Research has shown that people judge words as having bigger font size than non-words. This finding has been interpreted in terms of processing fluency, with higher fluency leading to judgments of bigger size. If so, symmetric numbers (e.g., 44) which can be processed more fluently are predicted to be judged as larger than asymmetric numbers (e.g., 43). However, recent research found that symmetric numbers were judged to be smaller than asymmetric numbers. This finding suggests that the mechanisms underlying size judgments may differ in meaningful and meaningless materials. Supporting this notion, we showed in Experiment 1 that meaning increased judged size, whereas symmetry decreased judged size. In the next two experiments, we excluded several alternative explanations for the differences in size judgments between meaningful and meaningless materials in earlier studies. This finding contradicts the notion that the mechanism underlying judgments of size is processing fluency.
number processing; processing fluency; size perception; symmetry
Preventive health checks may identify individuals with an unhealthy lifestyle and motivate them to change behaviour. However, knowledge about the impact of the different components included in preventive health checks is deficient. The aim of this trial is to evaluate whether including cardiorespiratory fitness testing in preventive health checks 1) increases cardiorespiratory fitness level and motivation to change physical activity behaviour and 2) reduces physical inactivity prevalence and improves self-rated health compared with preventive health checks without fitness testing.
An open-label, household-cluster, randomized controlled trial with a two-group parallel design is used. The trial is embedded in a population-based health promotion program, “Check your Health Preventive Program”, in which all 30–49 year-old citizens in a Danish municipality are offered a preventive health check. In each arm of the trial, 750 citizens will be recruited (1,500 in total). The primary outcome is cardiorespiratory fitness level assessed by submaximal cycle ergometer testing after one year. An intermediate outcome is the percentage of participants increasing motivation for physical activity behaviour change between baseline and two-weeks follow-up assessed using the Transtheoretical Model´s stages of change. Secondary outcomes include changes from baseline to one-year follow-up in physical inactivity prevalence measured by a modified version of the questions developed by Saltin and Grimby, and in self-rated health measures using the Short-Form 12, Health Survey, version 2.
This trial will contribute to a critical appraisal of the value of fitness testing as part of preventive health checks. The conduction in real-life community and general practice structures makes the trial findings applicable and transferable to other municipalities providing support to decision-makers in the development of approaches to increase levels of physical activity and improve health.
ClinicalTrials.gov Identifier: NCT02224248. Registered 8 August 2014.
Health examination; Cardiorespiratory fitness test; Exercise test; Cardiorespiratory fitness; Maximum oxygen uptake; Physical activity; Health behaviour; Motivation; Intention; Self-rated health
Care for overweight children in general practice involves collaboration with parents. Acknowledging the parents’ frames of references is a prerequisite for successful management. We therefore aimed to analyse parental beliefs about the presumed causes and consequences of overweight in children and expectations towards the GP. Moreover, we aimed at comparing the beliefs and expectations of parents of non-overweight children (NOWC) and parents of overweight children (OWC).
A cross-sectional survey. Data were obtained from a questionnaire exploring parents’ beliefs and expectations regarding overweight in children. The questionnaires were completed by parents following their child’s participation in the five-year preventive child health examination (PCHE).
Parental agreement upon statements concerning beliefs and expectations regarding overweight in children was measured on a Likert scale. Differences in levels of agreement between parents of non-overweight children and parents of overweight children were analysed using Chi-squared test and Fisher’s exact test.
Parents of 879 children completed and returned questionnaires. Around three fourths of the parents agreed that overweight was a health problem. A majority of parents (93%) agreed that the GP should call attention to overweight in children and offer counselling on diet and exercise. Almost half of the parents expected a follow-up programme. Parents of overweight children seemed to agree less upon some of the proposed causes of overweight, e.g. inappropriate diet and lack of exercise. These parents also had stronger beliefs about overweight disappearing by itself as the child grows up.
According to parental beliefs and expectations, general practice should have an important role to play in the management of child overweight. Moreover, our findings suggest that GPs should be aware of the particular beliefs that parents of overweight children may have regarding causes of overweight in their child.
