Using consecutive Rapid Participatory Appraisal studies to assess, facilitate and evaluate health and social change in community settings

bmc.gif Just published in BMC Public Health, an Open Access online journal:

Brown CS, Lloyd S, Murray SA. Using consecutive Rapid Participatory Appraisal studies to assess, facilitate and evaluate health and social change in community settings. BMC Public Health 2006; 6:68.BACKGROUND: To investigate how a relatively socio-economically deprived community's needs have changed over time, assess which recommendations from an earlier assessment were implemented and sustained, and consider whether serial Rapid Participatory Appraisal is an effective health research tool that can promote community development and has utility in assessing longitudinal change.
METHODS: Rapid Participatory Appraisal involves communities in identifying and challenging their own health-related needs. Information on ten health and social aspects was collated from existing documentation, neighbourhood observations, and interviews with a range of residents and key informants, providing a composite picture of the community's structure, needs and services.
RESULTS: The perceived needs after 10 years encompassed a wide construct of health, principally the living environment, housing, and lack of finance. Most identified upstream determinants of health rather than specific medical conditions as primary concerns. After the initial Rapid Participatory Appraisal many interviewees took the recommendations forward, working to promote a healthier environment and advocate for local resources. Interventions requiring support from outwith the community were largely not sustained.
CONCLUSION: Rapid Participatory Appraisal proved valuable in assessing long-term change. The community's continuing needs were identified, but they could not facilitate and sustain change without the strategic support of key regional and national agencies. Many repeatedly voiced concerns lay outwith local control: local needs assessment must be supported at higher levels to be effective.
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Changing physician knowledge, attitudes, and beliefs about migraine: evaluation of a new educational intervention

From the May 2006 issue of Headache: [full text by subscription]

Patwardhan MB, Samsa GP, Lipton RB, Matchar DB. Changing physician knowledge, attitudes, and beliefs about migraine: evaluation of a new educational intervention. Headache 2006; 46(5):732-741.

Objective: Use a presurvey of primary care providers (PCPs) enrolled in a continuing medical education (CME) program on headache management to ascertain their existing knowledge, attitudes, and beliefs regarding migraine and use a postsurvey to determine the extent to which the CME program has brought participant knowledge, attitudes, and skills closer to conformance with best evidence.
Background: Migraine is a common and debilitating condition, which PCPs may not always manage satisfactorily. In an effort to improve management, the American Headache Society has developed a CME program called BRAINSTORM that encourages PCPs to adopt the US Headache Consortium Guidelines for headache care.
Methods: A 20-item questionnaire was developed that covered the essential elements of migraine care. The questionnaire was administered before and after a BRAINSTORM* presentation to 254 consenting primary care clinicians attending a medical meeting at 1 of 6 sites. A control group of 112 comparable physicians who did not attend the presentation completed the same questionnaire. Prepresentation scores of attendees were compared to scores of nonattendees to assess the generalizability of results. Prepresentation scores on selected questions were used to assess participant baseline knowledge, attitudes, and beliefs. Pre- and postpresentation scores for attendees at all sites were compared using the Mantel-Haenszel statistic to assess the effectiveness of the BRAINSTORM CME. Pre- and postpresentation scores were compared by site using the Breslow-Day test to evaluate any differential impact based on CME location.
Results: Prepresentation scores of attendees and nonattendees were found to be similar. No significant difference in performance was noted across sites. A chi-square analysis revealed a statistically significant difference between pre- and postpresentation scores for 16 of the test’s 20 questions. In the pretest, all participants scored <66% on 2 questions related to prevalence, impact, and pathophysiology of migraine, 2 questions pertaining to history taking/physical examination, and 3 migraine management questions. Attendee scores improved to >66% posttest on all except 2 questions related to prevalence, impact, and pathophysiology of migraine.
Conclusion: Our results indicate that PCPs need to acquire greater understanding about the epidemiology and pathophysiology of migraine and may require guidance in history taking and physical examination of migraine patients. Improvement in scores posttest confirms that the BRAINSTORM program has a significant immediate impact on the knowledge, beliefs, and attitudes of participants. The program could be strengthened to improve emphasis in some areas where posttest scores showed no improvement.
*BRAINSTORM is a 2½-hour interactive program that uses video case vignettes, animation, and illustrations to examine the impact of headache on patients’ lives and teach the diagnosis and treatment of patients with migraine disorders. Four distinct modules, each 20 minutes in length, convey specific educational messages on
(1) understanding the prevalence and impact of migraine,
(2) understanding migraine mechanisms,
(3) history taking/physical examination and diagnosis of migraine, and
(4) migraine management.
Physician experts act as facilitators for the program. To ensure that a consistent message is conveyed in every presentation, facilitators are trained by AHS and provided with a guidebook and a CD-ROM. They guide participant discussion of the materials presented and ensure time for questions and answers. All participants are provided with a workbook, a CD-ROM with program material, and directions to other educational resources for physicians and patients.     
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NCBI’s Bookshelf: full-text books free online

