Using a Delphi Technique to Define Primary Care Behavioral Health Clinical Supervision Competencies.

There is an increasing need for Primary Care Behavioral Health (PCBH) workforce development (i.e., increase in well-trained PCBH providers) given the growth of behavioral health (BH) integration into primary care, specifically at a time when behavioral health needs are increasing because of the COVID-19 pandemic (Kanzler and Ogbeide in Psychol Trauma 12(S1):S177-S179, https://doi.org/10.1037/tra0000761 , 2020). Therefore, it is imperative to provide current and future behavioral health clinical supervisors in primary care settings specific competencies, given there are no current competencies specific to clinical supervision within the PCBH Model. Using a Delphi process, the authors identified and reached expert consensus on competencies for BH clinical supervisors in primary care. A purposive sample (in: Patton, Qualitative evaluation and research methods, Sage, Newbury Park, 1990) of fifteen experts (n = 15) in PCBH clinical training and education evaluated quantitative and qualitative domains and specific competencies associated with PCBH supervision gathered during an initial in-depth qualitative interview. This was followed by two subsequent rounds of quantitative Delphi surveys to reach consensus. The response rates from our panel of experts were 100% (15/15) for all stages (interviews, round one and round two surveys). Three domains (Primary Care Knowledge, Clinical Supervisor Development, and Clinical Supervision Skills) were rated as essential for providing clinical supervision with PCBH for pre-licensure level learners. The development of competencies will further support BH clinical supervisor needs, professional development, and provide a concrete way to evaluate progress towards teaching and training excellence. This will also have a great impact on the development of the future BH workforce within primary care.

Moral injury in post-9/11 combat-experienced military veterans: A qualitative thematic analysis.

War zone exposure is associated with enduring negative mental health effects and poorer responses to treatment, in part because this type of trauma can entail crises of conscience or moral injury. Although a great deal of attention has been paid to posttraumatic stress disorder and fear-based physiological aspects of trauma and suffering, comparatively less attention has been given to the morally injurious dimension of trauma. Robust themes of moral injury were identified in interviews with 26 post-9/11 military veterans. Thematic analysis identified 12 themes that were subsumed under four categories reflecting changes, shifts, or ruptures in worldview, meaning making, identity, and relationships. Moral injury is a unique and challenging clinical construct with impacts on the individual as well as at every level of the social ecological system. Recommendations are offered for addressing moral injury in a military population; implications for community public health are noted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Family physicians' suggestions to improve the documentation, coding, and billing system: a study from the residency research network of Texas.

BACKGROUND AND OBJECTIVES: The study's aim was to ascertain family physicians' suggestions on how to improve the commonly used US evaluation and management (E/M) rules for primary care. METHODS: A companion paper published in Family Medicine's May 2014 journal describes our study methods (Fam Med 2014;46(5):378-84). RESULTS: Study subjects supported preserving the overall SOAP note structure. They especially suggested eliminating bullet counting in the E/M rules. For payment reform, respondents stated that brief or simple work should be paid less than long or complex work, and that family physicians should be paid for important tasks they currently are not, such as spending extra time with patients, phone and email clinical encounters, and extra paperwork. Subjects wanted shared savings when their decisions and actions created system efficiencies and savings. Some supported recent payment reforms such as monthly retainer fees and pay-for-performance bonuses. Others expressed skepticism about the negative consequences of each. Aligned incentives among all stakeholders was another common theme. CONCLUSIONS: Family physicians wanted less burdensome documentation requirements. They wanted to be paid more for complex work and work that does not include traditional face-to-face clinic visits, and they wanted the incentives of other stakeholders in the health care systems to be aligned with their priorities.

Family physicians' opinions on the primary care documentation, coding, and billing system: a qualitative study from the residency research network of Texas.

