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Objective: To understand and describe the meaning of medications for patients. Methods: A metasynthesis of three different, yet complementary qualitative research studies, was conducted by two researchers. The first study was a phenomenological study of patients’ medication experiences that used unstructured interviews. The second study was an ethnographic study of pharmaceutical care practice, which included participant observation, in-depth interviews and focus groups with patients of pharmaceutical care. The third was a phenomenological study of the chronic illness experience of medically uninsured individuals in the United States and included an explicit aim to understand the medication experience within that context. The two researchers who conducted these three qualitative studies that examined the medication experience performed the meta-synthesis. The process began with the researchers reviewing the themes of the medication experience for each study. The researchers then aggregated the themes to identify the overlapping and similar themes of the medication experience and which themes are sub-themes within another theme versus a unique theme of the medication experience. The researchers then used the analytic technique, “free imaginative variation” to determine the essential, structural themes of the medication experience. Results: The meaning of medications for patients was captured as four themes of the medication experience: a meaningful encounter; bodily effects; unremitting nature; and exerting control. The medication experience is an individual’s subjective experience of taking a medication in his daily life. It begins as an encounter with a medication. It is an encounter that is given meaning before it occurs. The experience may include positive or negative bodily effects. The unremitting nature of a chronic medication often causes an individual to question the need for the medication. Subsequently, the individual may exert control by altering the way he takes the medication and often in part because of the gained expertise with the medication in his own body. Conclusion: The medication experience is a practice concept that serves to understand patients’ experiences and to understand an individual patient’s medication experience and medication-taking behaviors in order to meet his or her medication-related needs.

Objectives

To assess the impact of a closed‐loop electronic prescribing, automated dispensing, barcode patient identification and electronic medication administration record (EMAR) system on prescribing and administration errors, confirmation of patient identity before administration, and staff time.

Design, setting and participants

Before‐and‐after study in a surgical ward of a teaching hospital, involving patients and staff of that ward.

Intervention

Closed‐loop electronic prescribing, automated dispensing, barcode patient identification and EMAR system.

Main outcome measures

Percentage of new medication orders with a prescribing error, percentage of doses with medication administration errors (MAEs) and percentage given without checking patient identity. Time spent prescribing and providing a ward pharmacy service. Nursing time on medication tasks.

Results

Prescribing errors were identified in 3.8% of 2450 medication orders pre‐intervention and 2.0% of 2353 orders afterwards (p<0.001; χ2 test). MAEs occurred in 7.0% of 1473 non‐intravenous doses pre‐intervention and 4.3% of 1139 afterwards (p = 0.005; χ2 test). Patient identity was not checked for 82.6% of 1344 doses pre‐intervention and 18.9% of 1291 afterwards (p<0.001; χ2 test). Medical staff required 15 s to prescribe a regular inpatient drug pre‐intervention and 39 s afterwards (p = 0.03; t test). Time spent providing a ward pharmacy service increased from 68 min to 98 min each weekday (p = 0.001; t test); 22% of drug charts were unavailable pre‐intervention. Time per drug administration round decreased from 50 min to 40 min (p = 0.006; t test); nursing time on medication tasks outside of drug rounds increased from 21.1% to 28.7% (p = 0.006; χ2 test).

Conclusions

A closed‐loop electronic prescribing, dispensing and barcode patient identification system reduced prescribing errors and MAEs, and increased confirmation of patient identity before administration. Time spent on medication‐related tasks increased.

The present study examined the extent to which mothers were able to train their children, 2 boys with autism, to exchange novel pictures to request items using the picture exchange communication system (PECS). Generalization probes assessing each child's ability to mand for untrained items were conducted throughout conditions. Using a multiple baseline design, results demonstrated that both children improvised by using alternative symbols when the corresponding symbol was unavailable across all symbol categories (colors, shapes, and functions) and that parents can teach their children to use novel pictorial response forms.

