EBPT/PPPT III Final
Steps to Addressing Health Literacy
1) Create a Shame Free Environment - Open, welcoming, accepting - Identifying clues to presence of health literacy issue (eg. expression of being lost, stress and anxiety, avoidance, - Engage entire staff to be inclusive
General MI Principles (4)
1) Express empathy 2) Support Self-efficacy 3) Roll with Resistance 4) Develop discrepancy
Categories of Adult Learners (3)
1) Goal-oriented adult learner 2) Activity-oriented adult learner 3) Learning-oriented adult learner
Study Objective: Asking the Question
1) Need a well-defined question; e.g., - Does aerobic exercise training improve aerobic capacity in people recovering from stroke? - As compared to MRI, is the anterior drawer test accurate in diagnosing ACL tears? - Can fall risk be predicted based on cognitive-ability in the older population? - Can also perform these reviews with qualitative questions 2) Need to include a review of literature to support research question just like any other research study.
QUADAS Scale
For use when evaluating studies of diagnostic test accuracy
Elements of a Systematic Review
Formulate the review question and write the protocol Search for and include primary studies Assess study quality Extract data Analyze data Interpret results & write a report
Generalizability - Systematic replication
Systematic replication - done after direct replication shown. Define conditions under which intervention will be successful or fail. Vary one or two variables from original study in attempt to generalize to other similar, not identical situations.
Clinician's actions during (4) Action
Teach self-management techniques to prevent relapse
What is health behavior?
The actions that we do or don't do that impact our health; these can negatively or positively affect our health.
Self-efficacy
Feeling of empowerment; person's belief or confidence in his or her ability to succeed at making a change.
Structure of SS Designs - Core Elements (1)
First core element = repeated measurements - Repeated measurements of a response over time; allows researcher to observe trends and patterns of data; individual variability often obscured in groups and when measurements taken pre and post treatment - Measurements taken more frequently as compared to other types of experimental studies - Advantage is that this allows for observation of response patterns and can modify design if necessary
Components of Literacy Readability vs. Comprehension
Three main components: 1) Document literacy - person's ability to read forms; not much need for comprehension 2) Prose literacy - requires comprehension and understanding (reading an article from a newspaper, a book) 3) Quantitative literacy - being able to understand quantity and values; requires comprehension and computation Readability (needed for document literacy) vs. Comprehension (needed for prose literacy) Impacted by attention and focus - Stress and anxiety - Environment (busy, lots of distraction) Written vs. Spoken word - if the patient has low literacy level of the written word, the spoke word may also be difficult
Substance Use Disorders
Use - Occasional recreational use, no problems for user Abuse - Dangerous activity and use, causes significant problems at work, home, or school (personal, financial, or legal) Addiction - compulsive abuse even when negative consequences occur - individual unable to control use
Example of Multiple Baseline Design - Nonconcurrent Multiple Baseline Design
Used most often in clinical situations when similar subjects not available at same time for concurrent monitoring. Researcher arbitrarily determines length of several baselines and when a subject who meets criteria is enrolled, the subject is randomly assigned to one of the baselines. A weaker approach than concurrent baselines as external factors related to passage of time may be different for each baseline.
Downs and Black Quality Assessment Tool
Uses 27 questions to assess quality of article Grouped into 5 categories - Reporting - External Validity - Internal Validity - Bias - Internal Validity - Confounding (selection bias) - Power
Traditional, Narrative Reviews
Usually written by experts in the field, are qualitative, narrative summaries of evidence on a given topic. Typically, they involve informal and subjective methods to collect and interpret information. This method is good to initially gain knowledge about an unfamiliar topic Problem: info may be biased; may have not done a rigorous
Learning Style Preference
Visual - Auditory - Kinesthetic Learners
Assuring comprehension and adherence: Special Populations
Visual Impairments Hearing Impairments Impaired Cognition
Ultimate Outcomes
We also develop prognoses on ultimate outcomes of a condition. - Will I always need oxygen for activity? - Will I walk without a walker again? - Will my shoulder always be painful when I pitch? - Will my child be able to attend school like other children? Ultimate outcomes of a condition provides the context for the plan of care and treatment-related prognostic efforts are determined.
How does one's perception of locus of control influence their willingness to give patient education?
We may believe our education falls on deaf ears, but it's still our job to attempt to intervene upon poor health behaviors. It's our view or perception of our patient's locus of control (internal or external) that influences our willingness to educate
A Respondent shall appear for drug screening and testing at the facility designated by the executive director within __________ hours of initial contact by the board representative
six hours
Numeracy
the ability to read and interpret numbers
Jadad Scale
PRO: simple and quick CON: does not consider many important design issues
Geragogy Principles
- Elderly individuals are able to learn new material and perform new tasks - Individuals take longer to learn new material as they advance in age - Practice and purposeful redundancy can improve performance and knowledge in the older adult - Learning occurs more effectively if the older adult can make cognitive ties to old knowledge.
Emotional / Interpersonal Skill
"Most healthcare providers are aware that adherence depends not only on the patient's acceptance and understanding of education, but also on the provider's ability to persuade the patient that the intervention is meaningful. The patient's perception of the provider affects adherence." - Concern - Interest - Empathy - Credibility
Self-Efficacy - Health Behavior Theory
"Perceived self-efficacy refers to beliefs in one's capabilities to organize and execute the courses of action required to produce given levels of attainment." "an individual's sense that he or she can successfully carry out a particular health behavior needed to result in a desired outcome." Perception of empowerment
Signs and symptoms/behaviors associated with of depression
*See powerpoint*
General MI Principles: Develop discrepancy
- "Motivation for change occurs when people perceive a discrepancy between where they are and where they want to be" - Aid patient/client in examining and contrasting their current state and future (ideal) goals
Selection Criteria - Types of Studies
- "Subjects" are the studies - Inclusion/exclusion criteria for studies to be included in review. Based on type of studies, participants, outcomes. - Usually include RCTs, but may need to include cohort and case-control studies. - Reviews should also include conference proceedings, abstracts, theses and dissertations* *minimize bias as much as possible
A-B-A Design
- Adds a baseline phase after intervention phase; can show reversal to back to baseline; also be used to show the target behavior was maintained with withdrawal of intervention - Trying to show that intervention changed target behavior - If other variables caused changes during first two phases, behavior likely wouldn't revert to baseline during withdrawal - Target behavior needs to be reversible; any response that is learned or permanent won't show decrement when treatment withdrawn OR the second baseline phase can be a retention phase if interested in knowing if intervention caused a change in behavior *The behavior must be REVERSIBLE.
Why is this Important to Practice?
- After the examination, we consider the interventions that are available to address the patient/client needs - Consider PT past experiences, complexity of case, priorities of problem list, what the patient/client wants, etc. - PT and client consider trade-offs between benefits and risks for each intervention: > If this intervention (versus another) is applied, will the condition improve, regress, remain unchanged, or will a new problem develop? > If this intervention (versus another) is not applied, will the condition improve, regress, remain unchanged, or will a new problem develop?
General MI Principles: Roll with Resistance
- Ambivalence and resistance to change are naturally occurring feelings/emotions - Patients/clients are encouraged to develop their own solutions to the problems that they themselves have defined. - Invite patient/client to examine new perspectives of problem
What MI Doesn't Do...
