Decision making processes in people with symptoms of acute myocardial infarction: qualitative study

Objective To identify, the themes that influence decision making processes used by patients with symptoms of acute myocardial infarction. Design Qualitative study using semistructured interviews. Setting Two district hospitals in North Yorkshire. Participants 22 patients admitted to hospital with confirmed second, third, or fourth acute myocardial infarction. Main outcome measure Patients' perceptions of their experience between the onset of symptoms and the decision to seek medical help. Results Six main themes that influence the decision making process were identified: appraisal of In symptoms, perceived risk, previous experience, psychological and emotional factors, use of the NHS, and context of the event. Conclusions Knowledge of symptoms may not be enough to promote prompt action in the event of an acute myocardial infarction. Cognitive and emotional processes, individual beliefs and values, and the influence of the context of the event should also be considered in individual interventions designed to reduce delay in the event of symptoms of acute myocardial infarction

Emergency Stroke Calls: Obtaining Rapid Telephone Triage (ESCORTT) - a programme of research to facilitate recognition of stroke by emergency medical dispatchers

Background: Rapid access to emergency stroke care can reduce death and disability by enabling immediate provision of interventions such as thrombolysis, physiological monitoring and stabilisation. One of the ways that access to services can be facilitated is through emergency medical service (EMS)dispatchers. The sensitivity of EMS dispatchers for identifying stroke is < 50%. Studies have shown that activation of the EMSs is the single most important factor in the rapid triage and treatment of acute stroke patients. Objectives: To facilitate recognition of stroke by emergency medical dispatchers (EMDs). Design: An eight-phase mixed-methods study. Phase 1: a retrospective cohort study exploring stroke diagnosis. Phase 2: semi-structured interviews exploring public and EMS interactions. Phases 3 and 4: a content analysis of 999 calls exploring the interaction between the public and EMDs. Phases 5–7: development and implementation of stroke-specific online training (based on phases 1–4). Phase 8: an interrupted time series exploring the impact of the online training. Setting: One ambulance service and four hospitals. Participants: Patients arriving at hospital by ambulance with stroke suspected somewhere on the stroke pathway (phases 1 and 8). Patients arriving at hospital by ambulance with a final diagnosis of stroke (phase 2). Calls to the EMSs relating to phase 1 patients (phases 3 and 4). EMDs (phase 7). Interventions: Stroke-specific online training package, designed to improve recognition of stroke for EMDs. Main outcome measures: Phase 1: symptoms indicative of a final and dispatch diagnosis of stroke. Phase 2: factors involved in the decision to call the EMSs when stroke is suspected. Phases 3 and 4: keywords used by the public when describing stroke and non-stroke symptoms to EMDs. Phase 8: proportion of patients with a final diagnosis of stroke correctly dispatched as stroke by EMDs. Results: Phase 1: for patients with a final diagnosis of stroke, facial weakness and speech problems were significantly associated with an EMD code of stroke. Phase 2: four factors were identified – perceived seriousness; seeking and receiving lay or professional advice; caller’s description of symptoms and emotional response to symptoms. Phases 3 and 4: mention of ‘stroke’ or one or more Face Arm Speech Test (FAST) items is much more common in stroke compared with non-stroke calls. Consciousness level was often difficult for callers to determine and/or communicate. Phase 8: there was a significant difference (p = 0.003) in proportions correctly dispatched as stroke – before the training was implemented 58 out of 92 (63%); during implementation of training 42 out of 48 (88%); and after training implemented 47 out of 59 (80%). Conclusions: EMDs should be aware that callers are likely to describe loss of function (e.g. unable to grip) rather than symptoms (e.g. weakness) and that callers using the word ‘stroke’ or describing facial weakness, limb weakness or speech problems are likely to be calling about a stroke. Ambiguities and contradictions in dialogue about consciousness level arise during ambulance calls for suspected and confirmed stroke. The online training package improved recognition of stroke by EMDs. Recommendations for future research include testing the effectiveness of the Emergency Stroke Calls: Obtaining Rapid Telephone Triage (ESCORTT) training package on the recognition of stroke across other EMSs in England; and exploring the impact of the early identification of stroke by call handlers on patient and process outcomes. Funding: The National Institute for Health Research Programme Grants for Applied Research programme

Systematic review of the effectiveness of stage based interventions to promote smoking cessation

