Increasing clinician self-efficacy for screening and counseling adolescents for risky health behaviors: results of an intervention

Delivery and Impact of a Motivational Intervention for Smoking Cessation: A PROS Study

OBJECTIVES

We tested a Public Health Service 5As-based clinician-delivered smoking cessation counseling intervention with adolescent smokers in pediatric primary care practice.

METHODS

We enrolled clinicians from 120 practices and recruited youth (age ≥14) from the American Academy of Pediatrics Pediatric Research in Office Settings practice-based research network. Practices were randomly assigned to training in smoking cessation (intervention) or social media counseling (attentional control). Youth recruited during clinical visits completed confidential screening forms. All self-reported smokers and a random sample of nonsmokers were offered enrollment and interviewed by phone at 4 to 6 weeks, 6 months, and 12 months after visits. Measures included adolescents' report of clinicians' delivery of screening and counseling, current tobacco use, and cessation behaviors and intentions. Analysis assessed receipt of screening and counseling, predictors of receiving 5As counseling, and effects of interventions on smoking behaviors and cessation at 6 and 12 months.

RESULTS

Clinicians trained in the 5As intervention delivered more screening (β = 1.0605, P < .0001) and counseling (β = 0.4354, P < .0001). In both arms, clinicians more often screened smokers than nonsmokers. At 6 months, study arm was not significantly associated with successful cessation; however, smokers in the 5As group were more likely to have quit at 12 months. Addicted smokers more often were counseled, regardless of study arm, but were less likely to successfully quit smoking.

CONCLUSIONS

Adolescent smokers whose clinicians were trained in 5As were more likely to receive smoking screening and counseling than controls, but the ability of this intervention to help adolescents quit smoking was limited.

Adaptive instruction and learner interactivity in online learning: a randomized trial

The purpose of this study was to evaluate two online instructional design features, namely adaptation to learner prior knowledge and use of questions to enhance interactivity in online portrayals of physician-patient encounters, in the context of instructing surgical specialists to deliver perioperative tobacco interventions. An online learning module on perioperative tobacco control was developed, in formats incorporating permutations of adaptive/non-adaptive and high/low interactivity (i.e., 2 × 2 factorial design). Participants (a national sample of US anesthesiology residents) were randomly assigned to module format. Primary outcomes included tobacco knowledge, time to complete the module, and self-efficacy in delivering tobacco interventions. One hundred fourteen residents completed the module, which required a median of 60 min (interquartile range 49, 138). The difference in post-module tobacco knowledge score was similar for adaptive and non-adaptive formats [mean difference 0.3 of 10 possible (95% CI - 0.3, 1.0), p = 0.25] but time was shorter for the adaptive format [- 7 min (95% CI - 14, 0), p = 0.01] and knowledge efficiency (knowledge score divided by time) was higher [0.08 units (95% 0.03, 0.14), p = 0.004]. The level of interactivity had no significant effect on self-efficacy [- 0.1 on a 5-point scale (95% CI - 0.3, 0.1), p = 0.50] in delivering tobacco interventions (both outcomes using 5-point scales). Adapting online instruction to learners' prior knowledge appears to improve the efficiency of learning; adaptation should be implemented when feasible. Adding features that encourage learner interaction in an online course does not necessarily improve learning outcomes.

Caregiver Comfort in Adolescents Independently Completing Screening Tablet-Based Questionnaires at Primary Care Visits

PURPOSE

The objective of this study was to assess caregiver comfort regarding adolescent completion of computerized health screening questionnaires created for adolescents.

METHODS

We conducted a mixed-method, cross-sectional survey of caregivers of adolescent patients (n = 104) aged 12-18 years who had a medical visit between June 2017 and August 2017. Topics assessed included who completed the questionnaire, caregiver comfort and concern regarding questionnaire data, and caregiver reasons for involvement in completing the questionnaire. A one-way analysis of variance was used to compare the age of the adolescent and caregiver involvement in the questionnaire.

RESULTS

The majority of adolescents (64%) reported independent completion of the questionnaire. Thirteen percent of caregivers completed the questionnaire with no involvement of the adolescent and 23% reported that caregivers and adolescents completed the questionnaire in tandem. The majority of caregivers (84%) were comfortable with adolescents completing the questionnaire. A variety of reasons were identified for caregivers completing the questionnaire (time constraints, 22%; adolescent requested caregiver help, 19%; caregiver desired to answer questions, 14%; caregiver did not realize that the questionnaire was intended for the adolescent, 11%; caregiver believed that the adolescent was too young to respond alone, 11%). Caregiver comfort with adolescent completing the questionnaire increase with age.

