Peter S. Houts

Using pictographs to enhance recall of spoken medical instructions II

The first study in this series [Houts PS, Bachrach R, Witmer JT, Tringali CA, Bucher JA, Localio RA. Patient Educ. Couns. 1998;35:83-8] found that recall of spoken medical instructions averaged 14% but that, when pictographs (drawings representing the instructions) accompanied the spoken instructions and were present during recall, 85% of medical instructions were remembered correctly. Those findings suggested that spoken instructions plus pictographs may be a way to give people with low literacy skills access to medical information that is normally available only in written form. However, there were three important limitations to that study: (1) the subjects were literate and perhaps literate people remember pictograph meanings better than people with low literacy skills; (2) only short term recall was tested and, for medical information to be useful clinically, it must be remembered for significant periods of time and (3) a maximum of 50 instructions were shown in pictographs, whereas managing complex illnesses may require remembering several hundred instructions. This study addresses those limitations by investigating 4-week recall of 236 medical instructions accompanied by pictographs by people with low literacy skills. Subjects were 21 adult clients of an inner city job training program who had less than fifth grade reading skills. Results showed 85% mean correct recall of pictograph meanings immediately after training (range from 63 to 99%) and 71% after 4 weeks (range from 33 to 94%). These results indicate that people with low literacy skills can, with the help of pictographs, recall large amounts of medical information for significant periods of time. The impact of pictographs on symptom management and patient quality of life remains to be studied.

Project genesis: Assessing the efficacy of problem-solving therapy for distressed adult cancer patients

The efficacy of problem-solving therapy (PST) to reduce psychological distress was assessed among a sample of 132 adult cancer patients. A second condition provided PST for both the patient and a significant other. At posttreatment, all participants receiving PST fared significantly better than waiting list control patients. Further, improvements in problem solving were found to correlate significantly with improvements in psychological distress and overall quality of life. No differences in symptom reduction were identified between the 2 treatment protocols. At a 6-month follow-up, however, patients who received PST along with their significant other reported lower levels of psychological distress as compared with members of the PST-alone condition on approximately half of the outcome measures. These effects were further maintained 1-year posttreatment.

Caregiver burden and unmet patient needs

Four‐hundred eighty‐three patients with cancer and their informal caregivers were studied. Patients reported on met and unmet needs in personal care activities (bathing and dressing), instrumental activities (heavy and light housekeeping, cooking, shopping), transportation (medical and general), and home health care (health/treatment assistance). A minority (18.9%) experienced an unmet need. Hierarchical logistic regression was used to identify significant predictors of any unmet need. Patients were more likely to report any unmet needs when their illness/treatment resulted in restricted activity days, when their financial resources were reduced enough for them to apply for Medicaid or Public Assistance, or when their caregivers were not their spouses. Although in general, the likelihood of an unmet need decreased as the number of domains of assistance provided by the caregiver increased, if that care was associated with a high level of burden, the odds of a patient reporting an unmet need actually increased.

Women athletes with menstrual irregularity have increased musculoskeletal injuries.

We have performed a retrospective three-phase study to evaluate the effect of menstrual status upon musculoskeletal injuries in women athletes. Initially, we collected the menstrual and running histories of women participants in a regional 10-km footrace. In this study, 61% of the respondents to our questionnaire reported a continuous running program, and 39% reported an interruption of at least 3 months of their running program. The most common cause for interruption was injury. Those who had interrupted their running were more likely to have had irregular or absent menses and less likely to have been using oral contraceptives than the group of continuous runners. Secondly, we obtained information on the relationship between bone injury and menstrual status by reviewing the sports medicine records of 207 collegiate women athletes. We found that X-ray-documented fractures occurred in 9% of women athletes with regular menses and in 24% of women athletes with irregular or absent menses. Subsequently, we collected data from a larger population of more serious, but still recreational runners, participating in a national 10-km race. Each portion of this study has yielded similar results: those women who had been injured during their running program were more likely to have had absent or irregular menses, were less likely to have used oral contraceptives, and had been running for more years. We conclude that premenopausal women who have absent or irregular menses, while engaged in vigorous exercise programs, are at increased risk for musculoskeletal injury.

Unmet psychological, social, and economic needs of persons with cancer in pennsylvania

Six hundred twenty‐nine persons with cancer (PWC) selected from the Pennsylvania Cancer Registry plus 397 nonprofessional (support) persons involved in their care (SP) were interviewed to determine their views of the unmet psychological, social and economic needs of PWC. The most frequently mentioned unmet need was for help in dealing with emotional problems (estimated at 25% of PWC state‐wide). Other unmet need estimates ranged from 14% for financial to 4% for transportation, with 59% of PWC reporting at least one unmet need. Characteristics of PWC reporting unmet needs included being younger, a history of emotional problems, a chronic illness in addition to cancer, more advanced stage at diagnosis, and a diagnosis of lung cancer. The percent of PWC and CP reporting unmet needs were very similar. These findings indicate that more effective screening for psychosocial problems and referral to supportive services is needed.