Children; Overweight; Parents; Beliefs; Expectations; General practice
Depressive symptoms is associated with adverse cardiovascular outcomes in patients with myocardial infarction (MI), but the underlying mechanisms are unclear and it remains unknown whether subgroups of patients are at a particularly high relative risk of adverse outcomes. We examined the risk of new cardiovascular events and/or death in patients with depressive symptoms following first-time MI taking into account other secondary preventive factors. We further explored whether we could identify subgroups of patients with a particularly high relative risk of adverse outcomes.
Methods and Results
We conducted a prospective population-based cohort study of 897 patients discharged with first-time MI between 1 January 2009 and 31 December 2009, and followed up until 31 July 2012. Depressive symptoms were found in 18.6% using the Hospital Anxiety and Depression Scale (HADS-D≥8). A total of 239 new cardiovascular events, 95 deaths, and 288 composite events (239 new cardiovascular events and 49 deaths) occurred during 1,975 person-years of follow-up. Event-free survival was evaluated using Cox regression analysis. Compared to the 730 patients without depressive symptoms (HADS-D<8), the 167 patients with depressive symptoms (HADS-D≥8) had age- and sex-adjusted hazard ratios [HR] (95% confidence interval [CI]) of 1.53 (95% CI, 1.14–2.05) for a new cardiovascular event, 3.10 (95% CI, 2.04–4.71) for death and 1.77 (95% CI, 1.36–2.31) for a composite event. The associations were attenuated when adjusted for disease severity, comorbid conditions and physical inactivity; HR = 1.17 (95% CI, 0.85–1.61) for a new cardiovascular event, HR = 2.01 (95% CI, 1.28–3.16) for death, and HR = 1.33 (95% CI, 1.00–1.76) for a composite event. No subgroups of patients had a particularly high risk of adverse outcomes.
Depressive symptoms following first-time MI was an independent prognostic risk factor for death, but not for new cardiovascular events. We found no subgroups of patients with a particularly high relative risk of adverse outcomes.
To examine the association between mental health status after first-time myocardial infarction (MI) and new cardiovascular events or death, taking into account depression and anxiety as well as clinical, sociodemographic and behavioural risk factors.
Population-based cohort study based on questionnaires and nationwide registries. Mental health status was assessed 3 months after MI using the Mental Component Summary score from the Short-Form 12 V.2.
Central Denmark Region.
All patients hospitalised with first-time MI from 1 January 2009 through 31 December 2009 (n=880). The participants were categorised in quartiles according to the level of mental health status (first quartile=lowest mental health status).
Main outcome measures
Composite endpoint of new cardiovascular events (MI, heart failure, stroke/transient ischaemic attack) and all-cause mortality.
During 1940 person-years of follow-up, 277 persons experienced a new cardiovascular event or died. The cumulative incidence following 3 years after MI increased consistently with decreasing mental health status and was 15% (95% CI 10.8% to 20.5%) for persons in the fourth quartile, 29.1% (23.5% to 35.6%) in the third quartile, 37.0% (30.9% to 43.9%) in the second quartile, and 47.5% (40.9% to 54.5%) in the first quartile. The HRs were high, even after adjustments for age, sociodemographic characteristics, cardiac disease severity, comorbidity, secondary prophylactic medication, smoking status, physical activity, depression and anxiety (HR3rd quartile 1.90 (95% CI 1.23 to 2.93), HR2nd quartile 2.14 (1.37 to 3.33), HR1st quartile 2.23 (1.35 to 3.68) when using the fourth quartile as reference).
Low mental health status following first-time MI was independently associated with an increased risk of new cardiovascular events or death. Further research is needed to disentangle the pathways that link mental health status following MI to prognosis and to identify interventions that can improve mental health status and prognosis.
Cardiology; Myocardial Infarction < Cardiology; Mental Health; Epidemiology
Patients with hypertension are primarily treated in general practice. However, major studies of patients with hypertension are rarely based on populations from primary care. Knowledge of blood pressure (BP) control rates in patients with diabetes and/or cardiovascular diseases (CVDs), who have additional comorbidities, is lacking. We aimed to investigate the association of comorbidities with BP control using a large cohort of hypertensive patients from primary care practices.
