1
Clinical Problem
Social Anxiety is described by The Diagnostic and Statistical Manual of the American
Psychiatric Association (DSM-5) as a persistent fear of social situations where the person is
exposed to people or to possible scrutiny by others and fears that he/she will display
symptoms of anxiety or be perceived in a way that will be embarrassing and humiliating
(American Psychiatric Association, 2013). This topic was chosen as according to Kessler et
al. (2012) social anxiety is among the most common anxiety disorder affecting 13% of
individuals at some stage in their lives. From experience, and according to Krysta et al.
(2015) medication is the first line treatment for anxiety disorders due to accessibility.
Unfortunately, for people experiencing social anxiety most medications have adverse effects
such as increased agitation and sexual dysfunction (Rosen et al 1999) and some medication,
in particular benzodiazepines are highly addictive (Lader and Kyriacou, 2016). Townend et
al. (2008) report that CBT remains the psychological therapy with the widest and broadest
evidence base. Beck et al (1979) define Cognitive Behavioural Therapy (CBT) as a concept
where an individual’s emotions and behaviours are based on the way that they interpret the
world through their cognitions. NICE (2011) (cited in Clark, 2011) recommend psychological
therapies prior to medication for anxiety disorders however due to a lack of therapists in
mental health services this is not the case in clinical practice which led to the rationale for the
following research question.
2
Clinical question
Are psychological interventions more efficacious than pharmacological interventions to help
reduce social anxiety disorder (SAD) symptoms in adults?
Bragge (2010) explains that answerable clinical research questions have four essential
components known as PICO. This therapy type question was developed using these
components (P) Population: adults that experience social anxiety (I) Intervention:
Psychological interventions (C) Comparator: Pharmacological Interventions (O) Outcome:
reduction of social anxiety symptoms.
Search Strategy and Outcome
A systematic literature search was carried out using electronic databases which were
individually accessed via Queens Online, including MEDLINE, Science Direct, PschINFO
and Cochrane (see Appendix 1). Roberts and Dicenso (1999) suggest that questions in
relation to interventions and their effectiveness are best answered by randomized control
trials or based on the hierarchy of evidence, systematic reviews. BestBets.org was also
accessed for evidence based synopses.
The three papers the author deemed relevant to answer the clinical question above are as
follows;
Clark et al. (2003)
Nordahl et al (2016)
Davidson et al. (2004)
3
These three studies were chosen as their methodological design appeared to answer the
clinical questi ...
The document summarizes a study that aimed to map the underlying structure of the at-risk mental state (ARMS) by defining dimensions of subclinical psychopathology in ARMS subjects. 316 participants meeting criteria for ARMS were assessed using the CAARMS interview and other measures. Principal component analysis of the CAARMS items yielded five interpretable components ("Depression", "Disorganization", "Bodily-impairment", "Manic", and "Schizo-affective"). The "Depression" component was most strongly related to worse functioning and increased depressive symptoms. The identified components could provide a step towards a dimensional approach to assessing ARMS.
Physical activity and the prevention of depressionGiliano Campos
The document summarizes a systematic review examining whether physical activity (PA) can prevent the onset of depression. The review analyzed 30 prospective studies that assessed the relationship between baseline PA and subsequent depression. Twenty-five studies found that higher baseline PA was associated with a lower risk of developing depression later, providing evidence that PA may have a protective effect against future depression. Most of these studies were considered high quality. The review also found that as little as 10-29 minutes of daily PA or 150 minutes per week may help prevent depression. Greater amounts of PA provided even more protection. The majority of the evidence suggests PA can serve as a useful strategy for reducing depression risk from a public health perspective.
This article, "Casting a Wider Net in Behavioral Health Screening in Primary Care" found that the ORS identified more clients for behavioral healthcare consultation than the PHQ-9. A first step toward the upcoming RCT with PCOMS in an integrated setting.
Running head PSYCHIATRIC DIAGNOSIS1PSYCHIATRIC DIAGNOSI.docxtoltonkendal
Running head: PSYCHIATRIC DIAGNOSIS
1
PSYCHIATRIC DIAGNOSIS
11
Sharron Chambers
Psychiatric Diagnosis
Psychopathology PSY 645
Dr. Jennifer Weniger
October 23, 2017
Psychiatric Diagnosis
Explain psychological concepts in the patient’s presentation using professional terminology.
Brain and behavior are the psychological concepts used by the patient. The concept of the brain is related to the ability of the brain function to affect the sleeping routine and norms of a person (Kennedy, 2013). When it comes to the behaviors, it is apparent that the symptoms have changed the behaviors of the person in one way or another.
Identify symptoms and behaviors exhibited by the patient in the chosen case study.
a) Lack of sleep
b) Weakness
c) Daytime fatigue
d) Neck weakness
Match the identified symptoms to potential disorders in a diagnostic manual.
a) Lack of sleep control
Lack of sleep is one of the symptoms depicted by the patient. Lack of sleep is directly related to sleeping disorder regardless of the cause.
b) Weakness
Weakness is one of the symptoms that the patient talks about. When the body is not given enough rest, it becomes weak. The body needs time to convert what it has to energy (Kennedy, 2013). The activities that human beings engage in usually exhaust the body and it is therefore important to give the body a rest. Lack of sleep hinders one from giving the body a rest thus affecting the conversion of energy which leads to a weak body.
c) Neck weakness
The neck of a human being plays a pivotal role. When the body is not given enough rest, the neck becomes weak (Kennedy, 2013). Therefore, looking at the symptoms, it is apparent that they are connected to a sleeping disorder.
d) Daytime fatigue
A human being should sleep at night for him or her to be productive at during the day. When he or she does not do so, it is apparent that the body will not be in a good position to be effective.
Propose a diagnosis based on the patient’s symptoms and the criteria listed for the disorder(s) in the diagnostic manual.
Before conducting a diagnosis, it is important to know what the patient is suffering from. The reason why there is a conversation as well a session between the patient and the doctor is for the patient to explain the symptoms of his or her condition (Kennedy, 2013). Explaining the conditions helps the doctor to relate the symptoms to a potential illness or condition. By looking at the symptoms provided by the patient, in this case, it is apparent that the patient is suffering from a sleeping disorder. Therefore, the diagnosis that will take place, in this case, will be in line with the sleeping disorder. The following diagnosis will be the most effective for a sleeping disorder.
a) Polysomnography
Polysomnography is a test that is one of the most effective diagnosis strategies when it comes to sleeping disorders. The test is effective because of three different reasons. The first reason is that the test tri ...
1PAGE 21. What is the question the authors are asking .docxfelicidaddinwoodie
1
PAGE
2
1. What is the question the authors are asking?
They asked about a reduction in judgmental biases regarding the cost and probability associated with adverse social events as they are presumed as being mechanisms for the treatment of Social Anxiety Disorder (SAD). Also, the authors poised on the changes in judgmental biases as mechanisms to explain cognitive-behavioral therapy for social anxiety disorder. On top of that, they stated that methodological limitations extant studies highlight the possibility that rather than causing symptom relief, a significant reduction in judgmental biases tends to be consequences of it or correlate. Considerably, they expected cost bias at mid-treatment to be a predictor of the treatment outcome.
2. Why do the authors believe this question is important?
According to the authors, this question was relevant as methodological limitations of present studies reflect on the possibility that instead of causing symptom belief, a significant reduction in judgmental biases can be consequences or correlated to it. Additionally, they ought to ascertain the judgment bias between treated and non-treated participants. Significantly, this was important as they had to determine the impact of pre and post changes in cost and probability of the treatment outcomes. But, probability bias at mid-treatment was a predictor of the treatment outcome contrary to the cost bias at mid-treatment that could not be identified as a significant predictor of the treatment outcome.
3. How do they try to answer this question?
They conducted a study to evaluate the significant changes in judgmental bias as aspects of cognitive-behavioral therapy for social anxiety disorders. To do this, they conducted a study using information from two treatment studies; an uncontrolled trial observing amygdala activity as a response to VRE (Virtual Reality Exposure Therapy) with the use of functional magnetic resonance imaging and a randomized control trial that compared Virtual Reality Exposure Therapy with Exposure Group Therapy for SAD. A total of 86 individuals who met the DSM-IV-TR criteria for the diagnosis of non-generalized (n=46) and generalized (n=40) SAD participated. After completing eight weeks of the treatment protocol, the participants who identified public speaking as their most fearsome social situation were included. The SCID (Structured clinical interview for the DSM-IV) was used to ascertain diagnostic and eligibility status on Axis 1 conditions within substance abuse, mood and anxiety disorder modules. The social anxiety measures were measured with the use of BFNE (Brief Fear of Negative Evaluation), a self-reporting questioner that examined the degree to which persons fear to be assessed by other across different social settings. Additionally, the OPQ (Outcome Probability Questionnaire) self-reporting questionnaire was used to evaluate individual’s estimate on the probability that adverse, threatening events will occur at t ...
Advanced Regression Methods For Single-Case Designs Studying Propranolol In ...Stephen Faucher
This document discusses a study that used advanced regression methods to analyze data from a single-case design clinical trial of propranolol for treating agitation in patients with traumatic brain injury. The study was a double-blind, randomized clinical trial of 13 patients (9 men and 4 women) with traumatic brain injury. Logistic regression models found that propranolol was not associated with less agitation for most participants, though 4 participants did show a significant response. The study demonstrates how single-case design data can be analyzed using regression methods to obtain clinically and statistically significant information about psychological and medical treatments.
Individual expertise versus domain expertise (2014)Scott Miller
This document discusses the effectiveness of evidence-based practices (EBPs) for veterans with mental illness. It states that EBPs have led to unprecedented improvements for some veterans, not achieved in decades of prior treatment. However, more work needs to be done to refine EBPs and promote their wider use in clinical settings. Veterans and others with mental illness deserve the most effective care available now and in the future.
The feasibility and need for dimensional psychiatric diagnosesChloe Taracatac
This document discusses the feasibility and need for adding dimensional psychiatric diagnoses to complement traditional categorical diagnoses. It begins with an introduction on the terminology of categories vs dimensions. It then reviews literature supporting both the advantages of categorical and dimensional approaches. Specifically, categorical diagnoses improve reliability, communication and teaching, while dimensions better describe relationships between variables and clinical severity. The conclusion proposes preserving categorical definitions but adding dimensional criteria derived from the categories to incorporate both approaches into diagnostic systems.
The document summarizes a study that aimed to map the underlying structure of the at-risk mental state (ARMS) by defining dimensions of subclinical psychopathology in ARMS subjects. 316 participants meeting criteria for ARMS were assessed using the CAARMS interview and other measures. Principal component analysis of the CAARMS items yielded five interpretable components ("Depression", "Disorganization", "Bodily-impairment", "Manic", and "Schizo-affective"). The "Depression" component was most strongly related to worse functioning and increased depressive symptoms. The identified components could provide a step towards a dimensional approach to assessing ARMS.
Physical activity and the prevention of depressionGiliano Campos
The document summarizes a systematic review examining whether physical activity (PA) can prevent the onset of depression. The review analyzed 30 prospective studies that assessed the relationship between baseline PA and subsequent depression. Twenty-five studies found that higher baseline PA was associated with a lower risk of developing depression later, providing evidence that PA may have a protective effect against future depression. Most of these studies were considered high quality. The review also found that as little as 10-29 minutes of daily PA or 150 minutes per week may help prevent depression. Greater amounts of PA provided even more protection. The majority of the evidence suggests PA can serve as a useful strategy for reducing depression risk from a public health perspective.
This article, "Casting a Wider Net in Behavioral Health Screening in Primary Care" found that the ORS identified more clients for behavioral healthcare consultation than the PHQ-9. A first step toward the upcoming RCT with PCOMS in an integrated setting.
Running head PSYCHIATRIC DIAGNOSIS1PSYCHIATRIC DIAGNOSI.docxtoltonkendal
Running head: PSYCHIATRIC DIAGNOSIS
1
PSYCHIATRIC DIAGNOSIS
11
Sharron Chambers
Psychiatric Diagnosis
Psychopathology PSY 645
Dr. Jennifer Weniger
October 23, 2017
Psychiatric Diagnosis
Explain psychological concepts in the patient’s presentation using professional terminology.
Brain and behavior are the psychological concepts used by the patient. The concept of the brain is related to the ability of the brain function to affect the sleeping routine and norms of a person (Kennedy, 2013). When it comes to the behaviors, it is apparent that the symptoms have changed the behaviors of the person in one way or another.
Identify symptoms and behaviors exhibited by the patient in the chosen case study.
a) Lack of sleep
b) Weakness
c) Daytime fatigue
d) Neck weakness
Match the identified symptoms to potential disorders in a diagnostic manual.
a) Lack of sleep control
Lack of sleep is one of the symptoms depicted by the patient. Lack of sleep is directly related to sleeping disorder regardless of the cause.
b) Weakness
Weakness is one of the symptoms that the patient talks about. When the body is not given enough rest, it becomes weak. The body needs time to convert what it has to energy (Kennedy, 2013). The activities that human beings engage in usually exhaust the body and it is therefore important to give the body a rest. Lack of sleep hinders one from giving the body a rest thus affecting the conversion of energy which leads to a weak body.
c) Neck weakness
The neck of a human being plays a pivotal role. When the body is not given enough rest, the neck becomes weak (Kennedy, 2013). Therefore, looking at the symptoms, it is apparent that they are connected to a sleeping disorder.
d) Daytime fatigue
A human being should sleep at night for him or her to be productive at during the day. When he or she does not do so, it is apparent that the body will not be in a good position to be effective.
Propose a diagnosis based on the patient’s symptoms and the criteria listed for the disorder(s) in the diagnostic manual.
Before conducting a diagnosis, it is important to know what the patient is suffering from. The reason why there is a conversation as well a session between the patient and the doctor is for the patient to explain the symptoms of his or her condition (Kennedy, 2013). Explaining the conditions helps the doctor to relate the symptoms to a potential illness or condition. By looking at the symptoms provided by the patient, in this case, it is apparent that the patient is suffering from a sleeping disorder. Therefore, the diagnosis that will take place, in this case, will be in line with the sleeping disorder. The following diagnosis will be the most effective for a sleeping disorder.
a) Polysomnography
Polysomnography is a test that is one of the most effective diagnosis strategies when it comes to sleeping disorders. The test is effective because of three different reasons. The first reason is that the test tri ...
1PAGE 21. What is the question the authors are asking .docxfelicidaddinwoodie
1
PAGE
2
1. What is the question the authors are asking?
They asked about a reduction in judgmental biases regarding the cost and probability associated with adverse social events as they are presumed as being mechanisms for the treatment of Social Anxiety Disorder (SAD). Also, the authors poised on the changes in judgmental biases as mechanisms to explain cognitive-behavioral therapy for social anxiety disorder. On top of that, they stated that methodological limitations extant studies highlight the possibility that rather than causing symptom relief, a significant reduction in judgmental biases tends to be consequences of it or correlate. Considerably, they expected cost bias at mid-treatment to be a predictor of the treatment outcome.
2. Why do the authors believe this question is important?
According to the authors, this question was relevant as methodological limitations of present studies reflect on the possibility that instead of causing symptom belief, a significant reduction in judgmental biases can be consequences or correlated to it. Additionally, they ought to ascertain the judgment bias between treated and non-treated participants. Significantly, this was important as they had to determine the impact of pre and post changes in cost and probability of the treatment outcomes. But, probability bias at mid-treatment was a predictor of the treatment outcome contrary to the cost bias at mid-treatment that could not be identified as a significant predictor of the treatment outcome.
3. How do they try to answer this question?
They conducted a study to evaluate the significant changes in judgmental bias as aspects of cognitive-behavioral therapy for social anxiety disorders. To do this, they conducted a study using information from two treatment studies; an uncontrolled trial observing amygdala activity as a response to VRE (Virtual Reality Exposure Therapy) with the use of functional magnetic resonance imaging and a randomized control trial that compared Virtual Reality Exposure Therapy with Exposure Group Therapy for SAD. A total of 86 individuals who met the DSM-IV-TR criteria for the diagnosis of non-generalized (n=46) and generalized (n=40) SAD participated. After completing eight weeks of the treatment protocol, the participants who identified public speaking as their most fearsome social situation were included. The SCID (Structured clinical interview for the DSM-IV) was used to ascertain diagnostic and eligibility status on Axis 1 conditions within substance abuse, mood and anxiety disorder modules. The social anxiety measures were measured with the use of BFNE (Brief Fear of Negative Evaluation), a self-reporting questioner that examined the degree to which persons fear to be assessed by other across different social settings. Additionally, the OPQ (Outcome Probability Questionnaire) self-reporting questionnaire was used to evaluate individual’s estimate on the probability that adverse, threatening events will occur at t ...
Advanced Regression Methods For Single-Case Designs Studying Propranolol In ...Stephen Faucher
This document discusses a study that used advanced regression methods to analyze data from a single-case design clinical trial of propranolol for treating agitation in patients with traumatic brain injury. The study was a double-blind, randomized clinical trial of 13 patients (9 men and 4 women) with traumatic brain injury. Logistic regression models found that propranolol was not associated with less agitation for most participants, though 4 participants did show a significant response. The study demonstrates how single-case design data can be analyzed using regression methods to obtain clinically and statistically significant information about psychological and medical treatments.
Individual expertise versus domain expertise (2014)Scott Miller
This document discusses the effectiveness of evidence-based practices (EBPs) for veterans with mental illness. It states that EBPs have led to unprecedented improvements for some veterans, not achieved in decades of prior treatment. However, more work needs to be done to refine EBPs and promote their wider use in clinical settings. Veterans and others with mental illness deserve the most effective care available now and in the future.
The feasibility and need for dimensional psychiatric diagnosesChloe Taracatac
This document discusses the feasibility and need for adding dimensional psychiatric diagnoses to complement traditional categorical diagnoses. It begins with an introduction on the terminology of categories vs dimensions. It then reviews literature supporting both the advantages of categorical and dimensional approaches. Specifically, categorical diagnoses improve reliability, communication and teaching, while dimensions better describe relationships between variables and clinical severity. The conclusion proposes preserving categorical definitions but adding dimensional criteria derived from the categories to incorporate both approaches into diagnostic systems.
This document provides a critique of 4 recent meta-analyses published in Health Psychology. It finds problems with transparency and completeness in how the meta-analyses were reported. It also notes a dependence on small, underpowered original trials of generally poor quality. The document questions the clinical validity and utility of conclusions drawn from these meta-analyses due to issues like clinical heterogeneity among studies and lack of consideration of methodological quality. Overall, it aims to encourage more rigorous standards for meta-analyses to avoid inaccurate or exaggerated conclusions.
Expanding the Lens of EBP: A Common Factors in AgreementScott Miller
The authors explore the limitations of the traditional view of evidence-based practice with its emphasis on specific methods and diagnosis. An alternative is proposed based on the common factors.
Respond to posts of two peers in this discussion. As part of your.docxlanagore871
Respond to posts of two peers in this discussion. As part of your reply, comment on the ways in which your peer's annotated entries were effective in summarizing the studies for you, and ways in which the annotated entries could be more effective.. You need to respond about each peers posting which contains two articles.
Laurie Leitch, M., Vanslyke, J., & Allen, M. (2009). Somatic experiencing treatment with social service workers following hurricanes katrina and rita. Social Work, 54(1), 9-18.
Laurie Leitch, PhD, is the research director for the Foundation of Human Enrinchment and a coufounder of the Trauma Research Institute. Jan Vanslyke, PhD, and Marisa Allen, ABD, are senior evaluation specialists at Reid and Associates. The purpose of this study was to determine if the Somatic Experiencing Trauma Resiliency Model (SE/TRM) could "reduce the post disaster symptoms of social service workers“ who deliver services to individuals and communities after a disaster.
The researchers conducted a quantitative study of 142 social service workers who provided service after huricanes Katrina and Rita in New Orleans. The study was conducted on a nonrandom sample of 142 social service workers. 91 participants received SE/TRM and they were compared with 51 workers who did not receive SE/TRM and were matched via propensity score matching. They hypothesis was that the use of SE/TRM could reduce the symptoms of disaster relief workers post disaster. Data analysis showed that there was a significant difference between the two groups in relation to post disaster relief. The group that received SE/TRM showed significantly lower PTSD symptoms and psychological distress and higher levels of resiliency. The authors noted that all of the participants in this study were employed, which sets them apart from many disaster survivors as well as the study was not a „randomized control study“. Further research is needed to further study the effectiveness of SE/TRM in the field of disaster treatment.
Metcalf, O., Varker, T., Forbes, D., Phelps, A., Dell, L., DiBattista, A., Ralph, N., & O’Donnell, M. (2016). Efficacy of Fifteen Emerging Interventions for the Treatment of Posttraumatic Stress Disorder: A Systematic Review. Journal of Traumatic Stress, 29, 88-92.
The purpose of this study was to evaluate the effectiveness of 15 "new or novel interventions“ that are being utilizef for the treatment of PTSD. This work was funded by the Department of Veterans‘ Affaris and National Health and Medical Research Council Programs. The study eliminated appraoches that did not offer "moderate quality evidence from randomized controlled trials“ by a team of 5 Trauma Experts. To be included, studies also required adults over 18 years of age, 70% of the sample majority were diagnosed with PTSD and outcome data were reported for severity of symptoms and diagnosis. The approaches that fulfilled this critera are emotional freedom technique, yoga, mantra-based meditation and ac.
