Zika and Public Health: Understanding the Epidemiology and Information Environment.

Because Zika is a newly emerging infectious disease with little previous information known about it, there are many epidemiologic and clinical questions. The complexity of providing care to those who are at risk for infection or are already infected with Zika in this evidence-scarce environment cannot be understated. In this article, we provide an overview of the Zika virus (ZIKV) in the context of public health and pediatric health care. A broad public health focus is used to provide relevant information for addressing important questions about the epidemic and to facilitate communication with patients, parents, and caregivers within the current information environment. We explore issues regarding the epidemiology of the virus (including why ZIKV outbreaks are occurring), what has changed since the sporadic case reports before the outbreaks, why the true incidence is difficult to estimate, why attack rates vary by population and geography, and why the association between Zika and congenital Zika syndrome and Guillain-Barré syndrome have only come to light recently. Additionally, challenges related to the current information environment, traditional and informal information sources about the ZIKV, and examples of Zika public health communication campaigns are discussed. Importantly, we review the existing findings regarding the US population's Zika-related knowledge, attitudes, beliefs, and behavior by highlighting variations and gaps. We conclude by identifying related research questions that remain critical.

Testing the effects of a decision aid for prostate cancer screening.

There is an ever-growing trend toward more patient involvement in making health care decisions. This trend has been accompanied by the development of "informed decision-making" interventions to help patients become more engaged and comfortable with making these decisions. We describe the effects of a prostate cancer screening decision aid on knowledge, beliefs about screening, risk perception, control preferences, decisional conflict, and decisional anxiety. Data were collected from 200 males aged 50-70 years in the general population who randomly were assigned to exposure to the decision aid or no exposure as a control condition. A Solomon four-group design was used to test for possible pretest sensitization effects and to assess the effects of exposure to the decision aid. No significant pretest sensitization effects were found. Analysis of the exposure effects found that knowledge increased significantly for those exposed to the decision aid compared with those unexposed. Exposure to the decision aid also had some influence on decreasing both decisional conflict and decisional anxiety. Decision aids can play an important role in increasing patients' knowledge and decreasing anxiety when asked to make health care decisions.

Influence of a patient decision aid on decisional conflict related to PSA testing: a structural equation model.

OBJECTIVE: To examine the impact of a decision aid (DA) designed to promote informed decision making for screening with the prostate-specific antigen (PSA) test and to test a theoretical model of factors influencing decisional conflict. DESIGN: Structural equation modeling examined pathways between DA exposure, knowledge, schema, prostate cancer risk perceptions, decisional anxiety, and decisional conflict. Sample participants included 200 men from the general population (exclusive of African Americans) and 200 African American men. Half of the men in each subsample were randomly assigned to receive the DA. MAIN OUTCOME MEASURES: Decisional conflict regarding prostate cancer screening. RESULTS: The DA influences level of decisional conflict by increasing patient knowledge. This effect of knowledge on decisional conflict is indirect, however, through an association with greater perceived risk and lower decisional anxiety. Also, positive PSA schema was associated with lower decisional anxiety and decisional conflict. It is important that exposure to the DA had no impact on PSA schema. CONCLUSION: Schemas about testing must be considered in developing messages about the risks and benefits of testing. If schemas are counter to message content, mechanisms for modifying schemas must be incorporated into interventions.

Trials of decision aids for prostate cancer screening: a systematic review.

BACKGROUND: Patient decision aids are used to promote informed decision making. This review examines the methods and findings of studies that have evaluated the impact of prostate cancer screening decision aids on patient outcomes. METHODS: MEDLINE, the Cochrane Registry, reference lists, and abstracts from professional meetings were searched through December 2006. Search terms included prostate cancer screening and decision making. Studies were included if a patient education intervention for prostate cancer screening had been evaluated against a control condition. RESULTS: Eighteen eligible trials, involving 6221 participants, were identified. Sixteen studies enrolled primary care patients, while the remaining two studies were community-based. All the prostate cancer screening decision aids were in English, with varied reading levels. Consistent with previous reviews, the patient decision aids improved patient knowledge and made patients more confident about their decisions. The aids appeared to decrease interest in prostate-specific antigen testing and screening behavior among patients seeking routine care (relative risk [RR]=0.88, 95% confidence interval [CI]=0.81-0.97, p=0.008); the aids had no impact on the screening behavior of patients seeking screening services. Additionally, patients who received patient decision aids were more likely to prefer watchful waiting as a treatment option if they were found to have prostate cancer than were controls (RR=1.53, 95% CI=1.31-1.77, p<0.001). CONCLUSIONS: Prostate cancer screening decision aids enhance patient knowledge, decrease decisional conflict, and promote greater involvement in decision making. The absence of outcome measures that reflect all elements of informed decision making continues to limit the field.

