Activity Counseling Trial (ACT): rationale, design, and methods. Activity Counseling Trial Research Group

The Activity Counseling Trial (ACT) is a multicenter, randomized controlled trial to evaluate the effectiveness of interventions to promote physical activity in the primary health care setting. ACT has recruited, evaluated, and randomized 874 men and women 35-75 yr of age who are patients of primary care physicians. Participants were assigned to one of three educational interventions that differ in amount of interpersonal contact and resources required: standard care control, staff-assisted intervention, or staff-counseling intervention. The study is designed to provide 90% power in both men and women to detect a 1.1 kcal.kg-1.day-1 difference in total daily energy expenditure between any two treatment groups, and over 90% power to detect a 7% increase in maximal oxygen uptake, the two primary outcomes. Primary analyses will compare study groups on mean outcome measures at 24 months post-randomization, be adjusted for the baseline value of the outcome measure and for multiple comparisons, and be conducted separately for men and women. Secondary outcomes include comparisons between interventions at 24 months of factors related to cardiovascular disease (blood lipids/lipoproteins, blood pressure, body composition, plasma insulin, fibrinogen, dietary intake, smoking, heart rate variability), psychosocial effect, and cost-effectiveness, and at 6 months for primary outcome measures. ACT is the first large-scale behavioral intervention study of physical activity counseling in a clinical setting, includes a generalizable sample of adult men and women and of clinical setting, and examines long-term (24 months) effects. ACT has the potential to make substantial contributions to the understanding of how to promote physical activity in the primary health care setting.     

Perceived environmental predictors of physical activity over 6 months in adults: Activity Counseling Trial.

[Correction Notice: An erratum for this article was reported in Vol 27(2) of Health Psychology (see record 2008-12766-001). One result in Table 2 was misinterpreted in the text. It was reported that men who responded "yes" to frequently seeing people being active in their neighborhoods did about 75 minutes more physical activity per week (pPurpose: In the present study, the authors extend previous cross-sectional findings by using a prospective design to determine whether physical and social environmental characteristics predict physical activity over 6 months. Design: Inactive adults were recruited to the Activity Counseling Trial, a multicenter, randomized, controlled trial of physical activity intervention in primary care. Participants were 387 women and 474 men aged 35-75 years in 3 regions; 1/3 were minorities; 56% had some college education. Baseline perceived environmental variables were used to predict physical activity at 6 months, adjusting for experimental condition and other potential moderators. Measures: The validated 7-day physical activity recall interview was used to estimate minutes of moderate to vigorous physical activity. A standardized survey was used to measure social and physical environmental variables around the home and neighborhood. Results: Women reporting no unattended dogs and low crime in their neighborhoods and men reporting frequently seeing people being active in their neighborhoods did 50-75 more minutes of physical activity per week than did those with different environmental characteristics. Interactions of environmental variables with age group suggested that older adults may be more affected by environmental variables than are younger adults. Conclusions: Self-reported social and physical environmental variables were significantly related to moderate to vigorous physical activity among a diverse sample of adults living in 3 regions of the United States. These prospective findings strengthen the conclusion from previous cross-sectional studies that environmental variables are important correlates of physical activity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of interventions in health care settings on physical activity or cardiorespiratory fitness

INTRODUCTION: This paper reviews studies of physical activity interventions in health care settings to determine effects on physical activity and/or fitness and characteristics of successful interventions. METHODS: Studies testing interventions to promote physical activity in health care settings for primary prevention (patients without disease) and secondary prevention (patients with cardiovascular disease [CVD]) were identified by computerized search methods and reference lists of reviews and articles. Inclusion criteria included assignment to intervention and control groups, physical activity or cardiorespiratory fitness outcome measures, and, for the secondary prevention studies, measurement 12 or more months after randomization. The number of studies with statistically significant effects was determined overall as well as for studies testing interventions with various characteristics. RESULTS: Twelve studies of primary prevention were identified, seven of which were randomized. Three of four randomized studies with short-term measurement (4 weeks to 3 months after randomization), and two of five randomized studies with long-term measurement (6 months after randomization) achieved significant effect on physical activity. Twenty-four randomized studies of CVD secondary prevention were identified; 13 achieved significant effects on activity and/or fitness at twelve or more months. Studies with measurement at two time points showed decaying effects over time, particularly if the intervention were discontinued. Successful interventions contained multiple contacts, behavioral approaches, supervised exercise, provision of equipment, and/or continuing intervention. Many studies had methodologic problems such as low follow-up rates. CONCLUSION: Interventions in health care settings can increase physical activity for both primary and secondary prevention. Long-term effects are more likely with continuing intervention and multiple intervention components such as supervised exercise, provision of equipment, and behavioral approaches. Recommendations for additional research are given.     