CONCLUSION

We found the reason most caregivers gave for completing the questionnaires were related to clinic processes (e.g. time constraints). Caregivers were more likely to complete the questionnaire with younger adolescents. Thus, pediatricians should consider how to best prepare families for initial questionnaires in primary care.

Brief motivational interviewing intervention to reduce alcohol and marijuana use for at-risk adolescents in primary care

OBJECTIVE

The primary care (PC) setting provides a unique opportunity to address adolescent alcohol and other drug (AOD) use.

METHOD

We conducted a randomized controlled trial in 4 PC clinics from April 2013 to November 2015 to determine whether a 15-min brief motivational interviewing (MI) AOD intervention, delivered in PC, reduced alcohol and marijuana use and consequences. Adolescents ages 12-18 who came for an appointment during the 2.5-year study period were asked to be in the study and screened using the National Institute of Alcohol Abuse and Alcoholism Screening Guide. Those identified as at risk were randomized to the CHAT intervention or usual care (UC). Adolescents completed 4 web-based surveys at baseline and 3, 6, and 12 months postbaseline.

RESULTS

The sample (n = 294) was 58% female and 66% Hispanic, 17% Black, 12% White, 5% multiethnic or other, with an average age of 16 years. Compared to UC adolescents, CHAT adolescents reported significantly less perceived peer use of alcohol and marijuana at 3 months (alcohol: p < .0001; marijuana p = .01) and 6 months (alcohol: p = .04; marijuana p = .04). CHAT adolescents also reported marginally fewer negative alcohol consequences experienced at 6 months (p = .08). At 12 months, compared to UC, CHAT adolescents reported less perceived peer alcohol (p = .04) and marijuana (p < .01) use and fewer negative consequences from alcohol (p = .03) and marijuana (p = .04) use.

CONCLUSIONS

A brief MI intervention delivered in PC reduced negative consequences from alcohol and marijuana use 1 year later. Findings emphasize that adolescents can benefit from PC interventions that briefly and effectively address both alcohol and marijuana use. (PsycINFO Database Record

The Effect of Sexual and Reproductive Health Education on Knowledge and Self-Efficacy of School Counselors

PURPOSE

Enrichment of school counselors' knowledge would be an effective way to promote sexual and reproductive health (SRH) among adolescents. The present study aims to assess the effect of educational intervention on knowledge and self-efficacy of high school counselors on teenage SRH.

METHODS

A randomized controlled trial was conducted between June 2016 and March 2017. One hundred and twelve high school counselors from Tehran were recruited and randomized into two groups. The intervention was comprised of training courses on adolescent SRH as per two educational approaches: the team-based learning (TBL) and lecturing, which consisted of four sessions of 2hours in 2 weeks. The knowledge and feeling of self-efficacy in both groups were assessed at the beginning of the study and 8 weeks after the intervention by researcher-made questionnaires.

RESULTS

After intervention, the mean and standard deviation of the knowledge and self-efficacy scores increased significantly in both TBL and lecture groups (p < .001). However, the final mean (standard deviation) of counselors' knowledge and self-efficacy scores in the TBL group were significantly higher than that of those in the lecture group [20.06 (2.74) vs. 18.90 (2.95); p = .03 for knowledge and 43.01 (4.08) versus 41.15 (4.99); p = .03 for self-efficacy] with an almost moderate effect size d = .55 for both outcomes.

CONCLUSIONS

The better SRH knowledge and self-efficacy in TBL group can be indicative of the group's effect on making challenges, especially in subjects that are socio-religious by nature. It seems that applying learner-centered educational approaches such as TBL can facilitate achieving pre-assigned SRH goals.