This document discusses research methodology and how it can be applied to homeopathy. It defines different types of study designs including observational studies, treatment studies, randomized controlled trials, and meta-analyses. It explains how to apply these research methodologies to homeopathy through drug provings, clinical research studies, and disease-related studies while respecting homeopathic principles. Randomized controlled trials and meta-analyses are important for providing evidence but must be designed carefully to fit within homeopathic individualization and philosophy.
This document discusses research methodology and how it can be applied to homeopathy. It defines different types of study designs including observational studies, treatment studies, randomized controlled trials, and meta-analyses. It explains how to apply research methodologies like randomized controlled trials and meta-analyses to homeopathic drug provings and clinical research while respecting homeopathic principles. Clinical research in homeopathy should involve screening and confirming diagnoses, individualized case taking and prescribing for all patients regardless of group allocation in a blinded manner.
11. Identifying the Elements of the Limitations & ImplicationsGo tBenitoSumpter862
11. Identifying the Elements of the Limitations & Implications
Go to the Limitations/Implications section(s) and identify the limitations of the study and how those limitations impacted the whole study.
12. Identifying the Elements of the Conclusion Section
Go to the Conclusion section and identify the conclusive statements of the study and the recommendations made for future research.
POST # 1 EDITHA
When assessing an adolescent with bipolar disorder, what are some of the diagnostic and treatment challenges the clinician might face?
Bipolar disorder is a serious mental health disorder that is often first diagnosed during young adulthood or adolescence. Symptoms of the illness, however, also can appear in early childhood. Although once thought rare in children, diagnosis of bipolar disorder in children has significantly increased over the last decade (Papolos & Bronsteen, 2018). Despite the increased diagnosis of bipolar disorder in children, assessment and diagnosis remain challenging and controversial. This is, in part, because of the lack of research on this disorder in children and adolescents and the growing recognition that the disease can present differently in children from how it presents in adults (AACAP, 2019). Over the years, more attention has focused on the unique presentation of bipolar disorder in the young that has introduced new ways of looking at this disease and assessing it in children.
The importance of identifying the presence of bipolar disease at an early age is highlighted by data showing that adults in whom bipolar disease started at an early age have a more severe course of the illness compared with adult-onset disease. Early-onset disease is associated with a higher risk of suicide; severe mood lability and polarity; lower quality of life and greater functional impairment; higher rates of comorbidity; and a higher risk of substance use disorders compared with adult-onset disease (Papolos & Bronsteen, 2018). Although some children meet the criteria established for adults categorized in the DSM-5, many children fall outside these classical categories, and diagnosis in these children is particularly challenging and difficult (APA, 2013). For these children, additional information beyond what is provided in the DSM may help make an accurate diagnosis which causes increased challenges in assessment and diagnosis.
References
Papolos, D, & Bronsteen A. (2018) bipolar disorder in children: assessment in general pediatric practice. Curr Opin Pediatr, 25(3):419-426.
American Academy of Child and Adolescent Psychiatry (AACAP). (2019) bipolar disorder: Parents’ Medication Guide for Bipolar Disorder in Children & Adolescents.
American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association.
RESEARCH ARTICLE
Association of suicidal behavior with exposure
to suicide and suicide attempt: A systematic
...
11. Identifying the Elements of the Limitations & ImplicationsGo tSantosConleyha
11. Identifying the Elements of the Limitations & Implications
Go to the Limitations/Implications section(s) and identify the limitations of the study and how those limitations impacted the whole study.
12. Identifying the Elements of the Conclusion Section
Go to the Conclusion section and identify the conclusive statements of the study and the recommendations made for future research.
POST # 1 EDITHA
When assessing an adolescent with bipolar disorder, what are some of the diagnostic and treatment challenges the clinician might face?
Bipolar disorder is a serious mental health disorder that is often first diagnosed during young adulthood or adolescence. Symptoms of the illness, however, also can appear in early childhood. Although once thought rare in children, diagnosis of bipolar disorder in children has significantly increased over the last decade (Papolos & Bronsteen, 2018). Despite the increased diagnosis of bipolar disorder in children, assessment and diagnosis remain challenging and controversial. This is, in part, because of the lack of research on this disorder in children and adolescents and the growing recognition that the disease can present differently in children from how it presents in adults (AACAP, 2019). Over the years, more attention has focused on the unique presentation of bipolar disorder in the young that has introduced new ways of looking at this disease and assessing it in children.
The importance of identifying the presence of bipolar disease at an early age is highlighted by data showing that adults in whom bipolar disease started at an early age have a more severe course of the illness compared with adult-onset disease. Early-onset disease is associated with a higher risk of suicide; severe mood lability and polarity; lower quality of life and greater functional impairment; higher rates of comorbidity; and a higher risk of substance use disorders compared with adult-onset disease (Papolos & Bronsteen, 2018). Although some children meet the criteria established for adults categorized in the DSM-5, many children fall outside these classical categories, and diagnosis in these children is particularly challenging and difficult (APA, 2013). For these children, additional information beyond what is provided in the DSM may help make an accurate diagnosis which causes increased challenges in assessment and diagnosis.
References
Papolos, D, & Bronsteen A. (2018) bipolar disorder in children: assessment in general pediatric practice. Curr Opin Pediatr, 25(3):419-426.
American Academy of Child and Adolescent Psychiatry (AACAP). (2019) bipolar disorder: Parents’ Medication Guide for Bipolar Disorder in Children & Adolescents.
American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association.
RESEARCH ARTICLE
Association of suicidal behavior with exposure
to suicide and suicide attempt: A systematic
...
A Naturalistic Study Of Dissociative Identity Disorder And Dissociative Disor...Sara Alvarez
This study aimed to describe community treatment of dissociative disorders and determine if it is as effective as treatment for related conditions like PTSD. Analyses found that patients later in treatment engaged in less self-harm, had fewer hospitalizations, and higher functioning than early patients. Later patients also reported lower dissociation, PTSD, and distress symptoms than early patients. The effectiveness was comparable to treatments for chronic PTSD and depression with borderline personality disorder. This suggests extended dissociative disorder treatment may be beneficial.
Although many of you may not be interested in the psychometric details of the ORS and SRS, it does bear importantly on whether there are seen as credible. Jeff Reese and I (Duncan & Reese, 2013) recently exchanged views with Halstead, Youn, and Armijo (2013), debating when a measure is too brief and when it is too long. Here is our paper. First regarding when a measure is too brief: There is no doubt that 45 items, 30 items, or even 19 items is psychometrically better than 4 items, and that the increased reliability and validity of longer measures likely result in better detection, prediction, and ultimate measurement of outcome. But how much better is the really the question. Are these differences clinically meaningful and do they offset the low compliance rates and resulting data integrity issues from missing data? These are the questions that require empirical investigation to determine how brief is too brief, although from my experience, the verdict has already been rendered. But when is a measure too long? The answer is simple: When clinicians won’t use it.
This study examined factors related to posttraumatic stress symptoms (PTSS) in pediatric cancer patients and their caregivers. The researchers analyzed surveys from 31 patient-caregiver dyads. They found that patient-reported PTSS was predicted by self-reported worry, while caregiver-reported patient PTSS was predicted by the caregiver's perception of the patient's physical appearance. Additionally, caregiver-reported caregiver PTSS was predicted by the caregiver's report of the patient's psychosocial functioning. The results suggest discrepancies between how patients and caregivers view factors related to PTSS.
This document discusses the role of health sciences librarians in evidence-based practice and outlines several key points:
1) It defines evidence-based practice and describes the evolution of evidence-based medicine, noting its emergence as a new paradigm for medical practice.
2) It outlines the key steps in the evidence-based practice process, including question framing using structures like PICO, identifying different levels of evidence, critical appraisal of sources, and searching for and screening systematic reviews.
3) It discusses the role of librarians in supporting evidence-based practice through skills like developing comprehensive search strategies, selecting appropriate sources, and keeping detailed records to allow searches to be replicated. Librarians can teach
Rationale and Standards of Evidence in Evidence-Based Practice.docxmakdul
Rationale and Standards of Evidence in Evidence-Based Practice
OLIVER C. MUDFORD, ROB MCNEILL, LISA WALTON
AND KATRINA J. PHILLIPS
What is the purpose of collecting evidence to inform clinical practice in psychology concerning the effects of psychological or other interventions? To quote Paul’s (1967) article that has been cited 330 times before November 4, 2008, it is to determine the answer to the question: “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances?” (p. 111). Another answer is pitched at a systemic level, rather than concerning individuals. That is, research evidence can inform health-care professionals and consumers about psychological and behavioral interventions that are more effective than pharmacological treatments, and to improve the overall quality and cost-effectiveness of psychological health service provision (American Psychological Association [APA] Presidential Task Force on Evidence-Based Practice, 2006). The most general answer is that research evidence can be used to improve outcomes for clients, service providers, and society in general. The debate about what counts as evidence of effectiveness in answering this question has attracted considerable controversy (Goodheart, Kazdin, & Sternberg, 2006; Norcross, Beutler, & Levant, 2005). At one end of a spectrum, evidence from research on psychological treatments can be emphasized. Research-oriented psychologists have promoted the importance of scientific evidence in the concept of empirically supported treatment. Empirically supported treatments (ESTs) are those that have been sufficiently subjected to scientific research and have been shown to produce beneficial effects in wellcontrolled studies (i.e., efficacious), in more natural clinical environments (i.e., effective), and are the most cost-effective (i.e., efficient) (Chambless & Hollon, 1998). The effective and efficient criteria of Chambless and Hollon (1998) have been amalgamated under the term “clinical utility” (APA Presidential Task Force on Evidence-Based Practice, 2006; Barlow, Levitt, & Bufka, 1999). At the other end of the spectrum are psychologists who value clinical expertise as the source of evidence more highly, and they can rate subjective impressions and skills acquired in practice as providing personal evidence for guiding treatment (Hunsberger, 2007). Kazdin (2008) has asserted that the schism between clinical researchers and practitioners on the issue of evidence is deepening. Part of the problem, which suggests at least part of the solution, is that research had concentrated on empirical evidence of treatment efficacy, but more needs c01 20 April 2012; 12:43:29 3 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID= ...
An observational study observes subjects without intervening. A cohort study follows groups over time to compare outcomes based on exposure. This document defines and provides examples of cohort studies. It describes their design, strengths like establishing temporality between exposure and outcome, and ability to study multiple outcomes from one exposure. Examples include Framingham Heart Study, Swiss HIV Cohort Study, and a Danish study on psoriasis and depression.
This document discusses various epidemiological study designs used to assess health outcomes and answer clinical questions. It begins by outlining the 6 D's of health outcomes - death, disease, discomfort, disability, dissatisfaction, and destitution. It then describes key clinical questions and types of epidemiological studies including descriptive studies, analytical observational studies, and experimental/interventional studies. Descriptive studies involve systematically collecting and presenting data to describe a situation, while analytical studies aim to establish causes or risk factors by comparing groups. Specific analytical study designs covered include case-control studies, cohort studies, and randomized controlled trials.
Anorexia Nervosa Treatment A Systematic Review Of Randomized Controlled TrialsLisa Graves
This systematic review examined evidence from randomized controlled trials on the treatment of anorexia nervosa. The review identified 32 treatment studies and rated the quality. The evidence for medication treatments and behavioral treatments for adults with anorexia nervosa was found to be sparse and inconclusive. Variants of family therapy were shown to be efficacious for adolescents with anorexia nervosa, but not for adults. Overall, the review concluded that the evidence for anorexia nervosa treatment is weak due to small sample sizes, lack of standard outcome measures, high dropout rates, and lack of evidence examining differential outcomes based on sociodemographic factors.
Data stratification is the process of partitioning the data into distinct and non-overlapping groups since the
study population consists of subpopulations that are of particular interest. In clinical data, once the data is
stratified into sub populations based on a significant stratifying factor, different risk factors can be
determined from each subpopulation. In this paper, the Fisher’s Exact Test is used to determine the
significant stratifying factors. The experiments are conducted on a simulated study and the Medical,
Epidemiological and Social Aspects of Aging (MESA) data constructed for prediction of urinary
incontinence. Results show that, smoking is the most significant stratifying factor of MESA data, showing
that the smokers and non-smokers indicates different risk factors towards urinary incontinence and should
be treated differently.
Measure CritiqueCritiqued byDateName of measure FAD- .docxARIV4
Measure Critique
Critiqued by:
Date:
Name of measure: FAD- Family Assessment Devise
Developer(s):
Source reference (provide the complete citation, using correct APA format, of the article, book or website that contains the key information on the measure you are critiquing here):
Construct(s) assessed (e.g., depression, relationship satisfaction, stress):
Method of administration:
Summary of reliability evidence (this includes internal consistency reliability, usually Cronbach’s alpha and often test-retest reliability as well):
Summary of validity evidence (this may include discussions of content, criterion-related [concurrent and/or predictive], and construct [convergent and/or divergent] validity):
Describe the number of participants used to develop the measure and their demographic characteristics (e.g., age, gender, race/ethnicity):
Provide a brief summary of how clinicians have used this measure in therapy:
Recommendations for effective clinical use:
With what populations has this measure been used with (either clinically or in research) (e.g., age, gender, race/ethnicity, setting)
Find and briefly mention the purpose of 2-3 few research studies that have used the measure:
Provide a summary of the findings from one study that used this measure using this template:
Objective:
Method/Design:
Results:
What future research is needed on this measure?
Overall impression of measure:
References
Sample Measure Critique
Critiqued by: KL
Date: January 25, 2016
Name of measure: PHQ9
Developer(s): Kurt Kroenke, Robert L. Spitzer, & Janet B.W. Williams
Source reference:https://www.communitycarenc.org/media/related-downloads/depression-toolkit.pdf
Construct(s) assessed: Criteria-based diagnosis of depression in individuals seen in primary care and other medical and mental health facilities
Method of administration: Nine symptom checklist that can be professionally or self-administered (paper and pencil, electronically, or over the phone).
Summary of reliability evidence:
· Internal reliability was excellent, with a Cronbach’s alpha of 0.89 in a Primary Care Study and 0.86 in an OB-Gyn Study (Kroenke, Spitzer, & Williams, 2001).
· Test-retest reliability was very high at a 0.96 in a longitudinal study (Draper et al., 2008).
Summary of validity evidence:
In a study done by Kroenke et al. (2001), both criterion and construct validity were established as well as external validity. Construct validity was demonstrated in a sample of 580 primary care patients who underwent an independent re-interview. Criterion validity was shown by the strong association between PHQ-9 scores and functional status disability days and symptoms related difficulty. External validity was achieved by replicating the findings from 3,000 primary care patients in a second sample of 3,000 Ob-gyn patients.
· The PHQ-9 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 sores of 5, 10, 15, 20 fully represented mild, moderate, moderatel ...
Long-Term Outcome in Adults with Obsessive-Compulsive DisorderChristy Green
This study examined the long-term outcomes of 83 adults with obsessive-compulsive disorder (OCD) who were originally enrolled in placebo-controlled trials of serotonin reuptake inhibitors (SRIs) for OCD treatment between 10-20 years prior. The study found that only 20% of subjects had experienced remission of their OCD symptoms, while 49% still had clinically significant OCD symptoms. Initial response to SRI pharmacotherapy strongly predicted long-term outcome, with those who initially responded to SRIs more likely to experience remission over the long term. The study did not find an association between long-term outcome and OCD symptom dimensions.
Protection of human subjects,Phenomenon ,Methodology,Study design,Theoretical model,Significance of the study,Research problem,
WHAT IS THE IMPACT OF COMFORT CARE VERSES ALTERNATIVE CARE FOR THE CHRONIC DYING PATIENT FAMILY AND THE HEALTH CARE TEAM
M3 ch12 discussionConnecting Eligible Immigrant Families to Heal.docxjeremylockett77
M3 ch12 discussion
Connecting Eligible Immigrant Families to Health Coverage
Instructions:
Read the report
Connecting Eligible Immigrant Families to Health Coverage and Care
.
Write a one page post offering solutions to the problem from the nurse's standpoint.
.
Loudres eats powdered doughnuts for breakfast and chocolate that sh.docxjeremylockett77
Loudres eats powdered doughnuts for breakfast and chocolate that she can get out of the vending machines before class. Between classes , she grabs some chips and a caffine drink for lunch. By the end of the day, she is exhauted and cannot study very long before she falls asleep for a few hours. Then, she stays up untils 2.A.M to finish her work and take care of things she could not do during the day. She feels that she has to eat sugary foods and caffeinated drinks to keep her schedule going and to fit in all her activities. What advice would you give her?
.
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This document provides a critique of 4 recent meta-analyses published in Health Psychology. It finds problems with transparency and completeness in how the meta-analyses were reported. It also notes a dependence on small, underpowered original trials of generally poor quality. The document questions the clinical validity and utility of conclusions drawn from these meta-analyses due to issues like clinical heterogeneity among studies and lack of consideration of methodological quality. Overall, it aims to encourage more rigorous standards for meta-analyses to avoid inaccurate or exaggerated conclusions.
Expanding the Lens of EBP: A Common Factors in AgreementScott Miller
The authors explore the limitations of the traditional view of evidence-based practice with its emphasis on specific methods and diagnosis. An alternative is proposed based on the common factors.
Respond to posts of two peers in this discussion. As part of your.docxlanagore871
Respond to posts of two peers in this discussion. As part of your reply, comment on the ways in which your peer's annotated entries were effective in summarizing the studies for you, and ways in which the annotated entries could be more effective.. You need to respond about each peers posting which contains two articles.
Laurie Leitch, M., Vanslyke, J., & Allen, M. (2009). Somatic experiencing treatment with social service workers following hurricanes katrina and rita. Social Work, 54(1), 9-18.
Laurie Leitch, PhD, is the research director for the Foundation of Human Enrinchment and a coufounder of the Trauma Research Institute. Jan Vanslyke, PhD, and Marisa Allen, ABD, are senior evaluation specialists at Reid and Associates. The purpose of this study was to determine if the Somatic Experiencing Trauma Resiliency Model (SE/TRM) could "reduce the post disaster symptoms of social service workers“ who deliver services to individuals and communities after a disaster.
The researchers conducted a quantitative study of 142 social service workers who provided service after huricanes Katrina and Rita in New Orleans. The study was conducted on a nonrandom sample of 142 social service workers. 91 participants received SE/TRM and they were compared with 51 workers who did not receive SE/TRM and were matched via propensity score matching. They hypothesis was that the use of SE/TRM could reduce the symptoms of disaster relief workers post disaster. Data analysis showed that there was a significant difference between the two groups in relation to post disaster relief. The group that received SE/TRM showed significantly lower PTSD symptoms and psychological distress and higher levels of resiliency. The authors noted that all of the participants in this study were employed, which sets them apart from many disaster survivors as well as the study was not a „randomized control study“. Further research is needed to further study the effectiveness of SE/TRM in the field of disaster treatment.
Metcalf, O., Varker, T., Forbes, D., Phelps, A., Dell, L., DiBattista, A., Ralph, N., & O’Donnell, M. (2016). Efficacy of Fifteen Emerging Interventions for the Treatment of Posttraumatic Stress Disorder: A Systematic Review. Journal of Traumatic Stress, 29, 88-92.
The purpose of this study was to evaluate the effectiveness of 15 "new or novel interventions“ that are being utilizef for the treatment of PTSD. This work was funded by the Department of Veterans‘ Affaris and National Health and Medical Research Council Programs. The study eliminated appraoches that did not offer "moderate quality evidence from randomized controlled trials“ by a team of 5 Trauma Experts. To be included, studies also required adults over 18 years of age, 70% of the sample majority were diagnosed with PTSD and outcome data were reported for severity of symptoms and diagnosis. The approaches that fulfilled this critera are emotional freedom technique, yoga, mantra-based meditation and ac.
This document discusses research methodology and how it can be applied to homeopathy. It defines different types of study designs including observational studies, treatment studies, randomized controlled trials, and meta-analyses. It explains how to apply these research methodologies to homeopathy through drug provings, clinical research studies, and disease-related studies while respecting homeopathic principles. Randomized controlled trials and meta-analyses are important for providing evidence but must be designed carefully to fit within homeopathic individualization and philosophy.
This document discusses research methodology and how it can be applied to homeopathy. It defines different types of study designs including observational studies, treatment studies, randomized controlled trials, and meta-analyses. It explains how to apply research methodologies like randomized controlled trials and meta-analyses to homeopathic drug provings and clinical research while respecting homeopathic principles. Clinical research in homeopathy should involve screening and confirming diagnoses, individualized case taking and prescribing for all patients regardless of group allocation in a blinded manner.
11. Identifying the Elements of the Limitations & ImplicationsGo tBenitoSumpter862
11. Identifying the Elements of the Limitations & Implications
Go to the Limitations/Implications section(s) and identify the limitations of the study and how those limitations impacted the whole study.
12. Identifying the Elements of the Conclusion Section
Go to the Conclusion section and identify the conclusive statements of the study and the recommendations made for future research.
POST # 1 EDITHA
When assessing an adolescent with bipolar disorder, what are some of the diagnostic and treatment challenges the clinician might face?
Bipolar disorder is a serious mental health disorder that is often first diagnosed during young adulthood or adolescence. Symptoms of the illness, however, also can appear in early childhood. Although once thought rare in children, diagnosis of bipolar disorder in children has significantly increased over the last decade (Papolos & Bronsteen, 2018). Despite the increased diagnosis of bipolar disorder in children, assessment and diagnosis remain challenging and controversial. This is, in part, because of the lack of research on this disorder in children and adolescents and the growing recognition that the disease can present differently in children from how it presents in adults (AACAP, 2019). Over the years, more attention has focused on the unique presentation of bipolar disorder in the young that has introduced new ways of looking at this disease and assessing it in children.