Mediators of change in physical activity following an intervention in primary care: PACE

Lysozyme is able to lyse Gram-positive bacteria acting as muramidase on the peptidoglycan polymer. Gram-negative bacteria in vitro are not lysed by lysozyme. It was assumed that the peptido-glycan is protected by the outer membrane and thus that Gram-negative bacteria are not affected by lysozyme without the aid of other factors such as EDTA or complement which enable lysozyme to penetrate the outer membrane. Accidentally, Pellegrini et al. [(1992) J. Appl. Bacteriol., 72:180-187] found that lysozyme per se is able to kill some Gram-negative bacteria. On the basis of morphological and immunocytochemical findings obtained from chemically fixed bacteria, it was concluded that lysozyme does not lyse Gram-negative bacteria but affects the cytoplasm of for example, Escherichia coli, leading to its disintegration, whilst the membranes do not break down. In an attempt to clarify the action of lysozyme on E. coli, we employed cryotechniques including ultrarapid freezing, cryomicroscopy and freeze substitution, and immunolabeling. Bacteria that were immediately frozen after exposure to lysozyme remained morphologically intact. Individual bacteria plated on agar after exposure to lysozyme were mostly intact when frozen within a few seconds. However, inner and outer membranes of 80% of the bacteria were disrupted, whereas the cytoplasm of only a few bacteria showed signs of disintegration when bacteria were frozen with a delay of only 5 min of plating onto pure agar or agar containing growth medium. After a period of time of 15 min between plating onto agar and freezing, about 97% of the bacteria showed changes of disintegration of various extent. Immunolabeling showed that lysozyme binds to the outer cell membrane and may penetrate the membrane, reaching the periplasmic space and possibly the inner cell membrane. The ultrastructural findings and the results of antibacterial assays suggest that lysozyme is bactericidal for E. coli but is not able to induce disintegration. Disintegration is accomplished by changes of the environment starting at the cell membranes. The mechanism by which lysozyme penetrates the membrane, the way it acts to be bactericidal, and the way disintegration is initiated remain to be clarified.     

Perceived environmental predictors of physical activity over 6 months in adults: Activity Counseling Trial: Correction to Sallis et al. (2007).

Reports an error in Perceived environmental predictors of physical activity over 6 months in adults: Activity Counseling Trial by James F. Sallis, Abby C. King, John R. Sirard and Cheryl L. Albright (Health Psychology, 2007[Nov], Vol 26[6], 701-709). One result in Table 2 was misinterpreted in the text. It was reported that men who responded yes to frequently seeing people being active in their neighborhoods did about 75 minutes more physical activity per week (p2007-16656-008.) Purpose: In the present study, the authors extend previous cross-sectional findings by using a prospective design to determine whether physical and social environmental characteristics predict physical activity over 6 months. Design: Inactive adults were recruited to the Activity Counseling Trial, a multicenter, randomized, controlled trial of physical activity intervention in primary care. Participants were 387 women and 474 men aged 35-75 years in 3 regions; 1/3 were minorities; 56% had some college education. Baseline perceived environmental variables were used to predict physical activity at 6 months, adjusting for experimental condition and other potential moderators. Measures: The validated 7-day physical activity recall interview was used to estimate minutes of moderate to vigorous physical activity. A standardized survey was used to measure social and physical environmental variables around the home and neighborhood. Results: Women reporting no unattended dogs and low crime in their neighborhoods and men reporting frequently seeing people being active in their neighborhoods did 50-75 more minutes of physical activity per week than did those with different environmental characteristics. Interactions of environmental variables with age group suggested that older adults may be more affected by environmental variables than are younger adults. Conclusions: Self-reported social and physical environmental variables were significantly related to moderate to vigorous physical activity among a diverse sample of adults living in 3 regions of the United States. These prospective findings strengthen the conclusion from previous cross-sectional studies that environmental variables are important correlates of physical activity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Screening older adults for depression in primary care settings.