Background

Graphical symbols on in vitro diagnostics (IVD symbols) replace the need for text in different languages and are used on malaria rapid diagnostic tests (RDTs) marketed worldwide. The present study assessed the comprehension of IVD symbols labelled on malaria RDT kits among laboratory staff in four different countries.

Methods

Participants (n = 293) in Belgium (n = 96), the Democratic Republic of the Congo (DRC, n = 87), Cambodia (n = 59) and Cuba (n = 51) were presented with an anonymous questionnaire with IVD symbols extracted from ISO 15223 and EN 980 presented as stand-alone symbols (n = 18) and in context (affixed on RDT packages, n = 16). Responses were open-ended and scored for correctness by local professionals.

Results

Presented as stand-alone, three and five IVD symbols were correctly scored for comprehension by 67% and 50% of participants; when contextually presented, five and seven symbols reached the 67% and 50% correct score respectively. 'Batch code' scored best (correctly scored by 71.3% of participants when presented as stand-alone), 'Authorized representative in the European Community' scored worst (1.4% correct). Another six IVD symbols were scored correctly by less than 10% of participants: 'Do not reuse', 'In vitro diagnostic medical device', 'Sufficient for', 'Date of manufacture', 'Authorised representative in EC', and 'Do not use if package is damaged'. Participants in Belgium and Cuba both scored six symbols above the 67% criterion, participants from DRC and Cambodia scored only two and one symbols above this criterion. Low correct scores were observed for safety-related IVD symbols, such as for 'Biological Risk' (42.7%) and 'Do not reuse' (10.9%).

Conclusion

Comprehension of IVD symbols on RDTs among laboratory staff in four international settings was unsatisfactory. Administrative and outreach procedures should be undertaken to assure their acquaintance by end-users.

Aim

The aim of this study is to examine the attitudes of patients, who presented with advanced glaucoma in at least one eye, to participation in a randomised prospective trial comparing primary medical treatment with primary surgical treatment for advanced glaucoma.

Methods

Patients who had presented with advanced glaucoma (>15 dB loss mean deviation on Humphrey visual field testing) in at least one eye were asked to participate. Five focus groups comprising of 4–8 patients and consisting of 29 patients in total were undertaken. The group interviews were conducted by two experienced qualitative researchers, an ophthalmic clinician was present to clarify technical issues. The focus group discussions were taped and transcribed in full, and analysed through a process of familiarisation, open (inductive) coding, theme generation, theme refinement, and thematic mapping.

Results

Three overarching themes were identified: (1) the extent of patients' knowledge, (2) anxieties about surgery, and (3) concerns about compromised care due to trial involvement; these themes were further classified into eight sub-themes.

Conclusions

Patients' willingness to participate in randomised clinical studies is significantly connected to their level of comprehension and insight about the medical condition, its treatment, and the research process; misunderstandings about any of these aspects may act as a significant barrier to trial recruitment. Recruitment rates for future randomised trials may be enhanced by ensuring that patients have full and accurate information about the treatment alternatives, and that uncertainty exists for best patient outcomes between treatment options, and reassuring potential participants that the research process, in particular randomisation, will not compromise clinical care.

Optimal management of atopic dermatitis (AD) requires patients to adhere to self-care behaviors. Technologies, such as cell phones, have been widely adopted in the USA and have potential to reinforce positive health behaviors. We conducted a pilot study with 25 adolescents and adults age 14 years and older [mean 30.5 yrs, SD 13.4] with AD. Daily text messages (TMs) that provided medication reminders and AD education were sent for six weeks to participants. Our goals were to (1) measure changes in pre- and posttest scores in treatment adherence, self-care behaviors, disease severity, and quality of life and (2) assess the usability and satisfaction of the TM system. Significant improvements in treatment adherence, self-care behaviors, skin severity, and quality of life (P ≤ .001, .002, <.001, and .014, resp.) were noted postintervention. User feedback on the TM system was positive with 88% and 92% of participants reporting that the reminder TMs and educational TMs were helpful, respectively. In conclusion, study participants were receptive to using TMs as a reminder aid and educational tool. The positive trends observed are promising and lay the ground work for further studies needed to elucidate the full potential of this simple and cost-effective intervention.