The importance of identifying the presence of bipolar disease at an early age is highlighted by data showing that adults in whom bipolar disease started at an early age have a more severe course of the illness compared with adult-onset disease. Early-onset disease is associated with a higher risk of suicide; severe mood lability and polarity; lower quality of life and greater functional impairment; higher rates of comorbidity; and a higher risk of substance use disorders compared with adult-onset disease (Papolos & Bronsteen, 2018). Although some children meet the criteria established for adults categorized in the DSM-5, many children fall outside these classical categories, and diagnosis in these children is particularly challenging and difficult (APA, 2013). For these children, additional information beyond what is provided in the DSM may help make an accurate diagnosis which causes increased challenges in assessment and diagnosis.
References
Papolos, D, & Bronsteen A. (2018) bipolar disorder in children: assessment in general pediatric practice. Curr Opin Pediatr, 25(3):419-426.
American Academy of Child and Adolescent Psychiatry (AACAP). (2019) bipolar disorder: Parents’ Medication Guide for Bipolar Disorder in Children & Adolescents.
American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association.
RESEARCH ARTICLE
Association of suicidal behavior with exposure
to suicide and suicide attempt: A systematic
...
11. Identifying the Elements of the Limitations & ImplicationsGo tSantosConleyha
11. Identifying the Elements of the Limitations & Implications
Go to the Limitations/Implications section(s) and identify the limitations of the study and how those limitations impacted the whole study.
12. Identifying the Elements of the Conclusion Section
Go to the Conclusion section and identify the conclusive statements of the study and the recommendations made for future research.
POST # 1 EDITHA
When assessing an adolescent with bipolar disorder, what are some of the diagnostic and treatment challenges the clinician might face?
Bipolar disorder is a serious mental health disorder that is often first diagnosed during young adulthood or adolescence. Symptoms of the illness, however, also can appear in early childhood. Although once thought rare in children, diagnosis of bipolar disorder in children has significantly increased over the last decade (Papolos & Bronsteen, 2018). Despite the increased diagnosis of bipolar disorder in children, assessment and diagnosis remain challenging and controversial. This is, in part, because of the lack of research on this disorder in children and adolescents and the growing recognition that the disease can present differently in children from how it presents in adults (AACAP, 2019). Over the years, more attention has focused on the unique presentation of bipolar disorder in the young that has introduced new ways of looking at this disease and assessing it in children.
The importance of identifying the presence of bipolar disease at an early age is highlighted by data showing that adults in whom bipolar disease started at an early age have a more severe course of the illness compared with adult-onset disease. Early-onset disease is associated with a higher risk of suicide; severe mood lability and polarity; lower quality of life and greater functional impairment; higher rates of comorbidity; and a higher risk of substance use disorders compared with adult-onset disease (Papolos & Bronsteen, 2018). Although some children meet the criteria established for adults categorized in the DSM-5, many children fall outside these classical categories, and diagnosis in these children is particularly challenging and difficult (APA, 2013). For these children, additional information beyond what is provided in the DSM may help make an accurate diagnosis which causes increased challenges in assessment and diagnosis.
References
Papolos, D, & Bronsteen A. (2018) bipolar disorder in children: assessment in general pediatric practice. Curr Opin Pediatr, 25(3):419-426.
American Academy of Child and Adolescent Psychiatry (AACAP). (2019) bipolar disorder: Parents’ Medication Guide for Bipolar Disorder in Children & Adolescents.
American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association.
RESEARCH ARTICLE
Association of suicidal behavior with exposure
to suicide and suicide attempt: A systematic
...
A Naturalistic Study Of Dissociative Identity Disorder And Dissociative Disor...Sara Alvarez
This study aimed to describe community treatment of dissociative disorders and determine if it is as effective as treatment for related conditions like PTSD. Analyses found that patients later in treatment engaged in less self-harm, had fewer hospitalizations, and higher functioning than early patients. Later patients also reported lower dissociation, PTSD, and distress symptoms than early patients. The effectiveness was comparable to treatments for chronic PTSD and depression with borderline personality disorder. This suggests extended dissociative disorder treatment may be beneficial.
Although many of you may not be interested in the psychometric details of the ORS and SRS, it does bear importantly on whether there are seen as credible. Jeff Reese and I (Duncan & Reese, 2013) recently exchanged views with Halstead, Youn, and Armijo (2013), debating when a measure is too brief and when it is too long. Here is our paper. First regarding when a measure is too brief: There is no doubt that 45 items, 30 items, or even 19 items is psychometrically better than 4 items, and that the increased reliability and validity of longer measures likely result in better detection, prediction, and ultimate measurement of outcome. But how much better is the really the question. Are these differences clinically meaningful and do they offset the low compliance rates and resulting data integrity issues from missing data? These are the questions that require empirical investigation to determine how brief is too brief, although from my experience, the verdict has already been rendered. But when is a measure too long? The answer is simple: When clinicians won’t use it.
This study examined factors related to posttraumatic stress symptoms (PTSS) in pediatric cancer patients and their caregivers. The researchers analyzed surveys from 31 patient-caregiver dyads. They found that patient-reported PTSS was predicted by self-reported worry, while caregiver-reported patient PTSS was predicted by the caregiver's perception of the patient's physical appearance. Additionally, caregiver-reported caregiver PTSS was predicted by the caregiver's report of the patient's psychosocial functioning. The results suggest discrepancies between how patients and caregivers view factors related to PTSS.
This document discusses the role of health sciences librarians in evidence-based practice and outlines several key points:
1) It defines evidence-based practice and describes the evolution of evidence-based medicine, noting its emergence as a new paradigm for medical practice.
2) It outlines the key steps in the evidence-based practice process, including question framing using structures like PICO, identifying different levels of evidence, critical appraisal of sources, and searching for and screening systematic reviews.
3) It discusses the role of librarians in supporting evidence-based practice through skills like developing comprehensive search strategies, selecting appropriate sources, and keeping detailed records to allow searches to be replicated. Librarians can teach
Rationale and Standards of Evidence in Evidence-Based Practice.docxmakdul
Rationale and Standards of Evidence in Evidence-Based Practice
OLIVER C. MUDFORD, ROB MCNEILL, LISA WALTON
AND KATRINA J. PHILLIPS
What is the purpose of collecting evidence to inform clinical practice in psychology concerning the effects of psychological or other interventions? To quote Paul’s (1967) article that has been cited 330 times before November 4, 2008, it is to determine the answer to the question: “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances?” (p. 111). Another answer is pitched at a systemic level, rather than concerning individuals. That is, research evidence can inform health-care professionals and consumers about psychological and behavioral interventions that are more effective than pharmacological treatments, and to improve the overall quality and cost-effectiveness of psychological health service provision (American Psychological Association [APA] Presidential Task Force on Evidence-Based Practice, 2006). The most general answer is that research evidence can be used to improve outcomes for clients, service providers, and society in general. The debate about what counts as evidence of effectiveness in answering this question has attracted considerable controversy (Goodheart, Kazdin, & Sternberg, 2006; Norcross, Beutler, & Levant, 2005). At one end of a spectrum, evidence from research on psychological treatments can be emphasized. Research-oriented psychologists have promoted the importance of scientific evidence in the concept of empirically supported treatment. Empirically supported treatments (ESTs) are those that have been sufficiently subjected to scientific research and have been shown to produce beneficial effects in wellcontrolled studies (i.e., efficacious), in more natural clinical environments (i.e., effective), and are the most cost-effective (i.e., efficient) (Chambless & Hollon, 1998). The effective and efficient criteria of Chambless and Hollon (1998) have been amalgamated under the term “clinical utility” (APA Presidential Task Force on Evidence-Based Practice, 2006; Barlow, Levitt, & Bufka, 1999). At the other end of the spectrum are psychologists who value clinical expertise as the source of evidence more highly, and they can rate subjective impressions and skills acquired in practice as providing personal evidence for guiding treatment (Hunsberger, 2007). Kazdin (2008) has asserted that the schism between clinical researchers and practitioners on the issue of evidence is deepening. Part of the problem, which suggests at least part of the solution, is that research had concentrated on empirical evidence of treatment efficacy, but more needs c01 20 April 2012; 12:43:29 3 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID= ...
An observational study observes subjects without intervening. A cohort study follows groups over time to compare outcomes based on exposure. This document defines and provides examples of cohort studies. It describes their design, strengths like establishing temporality between exposure and outcome, and ability to study multiple outcomes from one exposure. Examples include Framingham Heart Study, Swiss HIV Cohort Study, and a Danish study on psoriasis and depression.
This document discusses various epidemiological study designs used to assess health outcomes and answer clinical questions. It begins by outlining the 6 D's of health outcomes - death, disease, discomfort, disability, dissatisfaction, and destitution. It then describes key clinical questions and types of epidemiological studies including descriptive studies, analytical observational studies, and experimental/interventional studies. Descriptive studies involve systematically collecting and presenting data to describe a situation, while analytical studies aim to establish causes or risk factors by comparing groups. Specific analytical study designs covered include case-control studies, cohort studies, and randomized controlled trials.
Anorexia Nervosa Treatment A Systematic Review Of Randomized Controlled TrialsLisa Graves
This systematic review examined evidence from randomized controlled trials on the treatment of anorexia nervosa. The review identified 32 treatment studies and rated the quality. The evidence for medication treatments and behavioral treatments for adults with anorexia nervosa was found to be sparse and inconclusive. Variants of family therapy were shown to be efficacious for adolescents with anorexia nervosa, but not for adults. Overall, the review concluded that the evidence for anorexia nervosa treatment is weak due to small sample sizes, lack of standard outcome measures, high dropout rates, and lack of evidence examining differential outcomes based on sociodemographic factors.
Data stratification is the process of partitioning the data into distinct and non-overlapping groups since the
study population consists of subpopulations that are of particular interest. In clinical data, once the data is
stratified into sub populations based on a significant stratifying factor, different risk factors can be
determined from each subpopulation. In this paper, the Fisher’s Exact Test is used to determine the
significant stratifying factors. The experiments are conducted on a simulated study and the Medical,
Epidemiological and Social Aspects of Aging (MESA) data constructed for prediction of urinary
incontinence. Results show that, smoking is the most significant stratifying factor of MESA data, showing
that the smokers and non-smokers indicates different risk factors towards urinary incontinence and should
be treated differently.
Measure CritiqueCritiqued byDateName of measure FAD- .docxARIV4
Measure Critique
Critiqued by:
Date:
Name of measure: FAD- Family Assessment Devise
Developer(s):
Source reference (provide the complete citation, using correct APA format, of the article, book or website that contains the key information on the measure you are critiquing here):
Construct(s) assessed (e.g., depression, relationship satisfaction, stress):
Method of administration:
Summary of reliability evidence (this includes internal consistency reliability, usually Cronbach’s alpha and often test-retest reliability as well):
Summary of validity evidence (this may include discussions of content, criterion-related [concurrent and/or predictive], and construct [convergent and/or divergent] validity):
Describe the number of participants used to develop the measure and their demographic characteristics (e.g., age, gender, race/ethnicity):
Provide a brief summary of how clinicians have used this measure in therapy:
Recommendations for effective clinical use:
With what populations has this measure been used with (either clinically or in research) (e.g., age, gender, race/ethnicity, setting)
Find and briefly mention the purpose of 2-3 few research studies that have used the measure:
Provide a summary of the findings from one study that used this measure using this template:
Objective:
Method/Design:
Results:
What future research is needed on this measure?
Overall impression of measure:
References
Sample Measure Critique
Critiqued by: KL
Date: January 25, 2016
Name of measure: PHQ9
Developer(s): Kurt Kroenke, Robert L. Spitzer, & Janet B.W. Williams
Source reference:https://www.communitycarenc.org/media/related-downloads/depression-toolkit.pdf
Construct(s) assessed: Criteria-based diagnosis of depression in individuals seen in primary care and other medical and mental health facilities
Method of administration: Nine symptom checklist that can be professionally or self-administered (paper and pencil, electronically, or over the phone).
Summary of reliability evidence:
· Internal reliability was excellent, with a Cronbach’s alpha of 0.89 in a Primary Care Study and 0.86 in an OB-Gyn Study (Kroenke, Spitzer, & Williams, 2001).
· Test-retest reliability was very high at a 0.96 in a longitudinal study (Draper et al., 2008).
Summary of validity evidence:
In a study done by Kroenke et al. (2001), both criterion and construct validity were established as well as external validity. Construct validity was demonstrated in a sample of 580 primary care patients who underwent an independent re-interview. Criterion validity was shown by the strong association between PHQ-9 scores and functional status disability days and symptoms related difficulty. External validity was achieved by replicating the findings from 3,000 primary care patients in a second sample of 3,000 Ob-gyn patients.
· The PHQ-9 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 sores of 5, 10, 15, 20 fully represented mild, moderate, moderatel ...
Long-Term Outcome in Adults with Obsessive-Compulsive DisorderChristy Green
This study examined the long-term outcomes of 83 adults with obsessive-compulsive disorder (OCD) who were originally enrolled in placebo-controlled trials of serotonin reuptake inhibitors (SRIs) for OCD treatment between 10-20 years prior. The study found that only 20% of subjects had experienced remission of their OCD symptoms, while 49% still had clinically significant OCD symptoms. Initial response to SRI pharmacotherapy strongly predicted long-term outcome, with those who initially responded to SRIs more likely to experience remission over the long term. The study did not find an association between long-term outcome and OCD symptom dimensions.
Protection of human subjects,Phenomenon ,Methodology,Study design,Theoretical model,Significance of the study,Research problem,
WHAT IS THE IMPACT OF COMFORT CARE VERSES ALTERNATIVE CARE FOR THE CHRONIC DYING PATIENT FAMILY AND THE HEALTH CARE TEAM
Similar to 1 Clinical Problem Social Anxiety is described by .docx (20)
M3 ch12 discussionConnecting Eligible Immigrant Families to Heal.docxjeremylockett77
M3 ch12 discussion
Connecting Eligible Immigrant Families to Health Coverage
Instructions:
Read the report
Connecting Eligible Immigrant Families to Health Coverage and Care
.
Write a one page post offering solutions to the problem from the nurse's standpoint.
.
Loudres eats powdered doughnuts for breakfast and chocolate that sh.docxjeremylockett77
Loudres eats powdered doughnuts for breakfast and chocolate that she can get out of the vending machines before class. Between classes , she grabs some chips and a caffine drink for lunch. By the end of the day, she is exhauted and cannot study very long before she falls asleep for a few hours. Then, she stays up untils 2.A.M to finish her work and take care of things she could not do during the day. She feels that she has to eat sugary foods and caffeinated drinks to keep her schedule going and to fit in all her activities. What advice would you give her?
.
Lori Goler is the head of People at Facebook. Janelle Gal.docxjeremylockett77
Lori Goler is the head
of People at Facebook.
Janelle Gale is the head
of HR Business Partners
at Facebook. Adam Grant
is a professor at Wharton,
a Facebook consultant,
and the author of Originals
and Give and Take.
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HBR.ORG
Let’s Not Kill
Performance
Evaluations Yet
Facebook’s experience shows
why they can still be valuable.
BY LORI GOLER, JANELLE GALE, AND ADAM GRANT
November 2016 Harvard Business Review 91
LET’S NOT KILL PERFORMANCE EVALUATIONS YET
tThe reality is, even when companies get rid of performance evaluations, ratings still exist. Employees just can’t see them. Ratings are done sub-jectively, behind the scenes, and without input from the people being evaluated.
Performance is the value of employees’ contribu-
tions to the organization over time. And that value
needs to be assessed in some way. Decisions about
pay and promotions have to be made. As research-
ers pointed out in a recent debate in Industrial and
Organizational Psychology, “Performance is always
rated in some manner.” If you don’t have formal
evaluations, the ratings will be hidden in a black box.
At Facebook we analyzed our performance man-
agement system a few years ago. We conducted fo-
cus groups and a follow-up survey with more than
300 people. The feedback was clear: 87% of people
wanted to keep performance ratings.
Yes, performance evaluations have costs—but
they have benefits, too. We decided to hang on
to them for three reasons: fairness, transparency,
and development.
Making Things Fair
We all want performance evaluations to be fair. That
isn’t always the outcome, but as more than 9,000
managers and employees reported in a global sur-
vey by CEB, not having evaluations is worse. Every
organization has people who are unhappy with their
bonuses or disappointed that they weren’t pro-
moted. But research has long shown that when the
process is fair, employees are more willing to accept
undesirable outcomes. A fair process exists when
evaluators are credible and motivated to get it right,
and employees have a voice. Without evaluations,
people are left in the dark about who is gauging their
contributions and how.
At Facebook, to mitigate bias and do things sys-
tematically, we start by having peers write evalua-
tions. They share them not just with managers but
also, in most cases, with one another—which reflects
the company’s core values of openness and transpar-
ency. Then decisions are made about performance:
Managers sit together and discuss their reports
face-to-face, defending and championing, debating
and deliberating, and incorporating peer feedback.
Here the goal is to minimize the “idiosyncratic rater
effect”—also known as personal opinion. People
aren’t unduly punished when individual managers
are hard graders or unfairly rewarded when they’re
easy graders.
Next managers write the performance reviews.
We have a team of analysts who examine evalua-
tions f.
Looking for someone to take these two documents- annotated bibliogra.docxjeremylockett77
Looking for someone to take these two documents- annotated bibliography and an issue review(outline)
to conduct an argumentative paper about WHY PEOPLE SHOULD GET THE COVID-19 VACCINE
Requirements:
Length: 4-6 pages (not including title page or references page)
1-inch margins
Double spaced
12-point Times New Roman font
Title page
References page
.
Lorryn Tardy – critique to my persuasive essayFor this assignm.docxjeremylockett77
Lorryn Tardy – critique to my persuasive essay
For this assignment I’ll be workshopping the work of Lisa Oll-Adikankwu. Lisa has chosen the topic of Assisted Suicide; she is against the practice and argues that it should be considered unethical and universally illegal.
Lisa appears to have a good understanding of the topic. Her sources are well researched and discuss a variety of key points from seemingly unbiased sources. Her sources are current, peer reviewed and based on statistical data.
Lisa’s summaries are well written, clear and concise. One thing I noticed is that the majority of her writing plan is summarized and cited at the end of each paragraph. I might suggest that she integrate more synthesis of the different sources, by combining evidence from more than one source per paragraph and using more in text citations or direct quotes to reinforce her key points.
I think that basic credentialing information could be provided for Lisa’s sources, this is something that looking back, I need to add as well. I think this could easily be done with just a simple “(Authors name, and their title, i.e. author, statistician, physician etc.…)”, when the source is introduced into the paper might provide a reinforced credibility of the source.
As far as connection of sources, as previously mentioned, I think that in order to illustrate a stronger argument, using multiple sources to reinforce a single key point would solidify Lisa’s argument. I feel that more evidence provided from a variety of different sources, will provide the reader with a stronger sense of credibility and less room for bias that could be argued if the point is only credited to one source.
One area that stuck out to me for counter argument, being that my paper is in favor of this issue, is in paragraph two where Lisa states that “physicians are not supposed to kill patients or help them kill themselves, and terminally ill patients are not in a position of making rational decisions about their lives.” I’d like to offer my argument for this particular statement. In states where assisted suicide (or as I prefer to refer to it, assisted dying) is legal, there are several criteria that a patient has to meet in order to be considered a candidate. These criteria include second, even third opinions to determine that death is imminent, as well psychological evaluation(s) and an extensive informed consent process that is a collaborative effort between the patient, the patient’s family, physicians, psychologists and nurses. It is a process that takes weeks to months. Patients that wish to be a candidate, should initiate the process as soon as they have been diagnosed by seeking a second opinion. As an emergency room nurse, I have been present for a substantial amount of diagnoses that are ‘likely’ terminal. Many of these patients presented to the emergency for a common ailment and have no indication that they don’t have the capacity to make such a decision. Receiving a terminal diagnos.
M450 Mission Command SystemGeneral forum instructions Answ.docxjeremylockett77
M450 Mission Command: System
General forum instructions: Answer the questions below and provide evidence to support your claims (See attached slides). Your answers should be derived primarily from course content. When citing sources, use APA style. Your initial posts should be approximately 150-500 words.
1. Describe and explain two of the Warfighting Functions.
2. How do commanders exercise the Command and Control System?
.
Lymphedema following breast cancer The importance of surgic.docxjeremylockett77
Lymphedema following breast cancer: The importance of
surgical methods and obesity
Rebecca J. Tsai, PhDa,*, Leslie K. Dennis, PhDa,b, Charles F. Lynch, MD, PhDa, Linda G.
Snetselaar, RD, PhD, LDa, Gideon K.D. Zamba, PhDc, and Carol Scott-Conner, MD, PhD,
MBAd
aDepartment of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA.
bDivision of Epidemiology and Biostatistics, College of Public Health, University of Arizona,
Tucson, AZ, USA.
cDepartment of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA.
dDepartment of Surgery, College of Medicine, University of Iowa, Iowa City, IA, USA.