Primary care is a logical environment for depression recognition in older adults. Most older adults are diagnosed and treated for depression by primary care providers. Recognition systems for depression in this setting are particularly needed because the prevalence of depression in older primary care patients may range from 7% to 36%, depending on the instrument and diagnostic criteria used. Implementing systematic detection systems in primary care settings has proven difficult. In one study, only one third of all physicians surveyed used any formal screening tool. Though a number of barriers to recognition of depression have been identified, the authors focus their discussion in this article on two, time and patient factors, and review two screening instruments, the Geriatric Depression Scale--Short Form and the Center for Epidemiologic Studies Depression Scale, that may be able to address these factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Difficulties in family practice residency training: Recommendations for training health psychologists in primary care settings.

We attempt to pursue a model for health psychologists by developing recommendations for behavioral science input into family practice residencies, gleaned from experiences of several health psychologists specifically trained to be directors of behavioral science programs of such medicine departments. This information is accumulated and based on a 7-year period at one university-based, inner-city program and two community-based hospitals. These recommendations are offered in the hope that health psychology training specialists will anticipate roadblocks associated with family practice residency training programs and will plan accordingly. Specifically, we make recommendations regarding program overview and training background, roadblocks (including medicine as the final authority), theoretical versus practical teaching orientation, resident time constraints, administrative support and priorities, and training effectiveness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized trial of a brief mental health intervention for primary care patients.

This randomized trial is a first evaluation of a brief psychotherapeutic intervention for primary care patients. Sixty-two participants were randomly assigned to the intervention or to treatment as usual. As compared with treatment as usual, the intervention led to significant reductions in symptoms of anxiety and depression. The reduction was maintained for 3 months after the end of treatment, but some return of symptoms occurred by 6 months after treatment. The treatment was well accepted by patients. This study provides good preliminary evidence for the effectiveness of this intervention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychology and the creation of health care settings.

The development of innovative relationships between psychologists and health care facilities is viewed as an example of "setting creation." These efforts involve predictable problems that are often not dealt with realistically due to a limited understanding of the setting-creation process. These arguments are applied to pediatric settings, where psychologists have recreated past problems by employing traditional helping approaches from their previous experience. (45 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Empirical support for psychological assessment in clinical health care settings.

Psychologists in health care settings today find it increasingly difficult to obtain authorization and appropriate reimbursement for psychological assessments from 3rd party payers. Authorization and reimbursement denials often are based on allegations that empirical support for the utility and validity of psychological tests is nonexistent or limited. This article reviews a sample of the considerable empirical support that exists for the utility and validity of a variety of psychological tests for a wide range of clinical health care applications. Informed by data such as these, psychologists should become more effective in their abilities to seek authorization and reimbursement for assessment and overturning denials. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Role functions of pediatric and health psychologists in health care settings.

686 pediatric and health psychologists completed questionnaires requesting background information concerning years of experience, current work settings, graduate training, and professional identification. Ss were also asked to describe services and functions they performed, difficulties they encountered, and general consultation goals. Results suggest that both groups are involved in a wide range of diagnostic, treatment, and consultative activities in health care settings and that there are many similarities in the ways they conceptualize their roles and how they function. However, pediatric psychologists were especially involved in clinical assessment activities, whereas research was a high priority for health psychologists. Other aspects of the roles, functions, and activities of these 2 groups are described. (15 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychological practice in primary care settings: Practical tips for clinicians.