Methods and Results
Using the Danish General Practice Database, we included 37 651 patients with hypertension from 231 general practices in Denmark. Recommended BP control was defined as BP <140/90 mm Hg in general and <130/80 mm Hg in patients with diabetes. The overall control rate was 33.2% (95% CI: 32.7 to 33.7). Only 16.5% (95% CI: 15.8 to 17.3) of patients with diabetes achieved BP control, whereas control rates ranged from 42.9% to 51.4% for patients with ischemic heart diseases or cerebrovascular or peripheral vascular diseases. A diagnosis of cardiac heart failure in addition to diabetes and/or CVD was associated with higher BP control rates, compared with men and women having only diabetes and/or CVD. A diagnosis of asthma in addition to diabetes and CVD was associated with higher BP control rates in men.
In Danish general practice, only 1 of 3 patients diagnosed with hypertension had a BP below target. BP control rates differ substantially within comorbidities. Other serious comorbidities in addition to diabetes and/or CVD were not associated with lower BP control rates; on the contrary, in some cases the BP control rates were higher when the patient was diagnosed with other serious comorbidities in addition to diabetes and/or CVD.
cardiovascular diseases; comorbidities; hypertension; primary care
To evaluate general practitioners’ (GPs’) assessment of potential overweight among children attending the five-year preventive child health examination (PCHE) by comparing their assessment of the children's weight-for-stature with overweight defined by body mass index (BMI) according to paediatric standard definitions.
A cross-sectional survey. Data were obtained from a questionnaire survey of children's health in general and their growth in particular.
The five-year preventive child health examination (PCHE) in general practice in the Central Denmark Region.
Children attending the five-year PCHE in general practice, regardless of their weight status.
Main outcome measures
Paediatric standard definitions for childhood overweight based on BMI were used as the gold standard for categorizing weight-for-stature. Identification of overweight was analysed with regard to sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the GPs’ assessment of weight-for-stature.
A total of 165 GPs conducted 1138 PCHEs. GPs assessed that 171 children had a weight-for-stature above normal. Use of the Danish Standards (DS), i.e. the Danish national growth charts for BMI, as the gold standard yielded a sensitivity of 70.1% (95% CI 62.0–77.3) and a specificity of 92.4% (95% CI 90.6–93.9). The sensitivity was influenced by the GPs’ use of BMI and the presence of previous notes regarding abnormal weight development.
At the five-year PCHE almost one-third of overweight children were assessed to be normal weight by GPs. Use of BMI and presence of notes on abnormal weight in medical records were positively associated with a higher identification. Hence, utilization of medical record data and BMI charts may refine GPs’ assessment of childhood overweight.
Assessment; children; Denmark; general practice; overweight; preventive child health examination
To describe lipid-lowering treatment in a primary care setting and how well target levels are reached. Furthermore, the aim is to describe long-term adherence to treatment.
Population-based cross-sectional study with follow-up.
A total of 139 general practices from three of five Danish regions, taking part in the ADDITION study from 2001 to 2006.
The study population comprises 1468 patients who started lipid-lowering drugs and were followed for a minimum of one year after starting treatment. Median time of follow-up after starting drug therapy was 936 days (range: 366–2068).
Of 1468 patients starting treatment, a total of 781 (53%) reached the treatment goal of total cholesterol <5.0 and low-density lipoprotein <3 mmol/l within one year after drug therapy start. The percentage increased throughout the study period from 27% of patients initiating treatment in 2001 to 66% of patients initiating treatment in 2005. Age over 50, repeated cholesterol measurements within three months after treatment start, larger initial dose, and calendar year of treatment start were associated with reaching the goal within the first year, and most recent total cholesterol measurement before start of treatment >7 mmol/L was associated with not reaching the goal in the first year. Among patients followed for a minimum of three years after drug therapy started (n = 536), adherence was 77%, 72%, 75% in the first, second, and third year respectively.