- Argue that the person has a problem and needs to change - Offer direct advice or prescribe solutions to the problem - Use an authoritative/expert stance - Function as a unidirectional information delivery system - Impose a diagnostic label (eg obese) - Behave in a punitive or coercive manner
Strategies for Evoking Change Talk
- Ask Evocative Questions - Explore Decisional Balance - Good Things/Not-so-good Things - Ask for Elaborations / Examples - Look Back (how are things different?) - Look Forward (If things continue as they are, how would things change?) - Query Extremes (best and worst things that would happen if they make the change?) - Use Change Rulers (what could you make the change from one number to another? - Explore Goals and Values - Come Alongside (side with the negative side "devils advocate")
Behaviors Suggestive of Inadequate Health Literacy Skills
- Asking staff for help - Bringing along someone who can read - Inability to keep appointments - Making excuses ("I forgot my glasses.") - Noncompliance with medication - Poor adherence to recommended interventions (e.g., changes to decrease acid reflux, such as elevating the head of the bed) - Postponing decision making ("May I take the instructions home?" or "I'll read through this when I get home.") - Watching others (mimicking behavior)
Details on MI
- Brief intervention that can be done in medical settings - Style of talking with clients or patients in a constructive manner about changing their behavior to reduce health risk. - Based on research looking at individuals' mechanisms for moving through change - Based on the premise that all of the tools needed for change are inherent in the individual - Successful change in health behavior is more possible if the change is initiated by the individual (facilitate) internal motivation to change)
Why aren't traditional, narrative reviews good enough?
- Can be subjective, prone to bias and error - Literature search may be patchy and inadequate - Selective citation of literature - No description of the methods used by the review - Usually not quantitative: can't pick up small effects - Readers can't judge the quality of the review - Readers can't replicate or verify the review - Hard to separate research evidence from anecdotal experiences
Sample Data - Calculating Risk Reduction
- Can understand the effect better if express the effect as a value that reflects the decrease in risk associated with the intervention relative risk reduction (RRR). Basically, this is a measure of how much risk is reduced in the experimental group compared to the control group. RRR = (CER - EER)/CER Tells us that there is a % reduction in risk from the condition associated with intervention as compared to control - If we want to understand the effect size or the actual difference in risk between two groups, can calculate the absolute risk reduction (ARR). This doesn't involve an explicit comparison to the control group ARR = CER - EER Means there is an absolute reduction in risk of recurring headaches associated with the intervention
Examples of Descriptive and Analytic observational studies?
- Case control and cohort studies are observational analytic studies - RCTs are experimental analytic studies to test effect of interventions on health outcomes
Multiple Baseline Designs (continued)
- Concurrent collection of baseline data across a minimum of three series - When baseline is stable, intervention applied to first series - When first series achieves stability during treatment, intervention applied to second series and so on. - Strengthens experimental control by showing independent baselines change only occurs when intervention is applied - Can be done across behaviors, conditions, subjects
Analytic Epidemiology: Measures of Association and Risk
- Deals with testing hypotheses; used in case-control and cohort studies. - Assesses relationship between exposure to a risk factor/event and development of disease/outcome - This is the process of determining prognosis predicting patient outcomes based on patient characteristics.
Length of phases
- Desirable to use fairly equal phase lengths; controls for maturation or motivational influence of subject - However, may need to extend phase until stability in target behavior is achieved - Recommended to have at least 3-4 points in a phase, but greater the number of data points, easier it is to see trends.
PEDro Scale
- Developed by PTs at University of Sydney - Looks at structure of paper as well as randomization, attrition, blinding, design and statistics - More comprehensive than Jadad Scale - Has reasonable reliability
Warning signs of suicide risk
- Direct and indirect comments - Preoccupation with death - Marked and sudden change in mood / happiness from depression without cause - Increased risk-taking & carelessness - Marked change in behavior - Final preparations - putting things in order - Prolonged grief with inability to adjust to loss - Spoken plan for suicide
When to refer - depression
- Discuss depressive feelings with patient - See if patient already receiving treatment - Ask about impairment of life function due to depression - Listen for signs of suicidal ideation - Refer anytime suicidal ideation is detected
Types of Elder Abuse and Neglect Defined in the Law
- Domestic Elder Abuse (several forms of maltreatment with person close to the elder) vs. Institutional Abuse (nursing homes, foster homes, group homes; those who provide care to elder) - Physical Abuse - Sexual Abuse - Emotional / Psychological Abuse - Neglect (refusal or failure to uphold obligations to provide to elderly person) - Abandonment (desertion of person who has obligation to care for person) - Financial or material exploitation - Self-neglect (behavior of elderly person when he or she is not receiving the care they need)
Descriptive Epidemiology
- Done when little known about disease occurrence. - Provides information used to plan healthcare; generate hypotheses about future research: 1) Person, place, time 2) Disease frequency - these measures will always include reference to population size and time period of observation > Prevalence > Incidence 3) Vital Statistics
Event Rates
- ER can examine differences between group response in terms of "event rates" - Event rate is number of people experiencing an event expressed as a proportion of the total number of people in the population: - Experimental event rate (EER) - the rate at which events occur in the experimental group; may be represented by a percentage or as a proportion - Control event rate (CER) - the rate at which events occur in the control group; may be represented by a percentage or as a proportion - Ratio of these two is relative risk (RR) associated with intervention: RR = EER/CER
Data Analysis in SS Research - Visual Analysis
- Examined visually within phase stability and across phases trends - Changes in level - Value of dependent variable or magnitude of performance - Look at last data point of baseline phase and compare to first data point of next adjacent phase - Mean levels can be described across levels - Changes in trend - celeration line
Discussion & Conclusions
- Final section of SLR - Discussion of findings - Reviewer's overall conclusions based on quality of evidence - Can be complex - Reviewer needs to integrate findings into a clinical context - Authors should also propose suggestions for future research
Knowledge Translation
- Gaps between knowledge: much evidence available, but it takes time to trickle down into practice and patient care; patients, health care providers and policy-makers KT (Knowledge Translation) - uses high quality knowledge in processes of decision making Moving knowledge into action involves applying research to patient care - Assists clinicians in best practice - Reduces unwanted variability - Improves outcomes for patients - Is efficient and cost effective
Knowledge Synthesis
- Have to begin with knowledge - Primary literature consumption is not feasible on a large scale for impacting clinical behaviors - An internist must read 34 primary literature articles daily to stay current in the field - Synthesis Documents are excellent resources Examples: Clinical Practice Guidelines, Systematic Review, PTnow, Stroke Engine
Barriers to Effective Patient Education
- Historical paternalistic view of healthcare providers - Skepticism created by free-market system - Over-reliance on technology to "figure out" and "fix"; the patient may trust Wikipedia more than the therapist sometimes
Presentation of Methodological Quality
- Identifies score on each criterion and overall score - May include level of evidence - Some reviewers choose a cut off score to indicate high vs. low quality - Allows reader to see overall quality of studies in the review
Retention and Transference of Knowledge?
- Imperative for behavioral change - Positive vs. Negative Transference - Factors of transference: Association Similarity Degree of Original Learning Critical Attribute Element
Analytic Epidemiology: Measures of Risk Based on Treatment Effect
- In a RCT, success is measured by difference in either beneficial or adverse outcomes between treatment and control groups; but not all patients respond the same way; some improve or get worse; some don't change - We also want to know what is the likelihood that our patient will benefit from the intervention - Analytic epidemiology procedures examines the likelihood that a particular patient will benefit from our intervention
Basic Strategies-Health Communication
- Know the audience - Tailor communication to needs of audience - Create a welcoming and supportive environment - Use plain language - Present information from audience's perspective - Confirm understanding - Offering only basic information required at the time - Keep information simple - Collaborate with patient, family, other providers, and community
Why Does the Gap Exist?
- Knowledge creation and dissemination are not enough to ensure use in the field. - Interventions not described in ways that can be replicated - Too much information, too little time - Lack of skills and confidence in critical appraisal
Generalizability
- Limited for external validity - No real proof it will work for others; but it might in patients with similar characteristics - Helps delineate specific characteristics of treatment that might be successful - Allows researcher to observe clinically strong effects that might have been ignored if results had not been statistically significant.