Purpose

Communication about feelings is a core element of human interaction. Aided augmentative and alternative communication systems must therefore include symbols representing these concepts. The symbols must be readily distinguishable in order for users to communicate effectively. However, emotions are represented within most systems by schematic faces in which subtle distinctions are difficult to represent. We examined whether background color cuing and spatial arrangement might help children identify symbols for different emotions.

Methods

Thirty nondisabled children searched for symbols representing emotions within an 8-choice array. On some trials, a color cue signaled the valence of the emotion (positive vs. negative). Additionally, symbols were either organized with the negatively-valenced symbols at the top and the positive symbols on the bottom of the display, or the symbols were distributed randomly throughout. Dependent variables were accuracy and speed of responses.

Results

The speed with which children could locate a target was significantly faster for displays in which symbols were clustered by valence, but only when the symbols had white backgrounds. Addition of a background color cue did not facilitate responses.

Conclusions

Rapid search was facilitated by a spatial organization cue, but not by the addition of background color. Further examination of the situations in which color cues may be useful is warranted.

Knowledge representation involves enumeration of conceptual symbols and arrangement of these symbols into some meaningful structure. Medical knowledge representation has traditionally focused more on the structure than the symbols. Several significant efforts are under way, at local, national, and international levels, to address the representation of the symbols though the creation of high-quality terminologies that are themselves knowledge based. This paper reviews these efforts, including the Medical Entities Dictionary (MED) in use at Columbia University and the New York Presbyterian Hospital. A decade's experience with the MED is summarized to serve as a proof-of-concept that knowledge-based terminologies can support the use of coded patient data for a variety of knowledge-based activities, including the improved understanding of patient data, the access of information sources relevant to specific patient care problems, the application of expert systems directly to the care of patients, and the discovery of new medical knowledge. The terminological knowledge in the MED has also been used successfully to support clinical application development and maintenance, including that of the MED itself. On the basis of this experience, current efforts to create standard knowledge-based terminologies appear to be justified.

This study tested the usability of a touch-screen enabled “Personal Education Program” (PEP) with Advanced Practice Registered Nurses (APRN). The PEP is designed to enhance medication adherence and reduce adverse self-medication behaviors in older adults with hypertension. An iterative research process was employed, which involved the use of: (1) pre-trial focus groups to guide the design of system information architecture, (2) two different cycles of think-aloud trials to test the software interface, and (3) post-trial focus groups to gather feedback on the think-aloud studies. Results from this iterative usability testing process were utilized to systematically modify and improve the three PEP prototype versions—the pilot, Prototype-1 and Prototype-2. Findings contrasting the two separate think-aloud trials showed that APRN users rated the PEP system usability, system information and system-use satisfaction at a moderately high level between trials. In addition, errors using the interface were reduced by 76 percent and the interface time was reduced by 18.5 percent between the two trials. The usability testing processes employed in this study ensured an interface design adapted to APRNs’ needs and preferences to allow them to effectively utilize the computer-mediated health-communication technology in a clinical setting.

This study tested the usability of a touch-screen enabled “Personal Education Program” (PEP) with Advanced Practice Registered Nurses (APRN). The PEP is designed to enhance medication adherence and reduce adverse self-medication behaviors in older adults with hypertension. An iterative research process was employed, which involved the use of: (1) pre-trial focus groups to guide the design of system information architecture, (2) two different cycles of think-aloud trials to test the software interface, and (3) post-trial focus groups to gather feedback on the think-aloud studies. Results from this iterative usability testing process were utilized to systematically modify and improve the three PEP prototype versions—the pilot, Prototype-1 and Prototype-2. Findings contrasting the two separate think-aloud trials showed that APRN users rated the PEP system usability, system information and system-use satisfaction at a moderately high level between trials. In addition, errors using the interface were reduced by 76 percent and the interface time was reduced by 18.5 percent between the two trials. The usability testing processes employed in this study ensured an interface design adapted to APRNs' needs and preferences to allow them to effectively utilize the computer-mediated health-communication technology in a clinical setting.