Many psychologists are finding new opportunities for practice in primary care settings. These settings challenge many aspects of traditional practice and require adaptation and innovation. Psychologists must consider changes in their site of practice, treatment duration, type of intervention, and role as part of a health care team. This article describes the culture of primary care medicine and offers 10 practical tips for the adaptation in psychological practice to primary care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Development and testing of a seven-day dietary recall. Dietary Assessment Working Group of the Worcester Area Trial for Counseling in Hyperlipidemia (WATCH)

Using multiple 24-hr recalls (24HR) we tested the Seven Day Dietary Recall (7DDR) developed to assess nutrient exposures, especially lipids, in dietary interventions and other clinical trials requiring measurement of effect over moderate time periods. A total of 261 individuals in three studies completed a 7DDR at the end of a 3- to 5-week period during which 3 to 7 24HR were telephone-administered on randomly selected days. One of these studies and data from one additional study (total n = 678) allowed us to test the ability of the 7DDR to predict serum lipid changes in an intervention setting. In correlation and linear regression analyses, high levels of agreement between 7DDR and 24HR were obtained. For total energy: r = 0.67 and b = 0.69, and for total fat intake (g/day): r = 0.67 and b = 0.80. When 7 days of 24HR were available agreement tended to be higher. For total energy: r = 0.69 and b = 0.95, and for total fat (g/day): r = 0.71 and b = 1.04. Data derived from the 7DDR and fit to the Keys and Hegsted equations closely predicted actual changes in total serum cholesterol (within 15% and 10%, respectively). The 7DDR is a relatively easily administered, sensitive method to assess short-term changes in dietary fat consumption in individuals.     

Strategies to implement alcohol screening and brief intervention in primary care settings: A structured literature review.

Although alcohol screening and brief intervention (SBI) reduces drinking in primary care patients with unhealthy alcohol use, incorporating SBI into clinical settings has been challenging. We systematically reviewed the literature on implementation studies of alcohol SBI using a broad conceptual model of implementation, the Consolidated Framework for Implementation Research (CFIR), to identify domains addressed by programs that achieved high rates of screening and/or brief intervention (BI). Seventeen articles from 8 implementation programs were included; studies were conducted in 9 countries and represented 533,903 patients (127,304 patients screened), 2,001 providers, and 1,805 clinics. Rates of SBI varied across articles (2–93% for screening and 0.9–73.1% for BI). Implementation programs described use of 7–25 of the 39 CFIR elements. Most programs used strategies that spanned all 5 domains of the CFIR with varying emphases on particular domains and sub-domains. Comparison of SBI rates was limited by most studies' being conducted by 2 implementation programs and by different outcome measures, scopes, and durations. However, one implementation program reported a high rate of screening relative to other programs (93%) and could be distinguished by its use of strategies that related to the Inner Setting, Outer Setting, and Process of Implementation domains of the CFIR. Future studies could assess whether focusing on Inner Setting, Outer Setting, and Process of Implementation elements of the CFIR during implementation is associated with successful implementation of alcohol screening, as well as which elements may be associated with successful, sustained implementation of BI. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Depression in ethnically diverse women: Implications for treatment in primary care settings.

What do health care practitioners need to know about providing adequate care for depressed minority women? This article examined the prevalence of depressive symptoms and clinical depression in ethnic minorities, the extent to which current health service utilization is congruent with needs, and the effectiveness of treatments provided to ethnic minorities in the primary care setting. The impact of ethnic minority women's sociocultural context on symptom expression and help-seeking behavior is also discussed. Finally, the clinical implications for accurate assessment and treatment of ethnic minority women by both medical and mental health practitioners working in the primary care sector are addressed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of psychologists in the care of Iraq and Afghanistan veterans in primary care settings.