A-B Design
- Limited in ability to control for threats to internal validity - Were there other events during the intervention that caused a change? - Need some evidence that treatment was responsible for target behavior and not other factors - "Replication of effects" - additional control to indicate that intervention was responsible for change in target behavior - Withdraw and reinstate baseline and treatment conditions - Replicate across more than one subject
Characteristics correlated with low literacy
- Low socioeconomic status - Elderly - Immigrants - Racial minorities - Prisoners - Rural residents - Poor health status
A-B-A-B Design
- Major advantage: provides two opportunities to examine effects of intervention - Provides stronger evidence for effect of intervention on target behavior - Replication during 2 separate intervention phases
Rating Scales
- Many types of rating scales to assess quality of papers - "Yes", "no", "unclear", "not applicable" - Sum the "yes" scores to obtain a total; higher the number of "yes's", the better the quality
3 Main predictors of adherence in patient education... Motivation influenced by...
- Motivation - Self-efficacy - Locus of Control - Patient's beliefs regarding his/her medical condition - value the patient places on the interventions - Patient's degree of confidence in following interventions
Tenets of Motivational Interviewing
- Motivation to change is elicited from the client, and not imposed from without. - It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence. - Direct persuasion is not an effective method for resolving ambivalence (has to be their own idea) - The counseling style is generally a quiet and eliciting one. - The counselor is directive in helping the client to examine and resolve ambivalence. - The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. - Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction with others.
Number Needed to Harm (NNH)
- NNH is the number of patients who need to be treated to cause 1 adverse outcome - Larger the NNH, less likely a patient is to experience an adverse outcome E.g., NNH of 100 means need to treat 100 patients to cause one adverse event E.g., NNH of 1 means that every person would have an adverse event. NNH is the inverse of attributable risk
Number Needed to Treat (NNT)
- NNT is a statistic that provides information about effectiveness in terms of patient numbers; it's really just another way to express absolute risk reduction - NNT is defined as number of patients that would need to be treated to prevent one adverse outcome or to achieve one beneficial outcome in a given time period. - Considered to be more clinically relevant because this statistic looks at effectiveness in terms of actual patient numbers.
Traditional experimental methods often viewed as barriers to research
- Need control groups - Large numbers of homogenous subjects - Because looking at group means, may not be able to differentiate characteristics of those patients who did respond to treatment from those who didn't improve
Interpretation of NNT
- No standard limits for NNT to dictate a treatment decision - NNT must be interpreted in terms of time period of a study - duration of treatment may make difference, so if comparing NNT values for different treatments, the outcomes must be measured within same time period - Interpretation of NNT will depend on baseline risk: patients may not all have same relative risk; age, gender, initial severity may alter relative risk - To compare NNTs, the outcomes of interest must be the same - e.g., NNT of 20 for preventing falls in elderly may be interpreted differently for NNT of 20 for preventing hip fx
Depression?
- Normal part of the grieving process - Increased awareness of individual's condition - "feelings of despair and hopelessness, negative shifts in perception, and decreased interest in activities that once provided pleasure." - May lead to neurochemical and/or biological changes leading to major depression - Mental illness in which a person experiences deep, unshakable sadness and diminished interest in nearly all activities. - Major Depression - dramatically impairs a person's ability to function at work and in social situations. - Dysthymia - depressed personality experiencing sadness and depressed mood throughout life as part of personality disorder
Education targeted towards multiple individuals, such as...
- Parents/ family/ caregivers - Siblings - Classmates - Teachers / inclusion specialists This requires a multidisciplinary approach, including... - PT, OT, SLP, Aud, nutritional services - Early intervention specialist, inclusion specialist, teacher, child psychologist, school counselor, etc. - Parent / family / caregiver / child
General MI Principles: Express empathy
- Patients/Clients more willing to open themselves up and share experiences - Allows therapist to assess when and where the patient/client may need support in the change process - Opens patient/client up to challenges posed by the therapist - Vital to Facilitate change
Ways to limit liability?
- Policy and procedures manuals - Complaint procedures - Education of employees
Treating patients with depression
- Positive effects of activity - Control in plan of care - Empowering activities - Success building - Goal writing considerations - Reassuring talk - Enlist increased social support - Be mindful of progression of depression
Clinical Practice Guideline (CPG)
- Provides advice to clinicians about care of patients with specific conditions - Make explicit the evidence base and rationale for those recommendations - Meant to be a starting place for decision-making about individual patients - Not rules, but guidelines.
Who to refer to - depression
- Psychiatrist - moderate depression with limitation of life function or suicidal ideation - Psychologist - minimal depression with no warning signs of suicidal ideation (???) - Counselor, clergy, social worker, etc.
MI Techniques/Style
- Reflective listening (allows patient to develop their own frame of reference) - Expressing empathy, acceptance and affirmation - Eliciting and selectively reinforcing the client's own self motivational statements expressions of problem recognition, concern, desire and intention to change, and ability to change - Monitoring the client's degree of readiness to change, and ensuring that resistance is not generated by jumping ahead of the client. - Affirming the client's freedom of choice and self-direction
Reliability in SS Designs
- Reliability is assessed concurrently within data collection - "Reliability checks" - two raters observe behavior at several sessions across each phase of behavior; agreement scores are obtained and averaged - Interrater reliability - measuring percent agreement between 2 raters (Kappa; k)
Still have to take SLRs with a grain of salt.....
- Research on quality of systematic reviews has shown that - Not all SLRs are truly systematic - The quality of SLRs are highly variable - Cochrane reviews, on average, may be more rigorous and better reported than journal reviews - However, recent studies show that even Cochrane reviews have methodological problems - Since the quality of systematic reviews cannot be taken for granted, the reader has the responsibility of critically appraising them
Educational concepts for adolescents?
- Same topics as with school age - Patient able to make all decisions for self - Emancipated minor and personal responsibility
Self-injurious behavior
- Self-mutilating or self-harm - Substance abuse - Eating disorders - Physical harm - Symptom not a diagnosis - Shouldn't be confused with suicide attempts - Should suggest consultation for psychiatric evaluation and treatment
Stage of development and educational considerations for Infants/Toddlers? How does learning occur? What is education targeted at in this age group?
- Sensorimotor stage of development - Learning occurs mostly through interaction with the physical world through sensory stimulation and motor development Education for the child at this age targeted at... - Sensory integration - Motor development - Progression of cognitive and psychomotor development
Providing Consequences
- Shaping The general rule is that you are reinforcing any behavior that is a closer approximation of the target behavior than the behavior you reinforced last. (e.g. playing "hot-cold") - Chaining Chaining is a procedure that begins with the first element in the chain and progresses to the last element (A to Z). In forward chaining, you start with the first task in the chain (A). Once the child can perform that element satisfactorily, you have him perform the first and second elements (A & B) and reinforce this effort - Backwards chaining This is often a very effective way of developing complex sequences of behavior
Recognizing Child Abuse in The Parent
- Shows little concern for the child - Denies the existence of—or blames the child for—the child's problems in school or at home - Asks teachers or other caregivers to use harsh physical discipline if the child misbehaves - Sees the child as entirely bad, worthless, or burdensome - Demands a level of physical or academic performance the child cannot achieve - Looks primarily to the child for care, attention, and satisfaction of emotional needs
Recognizing Child Abuse in The Child
- Shows sudden changes in behavior or school performance - Has not received help for physical or medical problems brought to the parents' attention - Has learning problems (or difficulty concentrating) that cannot be attributed to specific physical or psychological causes - Is always watchful, as though preparing for something bad to happen - Lacks adult supervision - Is overly compliant, passive, or withdrawn - Comes to school or other activities early, stays late, and does not want to go home
Meta-Analysis
- Similar to a SLR, but difference is... combines results of studies statistically to develop a single overall estimate of intervention effect - Pools data from individual studies; creates larger sample sizes; useful if smaller studies can't show meaningful outcomes - Meta-analysis and SLR terms often used interchangeably; both critically appraise a body of studies, but meta-analysis includes a quantitative analysis of data.
