Promoting Positive Health Behaviors

Promoting Positive Health Behaviors

Order Description
Application: Promoting Positive Health Behaviors
One strategy that has proven effective for improving population health outcomes is screening. Screening programs for breast, cervical, prostate, and colon cancer allow for early detection and treatment, thereby improving health outcomes. Advocates of early screening programs have sought to inform populations at risk of the value of participating in early screening.
Consider the following examples: In Florida, mobile mammography units have reached out to uninsured women and provided free mammograms. In Maryland, Wellmobiles go out into the community to provide primary and preventive health care services to geographically underserved communities and uninsured individuals across the state. Many such programs are available for individuals to participate in screening, regardless of ability to pay.
In this Assignment, you will evaluate the characteristics of preventive health programs that lead to successful outcomes.
To prepare:
Review the article “Improving Female Preventive Health Care Delivery Through Practice Change” found in this week’s Learning Resources. Consider why the Every Woman Matters program was not effective in meeting its goals.
Using the Walden Library and other credible websites, identify at least two successful advocacy programs for early cancer screening and evaluate the characteristics that made them effective based on the evidence presented in the article or website.
To complete:
Write a 3- to 5-page paper that includes the following:
Summarize the Every Woman Matters program and how the issue of women’s preventive health care was approached. Analyze possible reasons the program was ineffective.
Summarize the characteristics at least two prevention programs that advocate for early screening, describing what made them successful.
If you were the nurse leader in charge of developing a follow-up to the Every Woman Matters program, what strategies would you propose for creating a more effective prevention program?
SPECIAL COMMUNICATION
Improving Female Preventive Health Care Delivery
Through Practice Change: An Every Woman
Matters Study
Elisabeth L. Backer, MD, Jenenne A. Geske, PhD, Helen E. McIlvain, PhD,
Diane M. Dodendorf, PhD, and William C. Minier, MD
Background: The levels of breast and cervical cancer screening in Nebraska primary care remain suboptimal
despite awareness of their importance, and despite implementation of the Every Woman Matters
program to assist low-income women. The GAPS model was used to develop a practice-based intervention
to identify and reduce barriers to delivery of breast and cervical cancer screening services.
Methods: Seven primary care practices actively participated in this multimethod case study. A research
nurse collected data and facilitated the intervention process at each site. Qualitative data from
field notes, patient encounters, and in-depth interviews of physicians and key informants were collected
to describe the process of Papanicolaou and mammogram service delivery, and to identify barriers/facilitators
to screening, and potential change areas. Chart reviews provided information regarding the
preintervention and postintervention identification/execution of Papanicolaou smears and mammograms.
Qualitative and quantitative analyses led to individual practice case studies. Cross case comparisons
identified common themes.
Results: The individual practice plans for change had many commonalities, ie, developing screening
databases and reminder systems. The biggest differences involved practice contexts. Despite use of the
GAPS model and a financial incentive to obtain “buy in” from providers and staff, change was difficult
for all but 2 of the practices.
Conclusion: The complexity of practice context and its effect on change cannot be underestimated.
Individual practice providers and staff are often unaware of the potential challenges, and unable/unwilling
to overcome them. (J Am Board Fam Pract 2005;18:401– 8.)
The practice of screening for disease has been
shown to save lives, reduce health care costs, and
reduce suffering. Periodic screening for breast and
cervical cancer has been particularly effective in
reducing the burden of disease in women.1–6 Even
so, screening rates in many practices fall short of
recommended levels, leaving patients at unnecessary
risk.7,8 Barriers to screening exist at many
levels including the patient, physician, and practice
systems.9–12
Every Woman Matters (EWM), a state-run federally
funded program, is designed to remove barriers
to preventive breast and cervical cancer
screening by raising public awareness of the risk
and making screening more financially accessible to
low-income women. Eligible women receive a clinical
breast examination, mammography, and Papanicolaou
smear test at reduced or no cost. The
EWM program provides services to practices to aid
in implementation of the program. However, even
with this program, the level of breast and cervical
cancer screening falls short of the ideal.
Numerous decades of trying to improve preventive
service delivery have shown that there are no
magic bullets13,14; most interventions to alter physician
and practice behavior have shown only modest
success.15 Systematic reviews of change strate-
Submitted, revised, 14 April 2005.