Objective To evaluate the effectiveness of interventions using a stage based approach in bringing about positive changes in smoking behaviour. Design Systematic review. Data sources 35 electronic databases, catalogues, and internet resources (from inception to July 2002). Bibliographies of retrieved references were scanned for other relevant publications, and authors were contacted if necessary. Results 23 randomised controlled trials were reviewed; two reported details of an economic evaluation. Eight trials reported effects in favour of stage based interventions, three trials showed mixed results, and 12 trials found no statistically significant differences between a stage based intervention and a non-stage based intervention or no intervention. Eleven trials compared a stage based intervention with a non-stage based intervention, and one reported statistically significant effects in favour of the stage based intervention. Two studies reported mixed effects, and eight trials reported no statistically significant differences between groups. The methodological quality of the trials was mixed, and few reported any validation of the instrument used to assess participants’ stage of change. Overall, the evidence suggests that stage based interventions are no more effective than non-stage based interventions or no intervention in changing smoking behaviour. Conclusions Limited evidence exists for the effectiveness of stage based interventions in changing smoking behaviour

Predictors of delay in seeking medical help in patients with suspected heart attack, and interventions to reduce delay: A systematic review.

BACKGROUND: Coronary heart disease (CHD) is the major cause of morbidity and mortality in the UK for both men and women, with acute myocardial infarction (AMI) being the most frequently identified cause of mortality. Thrombolytic therapy in the early hours of an AMI provides considerable risk reduction in terms of damage to the heart and, depending on the agent used, leads to beneficial effects in survival. The effectiveness of thrombolytic therapy is dependent on prompt administration, which has led to increasing attention on the period between the onset of symptoms and treatment. Three different components are involved: patient decision time, transport time, and hospital time from admission to treatment. Patient decision time, defined as the time from onset of signs and symptoms of an AMI to the time when medical assistance is sought, has been found to account for most of this delay. Patient decision time combined with transport time is referred to as pre-hospital delay. The scope for reduction in morbidity and mortality that could result from shortening patient decision time has prompted researchers to investigate what influences patient decision time. Numerous studies have highlighted factors that may be associated with patient decision time, which in turn have prompted the implementation of interventions to improve peoples’ knowledge of the symptoms of AMI and the correct action to take when experiencing such symptoms. OBJECTIVES: To carry out two linked systematic reviews; one to identify the factors associated with patient decision time (referred to as patient delay), and one to evaluate the effectiveness of interventions aiming to reduce patient or pre-hospital delay. In particular, two research questions were addressed: 1) What are the factors that influence the time to seeking medical help following the onset of signs and symptoms of an AMI? 2) How effective are interventions that aim to reduce the time from the onset of signs and symptoms of an AMI to seeking medical help/arrival at hospital

Systematic review of interventions to reduce delay in patients with suspected heart attack

Methods: A systematic review was conducted. Fifteen electronic databases, the internet, and bibliographies of included studies were searched, and experts in the field of cardiac care were contacted. Randomised controlled trials (RCTs), controlled trials, and before and after studies conducted in any setting that assessed an intervention aimed at reducing time from onset of signs and symptoms of an AMI to seeking medical help and/or arrival in hospital were eligible for inclusion. Results: Eleven media/public education intervention studies met the inclusion criteria. Five (one controlled and four before and after studies) reported the intervention to have a statistically positive effect on delay time and six (two RCTs and four before and after studies) reported no statistically significant effect. Three (one RCT and two before and after studies) of five studies evaluating the effect of the intervention on emergency department visits reported an increase in this outcome as a result of the intervention, and both studies (one RCT and one before and after study) examining calls made to emergency switchboards reported an increase in this outcome after the intervention. Conclusions: There was little evidence that media/public education interventions reduced delay. There is some evidence that they may result in an increase in emergency switchboard calls and emergency department visits. Despite substantial expenditure of time and effort, methodological deficiencies of the studies mean that it is not possible to make definitive recommendations

A systematic review of the effectiveness of interventions based on a stages-of-change approach to promote individual behaviour change