Abstract
Background: Breast cancer-related arm lymphedema is a serious complication that can
adversely affect quality of life. Identifying risk factors that contribute to the development of
lymphedema is vital for identifying avenues for prevention. The aim of this study was to examine
the association between the development of arm lymphedema and both treatment and personal
(e.g., obesity) risk factors.
Methods: Women diagnosed with breast cancer in Iowa during 2004 and followed through 2010,
who met eligibility criteria, were asked to complete a short computer assisted telephone interview
about chronic conditions, arm activities, demographics, and lymphedema status. Lymphedema was
characterized by a reported physician-diagnosis, a difference between arms in the circumference
(> 2cm), or the presence of multiple self-reported arm symptoms (at least two of five major arm
symptoms, and at least four total arm symptoms). Relative risks (RR) were estimated using
logistic regression.
Results: Arm lymphedema was identified in 102 of 522 participants (19.5%). Participants treated
by both axillary dissection and radiation therapy were more likely to have arm lymphedema than
treated by either alone. Women with advanced cancer stage, positive nodes, and larger tumors
along with a body mass index > 40 were also more likely to develop lymphedema. Arm activity
level was not associated with lymphedema.
*Correspondence and Reprints to: Rebecca Tsai, National Institute for Occupational Safety and Health, 4676 Columbia Parkway,
R-17, Cincinnati, OH 45226. [email protected] Phone: (513)841-4398. Fax: (513) 841-4489.
Authorship contribution
All authors contributed to the conception, design, drafting, revision, and the final review of this manuscript.
Competing interest
Conflicts of Interest and Source of Funding: This study was funded by the National Cancer Institute Grant Number: 5R03CA130031.
All authors do not declare any conflict of interest.
All authors do not declare any conflict of interest.
HHS Public Access
Author manuscript
Front Womens Health. Author manuscript; available in PMC 2018 December 14.
Published in final edited form as:
Front Womens Health. 2018 June ; 3(2): .
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Love Beyond Wallshttpswww.lovebeyondwalls.orgProvid.docxjeremylockett77
Love Beyond Walls
https://www.
lovebeyondwalls
.org
Provide a brief background of your chosen nonprofit entity using evidence from their publications or any other published materials. Then evaluate the factors, which may include economic, political, historic, cultural, institutional conditions, and changes that contributed to the creation and growth (decline) of the nonprofit organization. Justify your response.
.
Longevity PresentationThe purpose of this assignment is to exami.docxjeremylockett77
Longevity Presentation
The purpose of this assignment is to examine societal norms regarding aging and to integrate the concepts of aging well and living well into an active aging framework that promotes longevity.
Using concepts from the Hooyman and Kiyak (2011) text and the Buettner (2012) book, consider the various perspectives on aging.
Identify the underlying values or assumptions that serve as the basis for longevity, including cultural, religious, and philosophical ideas.
Present an overview of three holistic aging theories.
Integrate the values, assumptions, and theories to indicate what is necessary for an active aging framework where individuals both live well and age well.
Presentations should be 10-15 minutes in length, use visual aids, and incorporate references from the course texts and 5 additional scholarly journal articles.
.
Look again at the CDCs Web page about ADHD.In 150-200 w.docxjeremylockett77
The CDC's page on ADHD aims to educate the general public about Attention Deficit Hyperactivity Disorder by providing facts and information on symptoms, diagnosis, and treatment. It presents ADHD as a real disorder with neurological causes in order to increase understanding and help those affected. As the nation's leading health protection agency, the CDC's role is to inform the public about health issues like ADHD.
M8-22 ANALYTICS o TEAMS • ORGANIZATIONS • SKILLS .fÿy.docxjeremylockett77
M8-22 ANALYTICS o TEAMS • ORGANIZATIONS • SKILLS .fÿy' ÿ,oÿ ()V)g
The Strategy That Wouldn't Travel
by Michael C. Beer
It was 6:45 P.M. Karen Jimenez was reviewing the
notes on her team-based productMty project tbr
what seemed like the hundredth time. I31 two days,
she was scheduled to present a report to the senior
management group on the project's progress. She
wasn't at all sure what she was going to say.
The project was designed to improve productiv-
it3, and morale at each plant owned and operated by
Acme Minerals Extraction Company. Phase one--
implemented in early 1995 at the site in Wichita,
I(amsas--looked like a stunning, success by the mid-
dle of 1996. Productivity and mo[ÿale soared, and
operating and maintenance costs decreased signifi-
cantly. But four months ago, Jimenez tried to
duplicate the results at the project's second
target--the plant in Lubbock, Texas--and some-
thing went wrong. The techniques that had worked
so well in Wichita met with only moderate success
in Lubbock. ProductMty improved marginally and
costs went down a bit, but morale actually seemed
to deteriorate slightl): Jimenez was stumped,
approach to teamwork and change. As it turned
out, he had proved a good choice. Daniels was a
hands-on, high-energy, charismatic businessman
who seemed to enjoy media attention. Within his
first year as CEO, he had pretty much righted the
floundering company by selling oft:some unrelated
lines of business. He had also created the share-
services deparnnent--an internal consulting organ-
ization providing change management, reengineer-
ing, total quailB, management, and other
services--and had rapped Jimenez to head the
group. Her first priority Daniels told her, would be
to improve productiviB, and morale at the com-
pany's five extraction sites. None of them were
meeting their projections. And although Wichita
was the only site at which the labor-management
conflict was painfiflly apparent, Daniels and Jimenez
both thought that morale needed an all-around
boost. Hence the team-based productivity project.
She tried to "helicopter up" and think about
the problem in the broad context of the com-
pany's history. A few ),ears ago, Acme had been in
bad financial shape, but what had really brought
things to a head--and had led to her current
dilemma--was a labor relations problem. Acme
had a wide variety of labor requirements For its
operations. The company used highly sophisti-
cated technologB employing geologists, geophysi-
cists, and engineers on what was referred to as the
"brains" side of the business, as well as skilled and
semi-skilled labor on the "brawn" side to run the
extraction operations. And in the summer of
1994, brains and brawn clashed in an embarrass-
ingly public way. A number of engineers at the
Wichita plant locked several union workers out of
the offices in 100-degree heat. Although most
Acme employees now felt that the incident had
been blown out of propo,'tion by the press, .
Lombosoro theory.In week 4, you learned about the importance.docxjeremylockett77
Lombosoro theory.
In week 4, you learned about the importance of theory, the various theoretical perspectives and the ways in which theory help guide research in regards to crime and criminal behavior.
To put this assignment into context, I want you to think about how Lombroso thought one could identify a criminal. He said that criminals had similar facial features. If that was the case you would be able to look at someone and know if they were a criminal! Social theories infer that perhaps it is the social structures around us that encourage criminality. Look around your city- what structures do you think may match up to something you have learned about this week in terms of theory? These are just two small examples to put this assignment into context for you. The idea is to learn about the theories, then critically think about how can one "show" the theory without providing written explanation for their chosen image.
Directions: With the readings week 4 in mind, please do the following:
1. Choose a theoretical perspective (I.e., biological, psychological sociological)
2. Look through media images (this can be cartoons, magazines, newspapers, internet stories, etc...) and select 10 images that you think depict your chosen theory without written explanation.
3. Provide a one paragraph statement of your theory, what kinds of behavior it explains and how it is depicted through images. Be sure to use resources to support your answer.
4. You will copy and paste your images into a word document, along with your paragraph. You do not need to cite where you got your images, but you do need to cite any information you have in number 3.
Format Directions:
Typed, 12 point font, double spaced
APA format style (Cover page, in text citations and references)
.
Looking over the initial material on the definitions of philosophy i.docxjeremylockett77
Looking over the initial material on the definitions of philosophy in
the course content section, which definition (Aristotle, Novalis,
Wittgenstein) would you say gives you the best feel for philosophy? What
is it about the definition that interests you? do you find there to be any problems with the definition? what other questions do you have regarding the meaning of philosophy?
ARISTOTLE :
Definition 1: Philosophy begins with wonder. (Aristotle)
Our study of philosophy will begin with the ancient Greeks. This is not because the Greeks were necessarily the first to philosophize. They were the first to address philosophical questions in a systematic manner. Also, the bodies of works which survive from the Greeks is quite substantial so in studying philosophy we have a lot to go on if we start with the Greeks.
Philosophy is, in fact, a Greek word. Philo is one of the Greek words for love: in this case the friendship type of love. (What other words can you think of that have "philo" as a part?) Sophia, has a few different uses in Greek. Capitalized it is the name of a woman or a Goddess: wisdom. Philosophy, then, etymologically, (that is from its roots) means love of wisdom.
But what exactly is wisdom? Is it merely knowledge? Intelligence? If I know how to perform a given skill does this necessarily imply that I also have wisdom or am wise?
The word "wise" is not in fact a Greek word. Remember for the Greeks that's "Sophia". Wise is Indo-European and is related to words like "vision", "video", "Veda" (the Indian Holy scriptures). The root has something to do with seeing. Wisdom then has to do with applying our knowledge in a meaningful and practically beneficial way. Perhaps this is the reason why philosophy is associated with the aged. Aristotle believes that philosophy in fact is more suitably studied by the old rather than the young who are inclined to be controlled by the emotions. Do you think this is correct? Nevertheless, whether Aristotle is correct or not, typically the elderly are more likely to be wise as they have more experience of life: they have seen more and hopefully know how to respond correctly to various situations.
Philosophy is not merely confined to the old. Aristotle also says that philosophy begins with wonder and that all people desire to know. Children often are paradigm cases of wondering. Think about how children (perhaps a young sibling or a son or daughter, niece or nephew of your acquaintance) inquistively ask their parents "why" certain things are the case? If the child receives a satisfying answer, one that fits, she is satisfied. If not there is dissatisfaction and frustration. Children assume that their elders know more than they do and thus rely on them for the answers. Though there is a familiar cliche that ignorance is bliss, (perhaps what is meant by this is that ignorance of evil is bliss), Aristotle sees ignorance as painful, a wonder that I would rather fill with knowledge. After all wha.
Lucky Iron Fish
By: Ashley Snook
Professor Phillips
MGMT 350
Spring 2018
Table of Contents
Executive Summary
Introduction
Human Relations Theory
Communications Issues
Intercultural Relations
Ethics Issues
Conclusion
Works Cited
Executive Summary
The B-certified organization that I chose is Lucky Iron Fish Enterprise which is located in Guelph, Ontario Canada. The company distributes iron fish that are designed to solve iron deficiency and anemia for the two billion people who are affected worldwide.
The human relations model is comprised of McGregor’s Theory X and Theory Y, Maslow’s Hierarchy of Needs, and theories from Peters and Waterman. These factors focus on the organizational structure of the company as it relates to the executives, the staff, and the customers. The executives provide meaningful jobs for the staff which gives them high levels of job satisfaction. Together, they are able to provide a product that satisfies the thousands of customers they have already reached.
Communication in this company flows smoothly. They implement open communication, encourage participation, and have high levels of trust among employees. Each of their departments are interconnected through teamwork.
Their intercultural relations, although successful, require a significant amount of time. They need to emphasize to the high context cultures that they are willing to understand their culture and possibly adopt some aspects of it. Additionally, they face barriers such as language dissimilarity and lack of physical store locations.
Ethics remains a top priority for this organization. They have high ethical standards that are integrated into their operations. They make decisions that do the most good for the most people, they do not take into consideration financial or political influence, and they strive to protect the environment through their sustainability measures.
Every employee is dedicated to improving the lives of those who suffer from iron deficiency
and anemia. As their organization grows, they continue to impact thousands of lives around the world. They are on a mission to put “a fish in every pot” (Lucky Iron Fish).
Introduction
Lucky Iron Fish, located in Guelph Canada, is a company that is dedicated to ending worldwide iron deficiency and anemia. They do this by providing families with iron fish that release iron when heated in food or water. They sell this product in developed countries in order to support their business model of buy one give one. Each time an iron fish is purchased, one is donated to a family in a developing country. They designed their product to resemble the kantrop fish of Cambodia; in their culture this fish is a symbol of luck. Another focus of theirs is to remain sustainable, scalable, and impactful (Lucky Iron Fish). Each of their products is made from recycled material and their packaging is biodegradable. Their organization has a horizontal stru.
Lucky Iron FishBy Ashley SnookMGMT 350Spring 2018ht.docxjeremylockett77
Lucky Iron Fish
By: Ashley Snook
MGMT 350
Spring 2018
https://www.youtube.com/watch?v=G6Rx3wDqTuI
Table of Contents
Case Overview
Introduction
Human Relations
Communications
Intercultural Relations
Ethics
Conclusion
Works Cited
https://www.youtube.com/watch?v=iY0D-PIcgB4
Video ends at 1:45
2
Case Overview
Company located in Guleph, Ontario Canada
Mission is to end iron deficiency and anemia
A fish in every pot
Gavin Armstrong, Founder/CEO
Introduction
Idea originated in Cambodia
Distribute fish through buy one give one model
Sustainable, scalable, impactful
Human Relations
McGregor’s Theory X and Y
-X: employees focused solely on financial gain
-Y: strive to improve worldwide health
Maslow’s Hierarchy of Needs
-Affiliation: desire to be part of a unit, motivated by connections
-Self-esteem: recognition for positive impact
Peters and Waterman
-Close relations to the customer
-Simple form & lean staff
Communications
Time and Distance
-Make product easily and quickly accessible
Communication Culture
-Encourages active participation
Teamwork
-Each role complements the overall mission
Gavin Armstrong Kate Mercer Mark Halpren Melissa Saunders Ashley Leone
Founder & CEO VP Marketing Chief Financial Officer Logistics Specialist Dietician
Intercultural Relations
High/Low Context
-Targets high context cultures
Barriers
-Language dissimilarity
Overcoming Barriers
-Hire a translator
Ethics
Utilitarianism
-Targets countries where majority of people will benefit
Veil of Ignorance
-Not concerned with financial influence
Categorical Imperative
-Accept projects only if environmentally friendly
Conclusion
Buy one give one model
Expansion
Sustainability
Works Cited
Guffey, Mary. “Essentials of Business Communication.” Ohio: Erin Joyner. 2008. Print.
“Lucky Iron Fish.” Lucky Iron Fish. Accessed 30 May 2018. https://luckyironfish.com/
“Lucky Iron Fish Enterprise.” B Corporation.net. Accessed 30 May 2018. https://www.bcorporation.net/community/lucky-iron-fish-enterprise
Lucky Iron Fish. “Lucky Iron Fish: A Simple
Solution
for a global problem.” Youtube. 28 October 2014. Accessed 4 June 2018. https://www.youtube.com/watch?v=iY0D-PIcgB4
“Lucky little fish to fight iron deficiency among women in Cambodia.” Grand Challenges Canada. Accessed 6 June 2018. http://www.grandchallenges.ca/grantee-stars/0355-05-30/
Podder, Api. “Lucky Iron Fish Wins 2016 Big Innovation Award.” SocialNews.com. 5 February 2016. Accessed 4 June 2018. http://mysocialgoodnews.com/lucky-iron-fish-wins-2016-big-innovation-award/
Zaremba, Alan. “Organizational Communication.” New York: Oxford University Press Inc. 2010. Print.
Lucky Iron Fish
By: Ashley Snook
Professor Phillips
MGMT 350.
look for a article that talks about some type of police activity a.docxjeremylockett77
look for a article that talks about some type of police activity and create PowerPoint and base on the history describe
-What is the role of a police officer in society? (general statement )
-how are they viewed by society?
what is the role of the police in this case?
how it is seems by society?
Article
An unbelievable History of Rape
An 18-year-old said she was attacked at knifepoint. Then she said she made it up. That’s where our story begins.
by T. Christian Miller, ProPublica and Ken Armstrong, The Marshall Project December 16, 2015
https://www.propublica.org/article/false-rape-accusations-an-unbelievable-story
.
Look at the Code of Ethics for at least two professional agencies, .docxjeremylockett77
Look at the Code of Ethics for at least two professional agencies, federal agencies, or laws that would apply to Health IT professionals. In two pages (not including the reference list), compare and contrast these standards. How much overlap did you find? Is one reference more specific than the other? Does one likely fit a broader audience, etc... Would you add anything to either of these documents?
.
Locate an example for 5 of the 12 following types of communica.docxjeremylockett77
Locate
an example for 5 of the 12 following types of communication genres:
Business card
Resume/CV
Rules and regulations
Policy handbook
Policy manual
Policy guide
Policy or departmental memorandum
Public policy report
Government grant
Government proposal
Departmental brochure or recruitment materials
Governmental agency social media (Twitter, Facebook, etc...)
Write
a 1,050- to 1,400-word paper in which you refer to your examples for each of the above listed communication genres. Be sure to address the following in your paper:
How does the purpose of the communication relate to the particular communication genre? In what ways does the genre help readers grasp information quickly and effectively? In what way is the genre similar or different than the other genres you chose?
What role has technology played in the development of the genre? How is it similar or different than the other genres you chose?
How does the use of these conventions promote understanding for the intended audience of the communication? How is it similar or different than the other genres you chose?
Is the communication intended for external or internal distribution? Describe ethical and privacy considerations used for determining an appropriate method of distribution. How is it similar or different than the other genres you chose?
Cite
at least three academic sources in your paper.
Format
your paper consistent with APA guidelines.
.
Locate and read the other teams’ group project reports (located .docxjeremylockett77
Locate and read the other teams’ group project reports (located in Doc Sharing).
Provide some comments for two reports in terms of what you think they did right, what you learned from these reports, as well as what else they could have done.
In addition, read the comments that other students made about your team’s report and respond to at least one of them.
Review ATTACHMENTS!!!!
.
it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
MATATAG CURRICULUM: ASSESSING THE READINESS OF ELEM. PUBLIC SCHOOL TEACHERS I...NelTorrente
In this research, it concludes that while the readiness of teachers in Caloocan City to implement the MATATAG Curriculum is generally positive, targeted efforts in professional development, resource distribution, support networks, and comprehensive preparation can address the existing gaps and ensure successful curriculum implementation.
How to Fix the Import Error in the Odoo 17Celine George
An import error occurs when a program fails to import a module or library, disrupting its execution. In languages like Python, this issue arises when the specified module cannot be found or accessed, hindering the program's functionality. Resolving import errors is crucial for maintaining smooth software operation and uninterrupted development processes.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
Main Java[All of the Base Concepts}.docxadhitya5119
This is part 1 of my Java Learning Journey. This Contains Custom methods, classes, constructors, packages, multithreading , try- catch block, finally block and more.
Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
Natural Products, In vitro evaluation techniques for Antioxidants, Antimicrobial and Anticancer drugs. In vivo evaluation techniques
for Anti-inflammatory, Antiulcer, Anticancer, Wound healing, Antidiabetic, Hepatoprotective, Cardio protective, Diuretics and
Antifertility, Toxicity studies as per OECD guidelines
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
How to Add Chatter in the odoo 17 ERP ModuleCeline George
In Odoo, the chatter is like a chat tool that helps you work together on records. You can leave notes and track things, making it easier to talk with your team and partners. Inside chatter, all communication history, activity, and changes will be displayed.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
1 Clinical Problem Social Anxiety is described by .docx
1. 1
Clinical Problem
Social Anxiety is described by The Diagnostic and Statistical
Manual of the American
Psychiatric Association (DSM-5) as a persistent fear of social
situations where the person is
exposed to people or to possible scrutiny by others and fears
that he/she will display
symptoms of anxiety or be perceived in a way that will be
embarrassing and humiliating
(American Psychiatric Association, 2013). This topic was
chosen as according to Kessler et
al. (2012) social anxiety is among the most common anxiety
disorder affecting 13% of
individuals at some stage in their lives. From experience, and
according to Krysta et al.
(2015) medication is the first line treatment for anxiety
disorders due to accessibility.
Unfortunately, for people experiencing social anxiety most
medications have adverse effects
2. such as increased agitation and sexual dysfunction (Rosen et al
1999) and some medication,
in particular benzodiazepines are highly addictive (Lader and
Kyriacou, 2016). Townend et
al. (2008) report that CBT remains the psychological therapy
with the widest and broadest
evidence base. Beck et al (1979) define Cognitive Behavioural
Therapy (CBT) as a concept
where an individual’s emotions and behaviours are based on the
way that they interpret the
world through their cognitions. NICE (2011) (cited in Clark,
2011) recommend psychological
therapies prior to medication for anxiety disorders however due
to a lack of therapists in
mental health services this is not the case in clinical practice
which led to the rationale for the
following research question.
2
3. Clinical question
Are psychological interventions more efficacious than
pharmacological interventions to help
reduce social anxiety disorder (SAD) symptoms in adults?
Bragge (2010) explains that answerable clinical research
questions have four essential
components known as PICO. This therapy type question was
developed using these
components (P) Population: adults that experience social
anxiety (I) Intervention:
Psychological interventions (C) Comparator: Pharmacological
Interventions (O) Outcome:
reduction of social anxiety symptoms.
Search Strategy and Outcome
A systematic literature search was carried out using electronic
databases which were
individually accessed via Queens Online, including MEDLINE,
Science Direct, PschINFO
and Cochrane (see Appendix 1). Roberts and Dicenso (1999)
suggest that questions in
relation to interventions and their effectiveness are best
answered by randomized control
4. trials or based on the hierarchy of evidence, systematic reviews.
BestBets.org was also
accessed for evidence based synopses.