Adherence Variables?
- Sociodemographic characteristics - Patient's beliefs and attitudes - Physical Therapists' behavior and rapport - Patient's perceived barriers and helplessness
Selection Criteria - Outcome Measures
- Something that measures improvement in condition or reduction of symptoms - May be specific instrument, impairment measure, etc.
Suicide - what to do
- Stop them from performing the act - Never leave the patient alone - Question intentions - Listen to the patient - Display empathy and understanding - Do not discredit patients feelings - Accentuate positives and alternatives - Alert family, friends, other caregivers - Refer patient to psychiatrist or other MD
Education principles & techniques for children with cognitive deficits (adolescents)?
- Strategies in educational research applied to motor learning - Strategies similar to motor learning theory
Second - Validate the Rule You need to test the CPR in different populations
- Test the rule in different populations of patients (RCT). Why? Ensures the results can be replicated in a different population of patients. - Predictor variables in first sample may have occurred by chance. - Some predictor variables may be unique to initial sample. - Essential that all persons administering the testing be trained to reduce any error in measurement. - Ensure that different therapists can administer the CPR testing and gain same results.
General MI Principles: Support Self-efficacy
- The patient/client must believe that change is possible and that they can be successful - Therapist must work to help the patient/ client stay motivated - Support can come from others than just the therapist (family, other patients who have had success in making change, others who are in the same stages of change, etc.)
Physical Therapists and Prognosis
- The risk of developing a future problem - The ultimate outcome of an impairment in body structures or function, an activity limitation or a participation restriction - The results of a physical therapy intervention. Patients/clients, families, third party payers are all interested in prognoses
Systematic Review
- Type of research design - Secondary analysis of original individual studies - NOT A LITERATURE REVIEW - Rigorous process of searching, critically appraising and summarizing existing info on a topic - Focus on effectiveness of interventions, accuracy of diagnostic tests or identifying prognostic factors
A Few Thoughts for Epidemiology
- Understanding relative risk associated with specific patient characteristics, activities or treatments can help us decide choice of intervention, who gets the intervention as well as the intensity and frequency of the intervention - This information can be used to make larger decisions regarding policy issues related to practice - Helps us gain insight regarding which patients might improve with an intervention
Warning signs that someone is injuring himself or herself include....
- Unexplained frequent injury including cuts and burns - Wearing long pants and sleeves in warm weather - Low self-esteem - Difficulty handling feelings - Relationship problems - Poor functioning at work, school or home
Relative Risk
- Used in cohort studies because these are PROspective studies; based on incidence of the outcome within the total group of subjects with (or without) the risk factor. - Relative risk is the ratio of the risk of developing an outcome in patients with a prognostic (risk) factor compared to the risk of patients without the prognostic (risk) factor.
Multiple Baseline Designs
- Useful in situations where ethical considerations of withdrawal of intervention exists and if behaviors are non-reversible or prone to carryover effects. - Multiple Baseline design can be used where effects are replicated across subjects, across treatment conditions or across multiple target behaviors. - Basic premise is that baseline data is available for all subjects simultaneously so that temporal effects cannot contaminate results
Calculating Odds Ratio
- Uses a contingency table - Ratio of the odds that a case is exposed divided by the odds that a control is exposed: (a/c)/(b/d) or ad/bc If OR = 1, means odds of developing disease no greater than chance;< 1 suggest a protective effect of exposure; > 1 suggests a causative or adverse effect of exposure.
Calculating Relative Risk
- Uses a contingency table (Exposure vs. Disease Presence) - Ratio of probability of an event occurring in an exposed group to the probability of the event occurring in the non-exposed group RR = [a/(a+b)]/[c/c+d)] If relative risk = 1, this is the null value; means risk of developing disease no greater than chance;< 1 means decreased risk of disease/event;> 1 means increased risk of disease/event. *Incidence of disease in exposed (intervention) group divided by the Incidence of disease in unexposed (control) group
Basic Elements for High-Quality CPGs
- Utilizing a systematic literature review - Establishing transparency and disclosing the methods used for all development steps - A multidisciplinary development group - Disclosure and management of both financial and non-financial conflicts of interests - Clear and unambiguous guideline recommendations - Using a specific grading systems to rate the strength evidence and recommendations - External peer review
Antecedent Techniques
- Verbal instructions - Verbal and tactile cues - Modeling - Fade antecedent techniques over time - Ideally replaced with naturally occurring cues
Risk of Future Adverse Event
- We are often concerned about risk of future event in patients who have a primary medical diagnosis; in this case we are concerned with secondary or tertiary intervention strategies > Falls as result of stroke or brain injury > Re-injury with return to work/sport following joint sprain > Skin breakdown as result of sensation loss or immobility - With movement into health/wellness, have become focused on primary prevention in our clients. **Prognosis is prediction of the course of disease or predicting patients' future as closely as possible.
Importance of Research Synthesis
- We need evidence for both clinical practice and for public health decision making - Where does evidence come from? > Given the explosion of medical literature and the fact that time is always scarce, review articles play a big role in decision-making > A good review is a state-of-the art synthesis of current evidence on a given research question
When can meta-analyses mislead?
- When a meta-analysis is done outside of a systematic review - When poor quality studies are included or when quality issues are ignored - When inadequate attention is given to heterogeneity
How are systematic reviews better?
- You don't have to be an "expert" to do one - More objective, less prone to bias and error - Literature search is comprehensive, exhaustive and repeatable - Clear description of the methods used - Explicit criteria for choosing studies - Includes assessment and discussion of quality of primary studies - Readers can replicate to verify the review
Those who must report child abuse/neglect?
- health care providers - mental health/social workers - clergy - teachers - police or law enforcement - commercial film or photographic print processor - court-appointed mediators
What impact do you think the following things has on one's health behavior.... - Individual's culture? - Psychological well-being? - Past experiences with health behavior change? - Family/friend support? - Major life experiences (eg. near-death experiences) What other things do you think impacts one's health behavior?
- religious beliefs - may not have the competence to understand why something is or isn't healthy for them - failures or successes - GET THE FAMILY INVOLVED
Andragogy Vs. Pedagogy: Motivation for Learning
1) Andragogy - Adult learners are inherently intrinsically motivated to learn rather than relying on extrinsic motivators. Internal motivators for adults include self-esteem, recognition, better quality of life, self-confidence, & self-actualization - Adult learners are turned off by extrinsic rewards applied to learning 2) Pedagogy - Learners are primarily motivated by external pressures, competition for grades, and the negative consequences for a failure.
Andragogy Vs. Pedagogy: The Role of the Learner's Experience
1) Andragogy - Adult learners define themselves through their accumulation of a unique set of life experiences - These experiences form great resources for learning through reflection and application through experiential and participatory learning - These experiences should be respected and treated with sensitivity. 2) Pedagogy - The learner comes to the activity with little life experience to draw upon and rely heavily on the experience of others for learning - The experience of the teacher/instructor is emphasized much greater and is used to guide the learning experience.