Background Over recent years, interest in reducing early mortality and preventing morbidity through lifestyle changes has grown exponentially. Interventions (or methods) used within healthcare settings to modify risky behaviours have increasingly been based on stage theories or staged approaches to behaviour change. The attraction of stage-based models lies in their ability to explain why interventions aimed at large groups or the general public, such as mass media or community interventions, are rarely universally effective. Stage-based models propose that ‘tailored’ interventions, which take into account the current stage an individual has reached in the change process, will be more effective than ‘one size fits all’ interventions. Despite the widespread use of stage-based models, it has been suggested that there is little evidence available about the effectiveness of this approach in changing behaviour. Therefore, this systematic review draws together information about the effectiveness of interventions based on the stages-of-change approach from different settings and different population groups. Objective To systematically assess the effectiveness of interventions using a stage-based approach in bringing about positive changes in health-related behaviour. Methods Search strategy A wide range of electronic databases were searched from inception to May 2000. In addition, searches of the Internet were carried out using a range of search engines. The bibliographies of retrieved references were scanned for further relevant publications. The authors of abstracts appearing in conferences proceedings identified by the literature search were contacted for further information about their research. Selection criteria Randomised controlled trials (RCTs) evaluating interventions, that aimed to influence individual health behaviour, used within a stages-of-change approach were eligible for inclusion. Only studies that reported health-related behaviour change such as smoking cessation, reduced alcohol consumption or dietary intake and stage movemphasizent were included. The target population included individuals whose behaviour could be modified, primarily in order to prevent the onset, or progression, of disease. There was no limitation of study by country of origin, language or date. Procedure Assessment of titles and abstracts was performed independently by two reviewers. If either reviewer considered a reference to be relevant, the full paper was retrieved. Full papers were assessed against the review selection criteria by two independent reviewers, and disagreemphasizents were resolved through discussion. Data were extracted by one reviewer into structured summary tables and checked by a second reviewer. Health behaviour change was the primary outcome of interest. Secondary outcomes included: assessment of stage movemphasizent, health-related outcomes, intermediate outcomes, any adverse effects resulting from the intervention, as well as cost-effectiveness data. Information about the implemphasizentation of each intervention and how the relevant professionüls were trained was also recorded where given. Any disagreemphasizents about data extraction were resolved by discussion. Each included trial was assessed against a comprehensive checklist for methodological quality and quality of the implemphasizentation of the ƒntervention. Quality assessment was performed by one reviewer and checked by a second, with disagreemphasizents resolved by discussion. Results Thirty-seven RCTs were included in the review. Three studies evaluated interventions aimed at prevention (two for alcohol consumption and one for cigarette smoking). In 13 trials the interventions were aimed at smoking cessation, seven studies evaluated interventions aimed at the promotion of physical activity, and five studies evaluated interventions aimed at dietary change. Six trials evaluated interventions aimed at multiple lifestyle changes. Two studies evaluated interventions aimed at the promotion of screening mammography, and one study evaluated an intervention aimed at the promotion of treatment adherence. Four of these studies also included an economic evaluation. Results of the quality assessment Methodological quality of the trials was mixed, and ranged from 2 to 11 out of 13 quality items present. The main problems were lack of detail on the methods used to produce true randomisation (methods of randomisation and concealment of allocation); lack of blinding of participants (where appropriate), outcome assessors and care-providers; and failure to use intention-to-treat analysis. The main issue with the quality of the implemphasizentation was lack of information on the validity of the instrument used to assess an individual’s stage of change. Evidence of effectiveness In one of the 13 trials aimed at smoking cessation the results could not be compared to a non-stage-based intervention, because only stage-based interventions were included. In four of the remaining 12 smoking cessation trials, significant differences favouring the intervention group for scores on quit rates were found; in three of these the comparator was a usual-care control group and in one a non-stage-based intervention. One study showed mixed outcomes. In the remaining seven smoking cessation trials no significant differences between groups in behavioural change outcomes were found. One of the seven trials aimed at the promotion of physical activity did not report any data on behaviour change. Three trials found no significant differences between groups in behavioural change outcomes. Two trials showed mixed effects, and one trial mainly showed significant effects in favour of the stage-based intervention. Two of the five trials aimed at dietary change reported significant effects in favour of the stage-based intervention; in one trial this was in comparison to a non-stage-based intervention and in the other to a usual-care control group. Two trials showed mixed effects, and in one trial no significant differences between groups in behavioural change outcomes were found. Three of the six studies aimed at multiple lifestyle changes showed no differences between groups for any outcomes included. Two studies showed mixed effects, and one study showed positive effects for all outcomes included: smoking cessation, fat intake and physical activity. One of the two trials aimed at the promotion of screening mammography found no significant differences between groups for nearly all outcomes. The other trial showed a significant difference in favour of the stage-based intervention. The trial aimed at the promotion of treatment adherence showed significant results in favour of the stage-based intervention. Two out of three trials aimed at prevention showed no significant differences between groups for any measure of behaviour change. The other trial showed mixed outcomes. Studies with low-income participants tended not to report effects favouring the stage-based intervention. Other study characteristics, such as number of respondents, age and sex of respondents, year of publication, setting and verification of outcome measures, seemphasized to have little relationship with the effectiveness of the stage-based intervention. Conclusions Overall there appears to be little evidence to suggest that stage-based interventions are more effective compared to non-stage-based interventions. Similarly there is little evidence that stage-based interventions are more effective when compared to no intervention or usual-care. Out of 37 trials, 17 showed no significant differences between groups, eight trials showed mixed effects, and ten trials showed effects in favour of the stage-based intervention(s). One trial presented no data on behavioural outcomes, and another included stage-based interventions only. Twenty trials compared a stage-based intervention with a non-stage-based intervention, ten trials reported no significant differences between groups, five reported mixed effects and five reported significant effects in favour of the stage-based intervention. There does not seem to be any relationship between the methodological quality of the study, the targeted behaviour or quality of the implemphasizentation (both in terms of exposure and in terms of full use of the model) and effectiveness of the stage-based intervention. The methodological quality of studies was mixed, and few studies mentioned validation of the stages-of-change instrument. In addition, there was little consistency in the types of interventions employed once participants were classified into stages and little knowledge about the types of interventions needed once people were classified. It was unclear in a number of trials whether the intervention was properly stage-based. Given the limited evidence for the effectiveness of interventions tailored to the stages-of-change approach practitioners and policy makers need to recognise that this approach has a status which appears to be unwarranted when it is evaluated in a systematic way