From the Department of Family Medicine (ELB, JAG,
HEM, WCM), and Munroe-Meyer Institute (DMD), University
of Nebraska Medical Center, Omaha, NE.
Funding: Support for the original research came from
the grant (to ELB), Early Detection and Control of Breast
and Cervical Cancer Cooperative agreement (U57/
CCU706734-06), through the Nebraska Department of
Health and Human Services “Every Woman Matters” Program.
Conflict of interest: none declared.
Corresponding author: Elisabeth L. Backer, MD, Department
of Family Medicine, 983075 Nebraska Medical Center,
Omaha, NE 68198-3075 (e-mail: ebacker@unmc.edu).
http://www.jabfp.org 401
gies recognize practices as complex systems and call
for more effective and complex strategies that assist
practices in initiating and sustaining change.16
Changing practice behavior entails teamwork
among clinicians and staff, requires flexibility and
willingness to change, and should be based on individualized
interventions based on each system’s
unique and dynamic pattern.15,17 The GAPS model
is based on these concepts. Using the GAPS model
to enhance preventive care and modify office operations,
we involved office staff at each step: goalsetting,
assessing existing routines, planning the
modification of routines, and providing support for
these improvements.17
Our practice-based intervention study was designed
in collaboration with the Nebraska Health
and Human Services EWM Program to help individual
practices identify barriers to their delivery of
breast and cervical cancer screening services, develop
plans for reducing barriers, and encourage
provision of the EWM program to low income
patients. We hypothesized that individualized, facilitated
interventions could significantly increase
the rates of up-to-date mammogram and Papanicolaou
test screening in these practices.
Methods
Design
We used a qualitative case study design to describe
the process of change that occurred in sample practices.
Quantitative data from chart audits were used
to measure changes in the number of mammogram
and Papanicolaou tests. The study protocol was
approved by the University of Nebraska Medical
Center Institutional Review Board (028-98-FB).
Sampling
A maximum variation sample of 7 practices resulted
from our sampling strategy to provide data from a
variety of practice types.18
After identifying all Nebraska primary care practices
enrolled in the EWM program that accepted
new patients, we eliminated practices participating
in other departmental studies, those that had participated
in our pilot study, and those situated beyond
a 100-mile radius of Omaha. After assembling
a numbered list of 100 clinics, we randomly selected
a starting number. The clinic corresponding
to this number, along with every additional twelfth
clinic listed, was chosen until 7 clinics were enrolled.
Participating clinics were advised of the study’s
purpose, and during the informed consent process,
providers and staff at participating clinics agreed to
1) allow the field researcher access to the clinic site,
staff, patients, and medical charts for review; and 2)
actively participate in the development and implementation
of a plan to improve and increase the
delivery of these services.
Data Collection
After obtaining informed consent, a research nurse
field worker entered each site for data collection
using the following protocol.
Baseline Data Collection
This took place during 2 visits over a 1-month
period. Data consisted of the following: 1) observational
field notes regarding the practice environment,
activities related to Papanicolaou smear and
mammogram screening, and adult female patient
encounters19,20; 2) audio-taped interviews with
physicians and key staff21,22; and 3) chart reviews of
the last 100 female patients between the ages of 19
and 64 seen in the clinic. These data were chosen
because they would enhance our understanding of
interactional patterns among individuals (physicians,
staff, and patients), the activities related to
Papanicolaou smear and mammogram screening,
and the attitudes of the physicians and staff toward
change. From these data, the analysis team would
be able to determine practice strengths and weaknesses,
and identify barriers to change. The field
worker used approximately the same approach and
time frame at every practice site.
Practice Feedback and Action Plan Development
On completion of baseline data collection, a feedback
session was scheduled with the physicians and
staff. The extent to which physicians and staff participated
in these sessions varied by practice site.
Feedback was given on rates of delivery of Papanicolaou
smears and mammograms based on information
gathered during the chart audits and on
observations related to practice barriers and
strengths. Participants were encouraged to identify
potential system changes that would improve their
screening rates and develop an action plan for
change.
