Gender, psychiatric disability, and dropout from peer support specialist training.

Although research indicates that the prevalence of psychiatric disability differs depending on gender, a paucity of information exists as to whether men and women with psychiatric disability also differ regarding service program outcomes. For a United States Southwest peer support specialist training program, this study examines whether gender moderates the association between psychiatric disability and a key outcome-training dropout. Data were collected for 78 men and 157 women with psychiatric disability and 137 men and 203 women with mental illness only. Logistic regression was used to examine the association between psychiatric disability and dropout, with gender as a moderator variable, and age, education, race/ethnicity, and substance use disorder as control variables. Of trainees with psychiatric disability, dropout was greater among men than women (34.6% and 20.4%, respectively; p < .05). Dropout was also greater among men with psychiatric disability than among men with mental illness only (34.6% and 15.3%; p < .01). In contrast, dropout was similar for women with psychiatric disability and mental illness only (20.4% and 18.7%; p > .05), and dropout was comparable among men and women with mental illness only (15.3% and 18.7%; p > .05). In summary, risk of dropout was substantially higher among men with psychiatric disability than women with psychiatric disability. Gender tailoring of the program's services should be considered to better support training completion. This study's findings also raise questions as to possible underrepresentation of men with psychiatric disability in the peer support workforce training pipeline. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Artificially sweetened beverages, sugar-sweetened beverages, plain water, and incident diabetes mellitus in postmenopausal women: the prospective Women's Health Initiative observational study.

Background: Sugar-sweetened beverages (SSBs) have been associated with an increased risk of diabetes mellitus (DM), whereas the association with artificially sweetened beverages (ASBs) is unclear.Objective: We aimed to evaluate the associations of ASB and SSB consumption with the risk of developing DM and the potential benefit of replacing SSBs with ASBs or water.Design: The national Women's Health Initiative recruited a large prospective cohort of postmenopausal women between 1993 and 1998. ASB, SSB, and water consumption was measured by lifestyle questionnaires, and DM was self-reported.Results: Of 64,850 women, 4675 developed diabetes over an average of 8.4 y of follow-up. ASBs and SSBs were both associated with an increased risk of DM with an HR of 1.21 (95% CI: 1.08, 1.36) comparing ASB consumption of ≥2 serving/d to never or <3 serving/mo, and an HR of 1.43 (95% CI: 1.17, 1.75) comparing SSB consumption of ≥2 serving/d to <1 serving/wk (1 serving = one 12-ounce can or 355 mL). Subgroup analysis found an increased risk of DM associated with ASBs only in the obese group. Modeling the substitution of SSBs with an equal amount of ASBs did not significantly reduce the risk of developing DM. However, statistically substituting 1 serving of ASBs with water was associated with a significant risk reduction of 5% (HR: 0.95; 95% CI: 0.91, 0.99), whereas substituting 1 serving of SSBs with water was associated with a risk reduction of 10% (HR: 0.90; 95% CI: 0.85, 0.95).Conclusions: ASBs were associated with a 21% increased risk of developing DM, approximately half the magnitude of SSBs (associated with a 43% increased risk). Replacing ASBs and SSBs with water could potentially reduce the risk. However, caution should be taken in interpreting these results as causal because both residual confounding and reverse causation could explain these results.

Relationship Between Marital Transitions, Health Behaviors, and Health Indicators of Postmenopausal Women: Results from the Women's Health Initiative.

BACKGROUND: Historically, marital status has been associated with lower mortality and transitions into marriage were generally accompanied by improved health status. Conversely, divorce has been associated with increased mortality, possibly mediated by changes in health behaviors. METHODS: This study uses data from a prospective cohort of 79,094 postmenopausal women participating in the Women's Health Initiative Observational Study (WHI-OS) to examine the relationship between marital transition and health indicators (blood pressure, waist circumference, body mass index [BMI]) as well as health behaviors (diet pattern, alcohol use, physical activity, and smoking) in a sample of relatively healthy and employed women. Linear and logistic regression modeling were used to test associations, controlling for confounding factors. RESULTS: Women's transitions into marriage/marriage-like relationship after menopause were associated with greater increase in BMI (ß = 0.22; confidence interval (95% CI), 0.11-0.33) and alcohol intake (ß = 0.08; 95% CI, 0.04-0.11) relative to remaining unmarried. Divorce/separation was associated with a reduction in BMI and waist circumference, changes that were accompanied by improvements in diet quality (ß = 0.78, 95% CI, 0.10-1.47) and physical activity (ß = 0.98, 95% CI, 0.12-1.85), relative to women who remained married. CONCLUSION: Contrary to earlier literature, these findings among well-educated, predominantly non-Hispanic white women suggest that marital transitions after menopause are accompanied by modifiable health outcomes/behaviors that are more favorable for women experiencing divorce/separation than those entering a new marriage.