This is a qualitative study using a focus group approach, conducted to determine factors influencing adherence to osteoporosis medications among older adults. Thirty-two patients aged 65 to 85 years from the greater Boston area who were prescribed an osteoporosis medication, 11 general medicine physicians and 1 nurse practitioner were recruited from Boston based hospitals affiliated with a large healthcare system. Focus groups consisting of 6 to 8 subjects including males and females were held separately for providers and patients and conducted until thematic saturation was reached. Responses were obtained from patients and providers during the focus group interviews conducted by a trained focus group moderator. All interviews were audio taped and transcribed by a medical transcriptionist.

According to patients, factors affecting adherence to osteoporosis drugs included lack of knowledge about osteoporosis, dissatisfaction with their doctor visits, side effects, and difficulty or failure to remember instructions for taking medications. Physicians reported lack of patient knowledge, structural barriers, medication side effects, and the inability to track patients’ adherence to their medications as barriers to adherence.

This study identifies the extent of and reasons for non-adherence as perceived by patients and providers, and provides insights into strategies to modify treatment plans to address non-adherence. The results from this study were used to develop a RCT to conduct and evaluate patient and physician targeted interventions to improve adherence to osteoporosis medications and to examine cost effectiveness of alternative strategies.

Background

The United States (US) Health Information Technology for Economic and Clinical Health Act of 2009 has spurred adoption of electronic health records. The corresponding meaningful use criteria proposed by the Centers for Medicare and Medicaid Services mandates use of computerized provider order entry (CPOE) systems. Yet, adoption in the US and other Western countries is low and descriptions of successful implementations are primarily from the inpatient setting; less frequently the ambulatory setting. We describe prescriber and staff perceptions of implementation of a CPOE system for medications (electronic- or e-prescribing system) in the ambulatory setting.

Methods

Using a cross-sectional study design, we conducted eight focus groups at three primary care sites in an independent medical group. Each site represented a unique stage of e-prescribing implementation - pre/transition/post. We used a theoretically based, semi-structured questionnaire to elicit physician (n = 17) and staff (n = 53) perceptions of implementation of the e-prescribing system. We conducted a thematic analysis of focus group discussions using formal qualitative analytic techniques (i.e. deductive framework and grounded theory). Two coders independently coded to theoretical saturation and resolved discrepancies through discussions.

Results

Ten themes emerged that describe perceptions of e-prescribing implementation: 1) improved availability of clinical information resulted in prescribing efficiencies and more coordinated care; 2) improved documentation resulted in safer care; 3) efficiencies were gained by using fewer paper charts; 4) organizational support facilitated adoption; 5) transition required time; resulted in workload shift to staff; 6) hardware configurations and network stability were important in facilitating workflow; 7) e-prescribing was time-neutral or time-saving; 8) changes in patient interactions enhanced patient care but required education; 9) pharmacy communications were enhanced but required education; 10) positive attitudes facilitated adoption.

Conclusions

Prescribers and staff worked through the transition to successfully adopt e-prescribing, and noted the benefits. Overall impressions were favorable. No one wished to return to paper-based prescribing.