Andragogy Vs. Pedagogy: Orientation to Learning
1) Andragogy - Adult learners desire an immediate application of knowledge. - Adult learners learn better through application of problem-solving of real-life contextual problems - Learning is organized around life/work situations rather than subject matter units 2) Pedagogy - Learning is a process of acquiring prescribed subject matter - Content units are sequenced according to the logic of the subject matter
Andragogy Vs. Pedagogy: The Learner's Self-Concept
1) Andragogy - Adults are self-directed and autonomous learners - Adults are able to determine their own learning needs and are responsible for their own learning - Adults perform self-evaluation of their own learning 2) Pedagogy - The learner is dependent upon the instructor for all learning - The teacher/instructor assumes full responsibility for what is taught and how it is learned - The teacher/instructor evaluates learning
Andragogy Vs. Pedagogy: Readiness to Learn
1) Andragogy - Change is likely to trigger a readiness to learn - Readiness to learn is directly related to the learners stage in development and life. - Adult learners are motivated to learn what is only or most relevant to their stage in life. - Adult learners have the ability to assess gaps between their current level of knowledge and understanding and the level of knowledge and understanding they need to have 2) Pedagogy - Students are more passive in their learning experience - Students are told what is to be learned in order to advance to the next level of mastery (ie. The next academic year or course)
First - Create the Rule (Derivation) These are the parameters that allow you to make better decisions.
1) Brain Storm - develop list of factors that may have predictive value. 2) Short List - Hone list to reasonable predictors... maybe 10 to 15 predictor variables. 3) Examine sample for absence or presence of each predictor variable; baseline measurements of each predictor variable for each participant completed - Examiner should be blinded from knowing whether patient has condition of interest. - Second examiner (blinded) compares results of clinical examination to a reference standard (measurement tool). 4) Analysis of data using logistic regression is used to determine the best set of predictor variables that maximizes accuracy of diagnosing condition of interest. 5) Use diagnostic accuracy statistics to express accuracy of CPR (sensitivity, specificity, LR, e.g., sensitivity is the proportion of patients with the condition who test positive on the CPR). *something that has a gold standard, you want a test with a high -LR (greater probability to rule out); a test that doesn't have a good gold standard perhaps needs a high +LR
MI Techniques - OARS
1) Open-ended questions - Are the key to encouraging patients to do most of the talking - Cannot be answered with a brief response or a yes or no answer - Invite a two-way conversation - Begin with words such as "how", "what" or phrases such as "tell me more about..." - Avoid beginning questions with "why" as that can put patients on the defensive. 2) Affirmations - Affirmations give the patient the message that "I see you and hear you" - May be a compliment or statement of appreciation and understanding - Your voice tone, eye contact and body language all can be affirming 3) Reflections - Reflective listening helps make sure that you understand what the patient is telling you - You can reflect what is written in a chart, what is said or what you observe - It helps the patient hear what she or he said and clarifies any misunderstanding - It may be helpful to remember to use a reflection after the patient answers a question; this avoids falling into the 'question-answer trap." 4) Summaries - Is a form of reflective listening - Can be used throughout an interaction to transition from topic to topic - Can be used at the end of an interaction to review what was discussed - Ends with an invitation for patient to respond (What did I miss? What else would be helpful today? What other questions do you have?)
Types of Child Abuse and Neglect Defined in the Law
1) Physical Abuse 2) Child Neglect - Physical Neglect - Educational Neglect - Emotional Neglect 3) Sexual Abuse 4) Emotional Abuse
Behavioral Programming Intervention with regard to pediatric education?
1) Positive Reinforcement - Tangible, Social, and Abstract - Seek out naturally occurring positive reinforcement - Observe child and ask family - Offer child choices 2) Antecedent Techniques - identify the conditions in the setting that are reinforcing the interfering behavior and then to modify the environment or activity so that the environmental conditions no longer elicit the interfering behavior. 3) Providing Consequences
Violence in Physical Therapy
1) Predict and prevent key - Clinching fist - Pacing back and forth - Angry facial expressions - Grunting, groaning, swearing - Tapping a foot - Refusing to engage in therapy - Throwing objects - Banging weights / equipment 2) Identify source of agitation 3) Do not confront or accuse patient 4) Redirect anger to positive outlet 5) Listen to patient and allow them to vent frustration 6) Compromise with patient 7) If all else fails, remove all other patients from the area and call for help / security 8) Document and report incident - Pt's perceived potential for violence/aggression - Signs of escalating anger - History of violence? Under what circumstances? - Therapist and pt's response to aggressor before, during, and after event - What could have been done to prevent the event from occurring
Evaluating Methodological Quality: Study bias related to internal validity
1) Selection bias - refers to how comparison groups in a study was formed (Random allocation and concealment of allocation) 2) Performance bias - refers to possible differences in provision of care to intervention and control groups of a study (Blinding of those who receive and give care) 3) Attrition bias - refers to loss of subjects across comparison groups (Do intention to treat analysis) 4) Detection bias - refers to possible differences in the outcomes assessment across groups
Baseline characteristics
1) Stability - consistency of responses over time 2) Trend - rate of change in behavior - Researcher wants a pattern showing constant level of target behavior with minimal variability - Most desirable baseline pattern shows constant level of behavior with minimal variability - Variable baseline presents problems for interpretation.
Lapse?
A Lapse is "a cessation of a healthy behavior, but the cessation is temporary and does not produce significant adverse effects." - Occurs in the maintenance and/or permanent maintenance stages - Minor Lapse - cessation is/was brief/fleeting - Major Lapse - cessation is/was nearly complete/complete
Steps to Addressing Health Literacy (continued)
2) Improve communication skills - Slow down, talk clear - Convey the most important ideas - Use lay terms - avoid medical jargon - Incorporate family members - Use visual aids
Social Learning Theory - Health Behavior Theory
A behavior is a combination of - Social & Physical Environments - Emotions, Self-Appraisals, Self-Efficacy *Behavior depends greatly on context
Trans-Theoretical Model: 5 consecutive stages of change from old to new health behavior
5 consecutive stages of change from old to new health behavior: 1) Pre-contemplation - not intending change 2) Contemplation - intend to change within 6 months 3) Preparation - actively planning to change within 30 days 4) Action - has initiated change within past 6 months 5) Maintenance - successfully modified behavior for more than 6 months The Trans-Theoretical model looks at readiness for change to decide on timing for intervention - Assessment & Intervention
Trans-Theoretical Model - Health Behavior Theory
A person's behavioral change occurs in a series of stages Major aspects of theory: - Stages of Change - Process of change (cognitive & behavioral mechanisms to modify health behavior) - Decisional balance (cost / benefit ratio analysis) - Temptation (urges or drives to engage in negative health behavior or to not engage in positive) - Confidence (patient's belief in their ability to overcome temptation)
Signs of Withdrawal
Sweating Impaired sleep Seizures Impaired motor coordination Faulty judgment Anxiety Shaking Slurred speech Fluctuating levels of consciousness Visual and tactile hallucinations
Most reporting goes grossly Underreported. What to use to screen for abuse?
Abuse Assessment Screen - Disability (AAS-D) Sexual, physical, & disability related abuse May be administered orally in taking a history or filled out by person.
Effective Health Information Is...