The three papers the author deemed relevant to answer the
clinical question above are as
follows;
Clark et al. (2003)
Nordahl et al (2016)
Davidson et al. (2004)
3
These three studies were chosen as their methodological design
appeared to answer the
clinical question posed. They were critically appraised using the
Critical Appraisal Skills
Programme (CASP UK, 2017) relevant tool as a foundation.
Nadelson and Nadelson (2014)
teaches that the CASP tools effectively cover the areas needed
to critically appraise evidence.
Initially, presumptions were made that databases would be
inundated with literature on this
5. topic but it became apparent that limited appropriate journals
were available. On reflection,
individuals with social phobia find it difficult to engage for fear
of being negatively appraised
(Amir et al. 2009), and therefore would find it difficult to
engage with psychiatric services
and clinical trials.
Critical appraisal
The randomized placebo-controlled trial by Clark et al. (2003)
set out to compare cognitive
therapy with fluoxetine in generalized social phobia. Sixty
patients aged between 18 and 60
years of age with a diagnosis of generalized social phobia as per
the DSM-IV criteria were
randomly assigned to three arms; Cognitive therapy, Fluoxetine
+ self-exposure and placebo
+ self-exposure.
The study by Clark et al. (2003) addressed a clearly focused
issue as the population studied,
the intervention given and the comparator are all presented in
the main body of the article
however, the outcomes are not clearly specified. Stanley (2007)
highlights that a primary
6. outcome will decide on the overall result of the study, adding
that an RCT must have only
one primary outcome and should be clearly defined. Stratified
randomisation was carried out
including two variables; gender and avoidant personality
disorder and allocation concealment
followed which both decrease bias and increase validity.
Stratified randomization, uses
random selection within each strata in an attempt to ensure that
no bias, deliberate or
4
accidental, interferes with the representative nature of the
patient sample (Altman & Bland
1999). Allocation to fluoxetine or placebo were double blinded,
this is important as blinding
seeks to reduce performance and ascertainment bias after
randomization (Altman & Schulz
2001). The groups appear to have been treated equally as
assessments were carried out by an
independent assessor which reduces bias and therefore increases
validity.
7. The study provides a paragraph of the patient’s characteristics
and emphasises that there were
no significant differences between the arms. A table of patient
characteristics and distribution
to arms would have made this clearer and limit any doubt of
bias. An explanation for the
patients that dropped out was also provided, however, a
CONSORT flow chart which would
show the flow of participants through each stage of the study
would have made it clearer.
An intention to treat (ITT) analysis was utilised and dropouts
were accounted for. ITT is a
strategy for the analysis of RCT’s that compares patients in the
original groups to which they
were randomly assigned (Hollis & Campbell 1999). ITT
analysis ensures true effects of a
study by accepting that noncompliance and protocol deviations
are likely to occur in actual
clinical practice (Gupta, 2011). ITT analysis therefore avoids
bias, as without it researchers
could selectively exclude participants from the groups they
were randomized to. Clark et al.
(2003) reported that they employed a self-report measure
developed by themselves which
8. could introduce bias and would make it difficult for other
researchers to replicate this study.
Overall, the researchers of this study appear to have covered
sufficient aspects to ensure
internal validity.
The randomised clinical trial by Nordahl et al. (2016) aims to
evaluate whether Paroxetine
(SSRI) is more effective than Cognitive therapy and whether a
combination of the treatments
is more effective than the single interventions in the treatment
of Social Anxiety Disorder
5
(SAD) with and without avoidant personality disorder (APD).
102 participants were
randomly allocated to four arms of the trial; Paroxetine, pill
placebo, Cognitive therapy (CT),
and a combination of Paroxetine and CT.
The study by Nordahl et al. (2016) clearly addressed a focused
issue as the population,
intervention, comparator and outcomes were clearly identified.
The rating scales ADIS-IV,
9. SCID-II, both the primary outcomes and the secondary
outcomes were rated and assessed by
independent evaluators increasing validity. However, it could be
suggested that these
independent assessors were blinded also as Karanicolas et al.
(2010) reports that bias can be
introduced both intentionally and unintentionally.
Similar to Clark et al. (2003) stratified randomization was
carried out to ensure equal
distribution of gender and Avoidant Personality Disorder (APD)
increasing validity.
According to Hidalgo et al. (2001) there is a higher incidence of
SAD in women with
Eikenaes (2015) adding that there is an uncertainty whether
APD and SAD are different
disorders, or are different degrees of severities of SAD. Triple
masking of the patient,
psychiatrist and principle investigator was carried out for the
arms receiving pills
(paroxetine/placebo), the goal of masking is to minimize
potential biases (Forder et al. 2005)
which therefore increases validity of the trial. The study also
informs us that 15% of the
10. patients were interviewed by telephone which could introduce
bias as not all the patients were
treated the same. As psychiatrists and therapists were all
experts in this study, allegiance bias
may have been introduced, allegiance bias in psychotherapy
outcome studies refers to the
results being distorted by the investigators’ theoretical or
treatment preferences (Wilson et al.
2011). Overall, the researchers appeared to cover sufficient
aspects for the reader to accept its
validity.
6
The randomized double blind placebo controlled trial by
Davidson et al. (2004) compared
fluoxetine (FLU), comprehensive cognitive behavioural group
therapy (CCBT) , placebo
(PBO) and the combinations of CCBT/FLU and CCBT/PBO to
treat generalized social
phobia over a 14 week period. 295 participants were randomized
evenly into the 5 arms,
11. primary outcomes were measured with the Brief Social Phobia
Scale and Clinical Global
Impressions scales and the secondary outcome was a videotaped
behavioural assessment
using the Subjective Units of Distress Scale (SUDS).
An evaluator independent from the team was blinded and
assessed both the primary outcomes
reducing bias and increasing validity. The study was carried out
at two academic outpatient
psychiatric centres in Durham and Pennsylvania covering large
populations.
Block randomization was carried out by a computer program
which reduces bias however the
researchers admit that this was not fully adhered to as they
‘balanced CCBT groups to
include at least 2 women and 2 men’ introducing selection bias
and decreasing the validity of
the study.
Compliance to medication was monitored by pill counts at each
visit and reviewing daily
medication logs. The validity of the study would have been
increased if blood tests had been
carried out by an independent laboratory to ensure compliance.
High degrees of non-
12. adherence in randomized controlled trials (RCTs) can lead to
failure to detect a true treatment
effect (Murali et al. 2017).
Primary outcomes measures were assessed by a blinded
independent evaluator increasing
validity. Blinding of data collectors and outcome adjudicators is
crucial to ensure unbiased
ascertainment of outcomes (Karanicolas et al. 2010) but the
blinding process was not
evaluated which leads to doubts whether blinding was
successful.
7
Internal validity is questioned in this trial as there are
possibilities for bias, furthermore the
duration of the trial lasted only 14 weeks, and therefore results
are to be viewed with caution.
Results:
In Clark et al. (2003) social phobia was measured on a social
phobia composite which was
based on seven individual social phobia measures. There was a
13. large effect size for Cognitive
therapy (CT) at posttreatment (1.31) and a small treatment
effect for Fluoxetine and self-
exposure (0.21) based on Cohen’s (1988) (cited in Clark et al.
2003) threefold classification
of effect size. Rice (2009) teaches that the larger the effect size,
the more powerful the
treatment intervention. Paired comparisons indicated that CT
was superior to fluoxetine +
Self exposure and Placebo + self-exposure on the social phobia
composite scale (group effect
9.5=p<.001.) and all seven individual measures at
posttreatment. Surprisingly, there was no
statistical significance between Fluoxetine+ Self-exposure
(effect size 0.92) and the control
Placebo+ self-exposure (effect size 0.56), post treatment.
In Nordahl’s et al. (2016) study, the primary outcome was
measured by the level of
symptoms on the Fear of Negative Evaluation questionnaire
(FNE). There were three
secondary outcome measures; Liebowitz Social Anxiety Scale
(LSAS), the Beck Anxiety
Inventory (BAI) and the Inventory of Interpersonal Problems
(IIP). This study resulted that
14. the combination group (Paroxetine and CT) were equal to the
Paroxetine group, post
treatment (mean difference = -2.166, p=0.806) on the FNE. At
the 12 month follow up there
was no difference between CT and the combination group,
however both were more effective
than the placebo and Paroxetine arms. On the secondary
measure the LSAS the CT group
alone performed better than any of the other 3 arms at the 12
month follow up. Of great
significance were the recovery rates 68% of the CT group
compared to 45% of the
8
combination group, 23% in the paroxetine group and 4% in the
placebo arm. Effect sizes
were high suggesting both clinical and statistical significance.
Davidson et al. (2004) resulted in Fluoxetine alone producing a
p value of <.01 from 0-4
weeks. At the end of treatment (14 weeks) a statistical
significance was established in all
arms except the placebo group on the primary outcome Brief
15. Social Phobia Scale (BSPS) and
the secondary outcome Social Phobia and Anxiety Inventory
(SPAI) indicating a p value of
<.05 and a confidence interval of 95%. However on the Clinical
Global Impressions Scale
(CGI), the second primary outcome, Fluoxetine and the
combination of CCBT+FLU were
superior at the end of treatment (p=.01) but no statistical
difference for CCBT or CCBT/PBO.
Du Prel et al. (2009) explain that a Confidence Interval (CI)
predicts the precision of the
results. If the CI is wide, the estimate of true effect lacks
precision and therefore doubts the
treatment effect. If the confidence interval is narrow, precision
is high, and we can be more
confident in the results. There was no statistical difference
between combined therapies and
monotherapies.
Clinical Bottom line
Based on the evidence from the above three studies,
psychological therapy, in particular a
form of CBT, and pharmacological therapy, in particular, a
SSRI, are both effective at
16. reducing symptoms of SAD, however, Cognitive Therapy was
superior in the long term in
two out of three of the studies. Interestingly, there was no
evidence found that a combination
of both interventions were more effective than their
monotherapies on recovery rates.
9
Applicability to Practice
In order for a trial to be clinically useful the results must also
be relevant to a definable group
of people in a clinical setting, this is known as external
validity/applicability (Rothwell 2005).
It is not stated where Clark et al. (2003) trial was carried out,
Davidson et al. (2004) study
was based in North Carolina and Philadelphia and the RCT by
Nordahl et al. (2016) was
carried out in Norway. The aforementioned increases external
validity as results are
applicable to the various nationalities in the local population.
17. All three studies utilised the
DSM and the majority of the outcome measures are utilised in
current practice indicating that
the results can be applied to the local population.
Clark et al (2003) and Nordahl et al. (2014) both had small
sample sizes assessing
approximately 20 participants per treatment group at post
treatment assessments reducing
applicability, as Everitt and Wessely (2004) report that a large
sample size is more
representative of the population and minimises random error.
The inclusion and exclusion criteria are well defined for all
three studies, participants were
both male and female with a primary diagnosis of social anxiety
disorder with Clark et al.
(2004) and Nordahl et al. (2016) both including avoidant
personality disorder but excluding
depression. This could limit the generalisability of these results
as the majority of the patients
that come in contact with the mental health services in Ireland
present with comorbid
psychiatric problems such as depression. This is supported by
Magee et al. (1996) who report
18. that 81% of people that experience social anxiety disorder
reported experiencing another
disorder with Katzelnick et al. (2001) adding that up to 35% of
sufferers of SAD experience
major depression with SAD preceding depression up to 12
years.
10
Despite these results, the majority of patients in the local area
being treated for social anxiety
are receiving some form of anti-depressants as the waitlist for
CBT is 3 months or more with
Magee et al. (1996) adding that people with social anxiety do
not regard themselves as
suffering from an anxiety disorder, but shy, and do not seek
help until comorbid disorders
such as depression, affect them.
Implementation
Whilst researching for this critically appraised topic it became
apparent the lack of RCT’s
and therefore, systematic reviews, that compare psychological
and pharmacological
19. interventions for SAD. The Cochrane Journal club was
suggested by the hospital librarian,
this club is aimed at healthcare professionals and covers a
single review of special interest,
selected from the new and updated reviews published in the
Cochrane Library. Lawrie et al
(2003) also suggests that mental health professionals establish a
local evidence-based
psychiatry journal club (EBPJC) which would develop critical
appraisal techniques and
encourage the implementation of evidence based practice.
Grol and Grimshaw (2003) reported that one of the most
consistent findings in health services
research is the gap between evidence based practice (EBP) and
actual clinical care. Grol and
Wensing (2004) reports that studies in countries such as the
United States and the
Netherlands suggest that up to 40% of patients do not receive
care according to current
scientific evidence, while 20% or more of the care provided is
not needed or potentially
harmful to patients.
In a study carried out by Melnyk et al. (2012) on nurses in the
20. United States, the two most
frequently cited barriers to EBP, were a lack of time and a
workplace resistance, mostly from
11
management, to change. This study proposes that EBP mentors
work alongside clinicians to
facilitate learning these skills and implement them into practice
consistently. Facilitation is
considered necessary for enabling successful implementation
and is described by Rycroft-
Malone, (2004) as the process of supporting the implementation
of evidence into practice and
support to aid nurses alter their attitudes and ways of working.
Organizations need to consider resources required for EBP as a
lack of resources are
unfavorable to the success of implementation (Dogherty et al,
2013), financial, personnel,
equipment, support, access to evidence, and time are all forms
of resources. From experience
as a mental health nurse, lack of time to access library facilities
and lack of
21. motivation/support to implement new practice are the main
restraining factors for frontline
staff. Thompson et al. (2008) supports this by pointing out that
busyness, in the context of
research utilization, includes multiple dimensions such as
physical time, but perhaps more
importantly, mental time.
It is evident in practice that mental health nurses are not
familiar with CBT techniques or the
benefits despite many years of experience as mental health
nurses. Most educational
institutions in Ireland do not provide basic psychological
therapy training to mental health
students, however, there is an emphasis placed on
pharmacology. It is important that
organizations examine existing resources that could be utilized
to promote change, that is,
facilitate nurses to attend training days, encouragement of
research, time allocated for
research and encourage staff to return to education on a part
time basis by providing
incentives such as; funding, study days and instill hope of post
progression/promotion
following their studies.
22. Lewin’s (1951) (cited in Bowers 2011) proposed a three-step
process to change management
which offers a structured approach to understanding and
changing behaviour in the workplace.
http://onlinelibrary.wiley.com/doi/10.1111/wvn.12009/full#wvn
12009-bib-0023
http://journals.rcni.com.queens.ezp1.qub.ac.uk/doi/full/10.7748/
ns.30.1.38.e9296
12
It relates well to healthcare practice, as its three stages of
‘unfreezing’, ‘moving’ and
‘refreezing’ are similar to the healthcare processes of
‘planning’, ‘implementing’ and
‘evaluating’ care. This process is outlined with the clinical
bottom line of this critical
appraisal in mind and focusing on the psychological therapy,
CBT.
Unfreezing/Planning: Approaching management with the
findings of this appraisal that
psychological therapies are more beneficial than
pharmacological therapies and the most cost
effective therapy for health services (Mavranezouli 2015). A
proposal would be presented to
23. hold workshops to educate mental health colleagues on the
evidence based benefits of CBT
and the basic techniques of CBT. Gage (2013) emphasize that
support must be gained from
senior management who have an appropriate area of
responsibility, and who would benefit
from this service improvement idea and support the
implementation of the project.
Moving/Implementing: Nursing staff acquire basic CBT skills
and implement them into daily
practice. Gage (2013) reports that if staff are involved in change
from the early stages they
are more likely to feel more invested in assisting with the
delivery of the change plan, with
Hall and Hord (2011) adding staff are more likely to accept
change than if it is not imposed
on them ‘from above’.
Refreezing/ evaluation: Staff to monitor for a decrease in
symptoms of SAD. Parkes and
O’Dell (2015) report that if changes are implemented it is
imperative that these changes are
audited to ensure the continued provision of quality care.
If the above implementation plan was a success, Mental Health
24. Nurses could then practice
basic CBT techniques with patients while they await an
appointment from a qualified
therapist. As a result, patients would then know what to expect
from therapy, attend their
appointment and limit the chance of deterioration. In addition,
it may encourage nursing staff
to return to higher education to train as Cognitive Behavioural
Psychotherapists.
13
Appendix 1: Search Strategies
Search on Medline: After using additional keywords and filters
my search finally resulted in 1 text
being retrieved Clark et al (2003) and deemed as appropriate for
critical appraisal following the
reading of each abstract. Filters used were: full text, published
in peer review journals and that the
keywords would be in the title of the text.
SEARCH MEDLINE: Key Words and Boolean Operator HITS
S1 Social Phobia 3410
25. S2 Cognitive therapy 21864
S3 Fluoxetine 11846
S4 1 AND 2 AND 3 17
Search on PsycINFO: The key words used were CBT, anxiety
and depression. The Boolean operator
AND was used. Filters were: journals, full text and that the
keywords would be in the title of the text.
Following inspection of the abstracts one was chosen for critical
appraisal (Nordahl et al. 2016)
SEARCH PsycInfo
Key Words and Boolean Operator
HITS
S1 Social Anxiety Disorder 4078
S2 Cognitive therapy 6863
S3 Paroxetine 958
S4 1 AND 2 AND 3 2
26. 14
Search on Science Direct: Filters were: journals, full text,
keywords would be in the title of the text
and year limit from 2014-2017 to locate the most recent
evidence. Following inspection of the
abstracts none was deemed appropriate for critical appraisal
SEARCH ScienceDirect
Key Words and Boolean Operator
HITS
S1 Social Phobia 2444
S2 AND psychological and Pharmacological
Interventions
331
Search on Cochrane: Following inspection of the abstracts one
was chosen for critical appraisal
(Davidson et al. 2004).
SEARCH Cochrane
27. Key Words and Boolean Operator
HITS
S1 Social Phobia 1120
S2 AND Fluoxetine 33
15
References:
1. Altman D.G, & Bland J.M. (1999) ‘Treatment allocation in
controlled trials: why randomise?’
BMJ 318: pp.1209.
2. Altman D.G. and Schulz, K.F. (2001) ‘Statistics notes:
Concealing treatment allocation in
randomised trials’ British Medical Journal 323, pp. 446–447.
3. American Psychiatric Association. (2013). Diagnostic and
Statistical Manual of Mental
Disorders: DSM-IV-TR. Washington, DC: American Psychiatric
28. Association.
4. Amir, N., Beard, C., Taylor, C. T., Klumpp, H., Elias, J.,
Burns, M., & Chen, X. (2009).
‘Attention Training in Individuals with Generalized Social
Phobia: A Randomized Controlled
Trial’, Journal of Consulting and Clinical Psychology, 77(5),
pp. 961–973.
5. Beck A.T., Rush A.J., Shaw B.F. & Emery, G. (1979)
Cognitive Therapy of Depression. New
York: Guilford Press
6. Bowers, B. (2011) ‘Managing change by empowering staff’,
Nursing Times, 107(32-33) pp.
19-21.
7. Bragge, P. (2010), ‘Asking good clinical research questions
and choosing the right study
design’, Injury, 41(1), pp. 3-6.
8. Canton J, Scott K.M.,& Glue, P. (2012) ‘Optimal treatment of
social phobia: systematic
review and meta-analysis’. Neuropsychiatric Disease and
Treatment, 8: pp. 203-215.
9. Critical Appraisal Skills Programme (2017). CASP
Randomised Controlled Trial Checklist.
[online] Available at: http://www.casp-uk.net/ Accessed:
29. 25/04/2017.
10. Clark, D.M., (2011) ‘Implementing NICE guidelines for the
psychological treatment of
depression and anxiety disorders: The IAPT experience’
International review of psychiatry,
23(4) 318-327.
11. Clark, D. M.; Ehlers, A, McManus, F., Hackmann, A,
Fennell, M., Campbell, H. Flower, T.
Davenport, C. & Louis, B. (2003) ‘Cognitive Therapy Versus
Fluoxetine in Generalized
Social Phobia: A Randomized Placebo-Controlled Trial’.
Journal of Consulting and Clinical
Psychology, 71(6) pp. 1058-1067.
https://www.ncbi.nlm.nih.gov/pubmed/?term=Canton%20J%5B
Author%5D&cauthor=true&cauthor_uid=22665997
https://www.ncbi.nlm.nih.gov/pubmed/?term=Scott%20KM%5B
Author%5D&cauthor=true&cauthor_uid=22665997
https://www.ncbi.nlm.nih.gov/pubmed/?term=Glue%20P%5BAu
thor%5D&cauthor=true&cauthor_uid=22665997
http://www.tandfonline.com/doi/abs/10.3109/09540261.2011.60
6803
http://www.tandfonline.com/doi/abs/10.3109/09540261.2011.60
6803
16
30. 12. Davidson, J.R.T., Foa, E.B., Huppert, J.D., Keefe, F.J.,
Franklin, M.E., Compton, J.S., Zhao,
N., Connor, K.M., Lynch, T.R., & Gadde, K.M. ‘Fluoxetine,
Comprehensive Cognitive
Behavioral Therapy, and Placebo in Generalized Social Phobia’.
Arch Gen Psychiatry. 61(10)
pp. 1005-1013.
13. Dogherty, E.J. Harrison, M.B. Graham, I.D, Vandy, A.D. &
Keeping-Burke, L. (2013)
‘Turning knowledge into action at the point-of-care: the
collective experience of nurses
facilitating the implementation of evidence-based practice’
Worldviews Evidence Based
Nursing 10(3) pp. 129-139.