In this work we propose the hypothesis that replacing the current system of representing the chemical entities known as amino acids using Latin letters with one of several possible alternative symbolic representations will bring significant benefits to the human construction, modification, and analysis of multiple protein sequence alignments. We propose ways in which this might be done without prescribing the choice of actual scripts used. Specifically we propose and explore three ways to encode amino acid texts using novel symbolic alphabets free from precedents. Primary orthographic encoding is the direct substitution of a new alphabet for the standard, Latin-based amino acid code. Secondary encoding imposes static residue groupings onto the orthography of the alphabet by manipulating the shape and/or orientation of amino acid symbols. Tertiary encoding renders each residue as a composite symbol; each such symbol thus representing several alternative amino acid groupings simultaneously. We also propose that the use of a new group-focussed alphabet will free the colouring of amino acid residues often used as a tool to facilitate the representation or construction of multiple alignments for other purposes, possibly to indicate dynamic properties of an alignment such as position-wise residue conservation.

Background

The question whether Developmental Dyscalculia (DD; a deficit in the ability to process numerical information) is the result of deficiencies in the non symbolic numerical representation system (e.g., a group of dots) or in the symbolic numerical representation system (e.g., Arabic numerals) has been debated in scientific literature. It is accepted that the non symbolic system is divided into two different ranges, the subitizing range (i.e., quantities from 1-4) which is processed automatically and quickly, and the counting range (i.e., quantities larger than 4) which is an attention demanding procedure and is therefore processed serially and slowly. However, so far no study has tested the automaticity of symbolic and non symbolic representation in DD participants separately for the subitizing and the counting ranges.

Methods

DD and control participants undergo a novel version of the Stroop task, i.e., the Enumeration Stroop. They were presented with a random series of between one and nine written digits, and were asked to name either the relevant written digit (in the symbolic task) or the relevant quantity of digits (in the non symbolic task) while ignoring the irrelevant aspect.

Result

DD participants, unlike the control group, didn't show any congruency effect in the subitizing range of the non symbolic task.

Conclusion

These findings suggest that DD may be impaired in the ability to process symbolic numerical information or in the ability to automatically associate the two systems (i.e., the symbolic vs. the non symbolic). Additionally DD have deficiencies in the non symbolic counting range.

Background:

A majority of community-dwelling older adults manage their own medication regimens. This study describes the development and first phase of testing of the Self-Medication Assessment Tool (SMAT), designed to screen for cognitive and functional deficits in relation to medication self-management among community-dwelling geriatric patients.

Objective:

To evaluate the face validity of the SMAT and to determine its acceptability among pharmacists.

Methods:

An instrument was designed, with 5 assessment scales to measure function, cognition, medication recall, and 2 aspects of adherence. The instrument included a standardized test kit and instructions for testers. Focus groups interviews, individual interviews, and surveys were used to determine the reactions of community and hospital-based pharmacists to the tool. Transcripts of the focus group and individual interviews were coded for main themes. Pharmacists’ ratings of usefulness, thoroughness, and ease of use, as well as their willingness to use the instrument, were compared with a neutral rating on a 7-point scale by means of 1-sample t tests.

Results:

Focus group interviews or individual interviews were conducted with 17 pharmacists and 3 pharmacy students (out of a potential population of about 300) who responded to an invitation to participate. The pharmacists felt that the tool would be useful in identifying difficulties with medication management and potential interventions, and they expressed a willingness to use it in their respective practices. Pharmacists working in hospital settings were slightly more willing than community pharmacists to use the tool. Interviewees highlighted ways to improve the tool before testing of its psychometric properties in the planned second phase of this project.

Conclusions:

The SMAT had strong face validity and was particularly acceptable for use by pharmacists in hospital settings.

Students’ capabilities to use symbolic information in classroom setting could be expected to influence their possibilities to be active and participating. The development of strategies for teachers to compensate for reduced capability need specific operational definition of symbolic behavior. Fifty-three students, aged 11–13 years old, 29 boys and 24 girls, from three classes in the same Swedish compulsory regular school participated in the current study. After a short training sequence 25 students (47%) were defined as showing symbolic behavior (symbolic), and 28 students (53%) were not (non-symbolic), based on their follow-up test performances. Symbolic and non-symbolic differed significantly on post-test performances (p < 0.05). Surprisingly, non-symbolic behavior deteriorated their performance, while symbolic enhanced their performance (p < 0.05). The results indicate that the operational definition used in the present study may be useful in further studies relating the capability to show symbolic behavior and students’ activity and participation in classroom settings.