Accurate Available Balanced Consistent Culturally Competent Evidence-based Reliable Repeated appropriately Targeted to reach most people Timely in its presentation Understandable
Learning Style Preference : Active and Reflective
Active and Reflective - Concrete Experience - Active Experimentation - Abstract Conceptualization - Reflective Observation
Definition of Addict
Addict - Drug use is compulsive, even when it results in negative consequences - Life revolves around drug use - difficult to control - Considerable time spent attaining substance, using drug, and recovering from drug use - Tolerance builds to substance with marked increase in volume of substance to elicit a response - Withdrawal occurs upon discontinuing use of the substance
Six Principles of Adult Learning
Adults... 1) are internally motivated and self-directed 2) bring life experiences and knowledge to learning experiences 3) are goal oriented 4) are relevancy oriented 5) are practical 6) are learners who like to be respected
Substance Abuse - DSM IV
Alcohol* Cannabis (marijuana)** Cocaine and amphetamines (speed) Opioids (morphine, heroin, oxycontin) Nicotine Caffeine Hallucinogens (LSD) Inhalants Sedatives Hypnotics Anti-anxiety medication *Most commonly abused substance **Most commonly abused illicit drug
Synthesis of Data
Allows reader to understand variations across studies and overall findings
Single Subject Design
An alternative to help draw conclusions about intervention based on response of single subject or several subjects. - Need to have good control over experimental approach - Have a hypothesis - IV = intervention - DV = patient response or target behavior that is observable, quantifiable and a valid indicator of effectiveness - Not the same thing as a case study or case study series
Andragogy?
Andragogy - The study or philosophy of how adults are best taught or come to knowledge and how this differs from younger learners Andragogy has a humanistic theoretical framework for educating adult populations and learners
Who must report adult abuse/neglect?
Any person who has reason to believe that abuse or neglect of an adult (eg. any person over 60years, any disabled person older than 18 years, or an emancipated minor)
Education Intervention in the Face of Health Illiteracy
Assessing Readability Flesch Reading Ease (Flesh-Eatting Leech?) method (Table 7.12) - Sentence length (in words) - Word length (in syllables) If sentences are active, simple sentences, it is at a lower reading level Gunning Fog formula Flesch-Kincaid formula - 1.0 (1st grade reading level - 50 (totally unreadable) Simple Measure of Gobbledygook (SMOG) formula
Assuring comprehension and adherence
Assuring comprehension and adherence - Provide oral and written materials together - Be repetitious - Utilize audiovisual materials / aids when available - Assess understanding > The Teach-back Method - Incorporate principles of education > Dale's Cone of Experiential Learning
Assuring Readability
Avoid Concept words ("global warming") - think low context Avoid Category words (eg. "you need to do more cardio") - be specific Avoid Value Judgment words ("good exercise" - be specific, use quantitative amounts Place context first in sentences - Table 7.18 Utilize active voice vs. passive voice
Concept of Literacy Expanded (Numeracy) - Basic - Computational - Analytical - Statistical - Health Numeracy
Basic Numeracy- recognize numbers and make sense of quantitative data without manipulation Computational Numeracy - count, quantify, compute, & use simple manipulation of numbers, items, quantities, or visual elements Analytical Numeracy- understanding of higher level mathematics: inferences, estimations, proportions, percentages, frequencies, and equivalence Statistical Numeracy - very high proficiency of mathematics: comprehend biostatistics, probability statements, critically analyze quantitative information, understanding of randomization, etc. Health Numeracy - access, process, interpret, communicate, and act on numerical, quantitative, biostatistical, graphical, and probabilistic health information in order to make health decisions
Example of Multiple Baseline Design - Across Behaviors
Because results replicated across three conditions at staggered times, unlikely external factors occurred at the time each treatment was initiated to cause the response change
Positive Behavioral Support
Behavior analysis to identify - Antecedents to improper behavior - Antecedents to appropriate behavior - Consequences of behaviors Development of replacing activities/behaviors Avoidance/management of negative antecedents
Health Promotion Model - Health Behavior Theory
Behavior is a combination of - Self-Efficacy - Influence of external modifying factors External Modifying Factors: - Demographic characteristics - Biological characteristics - Interpersonal influences - Situational influences - Behavioral influences - Internal (feels good) and External (friends are all doing) cues to action
Screening for addiction
CAGE acronym: Cut - Have you ever tried unsuccessfully to cut down your drinking (or other substance)? Angry - Does it make you angry when people suggest that you stop drinking? Guilty - Do you feel guilty when you drink? Eye-opener - Do you need an "eye-opener" to get started in the morning? (2 or more yes - inquire more about support)
Third - Conduct Impact Analysis The ability of the CPR to improve clinical outcomes
CPR must now be able to improve relevant clinical outcomes, increase patient satisfaction and decrease costs to be useful. Assesses how the CPR will impact practice, outcomes and cost. Requires comparison to "usual" practice. - Randomly assign individual patients to receive care based on CPR or have decisions based on standard practice - Randomly assign clinical sites to apply CPR or not for all patients - Look at morbidity, mortality, hospital stay...
Data Analysis - Celeration Line
Can calculate slope to estimate rate of change in target behavior
Target Behavior
Can reflect many different responses - Motor - e.g.; functional performance, ROM, gait characteristics - Physiological - e.g.; blood pressure, exercise responses - Verbal - e.g.; number of correct response to a question Need to operationally define the target behavior
Signs of Emotional Abuse
Consider the possibility of emotional maltreatment when the child: - Shows extremes in behavior, such as overly compliant or demanding behavior, extreme passivity, or aggression - Is either inappropriately adult (parenting other children, for example) or inappropriately infantile (frequently rocking or head-banging, for example) - Is delayed in physical or emotional development - Has attempted suicide - Reports a lack of attachment to the parent - Constantly blames, belittles, or berates the child - Is unconcerned about the child and refuses to consider offers of help for the child's problems - Overtly rejects the child
Signs of Neglect
Consider the possibility of neglect when the child: - Is frequently absent from school - Begs or steals food or money - Lacks needed medical or dental care, immunizations, or glasses - Is consistently dirty and has severe body odor - Lacks sufficient clothing for the weather - Abuses alcohol or other drugs - States that there is no one at home to provide care - Appears to be indifferent to the child - Seems apathetic or depressed - Behaves irrationally or in a bizarre manner - Is abusing alcohol or other drugs
Signs of Physical Abuse
Consider the possibility of physical abuse when the child: - Has unexplained burns, bites, bruises, broken bones, or black eyes - Has fading bruises or other marks noticeable after an absence from school - Seems frightened of the parents and protests or cries when it is time to go home - Shrinks at the approach of adults - Reports injury by a parent or another adult caregiver - Offers conflicting, unconvincing, or no explanation for the child's injury - Describes the child as "evil," or in some other very negative way - Uses harsh physical discipline with the child - Has a history of abuse as a child
Signs of Sexual Abuse
Consider the possibility of sexual abuse when the child: - Has difficulty walking or sitting - Suddenly refuses to change for gym or to participate in physical activities - Reports nightmares or bedwetting - Experiences a sudden change in appetite - Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior - Becomes pregnant or contracts a venereal disease, particularly if under age 14 - Runs away - Reports sexual abuse by a parent or another adult caregiver - Is unduly protective of the child or severely limits the child's contact with other children, especially of the opposite sex - Is secretive and isolated - Is jealous or controlling with family members
Evaluating Methodological Quality
Critically review each paper Two primary reviewers assess quality independently; then meet to compare their assessment When disagree, resolve by consensus or a third party
Locus of Control - Health Behavior Theory
Factors influencing our health can or cannot be influenced by our actions. - Internal locus of control - External locus of control Patient's perceptions of this zone of influence (what they have power or influence over) determines the patient's adherence to healthy behavior.
Change Talk (DARN CAT)
Defined as statements by the client revealing consideration of, motivation for, or commitment to change. Preparatory Change Talk (determine readiness to change) - Desire (I want to change) - Ability (I can change) - Reason (It's important to change) - Need (I should change)
What does it mean to be "at 100% at the speaker's disposal"? Why is this important?
Demonstrating therapeutic presence You need to assess if they understand.
Epidemiologic studies can be observational or experimental (sometimes quasi-experimental). Observational studies are characterized as...