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Over the next 1 to 3 months, depending on the
practice, the action plan was developed by the physicians/
staff and fieldworker. It involved 2 to 4
specific behavioral goals they wanted to implement,
the concrete steps to accomplish each goal, and a
specific person responsible for each goal. Practices
were encouraged to contact the fieldworker as
needed for assistance in the development and implementation
of their plan.
Follow-Up
The fieldworker returned to the practice at approximately
4, 8, and 12 months postbaseline to assess
progress on the action plan and provide encouragement
and assistance. Observational field notes dictated
after each visit outlined the progress made by
the practice and noted process issues affecting
progress. At the 12-month follow-up, chart reviews
were conducted on the last 100 female patients seen
in the clinic between the ages of 19 and 64.
Data Analysis
Our analysis team consisted of a behaviorist, a family
physician, and a research methodologist experienced
in qualitative and quantitative analysis methods.
Qualitative data from each practice were
initially read and analyzed individually. Notes were
made regarding the practice system strengths and
weaknesses, current protocols and system barriers,
the action plan and any progress made at the 4-, 8-,
and 12-month visits. The team then met to develop
a case study for each site describing the practice and
summarizing the key themes defining the practice’s
process of change.
Quantitative data from the chart audits were
analyzed using
2 goodness of fit tests to determine
whether significant improvements were achieved
over the course of this study with respect to the
performance and documentation of Papanicolaou
smears and mammograms.
In the final analyses, commonalities were explored
across case summaries. Of particular interest
were changes in breast and cervical cancer screening
rates; the extent of implementation of the action
plan; the practice’s perception of their accomplishments;
and common themes among the factors
defining change among the practices.
Results
Part A of this section contains information from the
qualitative case study summaries and quantitative
chart reviews. We made no interpretation of the
objective “success” or “failure” of each practice’s
action plan, but noted the general attitude in the
practice toward their results In part B, we identify
and discuss commonalities and salient themes
across practices.
Part A: Case Studies of Practice Sites
Practice 1
Context
This was a new single-provider practice focused on
building a financial patient base. Although the physician
did not seem particularly prevention-oriented,
his wife, the office manager, saw this project
as an opportunity to provide services that would
generate income and encourage patients to return
for care. Our project offered a cost-free evaluation,
advice, and assistance in improving clinical practice.
Goals
Practice 1 identified 4 target goals: 1) to develop a
“summary of care” chart form making it easier for
staff to identify patients in need of screening; 2) to
develop a postcard system encouraging patients
who obtained their screening elsewhere to ask to
have their test results sent to the practice; 3) to
increase patient awareness by making patient education
materials more readily available; and 4) to
create monthly computer-generated reminder lists
of patients in need of screening.
Results and Observations
The staff worked closely together as a team and
made steady progress on their plan. All 4 goals were
accomplished. On chart audits, the practice significantly
increased documentation of both mammograms
and Papanicolaou smears (23.3% to 60.4%
and 17.6% to 67.8%; P  .001), and updated women’s
medical records with respect to mammography
and cervical screening.
The staff displayed an ability to work as a cooperative
team toward goals that they saw as benefiting
both themselves and the practice. This was due
in large part to the office manager who led the
effort, despite a lack of physician leadership.
Practice 2
Context
This rural, hospital-owned clinic had one physician
and a part-time Physician’s Assistant. The physihttp://
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cian championed participation in the study and
enthusiastically generated ideas about how to improve
things. His staff seemed less enthusiastic.
The practice was owned by the hospital in a nearby
town, which required major changes to be approved
by the hospital first. Tension already existed
between the hospital and the clinic regarding management
issues before our study.
Goals
Practice 2 identified 3 target goals: 1) to develop a
reminder system/database to notify them of patients
needing screening; 2) to develop a prevention
flow sheet allowing staff to more readily identify
dates of needed service; and 3) to initiate community
outreach to raise public awareness.
Results and Observations
The practice was eventually able to accomplish the
first 2 goals. The database suggested in Goal 1 was
identified as an important tool by the physician,
and the staff reluctantly developed and implemented
its use. A new prevention flow sheet was
developed but required a lengthy approval process
by the hospital. No one took active ownership of
the third goal and it was not accomplished.