Introduction/Aims

Implicit bias can impact physician–patient interactions, alter treatment recommendations, and perpetuate health disparities. Medical educators need methods for raising student awareness about the impact of bias on medical care.

Setting

Seventy-two third-year medical student volunteers participated in facilitated small group discussions about bias.

Program Description

We tested an educational intervention to promote group-based reflection among medical students about implicit bias.

Program Evaluation

We assessed how the reflective discussion influenced students’ identification of strategies for identifying and managing their potential biases regarding patients. 67% of the students (n = 48) identified alternate strategies at post-session. A chi-square analysis demonstrated that the distribution of these strategies changed significantly from pre-session to post-session \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \left( {{X^2}\left( {11} \right) = 27.93,\,p < 0.01} \right) $$\end{document}, including reductions in the use of internal feedback and humanism and corresponding increases in the use of reflection, debriefing and other strategies.

Discussion

Group-based reflection sessions, with a provocative trigger to foster engagement, may be effective educational tools for fostering shifts in student reflection about bias in encounters and willingness to discuss potential biases with colleagues, with implications for reducing health disparities.

Objective

To describe the development of evidence-based electronic prescribing (e-prescribing) triggers and treatment algorithms for potentially inappropriate medications (PIMs) for older adults.

Design

Literature review, expert panel and focus group.

Setting

Primary care with access to e-prescribing systems.

Participants

Primary care physicians using e-prescribing systems receiving medication history.

Interventions

Standardised treatment algorithms for clinicians attempting to prescribe PIMs for older patients.

Main outcome measure

Development of 15 treatment algorithms suggesting alternative therapies.

Results

Evidence-based treatment algorithms were well received by primary care physicians. Providing alternatives to PIMs would make it easier for physicians to change decisions at the point of prescribing.

Conclusion

Prospectively identifying older persons receiving PIMs or with adherence issues and providing feasible interventions may prevent adverse drug events.

Aims

To describe a funded proposal for the development of an on-line evidence based educational program for the management of deteriorating patients.

Background

There are international concerns regarding the management of deteriorating patients with issues around the ‘failure to rescue’. The primary response to these issues has been the development of medical emergency teams with little focus on the education of primary first responders.

Design/Methods

A mixed methods triangulated convergent design.

In this four phase proposal we plan to 1. examine nursing student team ability to manage deteriorating patients and based upon these findings 2. develop web based educational material, including interactive scenarios. This educational material will be tested and refined in the third Phase 3, prior to evaluation and dissemination in the final phase.

Conclusion

This project aims to enhance knowledge development for the management of deteriorating patients through rigorous assessment of team performance and to produce a contemporary evidence-based online training program.

Little is known about older drivers’ preferences and attitudes about instrumentation design in vehicles. Yet visual processing impairments are common among older adults and could impact their ability to interface with a vehicle’s dashboard. The purpose of this study is to obtain information from them about this topic, using focus groups and content analysis methodology. A trained facilitator led 8 focus groups of older adults. Discussion was stimulated by an outline relevant to dashboard interfaces, audiotaped, and transcribed. Using multi-step content analysis, a trained coder placed comments into thematic categories and coded comments as positive, negative, or neutral in meaning. Comments were coded into these categories: gauges, knobs/switches, interior lighting, color, lettering, symbols, location, entertainment, GPS, cost, uniformity, and getting information. Comments on gauges and knobs/switches represented half the comments. Women made more comments about getting information; men made more comments about uniformity. Positive and negative comments were made in each category; individual differences in preferences were broad. The results of this study will be used to guide the design of a population-based survey of older drivers about instrument cluster forma, which will also examine how their responses are related to their visual processing capabilities.