Systematic review of the effectiveness of stage based interventions to promote smoking cessation

Objective: To evaluate the effectiveness of interventions using a stage based approach in bringing about positive changes in smoking behaviour. Design: Systematic review. Data sources: 35 electronic databases, catalogues, and internet resources (from inception to July 2002). Bibliographies of retrieved references were scanned for other relevant publications, and authors were contacted if necessary. Results: 23 randomised controlled trials were reviewed; two reported details of an economic evaluation. Eight trials reported effects in favour of stage based interventions, three trials showed mixed results, and 12 trials found no statistically significant differences between a stage based intervention and a non-stage based intervention or no intervention. Eleven trials compared a stage based intervention with a non-stage based intervention, and one reported statistically significant effects in favour of the stage based intervention. Two studies reported mixed effects, and eight trials reported no statistically significant differences between groups. The methodological quality of the trials was mixed, and few reported any validation of the instrument used to assess participants' stage of change. Overall, the evidence suggests that stage based interventions are no more effective than non-stage based interventions or no intervention in changing smoking behaviour. Conclusions: Limited evidence exists for the effectiveness of stage based interventions in changing smoking behaviour

Systematic review of the effectiveness of health behavior interventions based on the transtheoretical model

The Transtheoretical Model (TTM) has gained widespread popularity and acceptance, yet little is known about its effectiveness as a basis for health behavior intervention. A systematic review was conducted in order to evaluate the effectiveness of TTM interventions in facilitating health-related behavior change. Thirty-five electronic databases, catalogues, and internet resources were searched for relevant studies. In addition, the bibliographies of retrieved references were scanned for further relevant publications and authors were contacted for further information where necessary. Thirty-seven randomized controlled trials, targeting seven health-related behaviors, satisfied the inclusion criteria. Overall, the methodological quality of trials was variable, and there was limited evidence for the effectiveness of stage-based interventions as a basis for behavior change or for facilitating stage progression, irrespective of whether those interventions were compared with other types of intervention or with no intervention or usual care controls. The theoretical and practical implications of these findings are discussed. © 2005 Taylor & Francis Group Ltd

Systematic review of the effectiveness of health behavior interventions based on the transtheoretical model

The Transtheoretical Model (TTM) has gained widespread popularity and acceptance, yet little is known about its effectiveness as a basis for health behavior intervention. A systematic review was conducted in order to evaluate the effectiveness of TTM interventions in facilitating health-related behavior change. Thirty-five electronic databases, catalogues, and internet resources were searched for relevant studies. In addition, the bibliographies of retrieved references were scanned for further relevant publications and authors were contacted for further information where necessary. Thirty-seven randomized controlled trials, targeting seven health-related behaviors, satisfied the inclusion criteria. Overall, the methodological quality of trials was variable, and there was limited evidence for the effectiveness of stage-based interventions as a basis for behavior change or for facilitating stage progression, irrespective of whether those interventions were compared with other types of intervention or with no intervention or usual care controls. The theoretical and practical implications of these findings are discussed