The physician’s enthusiasm was not shared to
the same extent by his staff. He decided the Goal 1
database was an important tool and then left it
entirely to his staff to develop and implement without
first assuring their buy-in. Although it was
completed, the analysis team questioned whether
or not the database would later be kept up and used
by the staff. The physician did take ownership of
the prevention flow sheet but the hospital’s delays
in approving the new sheet were burdensome and
frustrating for him. The practice physician and staff
seemed to have little investment in Goal 3, leaving
it unaddressed without much further thought.
Despite the progress made on Goals 1 and 2, no
significant quantitative differences were seen in the
preventive service delivery rates. The analysis team
surmised that this may have been because of a lack
of “team buy-in” and/or the fact that it took so long
to implement the goals that results weren’t seen at
the time of the last chart audit. The physician
seemed to be the only one enthusiastic about
change and was not able to create this enthusiasm
in the other team members.
Practice 3
Context
This practice was an established high-volume, suburban
multispecialty group, owned by a large hospital
system. The clinic was a university teaching
site with close ties to its institution, which in turn
closely regulated its management and finances. The
providers included 3 physicians and a nurse practitioner.
Two of the physicians were gynecologists;
the third was a family physician. Women’s health
care was the practice’s focus. This orientation was
reflected in their high baseline screening rates. Organizationally,
each provider functioned independently,
and a nurse manager led the support staff.
Goals
Practice 3 identified 3 target goals: 1) to develop a
reminder system to inform patients that it was time
for their screening; 2) develop a common fact sheet
that all clinic providers would use to facilitate
tracking the need for screening; and 3) to increase
accessibility of patient education materials.
Results and Observations
Initial progress was made on the first 2 goals but
this faltered over time and no progress was made on
Goal 3. Their initial levels of screening were already
relatively high, and no significant quantitative
improvements were made.
Because each of the 3 providers functioned independently
and the change activities did not fall
within the scope of the providers, none of them
seemed to really adopt the plan as their personal
project. By default, the leadership role seemed to
fall to the nurse manager, who did not actively
guide the development and implementation of the
work plan, nor encourage participation from interested
staff. She seemed overextended in terms of
other responsibilities and her managerial and leadership
skills were underdeveloped. The staff lacked
cohesion; the turnover rate was high, and there was
noticeable disgruntlement related to salaries and
support by the larger institution. This practice
lacked any real champion for change despite their
agreement to participate. Because initial chart reviews
showed them to be doing a good job of
screening, there was little impetus from either
within or outside of the practice to energize additional
effort.
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Practice 4
Context
This was a privately owned, high volume, singleprovider
practice serving a rural, underserved,
mainly minority population. The clinic was fairly
new, had limited resources, and was striving for
financial viability. The physician was originally
from South America, and his staff consisted of family
members who were trained physicians but not
licensed to practice medicine in the United States.
The medical assistant, his sister, was a radiologist;
the clinic manager, his brother-in-law, was an orthopedic
surgeon. The entire family had committed
their lives to this small rural community and to
improving the health care of the local immigrant
Hispanic community.
Goals
Practice 4 identified 4 target goals: 1) to develop a
computerized recall reminder system for patients;
2) to implement a “health passport” for Hispanic
patients containing health information that could
be carried to another provider if they moved; 3) to
increase accessibility of patient education materials
in the clinic; and 4) to increase community outreach.
Results and Observations
The practice accomplished all the objectives established
to reach the 4 goals. Although there were no
statistically significant changes in screening on
chart audit, the trends for most of the quantitative
variables were in a positive direction (Papanicolaou
smears, 67.4% to 76.9%; mammograms, 25% to
38.9%).
The practicing physician’s behavior changed
very little and he was minimally involved with the
change plan. The support staff (primarily the clinic
manager) embraced the plan for change with enthusiasm
and efficiency, from its development to
final implementation. The analysis team speculated
that this was due to the underutilization of the
clinic manager’s skills/intellect, as well as his appreciation
of a new challenge. It seemed likely that
the changes would be sustained.