A taxonomy of the scope and organization of local sexually transmitted disease services for policy and practice

Local health departments (LHDs) and their organizational partners play a critical role in controlling sexually transmitted diseases (STDs) in the United States. We examine variation in the differentiation, integration, and concentration (DIC) of STD services and develop a taxonomy describing the scope and organization of local STD services. LHD STD programs (n = 115) in Alabama (AL) and California (CA) responded to surveys assessing STD services available in 2014. K-means cluster analysis identified LHD groupings based on DIC variation. Discriminant analysis validated cluster solutions. Differences in organizational partnerships and scope of STD services were compared by taxonomy category. Multivariable regression models estimated the association of the STD services organization taxonomy and five-year (2010–2014) gonorrhea incidence rates, controlling for county-level sociodemographics and resources. A three-cluster solution was identified: (1) low DIC (n = 74), (2) moderate DIC (n = 31), and (3) high DIC (n = 10). In discriminant analysis, 95% of jurisdictions were classified into the same types as originally assigned through K-means cluster analysis. High DIC jurisdictions were more likely (p < 0.001) to partner with most organizations than moderate and low DIC jurisdictions, and more likely (p < 0.001) to conduct STD needs assessment, comprehensive sex education, and targeted screening. In contrast, contact tracing, case management, and investigations were conducted similarly across jurisdictions. In adjusted analyses, there were no differences in gonorrhea incidence rates by category. Jurisdictions in CA and AL can be characterized into three distinct clusters based on the DIC of STD services. Taxonomic analyses may aid in improving the reach and effectiveness of STD services.

An examination of eating disorder education and experience in a 1-month adolescent medicine rotation: what is sufficient to foster adequate self-efficacy?

Objective Medical students and professionals report receiving limited education/training related to treating eating disorders. Because medical professionals are the point of initial contact for these patients and are involved necessarily in their treatment, sufficient knowledge on identification and intervention are imperative. This research set out to examine the impact of the eating disorder education and experience offered through a 1-month Adolescent Medicine rotation at a medical university on medical student/resident self-efficacy. Methods The 1-month rotation includes a standardized patient (SP) simulation, 1.5 h of didactic education, and 1 day observing the MD, nutritionist and psychologist within the outpatient Multidisciplinary Child/Adolescent Eating Disorders Clinic. All residents' (n = 132) eating disorder self-efficacy was assessed before (PRE) completing simulation and didactic session and again at the end of the 1-month rotation (END). Self-efficacy was also assessed after simulation and before the didactic session for group 1 (n = 92) and after simulation and didactic session for group 2 (n = 40). Results For group 1, self-efficacy was not significantly impacted PRE to POST. For group 2, self-efficacy significantly improved PRE to POST. POST to END changes were significant for both groups; however, group 2 scored significantly better across all self-efficacy areas at END. Conclusion Resident training in eating disorders requires more than is offered in many residency programs. SP simulation is strengthened as an effective training tool in assessing and promoting resident self-efficacy if it is followed by didactic education. Clinical observation and extended practice that includes ongoing guidance/feedback on performance is recommended in fostering self-efficacy.

Religious Affiliation, Religiosity, and Spirituality in Pediatric Residents: Effects on Communication and Self-Efficacy with Adolescents in a Clinical Setting

Religion and spirituality are known influences on medical providers' care of patients, but no studies have assessed resident beliefs related to patient perception of clinical care. The main objective of our study was to assess resident religious affiliation, religiosity, and spirituality in relation to self-efficacy and communication with patients during adolescent clinic visits. We found that religious affiliation and religiosity appear to affect patient perception of communication with residents during adolescent visits; spirituality had little noted effect. Further research is warranted, especially regarding resident and patient gender correlations and differences in religious affiliation effects on patient perception of care.

Physician Intervention to Positive Depression Screens Among Adolescents in Primary Care

PURPOSE

The objective of this study was to determine the effectiveness of computer-based screening and physician feedback to guide adolescent depression management within primary care.

METHODS

We conducted a prospective cohort study within two clinics of the computer-based depression screening and physician feedback algorithm among youth aged 12-20 years between October 2014 and October 2015 in Marion County (Indianapolis), Indiana.

RESULTS

Our sample included 2,038 youth (51% female; 60% black; mean age = 14.6 years [standard deviation = 2.1]). Over 20% of youth screened positive for depression on the Patient Health Questionnaire-2 and 303 youth (14.8%) screened positive on the Patient Health Questionnaire-9 (PHQ-9). The most common follow-up action by physicians was a referral to mental health services (34.2% mild, 46.8% moderate, and 72.2% severe range). Almost 11% of youth in the moderate range and 22.7% of youth in the severe range were already prescribed a selective serotonin reuptake inhibitor. When predicting mental health service referral, significant predictors in the multivariate analysis included clinic site (40.2% vs. 73.9%; p < .0001) and PHQ-9 score (severe range 77.8% vs. mild range 47.5%; p < .01). Similarly, when predicting initiation of selective serotonin reuptake inhibitors, only clinic site (28.6% vs. 6.9%; p < .01) and PHQ-9 score (severe range 46.7% vs. moderate range 10.6%; p < .001) were significant.