Families United/Familias Unidas: family group office visits to reduce risk factors for type 2 diabetes.

PURPOSE: The purpose of the Families United/Familias Unidas study was to evaluate the feasibility and efficacy of group office visits on reducing diabetes risk in a multiethnic, primary care population. METHODS: Adults, ages 18 to 70 years, with any diabetes risk factor were recruited to attend 12 group office visits over 6 months. Each participant identified 1 support person, age 14 to 70 years, to accompany them. Data were collected at baseline, postintervention, 6 months, and 12 months. Primary outcome measures were reduction in the total number of predefined, modifiable risk factors (ie, body mass index ≥25 kg/m(2); waist circumference ≥88 cm [women], ≥102 cm [men]; blood pressure ≥140/90 mm Hg; hemoglobin A1C ≥5.7%; fasting insulin ≥15 µU/mL; glycemic index ≥52.5% [women], ≥53.4% [men]; and physical activity <150 min/wk). RESULTS: Thirty-nine participants/supporters completed the intervention (mean age 47.8 ± 12.3 years, 69.2% female, 61.5% white, 35.9% Latino). Risk reduction analysis included only participants/supporters who remained paired at the intervention's end (n = 36). At baseline, primary participants (n = 18) had an average of 4.8 ± 1.6 (standard error) predefined risk factors; supporters (n = 18), 4.1 ± 1.4. Primary participants' risk factors decreased approximately 15% immediately after the 6-month intervention (absolute reduction of 1.1 risk factors) and increased to ~20% reduction 1 year postintervention (absolute reduction of 1.4 risk factors). Risk reduction was primarily due to decreases in dietary glycemic index and fasting insulin levels. CONCLUSIONS: Group visits provide an innovative and potentially efficacious model of diabetes prevention in multiethnic patients with heterogeneous risk factors.

Cultural competence education for practicing physicians: lessons in cultural humility, nonjudgmental behaviors, and health beliefs elicitation.

INTRODUCTION: Although numerous studies have examined cultural competence training, debate still exists about efficacious approaches to this training. Furthermore, little focus has been placed on training and evaluating practicing physicians. METHODS: A skills-based course on culturally competent diabetes care was developed and subsequently tested in a controlled trial of primary physicians caring for patients enrolled in one state's Medicaid program. We hypothesized that physicians completing the course would show higher levels of self-reported cultural competence as measured by a Cultural Competence Assessment Tool (CCAT) than those in the control group. Differences in CCAT subscale scores were also compared. RESULTS: Ninety physicians completed the study, with 41 in the control and 49 in the intervention group. Most were female (66%), with an average age of 44, and 12 years in practice. There were no significant differences on total CCAT score (212.7 ± 26.7 for control versus 217.2 ± 28.6 for intervention, p = .444) or subscales measuring cultural knowledge. There were significant positive differences on the subscales measuring physicians' nonjudgmental attitudes/behaviors (subscale score 2.38 ± 0.46 for control versus 2.69 ± 0.52 for intervention, p = .004) and future likelihood of eliciting patients' beliefs about diabetes and treatment preferences (3.11 ± 0.53 for control versus 3.37 ± 0.45 for intervention, p = .014). There was, however, a significant negative difference on the subscale measuring cultural self-awareness (3.48 ± 0.36 for control versus 3.26 ± 0.48 for intervention, p = .018). DISCUSSION: A predominantly skills-based approach to training physicians did not change aggregate measures of cultural competence, but did affect key attitudes and behaviors, which may better reflect the goals of cultural competence training.

Assessing culturally competent diabetes care with unannounced standardized patients.