14. Du Prel, J.B., Hommel, G., Röhrig, B., & Blettner, M.
(2009). ‘Confidence Interval or P-
Value? Part 4 of a Series on Evaluation of Scientific
Publications’ Deutsches Ärzteblatt
International, 106(19), pp. 335–339.
15. Egger, M., & Davey Smith, G. (1998). ‘Meta-analysis: Bias
in location and selection of
studies’ British Medical Journal, 316. pp. 221–225.
31. 16. Eikenaes, I., Egeland, J., Hummelen, B., & Wilberg, T.
(2015). ‘Avoidant Personality
Disorder versus Social Phobia: The Significance of Childhood
Neglect’. PLoS ONE, 10(3).
17. Everitt, B.S. and S. Wessely (2004), Clinical Trials in
Psychiatry. Oxford: Oxford University
Press.
18. Forder, P.M, Gebski, V.J., & Keech, A.C. (2005)
‘Allocation concealment and blinding:
when ignorance is bliss’. Medical Journal Australia, 182(2)
pp.87-89.
19. Gage, W. (2013) ‘Using service improvement methodology
to change practice’ Nursing
Standard 27(23) pp. 51-57.
20. Grol R, & Grimshaw J. (2003) ‘From best evidence to best
practice: effective implementation
of change’. Lancet 362: pp.1225-1230.
21. Grol, R. & Wensing, M. (2004) ‘What drives change?
Barriers to and incentives for achieving
evidence-based practice’ Medical Journal Australia 180 (6) pp.
57-60.
22. Gupta, S. K. (2011). ‘Intention-to-treat concept: A review’.
Perspectives in Clinical Research,
33. 27. Katzelnick, D.J., Kobak K.A., DeLeire, T., Henk H.J.,
Greist, J.H., Davidson, J.R., Schneier
F.R., Stein M.B., and Helstad, C.P. (2001) ‘Impact of
generalized social anxiety disorder in
managed care’. American Journal of Psychiatry.158(12) pp.
1999-2007.
28. Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky,
A. M., Wittchen, H-U. (2012)
Twelve-month and lifetime prevalence and lifetime morbid risk
of anxiety and mood
disorders in the United States’, International Journal of Methods
in Psychiatric Research,
21(3), pp. 169-184.
29. Krysta, K., Krzystanek, M., Janas-Kozik, M., Klasik, A. and
Krupka-Matuszczyk, I. (2015)
‘Impact of pharmacological and psychological treatment
methods of depressive and anxiety
disorders on cognitive functioning’, Journal of Neural
Transmission, 122(1), pp. 101-110.
30. Lader, M & Kyriacou, A. (2016), 'Withdrawing
Benzodiazepines in Patients With Anxiety
Disorders' Current Psychiatry Reports, 18 (1), pp. 1-8.
34. 31. Lawrie, S.M., McIntosh, A.M. and Sanjay, R. (2003)
Critical Appraisal for Psychiatry.
Edinburgh: Churchill Livingstone.
32. Magee W.J., Eaton W.W., Wittchen H.U., McGonagle
K.A.,& Kessler, R.C. (1996)
‘Agoraphobia, simple phobia, and social phobia in the National
Comorbidity Survey’ Arch
Gen Psychiatry. 53(2) pp. 159-168.
https://www.ncbi.nlm.nih.gov/pubmed/?term=Katzelnick%20DJ
%5BAuthor%5D&cauthor=true&cauthor_uid=11729016
https://www.ncbi.nlm.nih.gov/pubmed/?term=Kobak%20KA%5
BAuthor%5D&cauthor=true&cauthor_uid=11729016
https://www.ncbi.nlm.nih.gov/pubmed/?term=DeLeire%20T%5B
Author%5D&cauthor=true&cauthor_uid=11729016
https://www.ncbi.nlm.nih.gov/pubmed/?term=Henk%20HJ%5B
Author%5D&cauthor=true&cauthor_uid=11729016
https://www.ncbi.nlm.nih.gov/pubmed/?term=Greist%20JH%5B
Author%5D&cauthor=true&cauthor_uid=11729016
https://www.ncbi.nlm.nih.gov/pubmed/?term=Davidson%20JR%
5BAuthor%5D&cauthor=true&cauthor_uid=11729016
https://www.ncbi.nlm.nih.gov/pubmed/?term=Schneier%20FR%
5BAuthor%5D&cauthor=true&cauthor_uid=11729016
https://www.ncbi.nlm.nih.gov/pubmed/?term=Schneier%20FR%
5BAuthor%5D&cauthor=true&cauthor_uid=11729016
https://www.ncbi.nlm.nih.gov/pubmed/?term=Stein%20MB%5B
Author%5D&cauthor=true&cauthor_uid=11729016
https://www.ncbi.nlm.nih.gov/pubmed/?term=Helstad%20CP%5
BAuthor%5D&cauthor=true&cauthor_uid=11729016
https://www.ncbi.nlm.nih.gov/pubmed/11729016
https://www.ncbi.nlm.nih.gov/pubmed/?term=Eaton%20WW%5
BAuthor%5D&cauthor=true&cauthor_uid=8629891
36. dialysis patients: A systematic review’. BMC Nephrology, 18,
42.
36. Nadelson, S. & Nadelson, L.S. (2014) ‘Evidence-Based
Practice Article Reviews Using
CASP Tools: A Method for Teaching EBP’, Worldviews on
Evidence Based Nursing, 11(5)
pp. 344-346.
37. Nordahl H.M., Vogel P.A., Morken G., Stiles T.C., Sandvik
P., & Wells A. (2016)
‘Paroxetine, Cognitive Therapy or Their Combination in the
Treatment of Social Anxiety
Disorder with and without Avoidant Personality Disorder: A
Randomized Clinical Trial’
Psychotherapy and psychosomatics. 85 pp.346-356.
38. Parkes, J. & O’Dell, C. (2015) ‘Introducing students to
clinical audit’, Nursing Management,
22(7), pp. 22-26.
39. Rice, M.J. (2009) ‘Effect Size in Psychiatric Evidence-
Based Practice Care’ Journal
of the American Psychiatric Nurses Association 15(2) pp. 138 –
142.
40. Roberts, J. & Dicenso, A. (1999) ‘Identifying the best
research design to fit the question. Part
37. 1: quantitative designs’ Evidence-Based Nursing 2(1), pp.4-6.
41. Rosen, R.C., Lane, R.M.& Menza, M. (1999) ‘Effects of
SSRIs on sexual function: A critical
review’. Journal of Clinical Psychopharmacology 19: pp. 67–
85.
42. Rothwell, P.M. (2005), ‘External validity of randomised
controlled trials: To whom do the
results of this trial apply?’ The Lancet. 365(9453):pp. 82-93
https://www.ncbi.nlm.nih.gov/pubmed/?term=Fineout-
Overholt%20E%5BAuthor%5D&cauthor=true&cauthor_uid=229
22750
https://www.ncbi.nlm.nih.gov/pubmed/?term=Gallagher-
Ford%20L%5BAuthor%5D&cauthor=true&cauthor_uid=229227
50
https://www.ncbi.nlm.nih.gov/pubmed/?term=Kaplan%20L%5B
Author%5D&cauthor=true&cauthor_uid=22922750
https://www.ncbi.nlm.nih.gov/pubmed/15639683
19
43. Rycroft-Malone, J. (2004). ‘The PARIHS framework—A
framework for guiding the
implementation of evidence-based practice’. Journal of Nursing
Care Quality, 19, pp. 297–
304.
44. Stanley, K. (2007) ‘Design of randomized controlled trials’.
38. Circulation. 115 pp.1164–1169.
45. Thompson, D.S., O'Leary, K., Jensen, E. Scott-Findlay, S.,
O'Brien-Pallas, L. & Estabrooks,
C.A. (2008) ‘The relationship between busyness and research
utilization: it is about time’
Journal of Clinical Nursing. 17: pp. 539-548.
46. Wilson, G. T., Wilfley, D. E., Agras, W. S., & Bryson, S.
W. (2011). Allegiance Bias and
Therapist Effects: Results of a Randomized Controlled Trial of
Binge Eating Disorder.
Clinical Psychology : A Publication of the Division of Clinical
Psychology of the American
Psychological Association, 18(2), 119–125.
A Randomized Trial to Promote Physical Activity Among
Breast
Cancer Patients
Bernardine M. Pinto
The Miriam Hospital, Providence, Rhode Island, and W. Alpert
Medical School of Brown University
George D. Papandonatos
Brown University
39. Michael G. Goldstein
VHA National Center for Health Promotion and Disease
Prevention, Durham, North Carolina
Objective: Physical activity (PA) has been shown to provide
health benefits for breast cancer patients. The
effects of augmenting oncology health care provider (HCP)
advice for PA with 3 months of telephone
counseling versus contact control were evaluated in a
randomized trial. Methods: After receiving brief HCP
advice to become physically active, 192 women (age in years:
M � 60.0, SD � 9.9) who had completed
treatment for Stage 0-IV breast cancer were randomized to
telephone counseling to support PA (n � 106) or
contact control (n � 86). Their PA, motivational readiness,
fatigue, and physical functioning were assessed
at baseline (before receiving HCP advice), 3, 6, and 12 months.
Results: Telephone counseling produced
significant effects on the primary outcome of moderate-intensity
PA of about 30 min/week at both 3 months
(95% CI � 0.44, 57.32) and 6 months (95% CI � 3.06, 61.26).
Intervention participants were also more than
twice as likely as control participants to report improvements in
achieving PA guidelines of at least 150
min/week at 3 (OR � 2.43, 95% CI � 1.18, 4.98) and 6 months
(OR � 2.11, 95% CI � 1.00 – 4.48).
Telephone counseling was significantly more effective than
contact control in increasing motivational
readiness for PA at all follow-ups (ORs � 3.93– 6.28, all ps
�.003). No between-groups differences were
found for fatigue, while differential improvements in physical
functioning did not remain significant past 3
months (p � .01). Conclusion: HCP advice plus telephone
counseling improved PA among breast cancer
patients at 3 and 6 months and also differentially improved
patients’ motivational readiness at all follow-ups,
40. suggesting the potential for exercise promotion in cancer
follow-up care.
Keywords: breast cancer, physical activity, exercise, counseling
Supplemental materials:
http://dx.doi.org/10.1037/a0029886.supp
A growing number of cancer survivors face impairments in
physical functioning, increased fatigue and reduced quality of
life
(QOL), and increased risk for cardiovascular disease, obesity,
osteoporosis and future cancers (Institute of Medicine and the
National Research Council, 2006). Evidence suggests that
partic-
ipating in moderate-intensity physical activity (PA) for at least
three months improves physical functioning, QOL, and mood
and
reduces fatigue among cancer survivors (Agency for Healthcare
Research and Quality, 2004; Galvão & Newton, 2005; Knols,
Aaronson, Uebelhart, Fransen, & Aufdemkampe, 2005; Speck,
Courneya, Masse, Duval, & Schmitz, 2010). Cancer treatments
require frequent follow-up appointments that provide oncology
health care providers (HCPs) with opportunities to encourage
patients to change health risk behaviors. However, Sabatino and
colleagues (2007) found that only 25% of a national sample of
cancer survivors reported receiving a recommendation about ex-
ercise from their physicians.
HCPs have played a minimal role, if any, in PA interventions
for
cancer patients. One study involved breast cancer patients seen
at
adjuvant treatment consultation. Participants received either: a)
a
41. recommendation to exercise, b) a recommendation plus a
referral
to an exercise specialist, or c) usual care (Jones, Courneya,
Fairey,
& Mackey, 2004). PA assessments at 1 and 5 weeks revealed
greater PA participation in the group that received a recommen-
dation to exercise versus usual care. In our trial, HCPs were
asked
to provide PA advice to patients who had completed surgery and
adjuvant chemotherapy/radiation. Evidence suggests that it is
not
practical to rely on physicians to provide more intensive
interven-
Bernardine M. Pinto, Centers for Behavioral and Preventive
Medicine,
The Miriam Hospital, Providence, Rhode Island, and W. Alpert
Medical
School of Brown University; George D. Papandonatos, Center
for Statis-
tical Sciences, Brown University; Michael G. Goldstein, Office
of Patient
Care Services, VHA National Center for Health Promotion and
Disease
Prevention, Durham, North Carolina.
This research was funded by a grant from the American Cancer
Society
and Rays of Hope (RSGPB-03-243-01 PBP). We gratefully
acknowledge
the contributions of the research staff (Susan Abdow, Stephanie
Berube,
Christopher Breault, Jennifer Correia, Kelly Greenwood, and
Joyce Lee).
We thank the physicians who participated in the study and
assisted with
42. patient recruitment. The trial is registered in the Clinical Trials
Registry
(NCT 002 30711).
Correspondence concerning this article should be addressed to
Bernar-
dine M. Pinto, Centers for Behavioral and Preventive Medicine,
The
Miriam Hospital, One Hoppin St., Coro Bldg., Suite 314,
Providence, RI
02903. E-mail: [email protected]
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47. interactive health technology (de Vries & Brug, 1999) in our
interventions. Hence, we extended brief HCP advice with a
3-month telephone counseling program for PA.
The use of telephone-based interventions to promote PA in a
general population has been well documented (see reviews by
Castro & King, 2002; Eakin, Lawler, Vandelanotte, & Owen,
2007; Goode, Reeves, & Eakin, 2012). The studies reviewed
showed convincingly that such interventions are not only effica-
cious, but they also offer unique advantages of increased conve-
nience and access. There are also increased opportunities for
contact anywhere a telephone is accessible and increased time
efficiency. These advantages, together with the counselor’s
skills
and resources, can help promote PA among individuals who may
not be receptive to face-to-face contact or printed materials.
Telephone-based PA interventions over 6 –12 weeks have been
tested among small samples of breast cancer patients (Matthews
et
al., 2007; Mock et al., 1997) with positive effects on PA (Mat-
thews et al., 2007) and reductions in patients’ anxiety, fatigue,
and
sleeping difficulties (Mock et al., 1997). Telephone calls have
also
been used in PA interventions offered over 6 months and longer
to
breast, prostate, and other cancer survivors (Bennett, Lyons,
Winters-Stone, Nail, & Scherer, 2007; Demark-Wahnefried et
al.,
2006; Morey et al., 2009) with one study showing favorable
effects
at the end of a 6-month intervention (Bennett et al., 2007) and
another study with a 12-month intervention showing significant
group effects on PA and physical functioning (Morey et al.,
2009).
In sum, there is evidence to support the efficacy of telephone-
48. based interventions at postintervention in promoting PA among
cancer survivors. However, these PA interventions did not
involve
HCPs and a majority did not assess PA outcomes in the long-
term.
In this study, we used a telephone counseling program whose
efficacy had been previously tested among breast cancer
patients
(Pinto, Frierson, Rabin, Trunzo, & Marcus, 2005) to extend the
HCP advice. The comparison group also received HCP advice
and
telephone calls to control for contact as a more conservative test
of
the intervention. In addition, final assessment of outcomes oc-
curred 6 months after all intervention contact ended.
The primary purpose of this study was to examine the effects of
HCP advice to become physically active plus Telephone
Counsel-
ing (Intervention) versus HCP advice plus Contact Control
(Con-
trol) on self-reported minutes of PA (leisure and occupational
activity) of at least moderate-intensity at 3 months among
women
who had completed breast cancer treatment. We hypothesized
that
extending brief HCP advice by providing telephone counseling
specific to PA would produce stronger increases in PA at 3
months
than telephone contact of the same frequency that provided
health
monitoring. Secondary aims included examining maintenance of
intervention effects on PA at 6 and 12 months. We also
hypothe-
sized that the increased PA among intervention participants
would
49. maintain over time. Other goals included examining
intervention
effects on the proportion of participants who met PA guidelines
and on participants’ motivational readiness for PA at 3 months,
6
months, and 12 months. We hypothesized that a larger
proportion
of intervention participants would meet PA guidelines, and that
the
intervention group would progress further in motivational readi-
ness for PA. Finally, we sought to examine intervention effects
on
self-reported physical functioning and fatigue at follow-up. We
hypothesized that the intervention group would report improved
physical functioning and reduced fatigue at follow-ups
compared
with the control group.
Methods
Design
We conducted a randomized trial offering all participants HCP
advice for PA and then compared: (a) 12 weeks of additional
Telephone Counseling, and (b) Contact Control. Assessments
were
conducted at baseline, posttreatment (3 months), at 6 months
and
12 months. Institutional Review Boards at the Miriam Hospital
and
Women and Infants Hospital approved the study. The study was
conducted in accordance with the Helsinki Declaration from
2004 –2009.
Recruitment
50. Participants were recruited by informational letters sent by
oncologists and surgeons to their patients, and by in-person re-
cruitment at a hospital-based oncology clinic. HCPs were asked
to
review their nonurgent follow-up care schedules and to identify
women who had completed breast cancer treatment, had no
current
evidence of disease, and were expected to live � 12 months.
Letters were mailed to these patients approximately three
months
before their next visit. If patients were interested in the study,
they
were asked to contact the study staff who conducted an
eligibility
screen by telephone. Eligibility criteria: 1) female aged � 18
years, 2) completed primary and adjuvant treatment for breast
cancer (patients on hormone treatment such as Tamoxifen were
eligible), 3) � 5 years since treatment completion, 4) able to
read
and speak English, 5) provided consent for medical chart
review,
6) able to walk unassisted, 7) were relatively inactive (�30 min/
week of vigorous-intensity exercise or �90 min/week of
moderate-intensity exercise), and 8) had access to a telephone.
Participants were excluded if they had a prior history of cancer
or
if they had a medical or current psychiatric illness (e.g., cardio-
vascular disease, diabetes) that could hinder compliance with
the
study protocol.
We completed 351 initial telephone screens to determine study
eligibility (see Figure 1). Of those screened, 192 (54.7% of
phone
screens, 71% of eligible respondents) were eligible, interested,
51. and
eventually randomized. The study was designed to have 80%
power to detect a between-groups difference in change scores of
0.35 SD units at the 5% level of significance, based on cross-
sectional comparisons at 3 months. Due to recruitment
difficulties,
the study goal of 300 based on N � 125/group at 3 months
(starting from N � 150/group at baseline) could not be met
within
the time available. Based on 83 control and 88 intervention par-
ticipants with valid 7-day physical activity recall (PAR)
measures
at 3 months (see Figure 1), the minimum detectable between-
groups difference in change scores rose to 0.42 SD units. Given
the
observed 3-month change-score SD of 106 min/week, this trans-
lates to a 45-min difference in 3-month change scores, before
taking into account the additional power offered by the repeated
measures design.
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56. After providing informed consent, participants obtained medical
clearance from their oncologist. All participants received PA
ad-
vice from an oncologist/surgeon during a clinic visit (n � 100)
or
advice documented in a letter (n � 92) after they were referred
for
study participation during a clinic visit. After receiving HCP
advice, they were randomly assigned to the two study arms
using
a centrally administered randomization procedure that stratified
on
prior chemotherapy status (yes/no) and PA level (participants
classified as active vs. not based on a PA threshold of 30 min/
week). HCPs and staff conducting the assessments were blinded
to
participants’ group assignments. Participants and intervention
co-
ordinators were not blinded to group assignments.
HCP Advice
Oncologists and surgeons (n � 14, 29% women, mean years in
practice � 15.6, SD � 8.9, mean age � 50.8, SD � 9.6) at three
local hospitals and two private practices who were invited to
participate in the study received training (15–30 min) in
providing
brief PA advice (�5 min). The brief motivational counseling
protocol was derived from the 5As counseling strategy (address
the agenda, assess, advise, assist and arrange follow-up) used
previously for training physicians (Goldstein et al., 1999; Pinto,
Goldstein, Ashba, Sciamanna, & Jette, 2005). The HCP’s role
was
to provide patients a brief message about PA benefits,
57. recommend
30 min of moderate-intensity PA on most days of the week, and
arrange for follow-up with study staff.
Participants who were recruited via informational letters re-
ceived HCP advice at the next regularly scheduled clinic visit.
At
this visit, providers were cued by prompts placed on patients’
charts to deliver PA advice. Documentation of message delivery
was recorded on the chart prompt. Providers were allowed to
drop
patients from the study if the goal of moderate-intensity PA
would
be unsafe for the patient. After completing the clinic visit, each
participant was met by research staff, the chart prompt was col-
lected and her randomization status was determined. For partici-
pants recruited on-site (n � 92), HCPs recommended the study
to
patients seen in clinic. If interested, eligible and enrolled in the
study, the participant was given a letter from her HCP
document-
Initial phone screen for eligibility, n=351
Ineligible: 23.1% (n=81)
Too active=36
Medical issues=16
>10 years postdiagnosis=2
Ongoing psychological issues=3
No English fluency=2
Not able to exercise= 3
Enrolled in another study=6
HCP not participating=1
Other=12
Eligible at phone screen: 76.9% (n=270)
58. Eligible and randomized: 71.1% (n=192)
Not randomized: 28.9% (n=78)
No interest=18, Too busy=18
Lost contact=8, Family issues=5
Medical issues=4, Other reason=11
Reason unknown=14
TC Group (n=106) CC Group (n=86)
12-week PA Counseling 12-week Contact
Post-treatment assessment: 83.9% (n=89)
Attrition=17 (Lost contact=8, family issues=4,
cancer=2, no interest=2, too busy=1)
Primary outcome analyzed: 83.0% (n=88)
Post-treatment assessment: 97.6% (n=84)
Attrition=2 (Lost contact=2)
Primary outcome analyzed: 96.5% (n=83)
Monthly PA calls for 3 months
Monthly calls for 3 months
Oncology HCP advice
(in-person or by letter)
Assessment at 6 months: 81.1% (n=86)
Attrition=3 (Lost contact=1, family issues=1, no interest=1)
Primary outcome analyzed: 80.2% (n=85)
Assessment at 6 months: 93.0% (n=80)
Attrition=4 (No interest=2, too busy=1, surgery=1)
Primary outcome analyzed: 89.5% (n=77)
59. Assessment at 12 months: 79.2% (n=84)
Attrition=2 (Lost contact=1, cancer=1)
Primary outcome analyzed: 77.4% (n=82)
Assessment at 12 months: 90.6% (n=78)
Attrition=2 (too busy=1, death=1)
Primary outcome analyzed: 88.4% (n=76)
Figure 1. Flow diagram of participant recruitment,
randomization, and retention.
