Condet

Edgar D. Staren, MD, PhD, MBA

• Senior Vice President and Chief Medical Officer
• Cancer Treatment Centers of America
• Zion, Illinois
• Visiting Professor
• Department of General Surgery
• Rush Medical College
• Chicago, Illinois

The focus of the industry shifted to in-store (largely convenience store) promotional strategies symptoms lactose intolerance retrovir 100mg overnight delivery. It may be that the industry sees far more growth opportunities in the rest of the world than in the United States and has adjusted its promotional efforts accordingly treatment 4s syndrome purchase 100 mg retrovir amex. Since this category was not previously broken out separately medicine dosage chart buy discount retrovir 300mg on-line, it is difficult to determine its rate of growth relative to previous years medications vertigo generic retrovir 300mg line. In the 1960s and 1970s television was the dominant means of delivering tobacco advertising. The more teenagers (but not adults) in the audience, the greater the likelihood that the tobacco fi rms would sponsor the program (Pollay & Compton, 1992). One aspect of the agreement states: "[n]o Participating Manufacturer may take any action, directly or indirectly, to target Youth. Cigarettes accounted for 37% of gross sales at convenience stores and represent the second most significant source of gross profits for convenience stores (National Association of Convenience Stores, as reported in DiPasquale, 2002). Significant increases in tobacco promotion were noted from the period just prior to the implementation of the billboard ban (part of the Master Settlement Agreement) to the period just after the settlement these included: (1) the percentage of stores carrying interior store advertising for tobacco products and the extent of that advertising, (2) the percentage of stores carrying exterior advertising for tobacco products and the extent of that advertising, (3) the percentage of stores carrying a range of promotions, including gift-with-purchase, cents-off promotions, and multipack discounts, and (4) the percentage of stores carrying tobacco-related functional objects and the extent to which these objects were in the store (Wakefield et al. The specific nature of in-store cigarette product and ad placement as well as promotion is of particular relevance to this discussion given the frequency of youth shopping at convenience stores: nationally, three out of four teenagers shop at a convenience store at least once a week, staying an average of 10 minutes per visit-twice as long as adults; one third of both adults and teenagers stop in at least two or three times a week (Chanil 2002). Does this focus on in-store advertising and promotional efforts influence the cigarette purchasing behavior of youths A national study of over 17,000 9th- through 12th-grade-students at 202 schools in 1996 assessed the brand preferences of the 3,282 students who smoked. The findings indicated that where the stores featured Marlboro in their advertising and promotions, students in the nearby schools tended to prefer Marlboro. A study employing an experimental design exposed eighth and ninth graders to photos of a convenience store that was either dominated by or devoid of tobacco advertising. Lastly, exposure to in-store tobacco advertising led the youths to be weaker in their support of tobacco control measures such as restricting tobacco marketing and increasing tobacco prices (Henriksen et al. Presumably laws restricting access to tobacco products by minors would obviate the influence of in-store advertising and promotions. However, there is considerable evidence, based on national surveys of youths, that such laws have not been effective. More recently, the Monitoring the Future study results suggest that cigarettes are almost universally available to teens. Three separate studies show that cigarette promotions, not necessarily limited to in-store distribution, are associated with cigarette uptake by adolescents. In a time series analysis, the study concluded: "Large promotional pushes by cigarette marketers in the 1980s and 1990s appear to be linked with increased levels of daily smoking initiation among ninth graders" (Redmond, 1999, p. Those who initially had never smoked and were judged non-susceptible to smoking at time period one, but owned or were willing to use a cigarette promotional item, were more than twice as likely to have progressed towards smoking 21 months later. This remained true after controlling for a series of other factors including whether friends and/or family members smoked, gender, school performance and level of parents education (Sargent et al. When first telephoned in 1993, 1,752 of those approached had never smoked and indicated that they were not susceptible to smoking. When these adolescents were re-interviewed 3 years later, those who either initially possessed or were willing to possess a tobacco promotional item (such as a lighter or t-shirt) were almost three times more likely to indicate that they had started to smoke or intended to start, relative to those who did not own or were not interested in promotional items (Pierce et al. The Increased Importance of Packaging In a sense, the ultimate promotional device is the cigarette package, both because it represents a key element of the in-store display and is used repeatedly, coincident with product use. To do this it must look new and different enough to attract the attention of the consumer" (Liggett & Myers, 1963). More recently, referring to an innovative package introduced for Kool cigarettes, a senior B&W executive commented: "The response from consumers is `this is a pack to be seen with.