BACKGROUND AND OBJECTIVES: More effective diabetes care is desperately needed, especially for ethnic minority populations. Provider cultural competence promises to be an important means for reducing disparities in outcomes for patients with diabetes. The objectives of this study were to understand the role of cultural competence in the diabetes office visit. METHODS: Unannounced standardized patients (SPs) were sent to the offices of 29 family and internal medicine residents and practicing physicians. The SPs portrayed a Mexican American woman newly diagnosed with type 2 diabetes. Using a checklist developed with the input of experts in Hispanic/Latino health care and cultural competence, the SPs evaluated physicians' cultural competence, diabetes care, and general communications skills. RESULTS: The average total SP Checklist score was 70.7-11.0%, with a range of 43.9% to 90.2%. Physicians scored highly on items that measured general communication skills (95.9%) but were less likely to ask about social history (ie, family and community support issues, 51.9% and 48.1%, respectively). Sixty-seven percent of physicians ordered a hemoglobin A1c, 44% referred to ophthalmology, and 15% performed a monofilament exam. Physicians' inquiry into SPs explanatory model of disease (ie, asking about the SPs' views regarding their disease and its treatment) correlated with the performance of several diabetes treatment-related behaviors, Spearman's rho=.466. CONCLUSIONS: The findings provide support for a relationship between inquiry into patients' explanatory models of disease and effective diabetes care. Social history and explanatory model elicitation skills are vital parts of cultural competence training programs and potentially valuable tools for mitigating health disparities.

Families United/Familias Unidas: development and implementation of a family-based group office visit model for the primary prevention of type 2 diabetes.

PURPOSE: The purpose of this study is to describe the development and implementation of a new diabetes prevention intervention that combines the benefits of family support with the group office model. Intensive lifestyle modification can effectively delay the onset of type 2 diabetes, yet health providers are challenged in translating these results to their patients. The group outpatient visit model can provide a means to address prevention issues in a financially sustainable manner. METHODS: Materials from the Diabetes Prevention Program and a previously developed group office visit program were combined to create the Families United/Familias Unidas curriculum. The session content utilized a multiculturally tailored approach designed to help participants decrease portion size, decrease carbohydrate intake, increase physical activity, and increase resiliency. Adults aged 18 to 70 were recruited who had any diabetes risk factors but did not have diabetes. Eligible participants enlisted a support person, aged 14 to 70, to join them in the 6-month group office visit intervention. RESULTS: Twenty-nine pairs (n = 58) of primary participants plus support persons were recruited. Participants' average age was 45; 74% were female; 56.9% identified themselves as white and 37.9% as Hispanic/Latino. Over one-third had 4 or more diabetes risk factors. Twelve family group office visits were delivered over 6 months. The attendance rate for those who attended at least one session was 72%. CONCLUSIONS: Group office visits can provide a new sustainable model for diabetes prevention and are a natural fit for primary care physicians in collaboration with other health care professionals, such as dieticians or diabetes educators.

Pilot study of impact of medical-legal partnership services on patients' perceived stress and wellbeing.

UNLABELLED: Medical-legal partnerships (MLPs) bring legal services into health care settings to address patients' unmet legal needs. This pilot project examined whether MLP services impact patients' perceptions of stress and wellbeing. METHODS: Providers referred patients with legal concerns to the Tucson Family Advocacy Program (TFAP), an MLP within a family medicine clinic. Stress levels and wellbeing were assessed before and after legal services using self-administered 10-item Perceived Stress Scale (PSS-10) and Measure Yourself Concerns and Wellbeing (MYCaW) instruments. RESULTS: Sixty-seven participants completed pre- and post-service questionnaires. Within this group, the mean PSS-10 score decreased 8.1 points. Wellbeing scores improved by 1.8 points. Individual changes in perceived stress were strongly related to participants' level of concern regarding the particular legal issues addressed. CONCLUSIONS: Services in patient-centered medical homes to address unmet legal needs have the potential to reduce perceived stress and improve overall wellbeing. Additional studies concerning MLPs and patient outcomes are needed.

Concurrent and longitudinal predictors of self-esteem in elementary and middle school girls.