Although military personnel serving in Iraq and Afghanistan are at high risk of developing mental health problems, many report significant barriers to care and few seek help. Integrated primary care is a comprehensive model of health care that aims to improve access to care and provides a framework to assess and meet the complex psychiatric needs of newly returning veterans by embedding mental health specialists within primary care. We describe the role of psychologists in a Department of Veterans Affairs (VA) integrated primary care clinic that serves veterans of Iraq and Afghanistan. Psychologists based in primary care can assist veterans with reintegration to civilian life by providing rapid mental health assessment, normalizing re-adjustment concerns, planning for veterans’ safety, implementing brief interventions within primary care, facilitating transition to additional mental health care, and informing veterans of other available psychosocial services. A case example demonstrating the psychologist’s role highlights the benefits of an integrated care model. Implications of employing this model include reduction of symptoms and impairment by reducing stigma and barriers to seeking mental health care, increased motivation to engage in treatment, and implementation of early interventions. This model may also be beneficial in the civilian health care sector with groups that are at high risk for mental health problems, yet experience barriers to care, particularly stigma. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The impact of primary health care intervention on reinfection of soil-transmitted helminths in the community

A study to evaluate the impact of primary healthy (PCH)care practices on the prevention of reinfection of soil-transmitted helminths (STH) was carried out in Nakhon Si Thammarat Province, southern Thailand. Fecal samples from the inhabitants of Ban Paruhas, the implementing village, and Ban Pungsing, the control village, were examined following mass treatment with a three-day regimen of albendazole (400 mg). Training of health volunteers, implementation of a health education program through village broadcasting system and improvements in sanitation including increasing the number of latrines were carried out at Ban Paruhas village. After one year of implementation, prevalence and intensity of STH in both villages were determined using Kato-Katz's method. Pre- and post intervention stool examination results were compared. The overall prevalence of STH at post-intervention decreased significantly in both villages, with a greater degree of reduction appearing in ascariosis and hookworm infections in the village where PHC was implemented.     

Implementing the direct contact model to increase referrals for psychological services in primary care settings.

Generating a robust referral base from primary care clinics is an increasingly important and challenging task for professional psychologists. This article presents the direct contact model, an innovative system for generating this base without relying solely on traditional physician-initiated referral mechanisms. The direct contact model functions by (a) allowing patients direct access to services using the PRIMECARE Questionnaire and (b) having psychology staff take a proactive stance to initiate treatment. The utility of this model is explored, and suggestions for implementing the model in other settings are provided. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Rural Hawai'i Behavioral Health Program: Increasing access to primary care behavioral health for native Hawaiians in rural settings.

Health care access issues present significant challenges for rural populations and health providers. Psychology can support improved access and quality of rural health services through the development of integrated behavior health programs within primary care settings. This article reviews a clinical training and service delivery program, the Rural Hawai'i Behavioral Health Program, which has evolved in response to the pressing health needs of Native Hawaiians in rural communities. Native Hawaiian cultural factors and components of the primary care model that have supported the development of this program will be reviewed. Program expansion, sustainability, and treatment efficacy research will be discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of physical health functioning, mental health, and sociodemographic factors in determining the intensity of mental health care use among primary care medical patients.

The present study examined sociodemographic and attitudinal predisposing factors (gender, age, marital status, health insurance, household income, attitudes about mental health care), and need/illness variables (depression severity, physical and mental health functional status) as predictors of past-year mental health care use intensity (i.e., visit counts) and use/nonuse. The sample included 283 adult primary care patients from the Midwestern United States in a cross-sectional study. Nonlinear regression models demonstrated that past-year treatment use intensity was significantly associated with both married status and poorer physical health functioning, while the use (vs. nonuse) of treatment was associated with depression severity. A sociodemographic and attitudinal multivariate predictor model only explained 5% of the variance in treatment use intensity, but a need/illness model significantly contributed an additional 23% variance. Poorer physical health functioning was significant in predicting treatment use intensity, while depression severity was significant in predicting the use (vs. nonuse) of treatment. Results demonstrate the particular importance of physical health problems in determining the intensity of mental health care use, and depression severity in determining the use/nonuse of treatment, notwithstanding the restricted sociodemographic contour of the sample. (PsycINFO Database Record (c) 2010 APA, all rights reserved)