Practice 5
Context
This was a privately owned, solo practice in a rural
area. The physician was very enthusiastic about
having us come into the practice and had many
ideas for change although he expected to retire in
the next few years. He enjoyed conversing/communicating
with his patients, which caused him to be
chronically late. Despite the physician’s enthusiasm,
the practice overall felt stagnant, unfocused,
and disorganized. There was little evidence of prevention
being a priority.
Goals
Practice 5 identified 3 target goals: 1) to develop a
calendar reminder system so that patients could be
notified that screening was due; 2) to develop a
chart flow sheet so that staff could identify when
the next screening was due; and 3) to convert charts
into a more practical format. The practicality of the
third goal was questioned by the fieldworker but
kept in the plan at the physician’s insistence.
Results and Observations
There was some initial action taken on Goal 1 but
no progress in the other 2 goals. There were no
significant improvements noted in the chart audit
analysis.
The lack of success seemed primarily because of
a lack of effective leadership and carefully thought
out goals. Although this physician liked brainstorming
about changes that would improve practice,
he showed little interest in the sustained effort
necessary to accomplish them. His staff was continually
urging him to expedite his encounters so
that every patient could be seen, and they could
leave the office at a reasonable hour. They seemed
less optimistic and forthcoming about the possibility
of making practice changes, possibly because of
this constant tension and/or their past experiences
of his inconsistent follow through.
Practice 6
Context
This practice was a rural, privately owned clinic
with 2 providers, a physician and a nurse practitioner,
located in a lower socioeconomic area. The
clinic population experienced many of the psychosocial
problems typical of communities with low
incomes and few resources. Both providers displayed
strong initial support for the project. Early
impressions were of an efficient office interested in
change, and forward-thinking enough to have developed
a computerized database. As the study progressed,
significant tension was apparent in the
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relationship of the physician and the nurse practitioner.
Goals
Practice 6 identified 4 target goals: 1) to revise the
computer face sheet to collect necessary screening
data; 2) to train staff to be more familiar with the
EWM program and paperwork; 3) to develop reminder
letters to be sent to patients; and 4) to
promote community outreach.
Results and Observations
The practice completed Goals 1 and 2, partially
addressed Goal 3, and did not address Goal 4.
Their attitude toward these accomplishments was
negated by the tension within the clinic. There
were no significant improvements noted in the
chart audit analysis.
This practice was dealing with larger, although
less obvious, organizational problems at the time
that they agreed to the project. The longer the
fieldworker was in the practice the more it became
evident that there was significant tension between
the 2 providers. The nurse practitioner had taken
over the role as “champion” of the plan and leading
the effort of implementation. The support staff
showed little enthusiasm for change, noting that
they were already overcommitted; the office manager,
who was loyal to the physician, supported the
staff position. As the intervention progressed, the
nurse practitioner became increasingly marginalized
and eventually left the practice. This tension
and conflict between leaders significantly limited
the extent to which the practice members were able
to cooperate as a team to reach practice goals.
Practice 7
Context
Practice 7 was an established rural, hospital-owned
clinic with 3 physicians. This practice prided itself
on seeing a high volume of patients; this corresponded
with the high productivity expectation of
the larger health system. During the project, one
physician retired and 2 new physicians were hired.
Two to 3 months into the project it became obvious
to the fieldworker that there was significant
resistance from the staff. The lead physician’s response
was to reduce the number of goals.
Goals
Practice 7 initially identified 2 target goals: 1) to
increase community outreach; and 2) to develop a
system, consisting of a database form and a Post-It
note for the physicians to identify women eligible
for screening. At a 4-month follow-up, the plan was
modified to include only Goal 2.
Results and Observations
By the 12-month follow-up, progress had been
made on all the original goals. One of the new
physicians, interested in community outreach,
started giving talks in the community and took
ownership of the database form development. The
lead physician took responsibility for the Post-It
note and got it completed. There was, however, no
increase in screening demonstrated in the analysis
of the chart audit data.
Significant changes were occurring in this practice
at the time of the project, including the hiring
of a new clinic manager and 2 new physicians, and
the retirement of one provider. The physician leading
the group was very production and task-oriented.
He made decisions about participating in
this project but didn’t take leadership of its accomplishment.
Fortunately, a new physician, interested
in preventive medicine, was hired and took a leadership
role.