BACKGROUND AND OBJECTIVES: The study's aim was to deepen our understanding of family physicians' perceptions of the strengths and weaknesses of the widely used US documentation, coding, and billing rules for primary care evaluation and management (E/M) services. METHODS: This study used in-depth, qualitative interviews of 32 family physicians in urban and rural, academic, and private practices. Interviews were initiated with a series of grand tour questions asking participants to give examples and personal narratives demonstrating cost efficiencies and cost inefficiencies relating to the E/M rules in their own practices. Investigators independently used an immersion-crystallization approach to analyze transcripts to search for unifying themes and subthemes until consensus among investigators was achieved. RESULTS: The majority of participants reported that the documentation rules, coding rules, and common fees for procedures and preventive services were reasonable. The E/M documentation rules for all other visit types, however, were perceived by the participants as unnecessarily complicated and unclear. The existing codes did not describe the actual work for common clinic visits, which led to documenting and coding by heuristics and patterns. Participants reported inadequate payment for complex patients, multiple patient concerns in a single office visit, services requiring extra time beyond a standard office visit, non-face-to-face time, and others. The E/M rules created unintended negative consequences such as family physicians not accepting Medicare or Medicaid patients, inaccurate documentation, poor-quality care, and system inefficiencies such as unnecessary tests and referrals. CONCLUSIONS: Family physicians expressed many problems and frustrations with the existing E/M documentation, coding, and billing rules and felt the system undervalued and unappreciated them for the complex and comprehensive care they provide. Findings of this study could inform improved guidelines for primary care documentation, coding, and billing.

Measuring capability for healthy diet and physical activity.

PURPOSE: Patterns of diet and physical activity, major drivers of morbidity and mortality, are contingent on people's feasible opportunities to pursue healthy behaviors. Our objective for this mixed methods study was to develop measures of feasible opportunities for diet and activity. METHODS: The Capability Approach framework for evaluating people's real freedoms to pursue their values guided the research. A community-based participatory model was applied to conduct focus groups of adults with obesity or diabetes mellitus from an economically disadvantaged Latino community. Focus group themes were developed into survey items that assess how individual circumstances and neighborhood contexts influence opportunities for diet and activity. The prevalence of different influences was explored in a sample of 300 patients from a primary care safety net clinic. Scales measuring different aspects of opportunity were created through principal components analysis. RESULTS: Availability, convenience, safety, cost of food, and activity resources interact with individual circumstances, such as illness, depression, family and nonfamily supports, and scope of personal agency, to shape practical opportunities. Multiple vulnerabilities in availability of resources and moderators of resource use commonly occur together, intensifying challenges and creating difficult trade-offs. Only one-half of participants reported that physicians understood their difficulties pursuing activity, and just one-third for diet. CONCLUSIONS: Our results suggest that practical opportunities for healthy behavior can be measured as a primary target for clinical and public health assessment and intervention. The Capability Approach holds promise as a framework for developing interventions responsive to both personal and environmental determinants.

Family physicians' perceptions on how they deliver cost-effective care: a qualitative study from the Residency Research Network of Texas (RRNeT).

BACKGROUND AND OBJECTIVES: The aim of our study was to deepen our understanding of the factors that may explain the observational literature that more primary care physicians in an area contribute to better population health outcomes and lower health care costs. METHODS: This study used in-depth, qualitative interviewing of family physicians in both urban and rural, academic, and private practices. Interviews were initiated with a series of grand tour questions asking subjects to give examples and personal narratives demonstrating cost-effectiveness and cost inefficiencies in their own practices. An iterative open-coding approach was used to analyze transcripts to search for unifying themes and sub-themes until consensus among investigators was achieved. RESULTS: Thirty-eight respondents gave examples of how their decision-making approaches resulted in improved patient outcomes and lower costs. Family physicians' cost-effective care was founded on two themes-characteristic attitudes and skills of the physicians themselves and a thorough knowledge of the whole patient. Family physicians also felt their approaches to gathering information and then making diagnostic and treatment decisions resulted in fewer tests and fewer treatments ordered overall. Family physicians also delivered care in less expensive facilities and generated lower overall charges for physician fees. CONCLUSIONS: Family physicians perceived that their approaches to patient care result in medical decision making priorities and care delivery processes that contribute to more cost-effective health care. These outcomes were achieved less by providing preventive services and strictly adhering to guidelines but rather by how they individualized the management of new symptoms and chronic conditions.