Helping cancer patients cope: A problem-solving approach

Cancer and its Consequences A Problem-Solving Conceptualization of Coping - Theory, Research and Relevance to Cancer Problem-Solving Therapy for Cancer Patients - Overview, Process and Related Clinical Issues Critical Elements of Training Problem Orientation Problem Definition and Formulation Generation of Alternatives Decision Making Solution Implementation and Verification Practice, Practice, Practice Problem-Solving Education for Family Caregivers of Cancer Patients.

Unmet needs of persons with cancer in pennsylvania during the period of terminal care

A stratified random sample of recent cancer deaths was drawn from the Pennsylvania death registry, and 433 family members or close friends were interviewed concerning unmet needs during the last month of life. It was estimated that 72% of persons who died of cancer in Pennsylvania experienced at least one unmet service need during this period. The most frequently reported was help with activities of daily living, estimated at 42% of cancer deaths, involving over 11,000 persons each year in the state. There were significantly more unmet needs during the terminal period, compared with just after diagnosis, in activities of daily living, obtaining health care, transportation, and problems with medical staff. Our findings indicate a need to increase a broad range of support programs during the terminal period, especially of home‐care services.

Unmet psychosocial needs of Pennsylvanians with cancer: 1986-2005.

The purpose of the current study was to identify unmet psychosocial needs of cancer survivors, understand the distribution of needs across subgroups, and compare unmet needs in 2005 with those identified by Houts et al. in 1986.

Reported Practice Behaviors for Medical Care of Patients With Diabetes Mellitus by Primary-Care Physicians in Pennsylvania

Objective To compare the American Diabetes Association standards for the medical care of diabetic patients with reported care patterns. Research Design and Methods These standards were compared with reported care patterns obtained from a stratified random telephone survey of general practitioners, family physicians, and general internists in Pennsylvania. A total of 610 physicians completed the survey for a response rate of 73%. Results All primary-care physicians reported measurement of glycosylated hemoglobin, routine referrals to eye doctors, and patient self-monitoring of blood glucose < recommended. Nearly all physicians performed foot exams, but the exams were infrequent for many of the physicians. Significant and independent differences (P < 0.05) were noted between different groups of physicians. Older physicians and general practitioners reported patterns of care most different from the recommended standards for referral to eye doctors, measurement of glycosylated hemoglobin, and use of patient self-monitoring of blood glucose. General practitioners reported the lowest frequency of foot exams. Conclusions Educational programs on diabetes for primary-care physicians should focus on reported behaviors most different from recommended standards and may need to target subgroups of physicians to achieve a more uniform level of care for all diabetic patients.

Managed Problem Solving for Antiretroviral Therapy Adherence A Randomized Trial

BACKGROUND Adherence to antiretroviral therapy is critical to successful treatment of human immunodeficiency virus (HIV). Few interventions have been demonstrated to improve both adherence and virologic outcomes. We sought to determine whether an intervention derived from problem solving theory, Managed Problem Solving (MAPS), would improve antiretroviral outcomes. METHODS We conducted a randomized investigator blind trial of MAPS compared with usual care in HIV-1 infected individuals at 3 HIV clinics in Philadelphia, Pennsylvania. Eligible patients had plasma HIV-1 viral loads greater than 1000 copies/mL and were initiating or changing therapy. Managed Problem Solving consists of 4 in-person and 12 telephone-based meetings with a trained interventionist, then monthly follow-up calls for a year. Primary outcome was medication adherence measured using electronic monitors, summarized as fraction of doses taken quarterly over 1 year. Secondary outcome was undetectable HIV viral load over 1 year. We assessed 218 for eligibility, with 190 eligible and 180 enrolled, 91 randomized to MAPS and 89 to usual care. Fifty-six participants were lost to follow-up: 33 in the MAPS group and 23 in usual care group. RESULTS In primary intention-to-treat analyses, the odds of being in a higher adherence category was 1.78 (95% CI,1.07-2.96) times greater for MAPS than usual care. In secondary analyses, the odds of an undetectable viral load was 1.48 (95% CI, 0.94-2.31) times greater for MAPS than usual care. In as-treated analyses, the effect of MAPS was stronger for both outcomes. There was neither a difference by prior treatment status nor change in effect over time. CONCLUSIONS Managed Problem Solving is an effective antiretroviral adherence intervention over the first year with a new regimen. It was equally effective at improving adherence in treatment experienced and naïve patients and did not lose effect over time. Implementation of MAPS should be strongly considered where resources are available. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00130273.