In collaboration with authors and publishers, the National Center for Biotechnology Information (NCBI) is adapting biomedical books for the web. The Bookshelf is a growing collection of biomedical books that can be searched directly by typing a concept into the textbox above and selecting <Go>. Books are also linked to terms in PubMed abstracts: when viewing an abstract, select the <Books> link to see phrases within the abstract hyperlinked to book sections.  Search tip: If the chapter titles are not live links, copy and paste into the search box the titles of chapters you wish to read.   Sample titles:

Simulation and virtual reality in medical education and therapy: a protocol

This article was just published in Cyberpsychology & behavior : the impact of the Internet, multimedia and virtual reality on behavior and society. (How's that for a title?) The December 2005 issue is free and it contains some pretty interesting articles, such as Factors Influencing Adolescents Engagement in Risky Internet Behavior and Relationships among Internet Attitudes, Internet Use, Romantic Beliefs, and Perceptions of Online Romantic Relationships.

Roy MJ, Sticha DL, Kraus PL, Olsen DE. Simulation and virtual reality in medical education and therapy: a protocol. Cyberpsychol Behav 2006;9:245-247.

Abstract: Continuing medical education has historically been provided primarily by didactic lectures, though adult learners prefer experiential or self-directed learning. Young physicians have extensive experience with computer-based or "video" games, priming them for medical education- and treating their patients-via new technologies. We report our use of standardized patients (SPs) to educate physicians on the diagnosis and treatment of biological and chemical warfare agent exposure. We trained professional actors to serve as SPs representing exposure to biological agents such as anthrax and smallpox. We rotated workshop participants through teaching stations to interview, examine, diagnose and treat SPs. We also trained SPs to simulate a chemical mass casualty (MASCAL) incident. Workshop participants worked together to treat MASCAL victims, followed by discussion of key teaching points. More recently, we developed computer-based simulation (CBS) modules of patients exposed to biological agents. We compare the strengths and weaknesses of CBS vs. live SPs. Finally, we detail plans for a randomized controlled trial to assess the efficacy of virtual reality (VR) exposure therapy compared to pharmacotherapy for post-traumatic stress disorder (PTSD). PTSD is associated with significant disability and healthcare costs, which may be ameliorated by the identification of more effective therapy.
PubMed Record  

History and overview of theories and methods of chiropractic

These two articles were published in a recent issue of Clinical Orhtopaedics & Related Research:

DeVocht JW. History and overview of theories and methods of chiropractic: a counterpoint. Clin Orthop Relat Res 2006;444:243-249.

Abstract: Spinal manipulation has been used for its therapeutic effects for at least 2500 years. Chiropractic as we know it today began a century ago in a simplistic manner but has developed into to a well-established profession with 33 colleges throughout the world. During the initial, bumpy years, many people thought it had little more value than a placebo. Nevertheless, there have always been satisfied recipients of chiropractic care during the years, and the profession slowly gained prominence–mostly by word of mouth. More recently, personal opinions based on isolated incidents have given way to the results of numerous clinical and basic science studies, primarily regarding low back pain. As of 2002, 43 randomized trials of spinal manipulation for low back pain had been published with 30 showing more improvement than with the comparison treatment, and none showing it to be less effective. Other studies have shown that chiropractic care compared with medical care is safer, costs no more and often costs much less, and has consistently greater patient satisfaction for treatment of similar conditions. Consequently, there is now better public and professional opinion of chiropractic with coverage by insurance companies and government agencies. That trend is likely to continue.
PubMed Record   

Homola S. Chiropractic: history and overview of theories and methods. Clin Orthop Relat Res 2006;444:236-242.