CONCLUSIONS

When a computer-based decision support system algorithm focused on adolescent depression was implemented in two primary care clinics, a majority of physicians utilized screening results to guide clinical care.

Influence of mental health and alcohol or other drug use risk on adolescent reported care received in primary care settings

Background

To describe patterns of alcohol and other drug (AOD) use risk and adolescent reported primary care (PC) screening and intervention, and examine associations of AOD risk and mental health with reported care received.

Methods

We analyzed data from cross-sectional surveys collected from April 3, 2013 to November 24, 2015 from 1279 diverse adolescents ages 12–18 who reported visiting a doctor at least once in the past year. Key measures were AOD risk using the Personal Experience Screening Questionnaire; mental health using the 5-item Mental Health Inventory; binary measures of adolescent-reported screening and intervention.

Results

Half (49.2%) of the adolescents reported past year AOD use. Of the 769 (60.1%) of adolescents that reported being asked by a medical provider in PC about AOD use, only 37.2% reported receiving screening/intervention. The odds of reported screening/intervention were significantly higher for adolescents with higher AOD risk and lower mental health scores.

Conclusions

Adolescents at risk for AOD use and poor mental health are most likely to benefit from brief intervention. These findings suggest that strategies are needed to facilitate medical providers identification of need for counseling of both AOD and mental health care for at risk youth.

Trials registration

clinicaltrials.gov, Identifier: NCT01797835, March 2013.

FACTORS INFLUENCING LAY AND PROFESSIONAL HEALTH WORKERS' SELF-EFFICACY IN IDENTIFICATION AND INTERVENTION FOR ALCOHOL, TOBACCO, AND OTHER SUBSTANCE USE DISORDERS IN KENYA

The global burden of substance use disorders (SUDs), including alcohol and tobacco, disproportionately affect low- and middle-income countries (LMICs), considering their rising disease burden and low service capacity. Nested within a Kenyan training program, this study explores factors associated with healthcare providers' self-efficacy to treat SUD. Surveys of 206 healthcare workers were used to perform regression and sensitivity analysis assessing various factors association with self-efficacy. Self-efficacy for SUD was lower in those practicing in public facilities and perceiving a need for alcohol use disorder (AUD) training; while higher self-efficacy correlated with a higher proportion of patients with AUD in one's setting, access to mental health worker support, cannabis use at a moderate risk level, and belief that AUD is manageable in outpatient settings. Increasing awareness about SUD prevalence, identification, and treatment skills could improve the self-efficacy of LMICs' health care providers and therefore the willingness to implement more services for patients with SUDs.

A comprehensive theoretical framework for the implementation and evaluation of opt-out HIV testing

Opt-out HIV testing (in which patients are offered HIV testing as a default) is a potentially powerful strategy for increasing the number of people who know their HIV status and thus limiting viral transmission. Like any change in clinical practice, implementation of opt-out HIV testing in a health service requires a change management strategy, which should have theoretical support. This paper considers the application of three theories to the implementation and evaluation of an opt-out HIV testing programme: Behavioural Economics, the Health Belief Model and Normalisation Process Theory. An awareness, understanding and integration of these theories may motivate health care providers to order HIV tests that they may not routinely order, influence their beliefs about who should be tested for HIV and inform the operational aspects of opt-out HIV testing. Ongoing process evaluation of opt-out HIV testing programmes (based on these theories) will help to achieve individual health care provider self-efficacy and group collective action, thereby improving testing rates and health outcomes.

Gender differences in the association between conduct disorder and risky sexual behavior

Despite suggestions that there are gender differences in the association between conduct disorder (CD) and risky sexual behavior, limited empirical research has examined this question. Youth (N = 616) were recruited from four primary care clinics and completed questions related to risky sexual behavior, alcohol and marijuana use, and CD. Results of stratified multivariate models indicated that the association between CD and having four or more lifetime partners, having two or more partners in the last 3 months, and engaging in condomless sex was stronger among female youth. However, the association between CD and alcohol and other drug use before sex was stronger in male youth. This is an important contribution to our understanding of gender-specific manifestations of conduct disorder, and has the potential to inform screening and brief intervention efforts for this population.

Screening in Primary Care: What Is the Best Way to Identify At-Risk Youth for Substance Use?