Initial doses and the percentage reaching their goal increased substantially throughout the study period. Adherence to lipid-lowering treatment is relatively high in a primary care setting. However, current practice shows room for improvement if treatment recommendations are to be met.
Adherence; cardiovascular risk factors; dyslipidemia; family practice; prevention
To describe the rehabilitation status three months after first-time myocardial infarction (MI) to identify focus areas for long-term cardiac rehabilitation (CR) in general practice.
Population-based cross-sectional study.
Setting and subjects
Patients with first-time MI in 2009 from the Central Denmark Region. Data were obtained from patient questionnaires and from registers.
Of the 1288 eligible patients, 908 (70.5%) responded. The mean (SD) age was 67.1 (11.7) years and 626 (68.9%) were men. Overall, 287 (31.6%) of the patients lived alone and 398 (45.4%) had less than 10 years of education. Upwards of half (58.5%) of the patients stated that they had participated in hospital-based rehabilitation shortly after admission. A total of 262 (29.2%) were identified with anxiety or depressive disorder or both, according to the Hospital Anxiety and Depression Scale. Of these, 78 (29.8%) reported that they had participated in psychosocial support, and 55 (21.0%) used antidepressants. One in five patients smoked three months after MI although nearly half of the smokers had stopped after the MI. Regarding cardioprotective drugs, 714 (78.6%) used aspirin, 694 (76.4%) clopidogrel, 756 (83.3%) statins, and 735 (81.0%) beta-blockers.
After three months, there is a considerable potential for further rehabilitation of MI patients. In particular, the long-term CR should focus on mental health, smoking cessation, and cardioprotective drugs.
Depression; drug therapy; family practice; myocardial infarction; rehabilitation; smoking
“Motivational interviewing” (MI) has shown to be broadly applicable in the management of behavioural problems and diseases. Only a few studies have evaluated the effect of MI on type 2 diabetes treatment and none has explored the effect of MI on target-driven intensive treatment.
Patients were cluster-randomized by GPs, who were randomized to training in MI or not. Both groups received training in target-driven intensive treatment of type 2 diabetes. The intervention consisted of a 1½-day residential course in MI with half-day follow-up twice during the first year. Blood samples, case record forms, national registry files, and validated questionnaires from patients were obtained.
After one year significantly improved metabolic status measured by HbA1c (p < 0.01) was achieved in both groups. There was no difference between groups. Medication adherence was close to 100% within both treatment groups. GPs in the intervention group did not use more than an average of 1.7 out of three possible MI consultations.
The study found no effect of MI on metabolic status or on adherence of medication in people with screen detected type 2 diabetes. However, there was a significantly improved metabolic status and excellent medication adherence after one year within both study groups. An explanation may be that GPs in the control group may have taken up core elements of MI, and that GPs trained in MI used less than two out of three planned MI consultations. The five-year follow-up of this study will reveal whether MI has an effect over a longer period.
Alcohol abuse; blood pressure; Body Mass Index; motivational interviewing; type 2 diabetes
To describe the management of dyslipidaemia in patients with high risk of cardiovascular disease (CVD) and patients with a history of CVD identified by screening for diabetes in general practice in Denmark, concentrating on prescription of lipid-lowering drugs. Moreover, to analyse predicting factors for starting lipid-lowering drugs related to patient and general practice characteristics.
Population-based cross-sectional study with follow-up.
A total of 139 general practices from three of five Danish regions, totalling 216 GPs.
The study population comprised 4986 patients with a high risk of CVD and dyslipidaemia and 764 patients with a history of CVD and dyslipidaemia out of a population of 16 572 patients who completed screening for diabetes but were cleared for diabetes in the ADDITION study.
Of patients with a high risk of CVD and dyslipidaemia not receiving lipid-lowering drugs at the time of screening (n = 4823), 20% started lipid-lowering therapy within the follow-up period (median 2.1 years). This percentage was 45% (n = 536) for patients with CVD and dyslipidaemia (median follow-up period 1.6 years). Age over 50, high cholesterol, impaired fasting glucose and/or impaired glucose tolerance, minor polypharmacy, use of heart/circulation drugs, and cholesterol measurements after screening predicted the prescription of lipid-lowering drugs for patients at high risk of CVD. For patients with CVD, male gender, high cholesterol and use of heart/circulation drugs predicted the prescription of lipid-lowering drugs. No general practice characteristics were associated with different prescription habits.
