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Predictors
of Self-care Behavior in Adults With Type 2 Diabetes:
An RRNeST Study
TL Alright; M Parchman;
SK Burge; and the RRNeST Investigators
Background and Objectives: Four factors have been linked
with self-care behaviors in patients with type 2 diabetes:
(1) patient demographics, (2) doctor-patient relationship,
(3) stress, and (4) social context. This study determined
the relationship of each of these factors on self-care
behavior in diabetic family practice patients. Methods:
We conducted a cross-sectional survey of patients seeking
care in the outpatient clinics of the Residency Research
Network of South Texas (RRNeST), a network of six family
practice residency programs affiliated with the University
of Texas Health Science Center at San Antonio. A total
of 397 consecutive adults with type 2 diabetes presenting
for appointments with family medicine faculty and family
practice residents over a 6-month time period were surveyed
about various factors and their relationship to self-care
behavior pertinent to diabetes. Results: Self-care was
related to age, patient satisfaction with his/her doctor-patient
relationship, personal stress, and family context. Social
context, as reflected by the statement “My family understands
my diabetes,” was strongly associated with diet, exercise,
and medication adherence. Multivariate analysis demonstrated
that, after controlling for patient demographic characteristics
and patient satisfaction, personal stress and social
context were strongly associated with self-care, especially
diet. Conclusions: Social context, specifically the
family, is significantly associated with self-care behaviors.
Attempts to improve self-care behavior should include
the family members of the diabetic patient. Since family
physicians often provide care to multiple members of
the family, they are ideally positioned to implement
these interventions.
(Fam Med 2001;33(5):354-60.)
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Health Needs
of People Living Below Poverty Level
BA Elliott; MK Beattie; SE Kaitfors
Background and Objectives: Low-income populations,
especially persons without health insurance, suffer
disproportionately with a variety of chronic ailments,
postpone getting medical care, and have shorter life
spans. This study was conducted to better understand
the health care needs and behaviors of people living
in poverty. Methods: Participants for the study were
recruited through agencies serving low-income and homeless
people, neighborhood businesses, churches, and subsidized
housing units. All participants were adults who had
incomes below 200% of the federal poverty level. Subjects
completed face-to-face interviews to answer questions
about demographics and their concerns about health care.
Quantitative and qualitative analyses were performed.
Results: A total of 750 people were interviewed, with
729 providing usable data. Thirty-seven percent of subjects
reported spending at least part of the previous year
without health insurance. Fifty-six percent of these
individuals were persons who were employed but whose
employers did not provide health insurance. Reported
health concerns were access to care (reported by 21%
of subjects), costs of care (13%), and ability to purchase
medications (15%). Forty-five percent of subjects reported
receiving mental health services; these subjects were
concerned about their ability to continue receiving
care and to afford medications. Conclusions: The portion
of the low-income population that is uninsured for part
or all of a year is greater than in published reports.
The health behaviors of this group are easily understood
when coverage (if any), level of income, age, and health
care needs are considered.
(Fam Med 2001;33(5):361-6.)
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Smoking in
a Saudi Community: Prevalence, Influencing Factors,
and Risk Perception
S Siddiqui; DO Ogbeide; IA Khalifa
Background and Objectives: Smoking is a major preventable
cause of morbidity and mortality all over the world,
but little information is available about the prevalence
of smoking in Saudi Arabia. This study determined the
prevalence of and major factors influencing smoking
in our community. Methods: We used a questionnaire to
determine smoking prevalence of males over age 12 attending
a primary care clinic in Saudi Arabia. The questionnaire
included items about factors influencing the decision
to start smoking, attempts to stop smoking, and awareness
of the risks of smoking. Results: Of 634 subjects, 34.4%
(218) were current smokers, 16.4% (104) were ex-smokers,
and 49.2% (312) were nonsmokers. The most common (66%)
reason for starting smoking was friends’ influence.
About 75% had thought of stopping smoking, and 55% had
actually attempted to stop. The most common (34%) reason
reported for failed attempts to stop smoking was lack
of willpower. Awareness regarding the harmful effects
of smoking was high (97.2%). More than 80% thought that
a special smoking clinic would be helpful for quitting
smoking. Conclusions: Smoking prevalence is high in
our community in Saudi Arabia. Most of the smokers know
that smoking is dangerous and want to quit smoking but
fail to stop for various reasons. Interventions are
needed to decrease the prevalence of smoking in Saudi
Arabia. (Fam Med 2001;33(5):367-70.)
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Cancer Education
for the Generalist Physician
JL Smith
Background and Objectives: The care of cancer patients
has become increasingly complex and multidisciplinary,
while more responsibility for cancer care has been shifted
to primary care physicians. We developed a medical student
educational program to teach future primary care physicians
about care of cancer patients. Methods: The Multidisciplinary
Oncology Clerkship was designed for fourth-year medical
students planning to enter primary care residencies.
The clerkship has five major components: ambulatory
patient care, multidisciplinary conferences, skill stations,
problem-based learning in small groups, and supervised
objective structured clinical examinations. Learning
during the clerkship was evaluated with knowledge tests
before, immediately after, and 6 months after the clerkship.