Background

Sub-optimal adherence to prescribed medications is well documented. Barriers to medication adherence include medication side effects, cost, and forgetting to take or refill medications. Interactive Voice Response (IVR) systems show promise as a tool for reminding individuals to take or refill medications. This pilot study evaluated the feasibility and acceptability of using an IVR system for prescription refill and daily medication reminders. We tested two novel features: personalized, medication-specific reminder messages and communication via voice recognition.

Methods

Patients enrolled in a study of electronic prescribing and medication management in Quebec, Canada who were taking chronic disease-related drugs were eligible to participate. Consenting patients had their demographic, telephone, and medication information transferred to an IVR system, which telephoned patients to remind them to take mediations and/or refill their prescriptions. Facilitators and barriers of the IVR system use and acceptability of the IVR system were assessed through a structured survey and open-ended questions administered by telephone interview.

Results

Of the 528 eligible patients who were contacted, 237 refused and 291 consented; 99 participants had started the pilot study when it was terminated because of physician and participant complaints. Thirty-eight participants completed the follow-up interview. The majority found the IVR system's voice acceptable, and did not have problems setting up the time and location of reminder calls. However, many participants experienced technical problems when called for reminders, such as incorrect time of calls and voice recognition difficulties. In addition, most participants had already refilled their prescriptions when they received the reminder calls, reporting that they did not have difficulties remembering to refill prescriptions on their own. Also, participants were not receptive to speaking to an automated voice system.

Conclusion

IVR systems designed to improve medication compliance must address key technical and performance issues and target those individuals with reported memory difficulties or complex medication regimens in order to improve the utility of the system. Future research should also identify characteristics of medication users who are more likely to be receptive to IVR technology.

Background

Involving stakeholders and consumers throughout the content and study design ensures interventions are engaging and relevant for end-users. The aim of this paper is to present the content development process for a mHealth (mobile phone and internet-based) cardiac rehabilitation (CR) exercise intervention.

Methods

An innovative mHealth intervention was developed with patient input using the following steps: conceptualization, formative research, pre-testing, and pilot testing. Conceptualization, including theoretical and technical aspects, was undertaken by experts. For the formative component, focus groups and interviews with cardiac patients were conducted to discuss their perceptions of a mHealth CR program. A general inductive thematic approach identified common themes. A preliminary library of text and video messages were then developed. Participants were recruited from CR education sessions to pre-test and provide feedback on the content using an online survey. Common responses were extracted and compiled. An iterative process was used to refine content prior to pilot testing and conduct of a randomized controlled trial.

Results

38 CR patients and 3 CR nurses participated in the formative research and 20 CR patients participated in the content pre-testing. Participants perceived the mHealth program as an effective approach to inform and motivate patients to exercise. For the qualitative study, 100% (n = 41) of participants thought it to be a good idea, and 11% of participants felt it might not be useful for them, but would be for others. Of the 20 participants who completed the online survey, 17 out of 20 (85%) stated they would sign up to a program where they could receive information by video messages on a website, and 12 out of 20 (60%) showed interest in a texting program. Some older CR patients viewed technology as a potential barrier as they were unfamiliar with text messaging or did not have mobile phones. Steps to instruct participants to receive texts and view the website were written into the study protocol. Suggestions to improve videos and wording of texts were fed back to the content development team and refined.

Conclusions

Most participants thought a mHealth exercise program was an effective way to deliver exercise-based CR. The results were used to develop an innovative multimedia exercise intervention. A randomized controlled trial is currently underway.

Trial registration

ACTRN12611000117910

OBJECTIVE

To assess the feasibility and efficacy of two interventions for improving adherence to antiretroviral therapy regimens in HIV-infected subjects compared with a control intervention.

DESIGN

Randomized, controlled, pilot study.

SETTING

Department of Veterans Affairs HIV clinic and community-based HIV clinical trials site.