BACKGROUND

It is important to improve primary care providers' capability to identify youth at risk for alcohol and other drug use. To our knowledge, this is the first study to use Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria to compare screeners for youth for both alcohol and marijuana, given that these are the most frequently used substances by this age group.

METHODS

We compared the psychometric performance of 4 screeners: the National Institute on Alcohol Abuse and Alcoholism Screening Guide (NIAAA SG), the Alcohol Use Disorders Identification Test, the Car-Relax-Alone-Forget-Family and Friends-Trouble (CRAFFT) screener, and the Personal Experience Screening Questionnaire Problem Severity Scale (PESQ-PS) in identifying alcohol and marijuana use outcomes. Youth age 12 through 18 (N = 1573; 27% black, 51% Hispanic) were screened with the NIAAA SG, followed by a Web survey that included the other screeners and outcomes.

RESULTS

Sensitivity for alcohol outcomes indicated that the NIAAA SG (0.87) did not perform as well as the CRAFFT (0.97) or PESQ-PS (0.97) screeners but performed better than the Alcohol Use Disorders Identification Test (0.70). The pattern for sensitivity across screeners for marijuana outcomes was similar.

CONCLUSIONS

An important tradeoff in primary care settings is precision versus practicality. Because of brevity and focus on frequency of drinking, the NIAAA SG offers ease of administration and is good at identifying youth with probably problematic drinking levels. The PESQ-PS and the CRAFFT correctly identify more at-risk youth for alcohol and marijuana than the NIAAA SG. Future work is needed to elucidate how to efficiently and accurately identify at-risk youth in the primary care setting, including determining the best cutoff points to use to increase sensitivity.

Screening, Brief Intervention, and Referral to Treatment

Screening, Brief Intervention, and Referral to Treatment is a quick, effective technique with which to manage substance use in adolescents and young adults. Use of a validated measure for detecting substance use and abuse is significantly more effective than unvalidated tools or provider intuition. There are a variety of validated tools available to use in the adolescent/young adult population, and there are opportunities to increase the efficiency and scalability of screening by using computerized questionnaires. This area continues to evolve rapidly.

Integrated oral, mental and sexual health management for adolescents: a call for professional collaboration

BACKGROUND

Globally, young people account for 15.5% of the total global disability-adjusted life-years burden for all age groups. They face mental health, nutritional problems, accidental and intentional injuries, sexual and reproductive health problems, and substance abuse. These health challenges have effects on their oral health. This paper discusses the oral health problems adolescents face and suggests approaches for providing integrated oral and general health care for adolescents.

DISCUSSION

Oral health issues linked with adolescent health concerns include: malocclusion and esthetic concerns linked with mental health status; oral and maxillofacial injuries linked with accidental and intentional injuries; oral manifestations of sexually transmitted infections; oral leukoplakia and oral cancers linked with alcohol, tobacco and psychoactive substance abuse; and oral manifestations of anemia resulting from nutritional problems. Training oral health care providers on adolescent health and care could promote prompt diagnosis, management and prevention of complications associated with major health challenges affecting adolescents.

CONCLUSION

Adolescent oral health care needs focused attention: as a possible route for early diagnosis and management of general health problems and for promoting adolescent oral health care. Oral health care should be integrated into adolescent friendly services and oral health care providers should learn how to handle adolescents' health needs.

State-of-the-art office-based interventions to eliminate youth tobacco use: the past decade

Tobacco use and tobacco smoke exposure are among the most important preventable causes of premature disease, disability, and death and therefore constitute a major pediatric health concern. The pediatric primary care setting offers excellent opportunities to prevent tobacco use in youth and to deliver cessation-related treatment to youth and parents who use tobacco. This report updates a "state-of-the-art" article published a decade ago on office-based interventions to address these issues. Since then there has been marked progress in understanding the nature, onset, and trajectories of tobacco use and nicotine addiction in youth with implications for clinical practice. In addition, clinicians need to remain abreast of emerging nicotine delivery systems, such as electronic cigarettes, that may influence uptake or continuation of smoking. Although evidence-based practice guidelines for treating nicotine addiction in youth are not yet available, research continues to build the evidence base toward that goal. In the interim, practical guidelines are available to assist clinicians in addressing nicotine addiction in the pediatric clinical setting. This article reports current practices in addressing tobacco in pediatric primary care settings. It reviews our increasing understanding of youth nicotine addiction, summarizes research efforts on intervention in the past decade and additional research needed going forward, and provides practical guidelines for pediatric health care providers to integrate tobacco use prevention and treatment into their clinical practice. Pediatric providers can and should play an important role in addressing tobacco use and dependence, both in the youth they care for and in parents who use tobacco.

