contributors to relapse in the general population, such as negative aVect, depression, smoking cues, positive mood/celebration, etc. 2

Early Appointment Adherence Among Persons Living with HIV

Medical care for HIV disease may be most effective when medical surveillance and services are initiated early and consistently maintained over time. To benefit from continually improving HIV care regimens, persons living with HIV/AIDS must first adhere to their outpatient medical appointments. The purpose of this study was to examine psychosocial, illness, and demographic factors associated with appointment adherence problems early in HIV treatment. Results indicated that nonadherence to outpatient medical appointments was a significant problem. One hundred forty-four patients were followed for 6 months after their initial appointment at a public HIV clinic. One in five dropped out of treatment before completing their intake assessment (separate nurse and physician appointments). Men and individuals with lower levels of social support were most likely to drop out before seeing a physician. Emotional distress was not associated with early dropout, but elevated levels of anxiety and depression were found across the sample. Those still attending the clinic (n = 114) were then followed for 12 months after clinic enrollment. Overall, 35% of scheduled medical appointments were missed during this period. Higher baseline CD4 counts and injection drug use history were predictive of poor appointment adherence, but other demographic and psychosocial indices were not. These findings suggest increased research and early intervention efforts are needed to improve appointment adherence among persons living with HIV/AIDS.

Smoking cessation 3: Needed healthcare policy changes

Smoking is the primary preventable cause of mortality and morbidity in our society, killing more than 430,000 people each year--more than 1,000 a day. Despite this deadly record, the treatment of nicotine dependence has not been integrated into routine medical care. Although professionals from many healthcare fields can be effective providers of smoking cessation treatment, relatively few actually advise patients to quit smoking; and even fewer assist their patients in quitting. Systematic changes in healthcare policies are needed to rectify these problems and improve the provision of smoking cessation services. In this article, the issues of who should be providing cessation treatment, why more providers do not offer this service, and what changes should be made to ensure more widespread inclusion of smoking cessation treatment in future healthcare practice are examined.