The office manager and staff passively resisted
any efforts to include them in the change plan. The
lead physician, although unwilling to drop out of
the project, did little to encourage or facilitate staff
participation.
Part B: Commonalities and Themes
Comparison across practices noted 7 common
themes. First, although the goals generated by the
practices were remarkably similar, the specific
strategies used depended on the context of the
practice and the resources available to them.
Second, the nature and extent of the change
often depended on having a “champion” in the
practice promoting and emphasizing the importance
of the project and motivating others in the
team. This leadership was marked by the ability to
promote a strong sense of teamwork and the importance
of everyone’s effort.
Third, the burden of change fell primarily on
the support staff. Without strong leadership and
“buy in” at that level, change was unlikely to occur.
406 JABFP September–October 2005 Vol. 18 No. 5 http://www.jabfp.org
Fourth, most practices were already operating at
the capacity of their existing resources. However,
none of the practices considered this when developing
their action plan. Rather, it was a matter of
adding one more thing to a system that was already
operating at or beyond capacity.
Fifth, the focused intervention did provide an
important service to some practices in the form of
objective feedback, creative discussion, development
of a specific plan, and ongoing facilitation.
Sixth, the 2 newer and, possibly, more unstable
practices seemed to change to a greater extent,
supporting the idea of practices as complex adaptive
systems where change is more likely to occur
“on the edge of chaos.”23,24
Finally, those practices owned by a larger hospital
system were the least likely to change, possibly
due in part to the inertia/stability created by the
larger system.
Discussion
Our findings strongly support the concept of practices
as unique, complex organizational systems.25
Practices varied significantly in their missions, their
organizational flexibility, the individual personalities
of their providers and staff, the resources available
to the practice (and the control they had over
their use), and their organizational cohesiveness,
leadership, and ability to work as a team.17,26 Many
of the practices seemed so overwhelmed with daily
operational activities that the staff were resistant to
the added efforts required for change.27
Most practices had to struggle against the inertia
of their own stability whereas others had the added
inertia of a larger, corporate system that actively
discouraged individual change/instability.23,24
Practices 1 and 7 seemed to contain more instability
or chaos within their systems; for Practice l,
being small and new, this seemed to result in
greater flexibility. For Practice 7, the chaos of personnel
changes seemed to create less flexibility especially
on the part of the staff. Glieck (1987) in his
book on chaos discusses the way in which disorderly/
chaotic behavior creates anxiety within the system.
In systems with leadership that can contain/
channel the anxiety, it can be turned into creativity,
thereby generating greater complexity within the
system (Practice 1); in more complex systems
where leadership cannot contain the anxiety, this
may lead to increased control by the system,
thereby reducing instability/flexibility (Practice 7).
Practice 4 seemed to be the one practice that had
been underutilizing its own resources; through increased
creativity and focused interventions, they
were able to effectively promote change within
their practice.
Despite the barriers that mitigated significant
increases in screening in several of the practices, we
believe the concepts of the GAPS model to be
sound and recommend it as a practical structure by
which to initiate desired change in a complex organizational
system, such as a clinical practice setting.
17 In addition, our study highlighted the importance
of other process variables such as
leadership, cohesiveness, resources (including creativity),
and shared vision. These variables seemed
to influence the interactional process of change,
becoming barriers or strengths in the process.
There are limitations to interpreting our results,
the most significant being the lack of generalizability
resulting from our qualitative design and the
nonrepresentative nature of our sample. The qualitative
design, however, allowed us to gain a richer,
descriptive, in-depth look at the effects of our intervention
on a variety of practice types. Second,
the intervention limited the extent to which the
field worker was involved as a change agent, placing
more responsibility on the practices to create
change. Third, the limited follow-up period made
it difficult to assess whether the practice efforts
would translate into long-term change. Fourth,
measuring changes on chart audits was not an optimal
outcome measure, given their dependence on
the accurate recording of service delivery.
References
1. Eyre H, Kahn R, Robertson RM, et al. Preventing
cancer, cardiovascular disease, and diabetes: a common
agenda for the American Cancer Society, the
American Diabetes Association, and the American
Heart Association. Circulation 2004;109:3244 –55.