Results: Twenty-four students participated in the first
year of the clerkship. Program evaluation revealed that
the students’ scores on the knowledge test rose 40%
between the pre-clerkship and post-clerkship tests.
Retesting at 6 months demonstrated knowledge retention
of 90%. Conclusions: Multidisciplinary cancer education,
using the combination of problem-based learning, skill
stations, clinical exposure, and standardized patients,
increases the cancer-care knowledge of medical students
dedicated to a career in primary care.
(Fam Med 2001;33(5):371-5.)
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Where Are
We on Teen Sex? Delivery of Reproductive Health Servcies
to Adolescents by Family Physicians
EAS Kelts; MJ Allan; JD Klein
Background and Objectives: This study describes variation
in reproductive health preventive services delivery
to adolescents by family physicians in Upstate New York.
Methods: We surveyed a stratified random sample of 354
family physicians from three New York State metropolitan
statistical areas about the proportion of their adolescent
patients (ages 15–18) to whom they deliver preventive
reproductive health interventions. Responses were averaged
to create a preventive care practice score. Results:
Of 295 eligible respondents, 179 returned completed
surveys (61%). Eighty-one percent were male. Respondents
did not vary by geographical area. However, female family
physicians were less likely to respond than males, and
older family physicians were less likely to respond
than more-recent graduates. On average, family physicians
reported asking 79% of their adolescent patients about
contraceptive use, 73% about condom use, 72% about sexual
relationships, and 61% about sexual behaviors. Only
36% reported asking teens when they thought sex was
appropriate, and 30% had discussed sexual orientation.
Seventy-six percent of physicians discussed adolescents’
risks of HIV with adolescent patients, 78% advised adolescent
patients to use condoms, 21% gave handouts about HIV,
and 9% gave condoms to adolescent patients. Factors
associated with provision of more preventive reproductive
services included regularly discussing confidentiality,
more-recent medical school graduation, placing a high
value on the American Academy of Family Physicians recommendations,
having read Centers for Disease Control immunization
guidelines, having read American Academy of Pediatrics
guidelines, and female gender. Overall, these factors
explained 26% of the variance in provision of preventive
reproductive services. Conclusions: Family physicians
report providing most reproductive preventive services
to more than half of their patients. Female physicians,
older physicians, physicians who regularly discuss confidentiality,
and physicians who have a more-positive attitude toward
and familiarity with preventive care guidelines are
more likely to provide reproductive health screening
and counseling during adolescent visits.
(Fam Med 2001;33(5):376-81.)
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Family Medicine's
Failures: Reflections on Keystone III
JG Halvorsen
Background and Objectives: Even though curriculum skills
are widely acknowledged to be an important part of faculty
development in family medicine, reports of outcomes
of programs that teach those skills are rarely found
in the medical education literature. The Curriculum
Workshop Series, one part of a 1-year faculty development
fellowship for recent residency graduates, was designed
to teach curriculum skills to junior faculty. The Program:
Developed as part of the Harbor-UCLA Family Medicine
Faculty Development Fellowship, the Curriculum Workshop
Series consisted of monthly or twice-monthly group sessions,
readings, discussion, and individual projects with feedback
from colleagues and the instructor. Objectives included
developing an understanding of six fundamental steps
of curriculum development, completion of an individual
project, and giving and receiving feedback regarding
projects. Outcome measures included number of projects
implemented, the quality of projects, and participant
satisfaction. Outcomes: Eight fellows participated in
the Curriculum Workshop Series and completed projects.
Six of eight were implemented, providing three new curricular
opportunities and three enhancements to existing curricula
for three family practice residency programs. Review
of projects by outside experts showed that a majority
of the six steps were addressed by most fellows but
that more emphasis needed to be placed on the clarity
of the written curriculum, the link between teaching
strategies and specific learning objectives, and evaluation
of learners and projects. Participants endorsed the
relevance of curriculum skills, the practical step-by-step
approach to curriculum development, and the opportunity
to produce and implement an individual project. Conclusions:
The Curriculum Workshop Series provides a straightforward
format for teaching curriculum skills to junior faculty
and demonstrates that recent graduates have the ability
to make a contribution in the area of curriculum development.
The format presented here could readily be adapted to
other faculty development settings. Long-term outcomes
of this type of faculty development remain to be studied.
(Fam Med 2001;33(5):382-7.)
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of Contents]
Relational
Value: Bridging the Worldview Gap Between Patients and
Health Systems
JP Zubialde; JW Mold
Since its inception, family medicine has understood
the importance of a holistic approach to health care
and the benefits stemming from integrating health care
resources. This approach and its benefits have not,
however, been fully appreciated by consumers, payers,
and policy makers, especially in today’s dynamic marketplace.
Articulating the benefits of an integrated approach
is more likely to be effective if done in the language
of the marketplace and in a framework that helps them
understand the critical importance of relationships
that are needed for integrating consumers’ needs with
resources in systems. By using the concept of “value”
recognized within the marketplace, this article cr |