Contextual Factors One of the better studied contextual sources of information to make responses is the questionnaire itself (Bickart treatment for piles retrovir 100mg lowest price, 1993) symptoms neck pain discount 300 mg retrovir visa, including the manner in which questions are framed symptoms 2 weeks pregnant buy retrovir 300mg with mastercard, the order in which they are asked medicine quinine cheap 100mg retrovir, the response alternatives used to elicit their responses and other incidental information in the questionnaire that ends up serving an informative function rather than the pure recording function for which it was intended. The cognitive aspects of survey methodology literature shows that the manner of construction of a questionnaire affects the reports elicited, and can, in turn, affect later responses (see Sudman et al. The use of response alternatives increases when reports are made for another person for whom memorybased information is even less accessible than for oneself (Schwarz & Bienias, 1990), and as the task complexity increases (Bless, Bohner, Hild, & Schwarz, 1992). Given the number and types of scales used to elicit behavioral and other symptoms for conditions ranging from depression to diabetes, the manner of construction of these scales could affect risk judgments. Other contextual factors that have been examined include the enhanced accessibility of responses to earlier questions (Menon et al. Future research needs to be conducted to examine the effects of response scales on behavior identification and the likelihood of using the behavior to construct a risk judgment. Proxy Information Proxy-diagnosis is when you ask a person whether they believe someone they know is at risk of a disease. When judgments relate to another person whom one knows, such as a significant other, people are more likely to project their own attitudes and behaviors to the other person (Davis, Hoch, & Ragsdale, 1986). People tend to assume that those similar to themselves, share their attitudes and behaviors. Assessing whether proxy-reports are subject to the same contextual cues that self-reports are is an area for future research. Availability of Alternative Sources of Information Given that an over-arching goal of healthmarketers is to bring risk perceptions in line with reality (and objective data), a legitimate question is whether providing simply base-rates of an event can achieve this goal. For example, Weinstein and Lachendro (1982) were able to reduce the self-positivity bias by providing detailed, personalized information about the risk status of five other students or asking participants to imagine that they were the typical same-sex student. However, it is plausible that base-rates may not eliminate the self-positivity bias as consumers are notorious for ignoring base-rate information (Tversky & Kahneman, 1974). For example, respondents have been shown to ignore the format in which numerical information is provided and make judgments based on the absolute magnitudes of the number provided (Halpern, Blackman, & Salzman, 1989). This led to people perceiving "100% greater" to mean "twice" as large, and "200% greater" to also mean "twice" as large! Applying these findings to framing counter-biasing information to reduce under-reports of undesirable behaviors, Raghubir and Menon (1996) found that presenting information as "1 out of 5" (people performed the undesirable behavior) was less effective than presenting the same information as "20%. Drawing on Construal Level Theory (Trope & Liberman, 2000), they showed that temporal framing mimics the effects of temporal distance such that an "every day" framing makes risks seem more proximal and concrete than a "every year" framing, resulting in higher perceptions of self-risk, more concerned attitudes, higher intentions to behave in a precautionary manner, greater anxiety about the hazard, and enhanced effectiveness of risk communication. For example, they reported that perceptions of self-risk, measured on a 101-point probability scale went from 4. Furthermore, an "every day" attenuated the self-positivity bias was mitigated, but the "every year" framing enhanced it. Finally, these results were reversed when the health message was framed as "averting" a health hazard as opposed to "succumbing" to one, such that the "every day" frame increased the probability of avoiding the disease in the "avert" condition compared to the "every year" frame. Framing effects can be constructed at the geographical level, the psychological level, other demographic level, or at a mere aggregate statistical level. That is, suggesting that a million Americans have a problem would be less effective than suggesting that 100,000 Californians have the same problem (given California accounts for approximately 10% of the U. Examining these predictions as well as other forms and effects of framing are be interesting areas of future research. Individual Differences There are many individual difference variables that may also account for systematic differences in risk perceptions between groups of individuals. Depressive Tendency One of the few groups of people who have been shown to not have the selfpositivity bias are depressives. Their risk estimates are more realistic than the average population, a term referred to as "depressive realism" (cf. Alloy & Abramson, 1979; Keller, Lipkus, & Rimer, 2002; see Ackermann & DeRubeis, 1991, for a review). Depressives are less prone to self-positivity as they view their life and future in negative terms (Beck, 1967, 1976), have low self-esteem (Gerrard, Gibbons, Reis-Bergan, & Russell, 2000), with their risk estimates reflecting pessimism (versus an absolute risk level) and self-negativity (versus another person; Keller, Lipkus, & Rimer, 2002). Depressives appear to view their life and future in negative terms (Beck, 1967, 1976), relying more on chronically accessible negative self-constructs. Information processing in depressives has been shown to be context-dependent with a controlled decision to engage in (negative) self-referential thoughts preceding the automatic activation of self-related constructs (Bargh & Tota, 1988), which reflects a tendency to interpret a behavior as consistent with a chronically accessible construct (Higgins & King, 1981). Gender Women have been found to be more prone to depression, though this may simply reflect their higher likelihood of seeking assistance and diagnosis.