Medical student self-efficacy, knowledge and communication in adolescent medicine

OBJECTIVE

To evaluate student self-efficacy, knowledge and communication with teen issues and learning activities.

METHODS

Data were collected during the 8-week pediatric rotation for third-year medical students at a local children's hospital. Students completed a self-efficacy instrument at the beginning and end of the rotation; knowledge and communication skills were evaluated during standardized patient cases as part of the objective structured clinical examination. Self-efficacy, knowledge and communication frequencies were described with descriptive statistics; differences between groups were also evaluated utilizing two-sample t-tests.

RESULTS

Self-efficacy levels of both groups increased by the end of the pediatric rotation, but students in the two-lecture group displayed significantly higher self-efficacy in confidentiality with adolescents (t(35)=-2.543, p=0.02); interviewing adolescents, assessing risk, sexually transmitted infection risk and prevention counseling, contraception counseling were higher with marginal significance. No significant differences were found between groups for communication; assessing sexually transmitted infection risk was marginally significant for knowledge application during the clinical exam.

CONCLUSIONS

Medical student self-efficacy appears to change over time with effects from different learning methods; this higher self-efficacy may increase future comfort and willingness to work with this high-risk, high-needs group throughout a medical career.

Training in methods of preventing childhood obesity increases self-efficacy in nurses in child health services: a randomized, controlled trial

OBJECTIVE

To evaluate the effects of training in methods of preventing childhood obesity on self-efficacy (SE) in nurses.

METHODS

In a randomized, controlled trial conducted in child health services in Sweden, nurses in the intervention and control groups of the PRIMROSE prevention trial of childhood obesity were offered a 5-day workshop on dietary and physical activity interventions, and motivational interviewing. Self-efficacy for influencing parents to promote healthy dietary and physical activity behaviors in their children was measured using an 18-item instrument. Difference in SE between groups at post-assessment was analyzed using multiple linear regression analysis.

RESULTS

Compared to control nurses (n = 38), intervention nurses (n = 22) demonstrated higher SE (β = 14.70, P < .001).

CONCLUSIONS AND IMPLICATIONS

Training in methods of preventing childhood obesity increased SE in nurses. Self-efficacy should be included as a construct in evaluations of clinical training.

Tobacco use screening and treatment by outpatient psychiatrists before and after release of the American Psychiatric Association treatment guidelines for nicotine dependence

OBJECTIVES

We examined tobacco use screening and treatment by US psychiatrists before and after release of the 1996 American Psychiatric Association (APA) nicotine dependence treatment guidelines.

METHODS

We used data from the National Ambulatory Medical Care Survey to identify rates of tobacco screening and treatment by psychiatrists before the release of the guidelines (1993-1996) and during 2 postguidelines periods: 2001-2005 and 2006-2010. Multiple logistic regression was used to compare preguidelines and postguidelines rates.

RESULTS

Psychiatrists screened for tobacco use during 77% of visits from 1993 to 1996, 69% of visits from 2001 to 2005 (odds ratio [OR] = 0.69; 95% confidence interval [CI] = 0.64, 0.75), and 60% of visits from 2006 to 2010 (OR = 0.46; 95% CI = 0.43, 0.50). Psychiatrists provided cessation counseling to 12% of smokers from 1993 to 1996, 11% from 2001 to 2005 (OR = 0.97; 95% CI = 0.74, 1.26), and 23% from 2006 to 2010 (OR = 2.23; 95% CI = 1.74, 2.86). Psychiatrists prescribed nicotine replacement therapy to fewer than 1% of smokers during all 3 time periods.

CONCLUSIONS

Psychiatrists are screening for tobacco use at declining rates, and the proportion of smokers provided with treatment remains low.

Psychometric Evaluation of the Shared Decision-Making Instrument–Revised

The purpose of this study was to evaluate the psychometric properties of the Shared Decision-Making Inventory–Revised (SDMI-R) to measure four constructs (knowledge, attitudes, self-efficacy, and intent) theoretically defined as vital in discussing the human papillomavirus (HPV) disease and vaccine with clients. The SDMI-R was distributed to a sample ( N = 1,525) of school nurses. Correlational matrixes denoted moderate to strong correlations, indicating adequate internal reliability. Reliability for the total instrument was satisfactory (α = .874) along with Attitude, Self-Efficacy and Intent subscales .828, .917, .891, respectively. Exploratory factor analysis revealed five components that explained 75.96% of the variance.