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618 PINTO, PAPANDONATOS, AND GOLDSTEIN
ing “brief advice” elements (advise, assist and arrange follow-
up/
referral to study staff) and randomized. Advice documented in a
letter was used to reduce delays in study enrollment since the
next
clinic visit may have been more than 3 months later.
HCP Advice Plus Telephone Counseling (Intervention)
These participants received in-person instructions on how to
64. exercise at a moderate-intensity level, monitor heart rate, and
how
to warm up before and cool down after PA. They were given
home
logs to monitor PA participation and a pedometer (Digiwalker,
Yamax Corporation, Tokyo, Japan). The intervention was
individ-
ualized to the participant’s baseline PA (and motivational readi-
ness) such that, inactive participants were encouraged to be
phys-
ically active for at least 10 min on at least 2 days/week (these
goals
were higher for those who were physically active at baseline),
and the
goals were gradually increased over the 12 weeks to 30 min/day
on at
least 5 days/week (U.S. Department of Health and Human
Services,
1996). For participants who reported some level of PA at
baseline, the
exercise goals negotiated by the interventionist were higher.
Hence,
starting points and rates of PA progression varied across
participants
because these were individualized to increase the motivation
and
confidence of the participants. The counseling promoted
moderate-
intensity aerobic PA at 55– 65% maximum heart rate such as
brisk
walking, biking, or swimming.
Each participant received eight telephone calls over 12 weeks
(weekly for 4 weeks, biweekly for 8 weeks) from Intervention
Coordinators to support PA adoption. Counseling was based on
the
65. Transtheoretical Model and Social Cognitive Theory (Bandura,
1986; Prochaska & DiClemente, 1983), and it was tailored to
each
participant’s motivational readiness (Marcus & Simkin, 1993).
The counseling focused on strengthening self-efficacy for PA,
and
it trained participants in techniques such as self-monitoring of
PA,
setting PA goals, and planning for exercise. Cognitive processes
of
change were emphasized for participants in Contemplation, and
behavioral processes were emphasized for those in Preparation
(Marcus & Simkin, 1993). Specific components from
motivational
interviewing (conviction of the importance of PA to cancer
recov-
ery and confidence in becoming/staying active) were also
assessed
during the calls.
The PA counseling followed a structured format covering the
following topics: assessment of the past week’s PA (and
motiva-
tional readiness), assessment of health problems, exploration of
barriers to PA, assessment of the participant’s conviction of the
importance of PA, negotiation of PA goals for the following
week(s), assessment of the participant’s confidence in achieving
the goals, and review of the tip-sheets that were sent to the
participant. If participants reported physical symptoms such as
chest pain, they were referred to their physician for clearance to
resume study participation.
Participants were mailed a PA and a cancer survivorship
tip-sheet on topics such as body image, each week over the
12-week intervention. Finally, a letter summarizing the partic-
ipant’s progress was sent to her at weeks 2, 4, 8, and 12. After
66. the 3-month assessments were completed, monthly phone calls
over the next 3 months were provided to reinforce regular PA
and prevent lapses.
HCP Advice Plus Contact Control Group (Control)
These participants received eight calls over 12 weeks (weekly
for 4 weeks, biweekly for 8 weeks) during which the Symptom
Questionnaire (Winningham, 1993) was administered to monitor
problems such as headaches. Interventionists were trained not to
discuss PA with this group. If the participants reported PA, the
interventionist listened but did not provide any counseling
related
to PA. The goal was to match contact frequency with the inter-
vention group, with no attempt made to match call duration
across
groups. In addition, participants received cancer survivorship
tip-
sheets. After the 3-month assessment, they also received
monthly
phone calls for 3 months, during which the Symptom Question-
naire was administered.
Intervention Delivery
All telephone calls to study participants were audio-taped, and
25% of these tapes were randomly selected for review by the
principal investigator and a co-investigator to ensure fidelity to
protocol. In addition, participant issues were discussed during
weekly staff meetings.
Measures
Disease and treatment variables (from medical records) and
demographic information were obtained at baseline. At baseline
and subsequent assessments, body weight and height were mea-
67. sured. Participants received small incentives (e.g., $10 gift
cards)
for completing the assessments which included:
Seven-Day Physical Activity Recall (7-day PAR;Blair et al,
1985). This interviewer-administered measure (Sallis et al.,
1985; Sarkin, Campbell, & Gross, 1997) assesses hours spent in
sleep as well as moderate, hard, and very hard activity (leisure
and
occupational) over the past week. We were interested in the
weekly minutes of at least moderate-intensity PA, which we
ana-
lyzed as a continuous outcome (primary outcome) and as a
dichot-
omous indicator of whether participants met recommendations
(U.S. Department of Health and Human Services, 1996) of at
least
150 min/week of moderate-intensity PA.
Stage of Motivational Readiness for PA (Marcus, Rossi,
Selby, Niaura, & Abrams, 1992). This reliable and valid mea-
sure assesses an individual’s motivational readiness for PA
(Mar-
cus & Simkin, 1993). It classifies individuals into one of five
stages: precontemplation (individuals who do no PA and do not
intend to start), contemplation (those who do not participate in
PA
but intend to start), preparation (those who participate in some
PA
but not regularly), action (those who currently participate in
reg-
ular activity, but have done so for less than 6 months), and
maintenance (those who have participated in regular PA for 6
months or longer). For the purposes of this study, regular PA
was
defined as at least 30 min of moderate-intensity exercise on � 5
68. times per week. Since movement into Action/Maintenance has
been significantly associated with fitness improvements
(Marcus
& Simkin, 1993), we modeled motivational readiness as
dichoto-
mous, contrasting those who successfully transitioned into
Action/
Maintenance with those that did not.
MOS 36-Item Short Form Health Survey (SF-36; McHor-
ney, Ware, & Raczek, 1993; Ware & Sherbourne, 1992). This
assesses eight health concepts (e.g., physical functioning,
bodily
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73. (limitations
in physical activities) to a high score of 100 (no limitations).
Functional Assessment of Cancer Therapy Scale-Fatigue
(FACT-F). This 13-item scale is a brief, reliable, and valid
measure of the physical and functional effects of fatigue. It has
strong internal consistency, and it shows a significant positive
relationship with other measures of fatigue (Yellen, Cella, Web-
ster, Blendowski, & Kaplan, 1997). Scores on this measure
range
from 6 (high fatigue) to 52 (low fatigue).
Analyses
T tests for continuous variables and �2 tests for categorical
variables were used to examine the success of the randomization
procedure in balancing participants’ characteristics, including
baseline values of the outcomes of interest (see Table 1).
Similar
analyses were used to compare retained participants versus
drop-
outs.
Longitudinal trajectory modeling of continuous outcomes was
conducted using Linear Mixed Effects (LME) models, as imple-
mented in Splus 8.2 (Insightful Corporation, 2007). Mean
change
scores from baseline were adjusted for baseline values of each
outcome, and they were calculated separately by treatment
group
at each follow-up. Any variables showing significant between-
groups differences at baseline were also included as potential
confounders. Subject-specific random intercepts were used to
ac-
commodate within-subject correlation across time.
74. Of note, LME models employ likelihood-based estimation pro-
cedures that use all available data to produce consistent
estimates
of the regression coefficients (Daniels & Hogan, 2008; Little &
Rubin, 2002). Although they remain sensitive to drop out
patterns
that depend on the missing outcome itself, they are superior to
completers-only analyses or intention-to-treat approaches that
as-
sign a prespecified score to the missing data.
Longitudinal binary outcomes were analyzed using Generalized
Estimating Equation (GEE) methodology, as implemented in the
Correlated Data Library of Splus 8.2 (Insightful Corporation,
2007). Logistic regression models with a working independence
correlation matrix were used to estimate the effect of baseline
PA
levels and study arm on the odds of meeting or exceeding PA
guidelines at each follow-up (U.S. Department of Health and
Human Services, 1996, 2008). A similar GEE procedure was
used
to analyze movement into Action/Maintenance by study arm,
controlling for stage of change at baseline (Contemplation vs.
Preparation).
Results
Sample Characteristics
As seen in Table 1, 192 women (mean age � 60.0 years, SD �
9.9, mean time since diagnosis � 2.9 years, SD � 2.1) were
assigned to either intervention (n � 86) or control (n � 106),
using
a stratified randomization scheme. Overall, 22 intervention and
eight control participants withdrew or were dropped from the
trial
75. (see Figure 1). Attrition in the control group was consistently
low
across time, whereas the intervention group experienced higher
dropout at 3 months (n � 17), and limited losses thereafter.
Within-group comparisons in the intervention arm, in terms of
baseline characteristics, showed that 26% of dropouts had a
mas-
tectomy at 3 months versus 12% of retained participants (p �
.1).
Two participants sustained minor injuries related to falling off a
treadmill, and one died during the trial for reasons unrelated to
study participation.
Analyses revealed no statistically significant between-groups
differences on demographic variables or outcomes at baseline.
However, intervention versus control differences in
chemotherapy
rates (55% vs. 66%) and full-time employment (FTE) status
(55%
vs. 47%) were deemed meaningful enough to warrant further
examination of these variables as potential confounders of the
treatment-outcome relationship. Results suggested that
chemother-
apy did not affect any outcome of interest. However, FTE status
affected all outcomes other than fatigue, at least during the 12-
week intervention period. Therefore, longitudinal trajectories of
study participants were adjusted not only for baseline values of
each outcome, but also for FTE status, where warranted.
PA Outcomes
Seven-day PAR. Intervention participants outperformed con-
trol participants by about 30 min/week of at least moderate
inten-
sity PA at both 3 months (p � .048) and 6 months (p � .032),
76. but
this beneficial telephone counseling effect dissipated at 12
months
(p � .574). For illustrative purposes, we also included in Table
2
covariate-adjusted intervention and control change score
trajecto-
ries for a reference group of participants not in FTE with
baseline
PA levels set at the overall sample mean (45 min/week). These
can
be combined with the reported baseline PA and FTE effects to
construct anticipated PA trajectories for any study participant of
interest. For every additional hour by which a participant’s
base-
line PA level exceeded the sample mean, anticipated PA
increases
at follow-up were reduced in both study arms by 16 min at 3
months (p � .03), 35 min at 6 months (p � .001), and 28 min at
12 months (p � .001). In addition, FTE status increased weekly
PA levels by 46 min at 3 months (p � .002), but its effect was
attenuated at both 6 months (p � .604) and 12 months (p �
.643).
Meeting PA guidelines. Given the sensitivity of average PA
levels to the presence of outliers, we also estimated a logistic
regression model in which the binary response was an indicator
of
whether a participant was able to meet or exceed guidelines of
150
min/week of PA at follow-up (U.S. Department of Health and
Human Services, 2008). Results in Table 3 suggest beneficial
intervention effects at 3 months (OR � 2.43, p � .016) and 6
months (OR � 2.11, p � .05), but not at 12 months (OR � 1.16,
p � .704) for a reference group of participants not in FTE
report-
77. ing mean PA levels at baseline. As expected, higher PA at study
entry made it even more likely that a participant would succeed
in
meeting guidelines at follow-up: For every hour by which a
participant’s baseline PA exceeded the sample mean of 45 min/
week, the odds of meeting guidelines at follow-up rose by 11%
to
23% across study arms, depending on time point. Finally, FTE
status more than doubled the odds of meeting guidelines at 3
months (OR � 2.33, p � .02), but its effect was attenuated at
both
6 months (p � .366) and 12 months (p � .477).
T
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82. p-valueNo. % No. %
Race/Ethnicity
Non-Hispanic White 80 93 100 95 .79
Non-Hispanic Black 4 5 3 3
Hispanic 2 2 2 2
Marital status
Single 7 8 6 6 .81
Married/Living with partner 59 69 79 75
Divorced/Separated 12 14 12 11
Widowed 8 9 9 8
Employment status
Employed full-time 47 55 50 47 .27
Employed part-time 10 12 20 19
Unemployed 4 5 8 8
Retired 20 24 18 17
Homemaker/Medical leave 4 5 10 9
Educational level
High School Diploma 16 19 19 18 .99
Vocational/Trade School 5 6 6 6
Some college 24 28 28 26
Associate Degree 10 12 11 10
Bachelor Degree 14 16 20 19
Graduate School 17 20 22 21
Household income
Less than $29,999 8 10 13 13 .39
$30,000–$39,999 7 9 11 11
$40,000–$49,999 15 19 10 10
Over $50,000 49 62 63 65
Age in years
83. Mean (SD) 55.9 (9.9) 56.1 (9.9) .89
Body mass index
Mean (SD) 28.7 (5.1) 29.6 (6.2) .28
Cancer stage
0 12 14 12 11 .89
I 33 38 41 39
II 34 40 44 42
III/IV 7 8 9 8
Cancer treatmentb
Lumpectomy 66 77 76 73 .68
Lumpectomy with dissection 44 51 53 50 .96
Mastectomy 28 33 34 33 .91
Mastectomy with reconstruction 6 7 6 6 .95
Radiation 63 73 76 72 .94
Chemotherapy 47 55 69 66 .16
Hormone treatment 70 81 78 74 .32
Years since diagnosis
Mean (SD) 2.9 (2.1) 3.0 (2.2) .72
Motivational readiness
Contemplation 67 78 81 76 .13
Preparation 13 15 23 22
Action/Maintenance 6 7 2 2
PA guidelines
�150 PAR min/week 79 92 100 94 .70
�150 PAR min/week 7 8 6 6
7-day PAR (min/week)
Mean (SD) 46.8 (62.5) 42.9 (59.4) .67
84. FACT-F
Mean (SD) 38.1 (11.6) 39.3 (9.9) .47
SF-36 PF
Mean (SD) 72.8 (22.8) 77.2 (19.5) .15
Note. TC � Telephone Counseling; CC � Contact Control; PA
� Physical Activity; PAR � 7-day PAR; FACT-F � Functional
Assessment of Cancer
Therapy Scale-Fatigue; SF-36 PF � MOS 36-Item Short Form
Health Survey: Physical Functioning subscale.
a Percentages have been calculated on cases with available data.
b Each patient may have received more than one treatment;
percentages do not add to
100.
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89. 1983).
Telephone counseling appears to have produced long-lasting ef-
fects on motivational readiness among a reference group of par-
ticipants not in FTE that joined the study while in
Contemplation:
As seen in Table 3, such participants were much more likely to
have reached Action/Maintenance at 3 months (OR � 4.45, p �
.001) and 6 months (OR � 3.93, p � .003) if assigned to the
intervention than the control arm, and these intervention effects
were strengthened further at 12 months (OR � 6.28, p � .001).
Participants entering the study in Preparation were significantly
more likely to move to Action/Maintenance than those in
Contem-
plation, whether at 3 months (OR � 3.76, p � .002), 6 months
(OR � 2.57, p � .033), or 12 months (OR � 2.64, p � .041). In
contrast, FTE status more than doubled the odds of reaching
Action/Maintenance at 3 months (OR � 2.58, p � .02), but its
effect was attenuated at both 6 months (p � .373) and 12
months
(p � .725).
Table 2
Point Estimates and 95% Confidence Intervals for Change
Scores From Baseline to Follow-Upa
Outcome/Group
Follow-up
3 Months 6 Months 12 Months
Mean 95% CI Mean 95% CI Mean 95% CI
7-day PAR (min/week)
TC 59.70 (35.59, 83.80) 56.64 (32.22, 81.07) 44.06 (19.22,
90. 68.89)
CC 30.82 (5.13, 56.51) 24.48 (�1.43, 50.40) 35.61 (9.04, 62.17)
TC vs. CC 28.88 (0.44, 57.32) 32.16 (3.06, 61.26) 8.45
(�20.95, 37.86)
Baseline PARb �15.83 (�30.36, �1.30) �35.25 (�49.85,
�20.64) �27.76 (�42.40, �13.13)
FTE vs. not 46.10 (17.67, 74.52) 7.70 (�21.34, 36.73) �6.96
(�36.32, 22.41)
SF-36 PF
TC 3.73 (�0.39, 7.86) 4.79 (0.64, 8.95) 3.87 (�0.32, 8.06)
CC �2.74 (�7.14, 1.65) 1.09 (�3.42, 5.59) 1.11 (�3.40, 5.62)
TC vs. CC 6.48 (1.60, 11.35) 3.71 (�1.27, 8.69) 2.76 (�2.26,
7.77)
Baseline SF-36 �0.40 (�0.52, �0.29) �0.35 (�0.46, �0.23)
�0.35 (�0.47, �0.23)
FTE vs. not 6.49 (1.60, 11.38) 4.08 (�0.93, 9.09) 1.75 (�3.29,
6.80)
FACT-F
TC 4.53 (2.88, 6.18) 3.84 (2.17, 5.51) 3.69 (1.98, 5.39)
CC 3.41 (1.70, 5.13) 1.95 (0.18, 3.72) 1.44 (�0.31, 3.20)
TC vs. CC 1.12 (�1.26, 3.50) 1.89 (�0.54, 4.33) 2.44 (�0.20,
4.69)
Baseline FACT-F �0.40 (�0.51, �0.29) �0.37 (�0.48, �0.26)
�0.40 (�0.51, �0.29)
Note. TC � Telephone Counseling; CC � Contact Control; FTE
� Full-time employment; PAR � 7-day PAR; SF-36 PF � MOS
36-Item Short Form
Health Survey Physical Functioning subscale; FACT-F �
Functional Assessment of Cancer Therapy Scale-Fatigue.
a Boldface estimates denote p-values significant at � � .05. b
Baseline PAR expressed in hours/week.
Table 3
91. Longitudinal Logistic Regression Models Predicting
Achievement of PA Guidelines and Movement to
Action/Maintenance at Follow-Upa
Outcome/Coefficientb
Follow-up
3 Months 6 Months 12 Months
OR 95% CI OR 95% CI OR 95% CI
PA guidelines
TC 0.43 (0.23, 0.82) 0.39 (0.21, 0.73) 0.33 (0.17, 0.65)
CC 0.18 (0.09, 0.35) 0.18 (0.09, 0.36) 0.29 (0.15, 0.54)
TC vs. CC 2.43 (1.18, 4.98) 2.11 (1.00, 4.48) 1.16 (0.54, 2.52)
Baseline PAR 1.23 (1.08, 1.39) 1.12 (1.02, 1.23) 1.11 (1.03,
1.19)
FTE vs. not 2.33 (1.14, 4.76) 1.41 (0.67, 2.98) 0.76 (0.35, 1.63)
Action/Maintenancec
TC 0.27 (0.13, 0.57) 0.28 (0.14, 0.59) 0.35 (0.16, 0.74)
CC 0.06 (0.02, 0.15) 0.07 (0.03, 0.19) 0.06 (0.02, 0.15)
TC vs. CC 4.45 (2.02, 9.80) 3.93 (1.57, 9.80) 6.28 (2.29, 17.24)
Prep. vs. Con 3.76 (1.59, 8.86) 2.57 (1.08, 6.14) 2.64 (1.04,
6.70)
FTE vs. not 2.58 (1.16, 5.74) 1.45 (0.64, 3.26) 1.16 (0.50, 2.70)
Note. TC � Telephone Counseling; CC � Contact Control; FTE
� Full-time employment; Con � Contemplation; Prep. �
Preparation; PA � Physical Activity;
PAR � 7-day PAR.
a Boldface estimates denote p-values significant at � � .05. b
Baseline PAR expressed in hours/week. c Model estimated
among N � 184 participants
92. in Contemplation or Preparation at study entry.
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622 PINTO, PAPANDONATOS, AND GOLDSTEIN
Psychosocial Outcomes
Physical functioning. Intervention participants outperformed
control participants by 6.48 units on the SF-36 PF scale at 3
months (p � .01), but group differences narrowed at 6 months
(p � .147) and 12 months (p � .497). Table 2 displays
covariate-
adjusted intervention and control change score trajectories for a
reference group of participants not in FTE reporting with
average
SF-36 levels at baseline (75.21 units). Trajectories for other
study
participants can be constructed by noting that for every
additional
unit by which a participant’s baseline SF-36 score exceeded the
sample mean, anticipated SF-36 PF increases in both study
groups
were reduced by 0.35– 0.40 units at follow-up across study arms
(all ps � .001). In addition, FTE status increased physical func-
97. tioning by 6.49 units at 3 months (p � .01), but its effect was
attenuated at both 6 months (p � .112) and 12 months (p �
.497).