He characterized coping behaviors as attempts to change the world; automated responses enacted by individuals in order to control their environment symptoms diabetes order 100 mg retrovir with mastercard. In contrast symptoms 7 weeks pregnancy retrovir 300 mg cheap, he believed that expressive behaviors revealed something deeper about the psychology of the individual expressing them medications you can buy in mexico buy retrovir 100mg overnight delivery. For Maslow treatment concussion generic retrovir 100 mg online, expressive behaviors allow for the detection of primarily psychological phenomena, whereas coping behaviors incorporate worldly phenomena. Maslow desired more theory and research into expressive behaviors, although his writings on coping have been quite influential. A second classic approach that has greatly influenced modern day coping research stemmed from clinical psychological work on adaptation. According to this view, adaptive behavior in response to environmental stress was observable among all living organisms (Selye, 1956). This definition of stress was quite broad and encompassed all environmental changes affecting the organism. These adaptive processes were characterized by promoting two basic stress orientations: one directed at impelling the organism toward a perceived cause of stress (a vigilance or approach orientation) and an aversive orientation impelling the organism away from a perceived source of stress. Remnants of this classic motivational distinction still exist within modern coping theories, and more will be said of this distinction subsequently. In fact, a review of the coping literature determined that the coping inventory developed by Lazarus and Folkman based on their conceptual model is the most frequently used empirical coping measure (Schwarzer & Schwarzer, 1996). Their conception of coping emphasizes the conscious set of adaptive strategies individuals use to overcome stress, and they define coping as the set of constantly changing cognitive and behavioral efforts to manage specific external and/ or internal demands that are appraised as taxing with the goal of reducing stress (Lazarus & Folkman, 1984, p. According to this perspective, coping is a highly diverse activity encompassing a multitude of potential adaptive phenomena. Another key tenet of this view of coping relates to the conceptualization of coping as a process. The process-based view of coping is noteworthy because it distinguishes coping from related concepts, such as personality. They coined the term transactional model to represent their belief that coping processes reflect an interaction between personality and situational influences. Also apparent from the definition is the fact that coping is distinguished from its consequences by referring to coping processes as the efforts to reduce stress and negative emotion-the key consequences of coping behaviors. Using this basic construct definition, Lazarus and Folkman developed an appraisal-based model postulating both situational (state) and dispositional (trait) influences. The transactional model, like cognitive-emotional models, hinges on the core notion of cognitive appraisal (Roseman, Antoniou, & Jose, 1996; Roseman, Spindel, & Jose, 1990; Smith & Ellsworth, 1985). The primary appraisal involves key assessments of whether a perceived stimulus has motivational implications or "goal relevance" for an individual. Positive and negative implications are differentiated in an assessment of "goal congruence". Threat appraisals are characterized by the onset of fear, worry and other anxiety-related emotions (Skinner & Brewer, 2002). Whether a primary appraisal results in perceptions of threat or challenge fundamentally impacts the nature of secondary appraisal. Lazarus and Folkman stress the extemporaneous, reflexive nature of this process, whereby multiple appraisals (both primary and secondary) may occur nearly simultaneously and may often be codetermined by changing environmental conditions. That is to say, primary appraisals need not temporally precede secondary appraisals in practice, but the distinction between the two remains an important one in conceptualizing the cognitive processes preceding emotion and coping. According to these theories, appraisal processes give rise to the full range of human emotions, by implicating a unique action tendency. Lazarus formalized this linkage between stress appraisal and emotion, arguing that the two phenomena were inextricably linked (Lazarus, 1991). A growing body of research has begun to investigate these linkages, finding support for reliable associations between appraisal and emotion (Ellsworth & Smith, 1988; Folkman & Lazarus, 1988). The determination to employ a particular coping strategy is driven by an interaction of cognitive appraisal and emotional perceptions (Duhachek, 2005). Research has begun to establish these links, offering support for the existence of reliable associations between emotions and coping (Yi & Baumgartner, 2004). The structural properties of the coping process have been represented multiple ways in the coping literature. Researchers have conceptualized coping using several distinct competing conceptual frames (more will be said of this subsequently). In its simplest, most widely accepted form, the conceptualization of coping strategies contrasts problem-focused and emotion-focused means of coping.