A new paradigm for teaching behavior change: implications for residency training in family medicine and psychiatry

BACKGROUND

Primary care physicians (PCPs) provide ~50 % of all mental health services in the U.S. Given the widening gap between patient mental health needs and resources available to meet those needs, there is an increasing demand for family medicine and psychiatry trainees to master competencies in both behavioral medicine and primary care counseling during residency-if for no other reason than to accommodate the realities of medical practice given the oft present gap between the need for psychiatric services and the availability, quality, and/or affordability of specialized psychiatric care. To begin to address this gap, a skills-based, interactive curriculum based on motivational interviewing (MI) as a teaching method is presented.

METHODS

The curriculum described in this paper is a four-week block rotation taught in the second year of residency. Motivational interviewing (MI) is used as a teaching approach toward the goal of clinical behavior change. Residents' strengths, personal choice and autonomy are emphasized. Each week of the rotation, there is a clinical topic and a set of specific skills for mastery. Residents are offered a "menu" of skills, role modeling, role/real play, practice with standardized patients (SP), and direct supervision in clinic.

RESULTS

Thirty-nine residents have completed the curriculum. Based on residents' subjective reporting using pre-post scales (i.e., importance and confidence), all participants to date have reported substantial increases in confidence/self-efficacy using primary care counseling skills in their continuity clinic.

CONCLUSIONS

This paper presents an innovative, empirically based model for teaching the essential skills necessary for physicians providing care for patients with mental/emotional health needs as well as health-behavior change concerns. Implications for training in the broader context, particularly as it relates to multi-disciplinary and collaborative models of teaching/training are discussed.

Local public health systems and the incidence of sexually transmitted diseases

OBJECTIVES

We examined the associations of local public health system organization and local health department resources with county-level sexually transmitted disease (STD) incidence rates in large US health jurisdictions.

METHODS

We linked annual county STD incidence data (2005-2008) to local health department director responses (n = 211) to the 2006 wave of the National Longitudinal Study of Local Public Health Systems, the 2005 national Local Health Department Profile Survey, and the Area Resource File. We used nested mixed effects regression models to assess the relative contribution of local public health system organization, local health department financial and resource factors, and sociodemographic factors known to be associated with STD incidence to county-level (n = 307) STD incidence.

RESULTS

Jurisdictions with local governing boards had significantly lower county-level STD incidence. Local public health systems with comprehensive services where local health departments shoulder much of the effort had higher county-level STD rates than did conventional systems.

CONCLUSIONS

More integration of system partners in local public health system activities, through governance and interorganizational arrangements, may reduce the incidence and burden of STDs.

Relationship of training to self-reported competency and care of adolescents in an African health care setting

PURPOSE

Adolescent medicine is not a recognized specialty in most African countries and African healthcare providers receive little adolescent-specific training. We explored the association between training, self-reported competence, and clinical practice related to adolescent health in an African setting.

METHODS

A total of 119 healthcare providers of various disciplines who work with adolescent patients in Francistown, Botswana were surveyed regarding their adolescent-specific training, self-reported competence, and counseling practices. Self-reported competence and practices related to counseling adolescents about sexual activity, alcohol and/or drug use, human immunodeficiency virus (HIV)-specific issues, and mental health were explored.

RESULTS

In all, 50.4% of respondents had received HIV training with an adolescent-specific component. Fewer had received adolescent-specific training outside the context of HIV prevention and management. Respondents were significantly more likely to report higher competence for all items except for counseling adolescents about depression and anxiety if they had received any adolescent-specific training. Respondents who reported higher competence were significantly more likely to report more frequent counseling of their adolescent clients.

CONCLUSIONS

Our study suggests that adolescent-focused training is important for ensuring that adolescents receive counseling when presenting for routine healthcare in our setting. The mental health needs of adolescents do not seem to be adequately addressed by current training.

Peer relational victimization and somatic complaints during adolescence

PURPOSE

To develop effective prevention and intervention efforts that optimize adolescent health, factors must be identified that affect health outcomes. The purpose of this study was to examine the association between somatic symptomatology and experiences with relational victimization (RV).