Descriptive - used to observe and learn more about a disease or disability concerned with distribution or pattern of disease Analytic* - test hypotheses to determine if specific exposures are related to health status or disease occurrence
Measurement of Target Behavior
Direct measurement of the behavior itself 1) Frequency count - Can simply be the number of occurrences of behavior - Can be expressed as a percentage (number of occurrences divided by number opportunities) - Can be expressed as a rate (# of times over some period of time) 2) Duration - how long target behavior lasts; i.e., how long to maintain standing posture 3) Instrumentation that provides a quantitative score; i.e., score on an outcome assessment tool.
Generalizability - Direct replication
Direct replication - replicate results across several subjects or repeat study on same subject. External validity gets stronger if results replicated across subjects
Clinician's actions during (3) Preparation
Discuss resources and coping skills; support decision to take action; focus on SMART goals (actively planning to change within 30 days)
Clinician's actions during (1) Pre-contemplation
Educate, establish report and trust, provide insight into health behavior is negatively impacting them
Patient Empowerment
Educating and encouraging patients to expand their role in decision-making, health-related behaviors, and self-management of care.
Appropriate education for Parent/Caregiver education of infant/toddler?
Education for caregiver/parent is targeted at... 1) Psychomotor development of child 2) Gross motor status and motor milestones 3) Integration of primitive reflexes 4) Emergence of purposeful movement, language and social skills 5) Ways to promote active exploration and psychomotor development (eg. Toys and use of play) 6) Psychosocial development - Importance of trust - Nurturing and caring ability of the parent 7) Health promotion 8) Disease prevention 9) Safety
Educational interventions for preschoolers? How is the information conveyed to preschoolers?
Educational interventions for preschoolers include... - Modeling of appropriate behaviors - Role-playing fantasy - Functional play Information is conveyed by... - Verbal and non-verbal communication - Include child in decision-making process for interventions - Short, frequent sessions for education
American Physical Therapy Association (APTA): on sexual harassment
Environments in which physical therapy services are provided, or in which the work of the American Physical Therapy Association and its components is carried out, should be completely free of sexual harassment.
What is Epidemiology?
Epidemiology - study of distribution and cause of disease, injury or dysfunction *Definition expanded to include study of chronic disease, disability and health status.
Epistemology?
Epistemology - the study of how people learn and come to the knowledge that they have. (eg. Liberal/traditional, behavioral, cognitivist, constructivist)
Meta-Analysis: Evaluate heterogeneity Effect size
Evaluate heterogeneity - Want to make sure there is a common treatment effect (homogeneity) across studies and that any observed differences between the studies are due to chance Effect size - Estimate of magnitude of difference between groups - Larger difference, greater the "effect" of intervention - Develop effect size index for each study - allows for comparison across studies - Combine individual effect sizes into one common estimate of effect. Have to weight effect size of each study *Results are presented in a forest plot; shows results of each study and a cumulative summary.
Meta-Analysis compared with SLR
Extension of SLR > If studies meet criteria for homogeneity, then synthesize results across studies > Combining samples from small studies may increase ability to detect differences Advantages > Increase power > Improve estimates of effect size > Resolve uncertainty when conflicting results > Improve generalizability of findings
How does one's perception of locus of control influence their health behavior?
External locus of control - things happen to me (e.g. both parents died of a heart attack, so I guess I'm predestinated to have a heart attack) Internal locus of control - we're aware that our choices make a difference in my health
Education with Pediatrics and Instruction in Natural Environments?
Functional skills in child's own environment Little generalization or carryover of tasks or prerequisite skills Skills practiced in natural environment reinforced by... - Repetition - Naturally occurring positive reinforcement - Natural variation in stimulus conditions
Functionally illiterate
Functionally Illiterate - an individual who Reads, writes, & comprehends skills below a 5th grade level
Geragogy
Geragogy - the theory regarding the differences in how the elderly learn and think and the different considerations that must be made when teaching the elderly. Education must consider - Physical changes with aging - Cognitive changes with aging - Comorbidity interaction with learning - Motivation to learn
Health Belief Model - Health Behavior Theory
Health Belief Model - perception in following areas influences person's adherence to healthy behavior: - Susceptibility to the health threat - Severity of consequences of the health threat - Benefits of the recommended behavior on reducing health threat - Barriers or costs of the recommended behavior are less than the benefits of the behavior - Self-confidence in ability to make change successfully *this deals with the health behavior itself, but doesn't take into account of the psychology of the person doing the behavior
Health Literacy?
Health Literacy is "The patient's ability to read, understand, and take action in regard to health information to make appropriate healthcare decisions." - Literacy is prerequisite to health literacy, but doesn't directly lead to health literacy - Literacy is one of the most common variables that negatively impact patient adherence to therapeutic regimens and preventive health care
Hierarchies for evidence
Hierarchies for evidence-based medicine, i.e.; Sackett's level of evidence usually rank SLRs at top because conclusions based on synthesis of multiple articles rather than a single trial Potential for low quality does exist how review conducted and how individual studies synthesized. Types of Participants - Based on subject characteristics - Can be broadly or narrowly defined. Types of Interventions - Define the interventions - usually broad definitions
When to report?
Immediately
Infant/Toddler with chronic illness/developmental disabilities
Important to use family-centered care and education - Focused on the needs of the parent/caregiver and child - Aimed at empowerment and self-advocacy of parent/caregiver and child - UCEDD, LEND - Early Steps
What is instruction targeted at in preschool age?
Instruction continues to be targeted more towards child Learning occurring in multiple domains - Language and communication - Psychomotor - Social skills - Cognitive
Toddler age education
Instruction targeted towards toddler. It's important to constantly assess toddler's level of understanding in order to adjust instruction to the appropriate level of understanding - Slow and clear instructions - Allow time for comprehension and reaction - Tailor instruction to toddler's level of attention and cognitive capabilities
Reporting Family Violence
Is it a duty or ethical decision? No federal mandate for reporting family violence Each state has it's own law (eg. LA state law)
Learning Style Preference: Brain Dominance Theory
Left Brain - Uses logic - Detail oriented - Importance on facts - Words & language - Math & science - Knowing - Order/pattern perception - Reality-based - Rational - Systematic, directed - Sequential learning Right Brain - Uses feeling - "Big Picture" oriented - Imp on imagination - Symbols & images - Philosophy & religion - Believes - Spatial perception - Fantasy based - Emotional - Casual, free - Global learning
Hierarchy of Evidence
Level V (lowest): Expert opinion Level IV: Derived, but not validated; use with caution with patients similar to those in study Level III: Validated in only one narrow prospective sample Level II: Validation in one large prospective study; includes broad spectrum of patients; used in a variety of settings with confidence Level I (highest): At least one prospective study in a different population plus one impact analysis demonstrating change in clinician behavior with beneficial consequences
Marginally illiterate
Marginally illiterate - between 5th and 8th grade Characteristics correlated with low literacy
Major Depressive Disorder
Mood disorder characterized by at least one Major Depressive Episode, with clinical course Major Depressive Episode: - depressed mood or a loss of interest or pleasure in daily activities consistently for at least a 2 week period - represent a change from the person's normal mood - negatively impaired social, occupational, educational or other important functioning
Education with School Age (6-12 years)?
More independent and motivated learner - Capable of abstract thought - Creativity enhanced - driven to create something - Functional tasks/goal-oriented tasks - Competitiveness
Motivational Interviewing Defined
Motivational interviewing is a person-centered counseling method defined as collaborative conversation between therapist and patient MI is aimed at strengthening the person's own motivation for and commitment to change Addresses the common problem of ambivalence about change William Miller - psychotherapist - 1983
Neglect vs. Abuse?