There is a gap between the recommended lipid-lowering drug therapy and current practice, with a substantial under-treatment and a considerable delay in the first prescription of lipid-lowering drugs.
Cardiovascular risk factors; dyslipidaemia; family practice; prevention; screening
To describe patients’ evaluation of the contents of preventive cardiovascular consultations and to analyse whether their evaluation is shaped by self-reported cognitive and emotional effects and lifestyle changes two to six weeks after the consultations.
Questionnaire developed by means of qualitative studies.
Two counties in Denmark.
A total of 2450 subjects who had participated in a preventive cardiovascular consultation with their GP received a questionnaire; 1714 responded (70%); 1226 fulfilled the inclusion criteria, namely to be at increased risk of cardiovascular disease (CVD) but without having CVD.
Main outcome measures
Cognitive and emotional effects and lifestyle changes. Odds ratios (ORs) were calculated between self-reported issues raised during the consultations and self-reported lifestyle changes, cognitive and emotional effects.
Some 58–79% reported cognitive effects (knowledge about risk and disease), 22–57% lifestyle changes (diet, exercise, and smoking), 80–97% emotional effects related to relief and satisfaction, and 23% worries. Those who reported that a dialogue had taken place (e.g. information concerning risk of disease, life habits, life circumstances/daily living, perception of risk, knowledge about disease, and own possibilities for prevention) had ORs between 1.7 and 4.3 for reporting three or more cognitive effects and one or more lifestyle changes (p < 0.05). These issues were also significantly related to emotional effects such as feeling relieved and satisfied.
Patients report cognitive and emotional effects and healthy lifestyle changes following a cardiovascular preventive consultation and the magnitude of the effect is associated with the nature of the issues raised.
Denmark; evaluation; family practice; general practice; preventive consultation; questionnaire study; risk of CVD
To examine whether training GPs in motivational interviewing (MI) can improve type 2 diabetic patients’ (1) understanding of diabetes, (2) beliefs regarding prevention and treatment, and (3) motivation for behaviour change.
A randomized controlled trial including 65 GPs and 265 type 2 diabetic patients. The GPs were randomized in two groups, one with and one without MI training. Both groups received training in target-driven intensive treatment of type 2 diabetic patients. The intervention was a 1½-day residential course in MI with ½-day follow-up twice during the first year. The patient data stemmed from previously validated questionnaires.
Main outcome measures
The Health Care Climates Questionnaire assesses the patient–doctor relationship and type of counselling. The Treatment Self-Regulation Questionnaire assesses the degree to which behaviour tends to be self-determined. The Diabetes Illness Representation Questionnaire assesses beliefs and understanding of type 2 diabetes. The Summary of Diabetes Self Care Activities assesses the extent of various self-care activities related to type 2 diabetes.
The response rate to our questionnaires was 87%. Patients in the intervention group were significantly more autonomous and motivated in their inclination to change behaviour after one year compared with the patients from the control group. Patients in the intervention group were also significantly more conscious of the importance of controlling their diabetes, and had a significantly better understanding of the possibility of preventing complications.
MI improved type 2 patients’ understanding of diabetes, their beliefs regarding treatment aspects, their contemplation on and motivation for behaviour change. Whether our results can be sustained long term and are clinically relevant in terms of changes in risk profile advocates further research.
Client counselling; diabetes; motivational interviewing; patient counselling; prevention; psychological interview; RCT
Motivational interviewing approaches are currently recommended in primary prevention and treatment of cardiovascular disease (CVD) in general practice in Denmark, based on an empirical and multidisciplinary body of scientific knowledge about the importance of motivation for successful lifestyle change among patients at risk of lifestyle related diseases. This study aimed to explore and describe motivational aspects related to potential lifestyle changes among patients at increased risk of CVD following preventive consultations in general practice.