Thus medicine 751 order 300mg retrovir amex, competition may help to make volunteering medicine number lookup discount 300mg retrovir amex, as a product medicine used to stop contractions cheap retrovir 300mg on line, an even better one treatment 0f gout generic retrovir 300 mg visa. After all, many volunteers serve more than one organization (sometimes simultaneously), and, given that different tasks offer different benefits, the competition may only be fierce between very similar organizations or tasks. Indeed, the very fact that different types of volunteerism may offer different benefits may be useful to volunteer coordinators who seek to recruit and to retain volunteers, allowing them to attract the segment of the target audience that is most likely to be seeking the benefits they can offer or to position their opportunity against other opportunities that offer different benefits. After all, volunteering may take time away from work, from friends and family, and from leisure time and recreational activities. That is, by choosing to volunteer, people are suffering "opportunity costs" in addition to any other costs; the social marketer must try to beat out this form of competition, making a good offer to those potentially interested that tops other offers and opportunities that must be foregone. To date, research on volunteerism generated by the functional approach has focused on how volunteer work may allow people to satisfy important personal motivations. The extent to which volunteer activities are better than other activities at providing benefits matched to these motivations has not yet been determined. Yet, as successful as a benefit-to-benefit comparison may be for promoting volunteerism above other competing activities, it may not be enough to retain some volunteers. Research suggests that the factors that predict recruitment to volunteer activities and the factors that predict attrition from volunteer activities may be different. Although volunteer satisfaction has been identified as one predictor of sustained volunteerism. Thus, volunteer satisfaction may be a necessary, though not a sufficient, condition for ensuring longevity and warding off attrition. Instead, a focus on minimizing barriers that make volunteerism difficult to perform (as well as barriers that make benefits difficult to obtain) may also be required for greater retention of volunteers. Such barriers may include a lack of time or some degree of trouble in reaching the volunteer site. Only 12 out of 101 departing volunteers mentioned dissatisfaction as a reason for quitting. Such results point to the potential for ensuring retention of volunteers by minimizing these costs of volunteerism for the volunteer relative to the costs of other leisure time activities. Moreover, social expectations also may influence a volunteer to continue volunteering, as the social role of volunteer may become a core component of his or her identity. Finally, many people initiate their volunteer service because they have been contacted by a friend or acquaintance and asked to do so. In this way, some volunteers may engage in service because such helpful action is normative for their social group. Social norms, it should be recognized, may be either descriptive, reflecting the typical behaviors of a social group, or injunctive, reflecting behaviors that are strongly encouraged or discouraged by social groups. In this sense, volunteer service may be primarily influenced by descriptive norms-many people may volunteer because such behavior is typical of their friends and neighbors. However, Omoto and Snyder (2002) have suggested that volunteer work can reflect a psychological sense of community and this may be especially true when that community is made up of people who often engage in service. Research suggests that whereas prosocial behavior may be encouraged by social groups, these groups often impose few penalties for failing to engage in prosocial behavior. In certain situations, or for people who belong to a number of different social groups, competing norms may be available to guide behavior. More generally, there may be competing norms at play in determining whether individuals volunteer or not, and the strength of competing norms may create ambiguity about how or even whether to act. The political discourse surrounding volunteerism and its role in society has highlighted concerns that some types of service could be detrimental to society (though not going so far as to suggest that helpfulness itself should be avoided). From the perspective of others, however, volunteerism and the nonprofit sector as a whole, often contain associations of individuals that challenge the status quo and thereby offer society the potential for social change through social movements (for a fuller consideration of these tensions, see Van Til, 1988). In other cases, norms that suggest that one should not get involved appear to represent another form of concern for others. Moreover, whereas recipients of the help offered by volunteers can benefit in many ways from that help, the help given can carry a message that is unflattering to the recipient of help. People may see receiving help as threatening and those people who are most competent and efficacious may be especially likely to feel threatened by the prospect of being in the role of recipient (see Nadler & Fisher, 1986).