Fatigue. No significant group differences in fatigue levels
were found at follow-up. Illustrative intervention and control
change score trajectories are depicted in Table 2 for a reference
group of participants not in FTE reporting mean FACT-F scores
of
38.76 units at baseline. Trajectories for other participants can
be
calculated by noting that for every additional unit by which a
participant’s baseline FACT-F score exceeded the sample mean,
anticipated FACT-F increases in both study groups were
reduced
by 0.37– 0.40 units at follow-up (all ps � .001).
Intervention Delivery
The proportion of participants receiving in-person HCP advice
was balanced across study arms, with negligible intervention
ver-
sus control differences (51.12% vs. 52.83%, p � .93). In-person
HCP advice, as evidenced by completed chart prompts, was de-
livered to 98% of the participants who received in-person
advice
(mean duration of advice � 4.7 min, SD � 1.4). Eighty-six
percent
of the participants reported that their HCPs explained the health
benefits of PA, and 96% were satisfied with the advice. During
the
3-month intervention phase, a mean of 6.7 calls (SD � 1.81)
were
delivered to intervention participants and 7.1 calls (SD � 1.3)
to
control participants (p � .07; max. possible � eight calls). As
98. expected, calls in the intervention arm were of longer duration
(M � 15.0 min, SD � 5.8) than calls in the control arm (M �
9.0
min, SD � 3.9, p � .001).
Discussion
Our primary goal was to examine the effects of HCP advice plus
Telephone Counseling (Intervention) versus HCP advice plus
Con-
tact Control (Control) on participants’ PA at 3 months. HCPs
were
able to provide brief exercise advice, which the participants
found
satisfactory. We found that intervention participants
outperformed
control participants by about 30 min/week of at least moderate
intensity PA at 3 months and 6 months, but that this effect
dissipated at 12 months. In practical terms, this translates to PA
increases of one additional day/week in terms of USDHHS
guide-
lines (U.S. Department of Health and Human Services, 2008)
that
recommend moderate-intensity PA of at least 30 min/day on
five
or more days/week, or a minimum of 150 min/week overall.
Results were consistent across continuous and binary measures
of
PA (average 7-day PAR levels vs. proportion meeting PA guide-
lines of 150 min/week), which is reassuring, since the former
can
be susceptible to the influence of outliers.
On motivational readiness for PA, the outcome most closely
related to the theoretical basis underlying the intervention, we
99. found strong intervention effects that were maintained
throughout
the 12-month study period. In particular, intervention
participants
outperformed control participants in terms of moving from Con-
templation/Preparation at study entry to Action/Maintenance at
follow-up, a change in motivational readiness previously associ-
ated with fitness improvements (Marcus & Simkin, 1993). The
apparent discrepancy in the strength of intervention effects on
self-reported PA levels and on motivational readiness for PA at
12
months may be due to differences over the reference assessment
period (the previous week in the PAR vs. the previous 6 months
for
moving to the Action/Maintenance stage of motivational
readiness
for PA). As PA levels were elevated in the intervention group at
6
months relative to 12 months, motivational readiness at 12
months
may be capturing PA increases at the previous assessment point
not included in the 7-day PAR administered at 12 months.
The only other known study in which HCPs provided PA advice
to breast cancer patients, had effects assessed at 1 and 5 weeks
(Jones et al., 2004), so it is difficult to compare the results
across
studies, but it is clear that our study—which followed patients
for
much longer—found positive effects of HCP advice plus
telephone
counseling on PA at 3 months and 6 months. When considering
telephone-based interventions and short-term effects (3
months),
stronger effects on PA were found in our previous 12-week tele-
phone counseling intervention among breast cancer patients
100. (Pinto,
Frierson, et al., 2005). Significant effects on PA were also
found in
previous telephone counseling studies among breast cancer pa-
tients at 6 weeks (Mock et al., 1997) and at 12 weeks (Matthews
et al., 2007). In studies using other intervention approaches
such as
the effects of exercise recommendations alone, print materials
alone, pedometers alone, and a combination of print materials
and
pedometers among breast cancer survivors (Vallance, Courneya,
Plotnikoff, Yasui, & Mackey, 2007), larger group differences
(39
to 57 min/week across groups) were found at 3 months. When
considering PA outcomes at 12 months, a group difference of 13
min was achieved in a sample of 641 overweight, older long-
term
cancer survivors who received a 12-month PA and dietary inter-
vention via telephone and print materials or a delayed
intervention
(Morey et al., 2009). These interventions did not involve the
HCP,
and overlooking the HCP may present a missed opportunity for
supporting a healthy behavior such as exercise.
It is clear that the significant intervention effects in helping
breast cancer survivors meet PA guidelines at 3 months and 6
months dissipated at 12 months. One call/week over 12 weeks
had
produced significant increases in PA in a prior study among
breast
cancer survivors (Pinto, Frierson, et al., 2005). We had reduced
the
number of calls to eight in this trial which may account for
weaker
effects. Another explanation is that the inability to detect
101. between-
groups differences was driven by the increased PA reported by
control participants over time. Though intriguing, this increase
should not be interpreted to suggest that brief advice from HCPs
is
sufficient to increase long-term PA, because control participants
received not only HCP advice, but also similar frequency of
contact with research staff as intervention participants. This was
done to provide a more conservative test of the intervention.
However, it is possible that the contacts kept PA salient for
control
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623PHYSICAL ACTIVITY INTERVENTION
participants and reduced the ability to detect differential
interven-
tion effects. The true test of this explanation would involve a 3-
arm
study: HCP advice plus Telephone Counseling, HCP advice plus
Contact Control, and HCP Advice alone.
Study goals included examining intervention effects on psycho-
social outcomes. Group differences in fatigue were
106. nonsignificant,
and the intervention effects on self-reported physical
functioning
were not maintained past 3 months. Our study participants were
not screened for high levels of fatigue and/or poor physical
func-
tioning. Mean fatigue scores at baseline were similar to those in
another PA trial for breast cancer patients initiating adjuvant
chemotherapy in which significant improvement in fatigue in
the
PA group was not found (Courneya et al., 2007). Both study
groups showed improvements in fatigue, and in the absence of a
control group that received no intervention, these results are in-
conclusive. The strength of the effect size of exercise
interventions
on cancer patients’ fatigue has been found to be inconsistent
and
highly heterogeneous across studies (0.06 –2.26), and it may be
linked to a “take all comers” approach, that is, patients in the
studies may have had low fatigue levels (Speck et al., 2010).
Similarly, our study sample’s physical functioning was high at
baseline (compared with normative data; Ware, Kosinski, &
Dewey, 2000), suggesting possible “ceiling” effects.
The higher attrition at 3 months among participants receiving
telephone counseling rather than contact control (16.1% vs.
2.3%)
was surprising (see Figure 1 for reasons), and suggests that
study
demands may have been too burdensome for some breast cancer
participants. Although higher attrition among intervention
partic-
ipants is not uncommon (Dubbert, Morey, Kirchner, Meydrech,
&
Grothe, 2008), retention was at 94% in a previous trial using
telephone counseling (12 weekly calls in a 3-month
107. intervention)
to promote PA among breast cancer patients (Pinto, Frierson, et
al.,
2005).
The association of working full-time and increased PA at 3
months (but not thereafter) was surprising. Finding time to
exer-
cise is often a barrier for individuals who work, and this barrier
may be stronger among women who also have household
respon-
sibilities (Dishman, 1990). But it is also possible that the
women
who worked full-time may have had better health and fewer
comorbidities than those who were not working full-time.
This study, which is one of the first to promote PA in collabo-
ration with oncology follow-up, clearly showed that motivated
HCPs were able to provide brief advice to their patients (98%
completed chart prompts). The duration of advice was brief, as
intended, and participants were generally satisfied with the
advice.
The advice was associated with short-term and long increases in
PA in both groups who received calls focusing either on PA or
contact control. The improvement in PA in the control arm was
surprising, but it may also represent the growing awareness of
the
relevance of PA for cancer recovery. Future studies may want to
test the efficacy of HCP advice in the absence of a contact
control
arm on short-term and long-term outcomes. If such studies also
focus on psycho-social effects such as fatigue and physical
func-
tioning, it is important to also recruit patients who report high
levels of fatigue and low physical functioning in order to avoid
“floor” and “ceiling” effects.
108. Study limitations include an actively recruited sample of pa-
tients who were able to obtain physician consent and were
willing
to be randomized. The sample was relatively homogeneous with
regard to race/ethnicity and socioeconomic status limiting the
generalizability of the findings. HCPs were asked to provide
brief
exercise advice to patients during a follow-up visit, but we were
not able to assess whether advice was provided at subsequent
follow-up visits, which may be a confounder. Another drawback
is
that the measures of PA were based on self-report. While we
included a conservative contact control group (that may have
inadvertently kept PA salient for the CC arm), there was no true
control group in the study. Finally, it is possible that additional
effects might have been detected on self-reported physical func-
tioning had the sample included women with poorer functioning
at
baseline.
Strengths of the study include a large sample size of women
within 5 years of a breast cancer diagnosis, documented
delivery of
HCP advice, use of several standardized measures of PA,
motiva-
tional readiness and psycho-social outcomes, a theoretically
based
intervention, and follow-up assessments at 6 months and 12
months. Our results show that among motivated volunteer
HCPs,
providing brief advice was feasible in the context of a follow-up
visit, and when this advice was supplemented by telephone
coun-
seling, patients’ PA participation increased for at least 6
109. months.
HCP advice is perceived as credible to patients and if the advice
is
kept brief and does not take valuable time from the HCP-patient
encounter, it is not likely to be burdensome in the health care
setting. While we cannot be sure that HCP advice alone would
suffice (our study design does not allow us to draw that conclu-
sion), our results suggest that the HCP advice will require
supple-
mentation to support the adoption and maintenance of PA in this
patient population. There is scope for examining whether this
type
of intervention can be implemented in large health care systems
where cancer patients are monitored for follow-up care.
References
Agency for Healthcare Research and Quality. (2004).
Effectiveness of
behavioral interventions to modify physical activity behaviors
in general
populations and cancer patients and survivors (Evidence Report/
Technology Assessment, No. 102). Retrieved from
www.Ahrq.gov/
clinic/epcsums/pacansum.htm
Bandura, A. (1986). Social foundations of thought and action: A
social
cognitive theory. Englewood Cliffs, NJ: Prentice Hall.
Bennett, J. A., Lyons, K. S., Winters-Stone, K., Nail, L. M., &
Scherer, J.
(2007). Motivational interviewing to increase physical activity
in long-
term cancer survivors: A randomized controlled trial. Nursing
Research,
110. 56, 18 –27. doi:00006199-200701000-00003[pii]
Blair, S. N., Haskell, W. L., Ho, P., Paffenbarger, R. S., Jr.,
Vranizan,
K. M., Farquhar, J. W., & Wood, P. D. (1985). Assessment of
habitual
physical activity by a seven-day recall in a community survey
and
controlled experiments. American Journal of Epidemiology,
122, 794 –
804.
Castro, C. M., & King, A. C. (2002). Telephone-assisted
counseling for
physical activity. Exercise and Sport Sciences Reviews, 30, 64
– 68.
doi:10.1097/00003677-200204000-00004
Courneya, K. S., Segal, R. J., Mackey, J. R., Gelmon, K., Reid,
R. D.,
Friedenreich, C. M., . . . McKenzie, D. C. (2007). Effects of
aerobic and
resistance exercise in breast cancer patients receiving adjuvant
chemo-
therapy: A multicenter randomized controlled trial. Journal of
Clinical
Oncology, 25, 4396 – 4404.
doi:JCO.2006.08.2024[pii]10.1200/JCO
.2006.08.2024
Daniels, M. J., & Hogan, J. W. (2008). Missing data in
longitudinal
studies. Boca Raton, FL: Chapman & Hall/CRC.
doi:10.1007/S11749-
009-0141-2
115. in
at
ed
br
oa
dl
y.
624 PINTO, PAPANDONATOS, AND GOLDSTEIN
http://dx.doi.org/00006199-200701000-00003[pii]
http://dx.doi.org/10.1097/00003677-200204000-00004
http://dx.doi.org/JCO.2006.08.2024[pii]10.1200/JCO.2006.08.2
024
http://dx.doi.org/JCO.2006.08.2024[pii]10.1200/JCO.2006.08.2
024
http://dx.doi.org/10.1007/S11749-009-0141-2
http://dx.doi.org/10.1007/S11749-009-0141-2
Demark-Wahnefried, W., Clipp, E. C., Morey, M. C., Pieper, C.
F., Sloane,
R., Snyder, D. C., & Cohen, H. J. (2006). Lifestyle intervention
devel-
opment study to improve physical function in older adults with
cancer:
Outcomes from project LEAD. Journal of Clinical Oncology,
24, 3465–
3473. doi:24/21/3465[pii]10.1200/JCO.2006.05.7224,1532928
de Vries, H., & Brug, J. (1999). Computer-tailored interventions
motivat-
ing people to adopt health promoting behaviours: Introduction
116. to a new
approach. Patient Education and Counseling, 36, 99 –105.
doi:10.1016/
S0738-3991(98)00127-X
Dishman, R. K. (1990). Determinants of participation in
physical activity.
In C. Bouchard, R. J. Shephard, T. Stephens, J. R. Sutton, & B.
D.
McPherson (Eds.), Exercise, fitness and health (pp. 75–102).
Cham-
paign, IL: Human Kinetics.
Dubbert, P. M., Morey, M. C., Kirchner, K. A., Meydrech, E.
F., & Grothe,
K. (2008). Counseling for home-based walking and strength
exercise in
older primary care patients. Archives of Internal Medicine, 168,
979 –
986. doi:10.1001/archinte.168.9.979
Eakin, E. G., Lawler, S. P., Vandelanotte, C., & Owen, N.
(2007). Tele-
phone interventions for physical activity and dietary behavior
change: A
systematic review. American Journal of Preventive Medicine,
32, 419 –
434. doi:S0749-3797(07)00010-
4[pii]10.1016/j.amepre.2007.01.004
Galṽao, D. A., & Newton, R. U. (2005). Review of exercise
intervention
studies in cancer patients. Journal of Clinical Oncology, 23, 899
–909.
doi:10.1200/JCO.2005.06.085
117. Goldstein, M. G., Pinto, B. M., Marcus, B. H., Lynn, H., Jette,
A. M.,
Rakowski, W., . . . Tennstedt, S. (1999). Physician-based
physical
activity counseling for middle-aged and older adults: A
randomized trial.
Annals of Behavioral Medicine, 21, 40 – 47.
doi:10.1007/BF02895032
Goode, A. D., Reeves, M. M., & Eakin, E. G. (2012).
Telephone-delivered
interventions for physical activity and dietary behavior change:
An
updated systematic review. American Journal of Preventive
Medicine,
42, 81– 88. doi:S0749-3797(11)00742-
2[pii]10.1016/j.amepre.2011.08
.025
Insightful Corporation. (2007). S-Plus 8 for Unix user’s guide.
Seattle,
WA: Author.
Institute of Medicine and the National Research Council.
(2006). From
cancer patient to cancer survivor: Lost in transition.
Washington, DC:
National Academies Press.
Jones, L. W., Courneya, K. S., Fairey, A. S., & Mackey, J. R.
(2004).
Effects of an oncologist’s recommendation to exercise on self-
reported
exercise behavior in newly diagnosed breast cancer survivors: A
single-
blind, randomized controlled trial. Annals of Behavioral
118. Medicine, 28,
105–113. doi:10.1207/s15324796abm2802_5
Knols, R., Aaronson, N. K., Uebelhart, D., Fransen, J., &
Aufdemkampe,
G. (2005). Physical exercise in cancer patients during and after
medical
treatment: A systematic review of randomized and controlled
clinical
trials. Journal of Clinical Oncology, 23, 3830 –3842.
doi:10.1200/JCO
.2005.02.148
Little, R. J. A., & Rubin, D. B. (2002). Statistical analysis with
missing
data (2nd ed.). New York: J. Wiley & Sons.
Marcus, B. H., Bock, B. C., Pinto, B. M., Forsyth, L. H.,
Roberts, M. B.,
& Traficante, R. M. (1998). Efficacy of an individualized,
motivationally-tailored physical activity intervention. Annals of
Behav-
ioral Medicine, 20, 174 –180. doi:10.1007/BF02884958
Marcus, B. H., Rossi, J. S., Selby, V. C., Niaura, R. S., &
Abrams, D. B.
(1992). The stages and processes of exercise adoption and
maintenance
in a worksite sample. Health Psychology, 11, 386 –395.
doi:10.1037/
0278-6133.11.6.386
Marcus, B. H., & Simkin, L. R. (1993). The stages of exercise
behavior.
Journal of Sports Medicine and Physical Fitness, 33, 83– 88.
119. Matthews, C. E., Wilcox, S., Hanby, C. L., Der Ananian, C.,
Heiney, S. P.,
Gebretsadik, T., & Shintani, A. (2007). Evaluation of a 12-week
home-
based walking intervention for breast cancer survivors.
Supportive Care
in Cancer, 15, 203–211. doi:10.1007/s00520-006-0122-x
McHorney, C. A., Ware, J. E., Jr., & Raczek, A. E. (1993). The
MOS
36-Item Short-Form Health Survey (SF-36): II. Psychometric
and clin-
ical tests of validity in measuring physical and mental health
constructs.
Medical Care, 31, 247–263. doi:10.1097/00005650-199303000-
00006
Mock, V., Dow, K. H., Meares, C. J., Grimm, P. M.,
Dienemann, J. A.,
Haisfield-Wolfe, M. E., . . . Gage, I. (1997). Effects of exercise
on
fatigue, physical functioning, and emotional distress during
radiation
therapy for breast cancer. Oncology Nursing Forum, 24, 991–
1000.
Morey, M. C., Snyder, D. C., Sloane, R., Cohen, H. J., Peterson,
B.,
Hartman, T. J., . . . Demark-Wahnefried, W. (2009). Effects of
home-
based diet and exercise on functional outcomes among older,
overweight
long-term cancer survivors: Renew: A randomized controlled
trial. Jour-
nal of the American Medical Association, 301, 1883–1891.
doi:301/18/
120. 1883[pii]10.1001/jama.2009.643,2752421
Pinto, B. M., Frierson, G. M., Rabin, C., Trunzo, J. J., &
Marcus, B. H.
(2005). Home-based physical activity intervention for breast
cancer
patients. Journal of Clinical Oncology, 23, 3577–3587.
doi:23/15/
3577[pii]10.1200/JCO.2005.03.080
Pinto, B. M., Goldstein, M. G., Ashba, J., Sciamanna, C. N., &
Jette, A.
(2005). Randomized controlled trial of physical activity
counseling for
older primary care patients. American Journal of Preventive
Medicine,
29, 247–255. doi:S0749-3797(05)00278-
3[pii]10.1016/j.amepre.2005
.06.016
Pinto, B. M., Trunzo, J. T., Reiss, P., & Shiu, S. (2002).
Exercise partic-
ipation after diagnosis of breast cancer: Trends and effects on
mood and
quality of life. Psycho-Oncology, 11, 389 – 400.
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and
processes of
self-change of smoking: Toward an integrative model of change.
Journal
of Consulting and Clinical Psychology, 51, 390 –395.
doi:10.1037/0022-
006X.51.3.390
Sabatino, S. A., Coates, R. J., Uhler, R. J., Pollack, L. A.,
Alley, L. G., &
121. Zauderer, L. J. (2007). Provider counseling about health
behaviors
among cancer survivors in the United States. Journal of Clinical
On-
cology, 25, 2100 –2106. doi:10.1200/JCO.2006.06.6340
Sallis, J. F., Haskell, W. L., Wood, P. D., Fortmann, S. P.,
Rogers, T.,
Blair, S. N., & Paffenbarger, R. S., Jr. (1985). Physical activity
assess-
ment methodology in the Five-City Project. American Journal of
Epi-
demiology, 121, 91–106.
Sarkin, J. A., Campbell, J., Gross, L., Roby, J., Bazzo, S.,
Sallis, J., &
Calfas, K. (1997). Project grad seven day physical activity
recall inter-
viewer’s manual. Medicine and Science in Sports and Exercise,
29,
S91–102.
Speck, R. M., Courneya, K. S., Masse, L. C., Duval, S., &
Schmitz, K. H.
(2010). An update of controlled physical activity trials in cancer
survi-
vors: A systematic review and meta-analysis. Journal of Cancer
Survi-
vorship: Research and Practice, 4, 87–100. doi:10.1007/s11764-
009-
0110-5
U.S. Department of Health and Human Services. (1996).
Physical activity
and health: A report of the Surgeon General. Atlanta, GA:
Centers for
122. Disease Control and Prevention, National Center for Chronic
Disease
Prevention and Health Promotion, U.S. Government Printing
Office.
U.S. Department of Health and Human Services. (2008). 2008
physical
activity guidelines for Americans. Retrieved from
www.health.gov/
paguidelines
Vallance, J. K., Courneya, K. S., Plotnikoff, R. C., Yasui, Y., &
Mackey,
J. R. (2007). Randomized controlled trial of the effects of print
materials
and step pedometers on physical activity and quality of life in
breast
cancer survivors. Journal of Clinical Oncology, 25, 2352–2359.
doi:
25/17/2352[pii]10.1200/JCO.2006.07.9988
Ware, J. E., Jr., & Sherbourne, C. D. (1992). The MOS 36-Item
Short-
Form Health Survey (SF-36). I. Conceptual framework and item
selec-
tion. Medical Care, 30, 473– 483. doi:10.1097/00005650-
199206000-
00002
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