PARTICIPANTS

Fifty-five HIV-infected subjects on stable antiretroviral therapy regimens. Subjects were predominantly male (89%) and African American (69%), and had histories of heroin or cocaine use (80%).

INTERVENTIONS

Four weekly sessions of either nondirective inquiries about adherence (control group, C), cue-dose training, which consisted of the use of personalized cues for remembering particular dose times, and feedback about medication taking using Medication Event Monitoring System (MEMS) pill bottle caps, which record time of bottle opening (CD group), or cue-dose training combined with cash reinforcement for correctly timed bottle opening (CD+CR).

MEASUREMENTS

Opening of the pill bottle within 2 hours before or after a predetermined time was measured by MEMS.

RESULTS

Adherence to the medication as documented by MEMS was significantly enhanced during the 4-week training period in the CD+CR group, but not in the CD group, compared with the control group. Improvement was also seen in adherence to antiretroviral drugs that were not the object of training and reinforcement. Eight weeks after training and reinforcement were discontinued, adherence in the cash-reinforced group returned to near-baseline levels.

CONCLUSIONS

Cue-dose training with cash reinforcement led to transient improvement in adherence to antiretroviral therapy in a population including mostly African Americans and subjects with histories of drug abuse. However, we were not able to detect any sustained improvement beyond the active training period, and questions concerning the timing and duration of such an intervention require further study. Randomized, controlled clinical studies with objective measures of adherence can be conducted in HIV-infected subjects and should be employed for further evaluation of this and other adherence interventions.

Background

The question of whether symbolically mediated behavior is exclusive to modern humans or shared with anatomically archaic populations such as the Neandertals is hotly debated. At the Grotte du Renne, Arcy-sur-Cure, France, the Châtelperronian levels contain Neandertal remains and large numbers of personal ornaments, decorated bone tools and colorants, but it has been suggested that this association reflects intrusion of the symbolic artifacts from the overlying Protoaurignacian and/or of the Neandertal remains from the underlying Mousterian.

Methodology/Principal Findings

We tested these hypotheses against the horizontal and vertical distributions of the various categories of diagnostic finds and statistically assessed the probability that the Châtelperronian levels are of mixed composition. Our results reject that the associations result from large or small scale, localized or generalized post-depositional displacement, and they imply that incomplete sample decontamination is the parsimonious explanation for the stratigraphic anomalies seen in the radiocarbon dating of the sequence.

Conclusions/Significance

The symbolic artifacts in the Châtelperronian of the Grotte du Renne are indeed Neandertal material culture.

Objective

To evaluate the hypothesis that poor adherence to highly active antiretroviral treatment (HAART) would be more strongly related to cognitive impairment among older than among younger HIV-seropositive adults.

Setting and Participants

A volunteer sample of 431 HIV-infected adult patients prescribed self-administered HAART was recruited from community agencies and university-affiliated infectious disease clinics in the Los Angeles area.

Measurements

Neurocognitive measures included tests of attention, information processing speed, learning/memory, verbal fluency, motor functioning, and executive functioning. Medication adherence was measured using microchip-embedded pill bottle caps (Medication Event Monitoring System) and self-report. Latent/structural analysis techniques were used to evaluate factor models of cognition and adherence.

Results

Mean adherence rates were higher among older (≥50 years) than younger (<50 years) HIV-positive adults. However, latent/structural modeling demonstrated that neurocognitive impairment was associated with poorer medication adherence among older participants only. When cognitive subdomains were examined individually, executive functioning, motor functioning, and processing speed were most strongly related to adherence in this age group. CD4 count and drug problems were also more strongly associated with adherence among older than younger adults.

Conclusions

Older HIV-positive individuals with neurocognitive impairment or drug problems are at increased risk of suboptimal adherence to medication. Likewise, older adults may be especially vulnerable to immunological and neurocognitive dysfunction under conditions of suboptimal HAART adherence. These findings highlight the importance of optimizing medication adherence rates and evaluating neurocognition in the growing population of older HIV-infected patients.