John P. Allegrante

A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: implications for health education practice (part I).

Disability and poor quality of life attributable to chronic diseases such as arthritis, diabetes, and heart disease constitute challenging public health problems for American society. In the absence of any effective cure for these conditions, the secondary prevention of complications and improving quality of life and functional capacity through better disease self-management becomes critical and are key objectives of Healthy People 2010. The organizing focus of such disease self-management should be on improving coping, communication, and control by enhancing self-efficacy. Part I of this two-part article describes the common clinical features of chronic diseases and the diverse disease management strategies used for alleviating pain and preventing disability associated with these and reviews the role of self-efficacy as a theoretical framework for successful self-management interventions. Part II identifies and synthesizes the key research evidence for educational interventions designed to enhance individual self-efficacy perceptions and presents implications for practice in patient education.

Supervised fitness walking in patients with osteoarthritis of the knee. A randomized, controlled trial.

OBJECTIVE To assess the effect of a program of supervised fitness walking and patient education on functional status, pain, and use of medication in patients with osteoarthritis of the knee. DESIGN An 8-week randomized, controlled trial. SETTING Inpatient and outpatient services of an orthopedic hospital in an academic medical center. PATIENTS A total of 102 patients with a documented diagnosis of primary osteoarthritis of one or both knees participated in the study. Data were obtained on 47 of 51 intervention patients and 45 of 51 control patients. INTERVENTIONS An 8-week program of supervised fitness walking and patient education or standard routine medical care. MEASUREMENTS Patients were evaluated and outcomes assessed before and after the intervention using a 6-minute test of walking distance and scores on the physical activity, arthritis impact, pain, and medication subscales of the Arthritis Impact Measurement Scale (AIMS). RESULTS Patients randomly assigned to the walking program had a 70-meter increase in walking distance relative to their baseline assessment, which represents an improvement of 18.4% (95% Cl, 9.8% to 27.0%). In contrast, controls showed a 17-meter decrease in walking distance relative to their baseline assessment (P less than 0.001). Improvements in functional status as measured by the AIMS physical activity subscale were also observed in the walking group but not in the control group (P less than 0.001); patients assigned to the walking program improved 39% (Cl, 15.6% to 60.4%). Although changes in scores on the arthritis impact subscale were similar in the two groups (P = 0.093), the walking group experienced a decrease in arthritis pain of 27% (Cl, 9.6% to 41.4%) (P = 0.003). Medication use was less frequent in the walking group than in the control group at the post-test (P = 0.08). CONCLUSIONS A program of supervised fitness walking and patient education can improve functional status without worsening pain or exacerbating arthritis-related symptoms in patients with osteoarthritis of the knee.

Hip fractures among the elderly: causes, consequences and control

This review examines all pertinent literature sources published in the English language between 1966 to the present concerning hip fracture epidemiology, hip fracture injury mechanisms, and hip fracture management strategies. These data reveal hip fractures have several causes, but among these, the impact of falls and muscle weakness, along with low physical activity levels seems to be the most likely explanation for the rising incidence of hip fracture injuries. Related determinants of suboptimal nutrition, drugs that increase fall risk and lower the safety threshold and comorbid conditions of the neuromuscular system may also contribute to hip fracture disability. A number of interventions may help to prevent hip fracture injuries, including, interventions that optimize bone mass and quality, interventions that help prevent falls and falls dampening interventions. Rehabilitation outcomes may be improved by comprehensive interventions, prolonged follow-up strategies and ensuring that all aging adults enjoy optimal health.