2. Hayward RSA, Steinberg EP, Ford DE, Roizen MF,
Roach KW. Preventive care guidelines: 1991. Ann
Intern Med 1991;114:758–83.
3. McGinnis JM, Foefe WH. Actual causes of death in
the United States. JAMA 1993;270:2207–12.
4. National Cancer Institute. Working guidelines for
early cancer detection. Bethesda (MD): National Institutes
of Health; 1987.
5. U.S. Preventive Services Task Force. Guide to clinical
preventive services: an assessment of the effectiveness
of 169 interventions, 1st ed. Baltimore
(MD): Williams & Wilkins; 1989.
http://www.jabfp.org 407
6. U.S. Preventive Services Task Force. Guide to clinical
preventive services: an assessment of the effectiveness
of 169 interventions, 2nd ed. Baltimore
(MD): Williams & Wilkins; 1996.
7. U.S. Department of Health and Human Services.
Healthy people 2010: understanding and improving
health. Washington (DC): U.S. Government Printing
Office; November 2000.
8. U.S. Public Health Service. Healthy people 2000:
national health promotion and disease prevention
objectives and healthy schools. J Sch Health. 1991;
61:298 –328.
9. Frame PS. Health maintenance in clinical practice:
strategies and barriers. Am Fam Physician 1992;45:
1192–200.
10. Lurie N, Manning WG, Peterson C, Goldberg GA,
Phelps CA, Lillard L. Preventive care: do we practice
what we preach? Am J Public Health 1987;77:801– 4.
11. Solberg LI, Kottke TE, Brekke ML, Magnan S.
Improving prevention is difficult. Eff Clin Pract
2000;3:153–5.
12. Solberg LI, Kottke TE, Conn SA, Brekke ML, Calomeni
CA, Conboy CS. Delivering clinical preventive
services is a systems problem. Ann Behav Med 1997;
19:271– 8.
13. Grol R. Beliefs and evidence in changing clinical
practice. Br Med J 1997;315:418 –21.
14. Oxman A, Thomson MA, Davis DA, Haynes RB. No
magic bullets: a systematic review of 102 trials of
interventions to improve professional practice. Can
Med Assoc J. 1995;153:1423–31.
15. Goodwin MA, Zyzanski SJ, Zronek S, et al. A clinical
trial of tailored office systems for preventive service
delivery. The Study to Enhance Prevention by Understanding
Practice (STEP-UP). Am J Prev Med
2001;21:20–8.
16. Miller G. Supplying provider data via the Internet.
Health Manag Technol 1998;19:42– 44.
17. Dietrich AJ, Woodruff CB, Carney PA. Changing
office routines to enhance preventive care: the preventive
GAPS approach. Arch Fam Med 1994;3:
176–83.
18. Johnson JD. Selecting ethnographic informants.
Newbury Park (CA): Sage Publications; 1990.
19. Bogdewic SP. Participant observation. In: Crabtree
BF, Miller WL, eds. Doing qualitative research:
multiple strategies. Newbury Park (CA): Sage Publications;
1992.
20. Jorgensen D. Participant observation. Newbury Park
(CA): Sage Publications; 1989.
21. Crabtree BF, Miller WL. A qualitative approach to
primary care research: the long interview. Fam Med
1991;23:145–51.
22. Gilchrist VJ. Key informant interviewing. In:
Crabtree BF, Miller WL, eds. Doing qualitative research:
multiple strategies. Newbury Park (CA):
Sage Publications; 1992; p. 70–89.
23. Gleick J. Chaos: making a new science. New York:
Penguin Books, Ltd.; 1987.
24. Wheatley M. Leadership and the new science: learning
about organization from an orderly universe. San
Francisco (CA): Berrett-Koehler; 1992.
25. Miller WL, Crabtree BF, McDaniel R, Stange KC.
Understanding change in primary care practice using
complexity theory. J Fam Pract 1998;46:369 –76.
26. Aita V, Dodendorf DM, Lebsack JA, Tallia AF,
Crabtree BF. Patient care staffing patterns and roles
in community-based family practices. J Fam Pract
2001;50:889.
27. Jaen CR, Stange KC, Nutting PA. Competing demands
of primary care: a model for the delivery of
clinical preventive services. J Fam Pract 1994;38:
166–71.
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