BACKGROUND: The purpose of this study was to analyze the effects of factors related to self-esteem, both cross-sectionally and longitudinally, among 2 cohorts of girls over a period of 4 years, from elementary through middle school. METHODS: A multiethnic sample of 656 elementary school girls recruited from 13 schools in Hayward, CA, and Tucson, AZ, was evaluated annually over a 4-year period. The McKnight Risk Factor Survey IV was administered, which consists of 103 questions that assess self-esteem, appearance appraisal, effect of body changes, depressed mood, teasing, school performance, and other factors. In addition, participants' heights and weights were measured. RESULTS: The most important predictor of self-esteem in each grade was appearance appraisal, and, in all grades but the eighth, weight-related teasing by either boys or girls was also a predictor of self-esteem. Teasing about weight was more important than body weight itself in predicting self-esteem. Self-esteem was lower in girls who were teased about their weight, even if they believed that it had no effect on how they felt about themselves. School performance predicted self-esteem in grades 6 and 8. In longitudinal analyses, the participant's current perception of her appearance was more important than her previous level of self-esteem in predicting current self-esteem. CONCLUSIONS: The results of this study support the need to allocate funding to address the issue of teasing as 1 of the stressors in the school environment, and to explore further the important relationship between school performance and self-esteem.

Teaching culturally effective diabetes care: results of a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Increased cultural competence is a tool in the fight to eliminate health disparities in people with diabetes. However, questions remain regarding the best cultural competence teaching, evaluation, and dissemination methods. An Internet-based approach requires less facilitator time and provides greater ease of dissemination. We developed and tested a skills-focused, Internet-based course on cultural competence in the context of type 2 diabetes. METHODS: To test the effectiveness of the course, a randomized controlled trial was conducted on a national sample of 122 family medicine residents. The primary outcome was measured by changes in score on the Cultural Competence Assessment Tool (CCAT), a new self-assessment tool developed for this study. RESULTS: Total CCAT score increased significantly after the completion of the Internet course for 58 residents in the experimental group (83.55 before the course, 192.09 after the course) but did not change for the 64 residents in the control group (177.58 at baseline, 177.84 at end of study). On multivariate analysis, the only significant predictor of total CCAT score change was having taken the online course. CONCLUSIONS: A skills-based course on cultural competence, delivered via the Internet, is an effective educational strategy. It has potential for dissemination of standardized content.

KnowPain-50: a tool for assessing physician pain management education.

BACKGROUND: Despite a need for better physician pain management education, there are no widely accepted assessment or outcome measures to support this work. OBJECTIVE: Create a self-assessment tool to measure physician educational needs and the effectiveness of chronic pain educational programs. DESIGN: We used expert consensus to draft a 142-item survey that covered essential areas of chronic pain management. We tested the survey in 106 physicians, including 22 pain management experts and used predefined psychometric criteria to eliminate 70 items. We then eliminated 22 remaining items that did not correlate with the management of a standardized chronic pain patient by 27 academic physicians. We evaluated internal consistency using Cronbach's alpha. RESULTS: The final 50-item survey assessed physician knowledge, attitudes, and beliefs in: 1) initial pain assessment; 2) defining goals and expectations; 3) development of a treatment plan; 4) implementation of a treatment plan; 5) reassessment and management of longitudinal care; and 6) management of environmental issues. The survey demonstrated good internal consistency in all physician populations studied (alpha = 0.77-0.85). Average scores in 84 "pilot" physician users of a CME Website (135.8-138.5) were significantly lower (P < 0.01) than scores in 27 academic physicians (150.0), or 22 pain experts (177.5). CONCLUSIONS: This survey, the KnowPain-50, has good psychometric properties, correlates with clinical behaviors, and appears to distinguish between physicians with different levels of pain management expertise. It may be a useful measure of the effectiveness of physician pain management education programs.

The diverse functions of role models across primary care specialties.

BACKGROUND AND OBJECTIVES: This study investigated the relationship of role models to primary care specialty and gathered information on the attributes and functions of role models. METHODS: A questionnaire on medical school experiences and attitudes was administered to primary care graduates from 24 US medical schools. RESULTS: Questionnaires were completed by 1,457 physicians. Sixty-three percent of primary care respondents had a role model. Having a role model was significantly related to current specialty and ethnicity. Respondents most valued their role models' patient relationships. For family medicine and internal medicine graduates, having a role model was related to more contact and more-positive views of faculty in their specialty. Those with a role model reported that primary care was encouraged at their medical school and were more satisfied with their specialty choice. CONCLUSIONS: Role models may be more important to students who are not well represented among medical school faculty, namely women, underrepresented ethnic minorities, and those interested in family medicine. For family medicine graduates, role models function to moderate negative stereotypes. Role models may also make explicit the values of physicians in that specialty, making students more informed when choosing a specialty and as a consequence more satisfied with the decision.