A Practice-Based Trial of Motivational Interviewing and Adherence in Hypertensive African Americans

BACKGROUND Poor medication adherence is a significant problem in hypertensive African Americans. Although motivational interviewing (MINT) is effective for adoption and maintenance of health behaviors in patients with chronic diseases, its effect on medication adherence remains untested in this population. METHODS This randomized controlled trial tested the effect of a practice-based MINT counseling vs. usual care (UC) on medication adherence and blood pressure (BP) in 190 hypertensive African Americans (88% women; mean age 54 years). Patients were recruited from two community-based primary care practices in New York City. The primary outcome was adherence measured by electronic pill monitors; the secondary outcome was within-patient change in office BP from baseline to 12 months. RESULTS Baseline adherence was similar in both groups (56.2 and 56.6% for MINT and UC, respectively, P = 0.94). Based on intent-to-treat analysis using mixed-effects regression, a significant time x group interaction with model-predicted posttreatment adherence rates of 43 and 57% were found in the UC and MINT groups, respectively (P = 0.027), with a between-group difference of 14% (95% confidence interval, -0.2 to -27%). The between-group difference in systolic and diastolic BP was -6.1 mm Hg (P = 0.065) and -1.4 mm Hg (P = 0.465), respectively, in favor of the MINT group. CONCLUSIONS A practice-based MINT counseling led to steady maintenance of medication adherence over time, compared to significant decline in adherence for UC patients. This effect was associated with a modest, nonsignificant trend toward a net reduction in systolic BP in favor of the MINT group.

Health Behavior and Academic Achievement Among Adolescents: The Relative Contribution of Dietary Habits, Physical Activity, Body Mass Index, and Self-Esteem

This study tested a structural equation model to estimate the relationship between health behaviors, body mass index (BMI), and self-esteem and the academic achievement of adolescents. The authors analyzed survey data from the 2000 study of Youth in Iceland , a population-based, cross-sectional sample of 6,346 adolescents in Iceland. The model demonstrated good fit with chi-square of 2685 (n = 5,810, df = 180), p < .001, Comparative Fit Index value of .94, and a root mean square error of approximation of .049. Lower BMI, physical activity, and good dietary habits were all associated with higher academic achievement; however, health behavior was positively and robustly associated with greater self-esteem. Self-esteem was positively influenced both through physical activity (β = .16) and the consumption of fruits and vegetables (β = .14). In contrast, poor dietary habits negatively influenced self-esteem and academic achievement, and self-esteem was negatively influenced by increasing levels of BMI (β = —.05).

Development and evaluation of a medication adherence self-efficacy scale in hypertensive African-American 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.

A Randomized Controlled Trial of Positive-Affect Intervention and Medication Adherence in Hypertensive African Americans

BACKGROUND Poor adherence explains poor blood pressure (BP) control; however African Americans suffer worse hypertension-related outcomes. METHODS This randomized controlled trial evaluated whether a patient education intervention enhanced with positive-affect induction and self-affirmation (PA) was more effective than patient education (PE) alone in improving medication adherence and BP reduction among 256 hypertensive African Americans followed up in 2 primary care practices. Patients in both groups received a culturally tailored hypertension self-management workbook, a behavioral contract, and bimonthly telephone calls designed to help them overcome barriers to medication adherence. Also, patients in the PA group received small gifts and bimonthly telephone calls to help them incorporate positive thoughts into their daily routine and foster self-affirmation. The main outcome measures were medication adherence (assessed with electronic pill monitors) and within-patient change in BP from baseline to 12 months. RESULTS The baseline characteristics were similar in both groups: the mean BP was 137/82 mm Hg; 36% of the patients had diabetes; 11% had stroke; and 3% had chronic kidney disease. Based on the intention-to-treat principle, medication adherence at 12 months was higher in the PA group than in the PE group (42% vs 36%, respectively; P =.049). The within-group reduction in systolic BP (2.14 mm Hg vs 2.18 mm Hg; P = .98) and diastolic BP (-1.59 mm Hg vs -0.78 mm Hg; P = .45) for the PA group and PE group, respectively, was not significant. CONCLUSIONS A PE intervention enhanced with PA led to significantly higher medication adherence compared with PE alone in hypertensive African Americans. Future studies should assess the cost-effectiveness of integrating such interventions into primary care. Trial Registration clinicaltrials.gov Identifier: NCT00227175.