Those studies with significant findings for the outcomes of death by suicide medicine and manicures cheap 300mg retrovir overnight delivery, suicide attempts treatment neuropathy cheap retrovir 100mg fast delivery, or suicidal ideation were selected for inclusion medications nursing purchase retrovir 300mg with mastercard. Table 1 provides more detailed descriptions of the intervention and comparison conditions evaluated in each study internal medicine buy retrovir 100mg with visa, as well as the assessed outcomes and results. The study found that the rate of suicide for the intervention condition was significantly lower than that for the control group for the first 2 years of follow-up. More attention has been given to investigating the effect of follow-up care on preventing or reducing suicide attempts and self-directed violence. An Australian study9,10 recruited patients from toxicology units following intentional self-poisoning and randomly assigned them to receive either follow-up postcards or no intervention. This study found that participants assigned to receive the postcards had fewer numbers of intentional self-poisoning behaviors than controls over a 24-month follow-up period. Three other studies have found significant results for follow-up interventions, depending on the specific individual who performed the follow-up contact. One compared13 follow-up by a mental health worker, follow-up by a crisis volunteer, and no follow-up for patients discharged from a hospital after a suicide attempt. The study found a significant reduction in repeat suicide attempts for follow-up by a mental health worker compared to follow-up by a crisis center volunteer or no follow-up. Torhorst and colleagues14 reported that the rate of suicide attempts in the group of patients who saw a different therapist for treatment following discharge from the hospital was lower than that of patients who saw the same clinician who treated them in the hospital. A retrospective chart review study,15 on the other hand, found that both continuity of care alone and contact with the same professional predicted reduced suicide risk in discharged patients who had died by suicide and matched controls. In summary, there are several studies with promising initial findings concerning the efficacy of follow-up care and suicide prevention. Specifically, research suggests that clinicians who reach out to patients (especially those patients not engaged in treatment) using caring letters to express concern and support may help to reduce the rate of suicide following discharge from a psychiatric hospital. Outreach programs that provide comprehensive mental health treatment and emphasize follow-up and continuity of care following discharge from the hospital may also help to prevent repeat suicide attempts. Gaps and Limitations of the Current State of the Science Although findings from these studies warrant optimism that follow-up services can ultimately be an effective strategy for suicide prevention, there are several gaps in our current knowledge, as well as major limitations. Although several studies have demonstrated efficacious follow-up services for preventing suicide attempts and self-directed violence, these outcomes are only proxies for death by suicide and may not generalize to services that will actually prevent suicide. Additionally, the studies that have found positive results have not investigated the mechanisms by which the follow-up services affected outcomes. Further, our knowledge of effective services for specific subpopulations, particularly those at high risk relative to the general population, is severely limited. Additionally, existing studies have recruited patients mostly from acute treatment settings. Research16 has found that most individuals who attempt suicide seek no treatment following their attempt. Thus, it is unclear whether findings from studies of follow-up services conducted to date can be generalized to other settings, such as primary care, outpatient mental health, or other community settings. Finally, the failure to replicate studies that have found significant effects is a major gap in the literature. Although developing novel interventions is important, there has been less emphasis placed on replicating studies with positive results or improving existing interventions that have been found to be effective. Those problems discussed previously that also apply to follow-up services research include (1) failure to provide operational definitions or use a standardized nomenclature for assessing suicide, suicide attempts, suicidal ideation, and other related behaviors; (2) failure to include reliable and validated outcome measures; and (3) failure to control for sources of bias. Methodological problems such as those outlined here led to the following conclusion in the Veterans Affairs systematic review: "Overall, these intervention trials had methodological limitations that resulted in their providing only low strength and insufficient evidence to properly draw conclusions on the effectiveness of the various treatment interventions and follow-up strategies. These needs include (1) improving methodological rigor in future studies; (2) developing additional follow-up services and paradigms that are cost-effective and innovative; (3) expanding research to additional settings and subpopulations; and (4) replicating and disseminating evidence-based follow-up services. Third, future research should include methods to address ambivalent suicidal behavior.

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