Declining interest in family medicine: perspectives of department heads and faculty.

BACKGROUND AND OBJECTIVES: In 2003, US seniors filled 42% of family practice residency positions, the lowest percentage in the specialty's recent history. We hypothesized that institutional support, contact with family medicine faculty, and faculty satisfaction would be positively related to choice of family practice and that faculty satisfaction would be negatively affected by increasing pressure for clinical productivity. METHODS: We surveyed department heads and faculty at 24 US allopathic medical schools, selected by their rate of family medicine graduates from 1997 to 1999 and the size of the school. Twelve of these schools had an increase in rates of graduates selecting family practice, and 12 showed decreases. RESULTS: Department heads and faculty from schools with an increase in student entry into family practice residencies were significantly more likely to report financial and philosophical support from their state legislature or medical school administration. Faculty ranked patient care as most valued at their institutions, followed by teaching, research, and service. A common theme emerging from both the faculty and department head surveys was an inverse relationship between research activity and graduates choosing family practice. CONCLUSIONS: This study demonstrates the importance of upper-level institutional support on family practice specialty choice. It also highlights a need for further examination of the specialty's relationship to research.

Lessons not learned from the generalist initiatives.

The grouping of the primary care specialties (general internal medicine, general pediatrics, and family medicine) for research purposes is at best limiting the value of the information that is found and, at worst, leading researchers to erroneous conclusions. For example, three large studies each showed differences in abilities to predict students' specialty choices in primary care (e.g., in one study, the investigators correctly predicted 3% of those choosing general internal medicine, 29% considering general pediatrics, and 51% considering family medicine). These and related findings suggest that medical students entering the three primary care specialties are not a homogeneous group. While there were some factors predictive for all primary care specialties, there were more factors that were unique to the individual specialties Grouping the specialties may not reveal factors that are significantly related to only one of the specialties. In addition, when a variable operates in different ways for different specialties, findings where the specialties are combined can show a reduced effect of that variable or even no effect, because the directions of effects cancel each other. Researchers can fruitfully examine the primary care specialties as a group but at the same time report their data for the individual specialties, which would greatly increase our knowledge both of primary care and also about the similarities and dissimilarities of its component specialties. However, the best models continue to be either research in which the sample size is large enough to compare specialty groups statistically or research with a focus on just one of the primary care specialties.

Can Internet-based education improve physician confidence in dealing with domestic violence?

BACKGROUND AND OBJECTIVES: Domestic violence (DV) is a common, under-recognized source of visits to health care professionals. Even when recognized, physicians are reluctant to deal with DV, citing a lack of education and lack of confidence in addressing issues presented by DV patients. Only a small number of DV education programs have been shown to lead to improvements in professional knowledge and confidence, and these are intensive, multi-day courses. We sought to develop an on-line DV education program that could achieve improvements in physician confidence and attitudes in managing DV patients comparable to classroom-based courses. METHODS: We created an interactive, case-based DV education program targeted to physicians caring for DV patients. We tested the effectiveness of this program in changing attitudes and beliefs in a randomized, controlled trial of Kansas physicians who volunteered to participate in a study of on-line continuing medical education. We measured program effectiveness with an externally developed and validated pretest/posttest instrument. RESULTS: Sixty-five physicians completed the pretest/posttest, 28 of whom were assigned to receive the on-line DV program. We found a +17.8% mean change in confidence (self efficacy) for physicians who took the DV program versus a -.6% change for physicians who did not take the program. We also found improvements in other important areas associated with poor management of DV patients. These changes were similar or greater in magnitude to those reported by others who have used the same survey tool to evaluate an intensive, multi-hour classroom approach to DV education. User satisfaction with the on-line program was high. CONCLUSIONS: An interactive, case-based, on-line DV education program that teaches problem-solving skills improves physician confidence and beliefs in managing DV patients as effectively as an intensive classroom-based approach. Such programs may be of benefit to those seeking to improve their personal skills or their health care delivery system's response to DV.