Neglect - failing to adequately provide for an individual's physical, medical, financial, and/or psychological needs Abuse - the experience of highly stressful events inflicted by another person that is beyond the individual's capacity to cope and that impairs the individual's sense of well being; can be physical, psychological, sexual, or a combination *Often occurs within a power hierarchy
National Assessment of Adult Literacy (2003)
Non-literate in English - 4% - 7 million could not answer simple test questions - 4 million had language barriers Below Basic (4-5th grade reading level) - 14% - 30 million people - no more than the most simple and concrete literacy skills Basic - 29% - 63 million people - can perform simple and everyday literacy activities Intermediate - 44% - 95 million people - can perform moderately challenging literacy activities Proficient - 13% - 28 million people - can perform complex and challenging literacy activities
Odds Ratio
Odd Ratio - used in case control study; define number of subjects with and without the outcome and then identify risk factor distribution retrospectively. Because subjects are purposefully chosen based on presence or absence of disease, can't determine incidence of disease, so we can calculate an odds ratio **The odds ratio reflects the odds that an individual with a prognostic factor (risk) factor has an outcome of interest, as compared to the odds for an individual without the prognostic (risk) factor. Basically, odds ratio gives us an idea of how strongly the risk factor is associated with the outcome. Very similar to relative risk.
Risk factors of family violence
Past history of abuse Psychiatric disorder Substance abuse Poor education Lack of access to health care Inadequate nutrition Lack of day care and social supports Social isolation of the family
Patient education for school age children? Education strategies?
Patient education for school age children should include... - Injury Prevention - Health Promotion - Information about injury/illness/disorder - Education strategies include... - Interesting and different - Audiovisual materials/aids - Computer / technology based
Pedagogy?
Pedagogy - The study or philosophy of how people are best taught to impact their learning (i.e. Beliefs of pedagogy related to individuals' beliefs of epistemology)
Who is Liable?
Perpetrator Employer (not liable for damages)
Effects of Family Violence
Physical effects at time of abuse Psychological effects following abuse - 40-70% patients in psyche institutions victims of abuse - Post-traumatic stress disorder, depression, anxiety, etc. Personality disorders and changes - Eating disorders - Attention-deficit disorders - Self-injurious behavior - Substance abuse Relationship problems - Difficulty with trust and physical/emotional attachment
Developmental stages for School Age (6-12years) Children?
Piaget: Concrete operational stage Erikson: Industry versus Inferiority
Developmental stage for adolescents: 12-18 years of age?
Piaget: Formal operational stage Erikson: Identity versus role confusion
Stage of development for Preschool Age (3-6 years)?
Piaget: Preoperational Erikson: Initiative vs. Guilt
Disease Frequency measures?
Prevalence - proportion of existing cases in a population at a time Incidence - the number of new cases in a population during a specified time. Vital statistics
Clinician's actions during (5) Maintenance
Prevent relapse and encourage long-term change; manage situations that can "trigger" behaviors to relapse; reinforce lifestyle change
Clinician's actions during (2) Contemplation
Provide motivational messages, help patient evaluate pros and cons of changing behavior (intension to change within 6 months)
Drugs and Alcohol in the Workplace
Randomize drug testing - whose rights are right? How to handle employees with drug/alcohol abuse problems? What is the consequence of practicing physical therapy under the influence?
Relapse?
Relapse - "a cessation of a healthy behavior that is longer than temporary and produces significant adverse effects." - Minor or major relapses - Occurs only in the maintenance stage - Moves individual back to the preparation stage
Confidence Intervals
Remember, that ARR and NNT are point estimates and so should be presented with a confidence interval for accurate interpretation, so can calculate the CI. So we are 95% confident that true population AAR is between 36% and 70% (53% ± 16.7%) and 95% confident that NNT is between 1.43 and 2.75.
Search Strategy
Review process needs to include description of search strategy - Databases, search terms, language - Hand-searching from reference lists; journals - Grey literature - unpublished studies or items obtained thru other sources. - Retrieving papers; still may have many papers, but end up discarding many. Need to indicate reasons for excluding papers.
Structure of SS Designs - Core Elements (2)
Second core element = Design phases Design phases: at least two phases (1) Baseline phase - prior to treatment or "control" condition - Analogous to control group - Reflects natural state of target behavior over time in absence of IV - Provides standard of comparison for evaluating potential cause and effect relationship between intervention and target behavior - Key difference between case studies and even experimental designs *May not ethical to withhold treatment during baseline phase, especially when it is life-threatening (2) Intervention phase - "treatment" condition Important to measure target behavior at multiple times across both phases
Clinical Prediction Rules (CPR)s
Sensitivity, specificity and likelihood ratios are useful in supporting a diagnosis or prognostic classification. eg. +LR is good if 10 and -LR is good if 1/10 In real situation, patient care decisions are often much more complex; and requires a combination of several predictors to support a conclusion. CPRs quantify contributions of multiple variables to the diagnosis, prognosis or likely treatment response for individual patients. The objective of CPRs is to decrease the uncertainty by demonstrating how specific clusters of clinical findings can be used to make a diagnosis or predict outcomes.
Sexual Harassment
Sexual Harassment - unwelcome sexual advances, requests for sexual favors, or other verbal or physical conduct of a sexual nature when: It is a term or condition of an individual's employment Used as the basis for employment decisions Unreasonably interfering with an individual's work performance or creating an intimidating, hostile, or offensive working environment.
Factors in Motivation of the Adult Learner?
Social Relationships External Expectations Social Welfare Personal Advancement Escape or Stimulation Cognitive Interest
Feedback and Reinforcement?
Specific vs. general feedback Positive vs. negative feedback/ reinforcement Distributed vs. blocked practice Scaffolding
Two additional stages to Trans-Theoretical Model?
Stage 1 (0) Primordial Stage - "A patient/client in the primordial stage is not aware that she or he has a health related problem and/or that she or he is unknowingly engaging in a behavior that is unhealthy." - Patient education is critical - Psychological and interpersonal skills required - Psychological counseling referral outside of PT practice may be required as well Stage 7 Permanent Maintenance Stage - "the behavior itself is reinforcing and the person is intrinsically motivated to continue the healthy behavior." - Health behavior becomes second nature - Not being able to perform the health behavior causes discomfort or unsettled feeling - Usually takes months to years to reach the permanent stage - Individuals may never reach the permanent stage with some health behaviors
Process of Systematic Literature Review and Meta-Analysis
State the study objective> Develop the protocol> Develop search strategy> Conduct the search> Retrieve Relevant Papers> Screen and Select Papers that meet established criteria> Evaluate Methodologic Quality of Selected Studies> Analyze and synthesize findings> One of two paths: Determine if statistical data are sufficient for further analysis if... Yes) Report results of systematic Review No) Analyze Effect Size Estimates > Report results of Meta-Analysis
Change Talk (DARN CAT) continued
Statements by the client revealing consideration of, motivation for, or commitment to change. Implementing Change Talk: - Commitment (I will make changes) - Activation (I am ready, prepared, and willing to change) - Taking steps (I am taking specific actions to change)
Who is ultimately responsible?
These are the factors that influence our willingness to educate our patients: Two-By-Two square: who is responsible for causing the problem? Who is responsible for providing the solution? Four models: Moral model: patients are held responsible for both problems and solutions and are believed to need only proper motivation. Compensatory model: patients are responsible only for solutions and are believed to need power. Medical model: patients are responsible for neither problems nor solutions and are thought to need treatment. Enlightenment model: patients are responsible for problems, but are unable or unwilling to provide solutions; they need discipline.
Expressive Skills
Your ability to get your point across - Getting the other person's attention - Conveying the information - Checking the other person's understanding > What are some examples of expressive skills? > What do you think are some expressive skills that you have and display well? > What are the expressive skills that you need to work on?
Locus of Control
individual's generalized expectations concerning control over future events.