Abstract: Chiropractic is one of the most controversial and poorly defined healthcare professions with recognition and licensure in the United States. Chiropractic was started by D. D. Palmer, a magnetic healer who formulated the vertebral subluxation theory. The profession was developed by his son, B. J. Palmer. Although the definition of chiropractic as a method of correcting vertebral subluxations to restore and maintain health is questionable, spinal manipulation is of value in the treatment of some types of back pain. The chiropractic profession is still based on the vertebral subluxation theory, and has the confusing image of a back specialty capable of treating a broad scope of health problems. Despite opposition to use of spinal manipulation as a method of treating a broad scope of health problems (as opposed to the generally accepted use of manipulation in the treatment of back pain), chiropractors seek support as primary care providers in alternative medicine. It is essential to understand the theories, philosophies, and methods of chiropractic for an objective evaluation.
PubMed Record  

View all chiropractic posts.

Financial conflict of interest disclosure and voting patterns at Food and Drug Administration Drug Advisory Committee meetings

Thanks to Bob Morrow for sending along this reference from the current issue of JAMA.

Lurie P, Almeida CM, Stine N, Stine AR, Wolfe SM. Financial conflict of interest disclosure and voting patterns at Food and Drug Administration Drug Advisory Committee meetings. JAMA 2006;295:1921-1928.
CONTEXT: In January 2002, the US Food and Drug Administration (FDA) issued a draft guidance requiring more detailed financial conflict of interest disclosure at advisory committee meetings.
OBJECTIVES: To characterize financial conflict disclosures at drug-related meetings, and to assess the relationship between conflicts and voting behavior at meetings that considered specific products.
DESIGN AND SETTING: Cross-sectional study using agendas and transcripts from all FDA Drug Advisory Committee meetings (2001-2004) listed on the FDA Web site.
MAIN OUTCOME MEASURES: Conflict rates, type, and size. The relationship between having a conflict and voting in favor of the index drug was described for each voter using Mantel-Haenszel relative risks and Monte Carlo simulations; Spearman rho was used for a meeting-level analysis comparing rates of conflict with voting patterns. The impact of the removal of persons with conflicts of interest on the vote margins was also evaluated.
RESULTS: A total of 221 meetings held by 16 advisory committees were included in the study. In 73% of the meetings, at least 1 advisory committee member or voting consultant disclosed a conflict; only 1% of advisory committee members were recused. For advisory committee members (n = 1957) and voting consultants combined (n = 990), 28% (n = 825) disclosed a conflict. The most commonly specified conflicts were consulting arrangements, contracts/grants, and investments. Nineteen percent of consulting arrangements involved over 10,000 dollars, 23% of contracts/grants exceeded 100,000 dollars, and 30% of investments were over 25,000 dollars. The meeting-level analysis did not show a statistically significant relationship between conflict rates (“index conflict,” “competitor conflict,” or “any conflict”) and voting patterns, but a weak, statistically significant positive relationship was apparent for competitor conflict and any conflict in the Mantel-Haenszel analyses. The Monte Carlo analyses produced similar findings in the competitor conflict analysis only. In all 3 conflict categories, the exclusion of advisory committee members and voting consultants with conflicts would have produced margins less favorable to the index drug in the majority of meetings, but this would not have changed whether the majority favored or opposed the drug.
CONCLUSIONS: Disclosures of conflicts of interest at drug advisory committee meetings are common, often of considerable monetary value, and rarely result in recusal of advisory committee members. A weak relationship between certain types of conflicts and voting behaviors was detected, but excluding advisory committee members and voting consultants with conflicts would not have altered the overall vote outcome at any meeting studied.
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Friday Fun: Listen to Neil Young’s Living With War, for free

[See also Friday Fun: The ArchivesNeil Young's new album Living With War is available for free from his Living with War blog, starting today. The album will be available available in stores early May.

You can listen to it online  or host the music on your own site.  Here is Neil's Web site.

I can hardly wait to get home and listen to the new album. Then I will put on my old love beads and listen to Phil Ochs.