The Galway Consensus Conference: international collaboration on the development of core competencies for health promotion and health education

Developing a competent health promotion workforce is a key component of capacity building for the future and is critical to delivering on the vision, values and commitments of global health promotion. This paper reports on an international consensus meeting to identify core competencies, jointly organized by the International Union for Health Promotion and Education (IUHPE), the Society for Public Health Education (SOPHE) and the US Centers for Disease Control (CDC), with participation from international leaders in the field, that took place at the National University of Ireland, Galway, in June 2008. The purpose of the meeting is outlined and the outcomes in terms of strengthening global exchange, collaboration and common approaches to capacity building and workforce development are discussed. The Consensus Statement, based on the proceedings of the meeting, outlines core values and principles, a common definition and eight domains of core competency that are required to engage in effective health promotion practice. The core domains of competency agreed to at the meeting are: catalysing change, leadership, assessment, planning, impementation, evaluation, advocacy and partnerships. A summary of the Consensus Statement is presented and further dialogue and discussion are invited in order to continue the process of building international consensus with regard to health promotion core competencies. (Global Health Promotion, 2009; 16 (2): pp. 5—11)

Self-Efficacy Mediates the Relationship Between Depressive Symptoms and Medication Adherence Among Hypertensive African Americans:

Many studies have documented the negative effects of depression on adherence to recommended treatment; however, little is known about the mechanism underlying this relationship. Using the Kenny and Baron analytic framework of mediation, the authors assessed whether self-efficacy mediated the relationship between depression and medication adherence in 167 hypertensive African Americans followed in a primary care practice. Depressive symptoms are associated with poor medication adherence (β = .013, p = .036) and low self-efficacy (β = —.008, p = .023). Self-efficacy is negatively associated with medication adherence at follow-up (β = —.612, p < .001). The relationship between depressive symptoms and medication adherence becomes nonsignificant when controlling for self-efficacy (β = .010, p = .087). Implications for further examination into the mediating role of self-efficacy and the deleterious effect of depression on medication adherence are discussed.

A Randomized Controlled Trial of Positive-Affect Induction to Promote Physical Activity After Percutaneous Coronary Intervention

BACKGROUND Within 1 year after percutaneous coronary intervention, more than 20% of patients experience new adverse events. Physical activity confers a 25% reduction in mortality; however, physical activity is widely underused. Thus, there is a need for more powerful behavioral interventions to promote physical activity. Our objective was to motivate patients to achieve an increase in expenditure of 336 kcal/wk or more at 12 months as assessed by the Paffenbarger Physical Activity and Exercise Index. METHODS Two hundred forty-two patients were recruited immediately after percutaneous coronary intervention between October 2004 and October 2006. Patients were randomized to 1 of 2 groups. The patient education (PE) control group (n = 118) (1) received an educational workbook, (2) received a pedometer, and (3) set a behavioral contract for a physical activity goal. The positive-affect/self-affirmation (PA) intervention group (n = 124) received the 3 PE control components plus (1) a PA workbook chapter, (2) bimonthly induction of PA by telephone, and (3) small mailed gifts. All patients were contacted with standardized bimonthly telephone follow-up for 12 months. RESULTS Attrition was 4.5%, and 2.1% of patients died. Significantly more patients in the PA intervention group increased expenditure by 336 kcal/wk or more at 12 months, our main outcome, compared with the PE control group (54.9% vs 37.4%, P = .007). The PA intervention patients were 1.7 times more likely to reach the goal of a 336-kcal/wk or more increase by 12 months, controlling for demographic and psychosocial measures. In multivariate analysis, the PA intervention patients had nearly double the improvement in kilocalories per week at 12 months compared with the PE control patients (602 vs 328, P = .03). CONCLUSION Patients who receive PA intervention after percutaneous coronary intervention are able to achieve a sustained and clinically significant increase in physical activity by 12 months. Trial Registration clinicaltrials.gov Identifier: NCT00248846.