Individual interviews with 12 patients at increased risk of CVD within 2 weeks after the consultation. Grounded theory was used in the analysis.
Ambivalence related to potential lifestyle changes was the core motivational aspect in the interviews, even though the patients rarely verbalised this experience during the consultations. The patients experienced ambivalence in the form of conflicting feelings about lifestyle change. Analysis showed that these feelings interacted with their reflections in a concurrent process. Analysis generated a typology of five different ambivalence sub-types: perception, demand, information, priority and treatment ambivalence.
Ambivalence was a common experience in relation to motivation among patients at increased risk of CVD. Five different ambivalence sub-types were found, which clinicians may use to explore and resolve ambivalence in trying to aid patients to adopt lifestyle changes. Future research is needed to explore whether motivational interviewing and other cognitive approaches can be enhanced by exploring ambivalence in more depth, to ensure that lifestyle changes are made and sustained. Further studies with a wider range of patient characteristics are required to investigate the generalisability of the results.
Motivational interviewing has been shown to be broadly usable in a scientific setting in the management of behavioural problems and diseases. However, data concerning implementation and aspects regarding the use of motivational interviewing in general practice is missing.
To evaluate GPs' conception of motivational interviewing in terms of methods, adherence to and aspects of its use in general practice after a course.
In a randomised controlled trial concerning intensive treatment of newly diagnosed patients with type 2 diabetes detected by screening, the GPs were randomised to a course in motivational interviewing or not. The study also included a third group of GPs outside the randomised controlled trial, who had 2 years previously received a similar course in motivational interviewing.
General practice in Denmark.
The intervention consisted of a 1.5-day residential course in motivational interviewing with 0.5-day follow-ups, twice during the first year. Questionnaire data from GPs were obtained.
We obtained a 100% response-rate from the GPs in all three groups. The GPs trained in motivational interviewing adhered statistically significantly more to the methods than did the control group. More than 95 % of the GPs receiving the course stated that they had used the specific methods in general practice.
A course in motivational interviewing seems to influence GPs professional behaviour. Based on self-reported questionnaires, this study shows that the GPs after a course in motivational interviewing seemed to change their professional behaviour in daily practice using motivational interviewing compared with the control group. GPs evaluated motivational interviewing to be more effective than ‘traditional advice giving’. Furthermore, GPs stated that the method was not more time consuming than ‘traditional advice giving’.
client counselling; diabetes; motivational interviewing; psychological interview
Motivational Interviewing is a well-known, scientifically tested method of counselling clients developed by Miller and Rollnick and viewed as a useful intervention strategy in the treatment of lifestyle problems and disease.
To evaluate the effectiveness of motivational interviewing in different areas of disease and to identify factors shaping outcomes.
Design of study
A systematic review and meta-analysis of randomised controlled trials using motivational interviewing as the intervention.
After selection criteria a systematic literature search in 16 databases produced 72 randomised controlled trials the first of which was published in 1991. A quality assessment was made with a validated scale. A meta-analysis was performed as a generic inverse variance meta-analysis.
Meta-analysis showed a significant effect (95% confidence interval) for motivational interviewing for combined effect estimates for body mass index, total blood cholesterol, systolic blood pressure, blood alcohol concentration and standard ethanol content, while combined effect estimates for cigarettes per day and for HbA1c were not significant. Motivational interviewing had a significant and clinically relevant effect in approximately three out of four studies, with an equal effect on physiological (72%) and psychological (75%) diseases. Psychologists and physicians obtained an effect in approximately 80% of the studies, while other healthcare providers obtained an effect in 46% of the studies. When using motivational interviewing in brief encounters of 15 minutes, 64% of the studies showed an effect. More than one encounter with the patient ensures the effectiveness of motivational interviewing.
Motivational interviewing in a scientific setting outperforms traditional advice giving in the treatment of a broad range of behavioural problems and diseases. Large-scale studies are now needed to prove that motivational interviewing can be implemented into daily clinical work in primary and secondary health care.
body mass index; interview, psychological; meta-analysis; motivation; randomised controlled trials; review, systematic