Perceptions of childhood obesity on the Texas-Mexico border.

OBJECTIVES: We sought to determine the extent of intracultural consensus in perceptions of childhood obesity among Mexican American mothers living on the Texas-Mexico border. DESIGN AND SAMPLE: A descriptive, cross-sectional study examined women's judgments about the parameters of childhood obesity. The convenience sample consisted of 61 Mexican American women who were mothers of at least 1 child under age 18. MEASURES: Participants underwent an anthropometric assessment and were surveyed regarding self-perceived weight and household food security. They were then shown photographs of 36 Mexican American boys ages 6 and 7 and asked to sort them into categories by weight status; they also selected 3 children they believed represented the healthiest, most appropriate weight for age. Accuracy scores were computed and examined for bivariate relationships with women's own body mass index (BMI) and survey responses. RESULTS: We found considerable intracultural variation in women's judgments, which could not be explained by the anthropometric and survey variables tested. Women selected a wide range of percentiles as representative of a healthy child. On average, about half of the truly overweight children (BMI>or=95th percentile), however, were considered normal or even underweight. CONCLUSIONS: Local perceptions and language may not correspond to CDC/WHO clinical standards. Larger studies are needed to confirm these preliminary findings.

Explaining low rates of autism among Hispanic schoolchildren in Texas.

In data from the Texas Educational Agency and the Health Resources and Services Administration, we found fewer autism diagnoses in school districts with higher percentages of Hispanic children. Our results are consistent with previous reports of autism rates 2 to 3 times as high among non-Hispanic Whites as among Hispanics. Socioeconomic factors failed to explain lower autism prevalence among Hispanic schoolchildren in Texas. These findings raise questions: Is autism underdiagnosed among Hispanics? Are there protective factors associated with Hispanic ethnicity?

Evening primrose oil.

Evening primrose oil (Oenothera biennis) is a commonly used alternative therapy and a rich source of omega-6 essential fatty acids. It is best known for its use in the treatment of systemic diseases marked by chronic inflammation, such as atopic dermatitis and rheumatoid arthritis. It is often used for several women's health conditions, including breast pain (mastalgia), menopausal and premenstrual symptoms, cervical ripening, and labor induction or augmentation. However, there is insufficient evidence to make a reliable assessment of its effectiveness for most clinical indications. The current evidence suggests that oral evening primrose oil does not provide clinically significant improvement in persons with atopic dermatitis, and that it is also likely ineffective for the treatment of cyclical mastalgia and premenstrual syndrome. However, most trials to date have significant methodologic flaws and must be considered preliminary. The use of evening primrose oil during pregnancy is not supported in the literature and should be avoided. Evening primrose oil is generally well tolerated, with reported minor adverse effects, including gastrointestinal upset and headaches. Optimal dosing standards and treatment regimens await clarification in adequately powered clinical trials.

Culture-bound syndromes in Hispanic primary care patients.

INTRODUCTION: We sought to document Hispanic primary care patients' knowledge and experience of five culture-bound syndromes (CBS), as well as the basic socio-cultural correlates of these disorders. METHODS: A convenience sample of 100 adult Hispanic patients presenting in an urban South Texas primary care clinic was recruited to complete a brief cross-sectional survey, presented in an oral format. Interviews sought information concerning five culture-bound syndromes--susto, empacho, nervios, mal de ojo, and ataques de nervios. Additional demographic, socio-economic, and acculturation data was collected. Descriptive and bivariate statistics (chi square, Fisher's) were used to assess relationships among variables and experience with each CBS. A multivariate logistic analysis was conducted to determine the possible contributions of age, gender, acculturation, and education to the personal experience of a culture-bound syndrome. RESULTS: Results indicate that 77% of respondents had knowledge of all five syndromes, with 42% reporting having personally experienced at least one CBS. Nervios was the most commonly suffered disorder, being reported by 30 respondents. This was followed, in declining order ofprevalence, by susto, mal de ojo, empacho, and ataques de nervios. Multivariate logistic regression analysis found that higher education beyond high school was associated with a slightly decreased likelihood of reporting having suffered from any culture-bound syndrome. While co-occurrence among these disorders occurred, the patterns of predictors suggest that the co-occurrence is not a reflection of mislabeling of one common syndrome. CONCLUSION: Knowledge of and experience with culture-bound syndromes is common among Hispanic primary care patients in South Texas. Healthcare providers ought to consider discussing these illnesses in a non-judgmental manner with patients who present with symptoms that are consistent with these syndromes. Future studies, with larger sample sizes, are warranted to elucidate the nature of culture-bound disorders and their relationships with conventional diagnostic entities and treatment-seeking behaviors.