METHODS

We prospectively tested the unique role of relational peer victimization in predicting adolescents' somatic complaints (SC), while accounting for their previous physical symptoms and peer victimization experiences (i.e., relational and physical victimization), as well as concurrent experiences with physical victimization (PV). Questionnaires were administered to 1,595 students (52% females) from eight schools in one school district (grades, 5-8) in the Midwestern part of the United States during the fall and spring sessions of the academic school year. Self-reported measures included demographic characteristics, victimization experiences, and assessment of SC.

RESULTS

RV was a unique predictor of increased somatic symptoms, even after controlling for adolescents' sex, grade level, initial SC, previous victimization experiences, and concurrent experiences with PV. Notably, RV was a stronger predictor of somatic symptoms than was PV.

CONCLUSIONS

Our findings underscore the need for a comprehensive approach when addressing adolescents' physical health symptoms. Adolescents may benefit from clinicians looking beyond the obvious and using gentle probing to uncover how unique experiences with RV may be associated with overall health.

'Adolescence is difficult, some kids are difficult': general practitioner perceptions of working with young people

General practitioners (GPs) are the health care providers from which young people are most likely to seek help. However, the rate at which young people access GPs is less than ideal. Four focus groups were conducted with groups of GPs in New South Wales to inform the development of a GP training program on youth health. Analysis of the focus group interviews yielded three themes that describe the context in which GPs work with young people, how GPs see young people and their work with them, and GPs' expressed training preferences. GPs described working with young people as difficult, which in turn suggests that the self-efficacy of GPs may need to be addressed in training and resource development. GPs also described systemic barriers to working with young people that can be addressed through training, advocacy and policy development.

Enhancing Drug Treatment Program Staff's Self-Efficacy to Support Patients' HCV Needs

To increase HCV-related support for patients in substance abuse treatment programs, we implemented an on-site staff training in 16 programs throughout the United States. It aimed to increase participants' self-efficacy in assisting patients with their HCV-related needs. Findings indicate that participants' self-efficacy increased both 1- and 3-months post-training, resulting in providers' perceptions that they were better able to support patients regarding HCV. Implementing an engaging and interactive HCV training for social workers and other substance abuse treatment program staff has the potential to increase their HCV knowledge, self-efficacy, and the HCV-related assistance provided to patients both in the short- and longer-term.

Detecting emotional disorder in young people in primary care

PURPOSE OF REVIEW

Screening young people for emotional disorder in primary care has seemed sensible given most attend annually and most mental disorder is undetected. Yet evidence supporting screening has been scant. This review considers recent progress around conceptual frameworks, epidemiological findings, accuracy of available instruments and evidence for effectiveness of screening in reducing the burden of emotional disorders.

RECENT FINDINGS

Despite better evidence about the accuracy of screens in identifying adolescent depression and possible benefits of early intervention with current treatments, demonstration of improved health outcomes and cost-effectiveness is still lacking. Even when screening detects mental disorder other factors such as readiness for care and availability of effective treatments may affect responses. Best results are obtained when screening is linked to collaborative models of care. Evidence around harms from screening is scant but debate exists over potential harms of false-positives such as stigma and increased strain on healthcare resources.

SUMMARY

There is growing consensus that, if screening for emotional disorder is to be effective in primary care, facilitated access of identified young people to effective treatment options is necessary. Further research is required to demonstrate that routine screening will improve mental health outcomes and be cost-effective.

Are adolescents being screened for emotional distress in primary care?

PURPOSE

To assess primary care providers' rates of screening for emotional distress among adolescent patients.

METHODS

Secondary data analysis utilizing data from: (1) well visits in pediatric clinics within a managed care plan in California, and (2) the 2003 California Health Interview Survey (CHIS), a state population sample. The Pediatric clinic sample included 1089 adolescent patients, ages 13 to 17, who completed a survey about provider screening immediately upon exiting a well visit. The CHIS sample included 899 adolescents, ages 13 to 17, who had a routine physical exam within the past 3 months. As part of the survey, adolescents answered a question about whether they had talked with their provider about their emotions at the time of the exam. Logistic regressions, controlling for age, gender, race/ethnicity, and adolescent depressive symptoms were performed.

RESULTS

About one-third of adolescents reported a discussion of emotional health. Females were significantly more likely to be screened than males (36% vs. 30% in clinic; 37% vs. 26% in CHIS); as were older and Latino adolescents in the clinic sample. Although 27% of teens endorsed emotional distress, distress was not a significant predictor of talking to a provider about emotions.

CONCLUSIONS

Primary care clinicians/systems need to better utilize the primary care visit to screen adolescents for emotional health.