Metaphors to cure by: Tojolab'al Maya midwifery and cognition.

The southern Mexican state of Chiapas has the highest concentration of indigenous peoples in Mexico and ranks first among all states for the percentage of births attended by nurses or midwives. Efforts to improve maternal and child health in this region, therefore, must engage indigenous midwives and healers in a meaningful way, which presupposes an understanding and respect for the area's rich ethnomedical traditions. To this end, the present paper synthesises findings of in-depth ethnographic fieldwork by the author among Tojolab'al Mayan midwives. Several cultural themes underlying cognitive models of reproductive health are presented. Results indicate that several prominent metaphors relating to natural cycles of agricultural growth, death and regeneration form a bridge that links human fertility and illness to a living, dynamic cosmology. As suggested by quantitative analyses presented here, these 'metaphors to cure by' provide clues that are likely to prove central to the translation of public health programmes and clinician-patient communication in this population.

Herbal and other complementary medicine use by Texas midwives.

This cross-sectional survey sought to document complementary and alternative medicine (CAM) use by Texas midwives, as well as to determine whether licensed direct-entry midwives (LMs) and certified nurse-midwives (CNMs) differed significantly in their patterns of use. All respondents (n = 69) indicated that they used, recommended, or referred their clients for at least one CAM therapy during the preceding year. Ninety percent (90%) of respondents used, recommended, or referred their clients for an herbal remedy (not including homeopathic tinctures). Herbal therapies were among the top three modalities recommended for 7 of 12 (58%) clinical indications. Herbs were the most salient CAM therapy used for cervical ripening (83%), followed closely by use for nausea, vomiting, and hyperemesis (80%), and labor induction (77%). Herbal therapies also constituted 50% or more of the CAM therapies used for the following indications: anemia/iron supplementation (70%), perineal healing (66%), and anxiety/stress/fatigue (50%). LM respondents used, recommended, or referred their clients for a greater number of herbal therapies compared to CNMs. While several of the CAM modalities used or recommended by Texas midwives show potential for clinical benefit, few have been studied sufficiently to determine their efficacy or safety during pregnancy.

A qualitative study of Mexican American adolescents and depression.

Depressive disorders are present in a high percentage of Mexican American adolescents. Among the US Mexican American population, suicide is the fourth leading cause of death among 10- to 19-year-olds. Little research, however, has focused on Mexican American adolescents' knowledge and views about depression and seeking help for depression. Results from a qualitative study on Mexican American adolescents' attitudes about depression are investigated in this paper. Sixty-five high school and middle school students in a largely Mexican American, urban school district in San Antonio, Tex, participated in 9 semistructured, focus group interviews where participants were asked questions to elicit their understanding of depression, treatment for depression, and words used to describe it. Coding of salient words and themes from transcribed interviews were entered into Atlas. ti for qualitative analysis. Three themes emerged: (1) adolescents' definitions of depression, (2) beliefs about adolescent depression, and (3) treatment for adolescent depression. While depressive symptoms among Mexican American adolescents are common and recognized, resource and treatment knowledge is scarce. An understanding of the beliefs, attitudes, and knowledge of these adolescents can provide crucial information about the content and structure of a universal, school-based, peer-facilitated depression awareness program.