Outcomes of a randomized trial of continuum of care services for children in a child welfare system.

The Connecticut Department of Children and Families Title IV-E waiver demonstration evaluated whether the well-being of children approved for residential mental health services could be improved, and lengths of stay in restrictive placements reduced, by providing case rate payments to community agencies to provide continuum of care services. Children between ages 7 and 15 were randomly assigned to either the demonstration group (n = 78) or to usual state-supported services (n = 79). One-year outcome results indicated that in a situation that is less costly, improvement in outcomes occurred in less restrictive settings. Continuum of care services were more effective in 1) returning children to in-home placements, 2) reducing the length of stay in restrictive placements, and (3) utilizing higher levels of case management through coordination among agencies and family support services.

Evidence-based treatments in the field: a brief report on provider knowledge, implementation, and practice.

This study examined familiarity, perceived effectiveness, and implementation of evidence-based treatments for children in community settings. A sample of service providers in agencies affiliated with federal programs to improve children's mental health services was identified using a snowball sampling procedure. Forty-four percent of the sample (n = 616) responded to a Web-based survey designed to collect data on evidence-based treatments. High familiarity with, relatively high-perceived effectiveness, and generally high use of evidence-based treatments were reported. Partial implementation of treatment protocols within the context of few agency mandates and widely ranging supports for the implementation of evidence-based treatments was found. Results support the inclusion of more complex models of diffusion, dissemination and implementation in research, and development efforts for evidence-based treatments.

Use of the family resource scale in children's mental health: reliability and validity among economically diverse samples.

The adequacy of a family's resources has implications for child and family service processes and outcomes. The field needs tools to assess resources in a manner relevant to children's services research. The purpose of this study was to examine the reliability and validity of the FRS among families caring for children who are receiving mental health services and to compare its measurement quality across samples that differ on economic variables. Exploratory and confirmatory factor analyses supported similar factor structures across samples, and internal consistency was equivalent. Findings from the regression analyses provided evidence of construct validity for the FRS. Overall, findings indicated that the FRS holds promise as a reliable and valid tool for assessing perceived adequacy of concrete resources among economically diverse families of children with emotional and behavioral disorders. However, the FRS could benefit from some refinements; those recommendations are discussed.

Estimating prevalence, incidence, and disease-related mortality for patients with epilepsy in managed care organizations.

PURPOSE: The purpose of the present study was to apply computer algorithms to an administrative data set to identify the prevalence of epilepsy, incidence of epilepsy, and epilepsy-related mortality of patients in a managed care organization (MCO). METHODS: The study population consisted of members enrolled in Lovelace Health Plan, a component of Lovelace Health Systems, a statewide MCO headquartered in Albuquerque, New Mexico. Patient records were obtained from July 1996 to June 2001. Four logistic regression models with high sensitivity and specificity were applied to 1-, 3-, and 5-year time frames in which members were continuously enrolled in the MCO. Incidence was defined for patients who did not have an epilepsy-associated code in the 18 months before the first diagnosis entry. Mortality estimates in the population also were assessed by using a matched control group and linkage to a statewide death registry. RESULTS: The data yielded estimated prevalence rates of 7-10 per 1,000, depending on age, sex, ethnicity, and time interval. Annualized incidence was 47 per 100,000 for members continuously enrolled for 3 years and 71 per 100,000 for members continuously enrolled for 5 years. Crude mortality rates were 2-2.5 times higher for epilepsy patients identified with the algorithms than for the matched controls. Conditional logistic regression indicated that the odds of death for epilepsy patients as compared with controls ranged from 1.24 to 2.06. CONCLUSIONS: Accurate estimation of prevalence, incidence, and mortality rates for epilepsy is an essential component of disease management in MCOs. The algorithms in this project can be used to monitor trends in prevalence, incidence, and mortality to inform decisions critical to improving the health care needs and quality of life for patients with epilepsy.

Developing a computer algorithm to identify epilepsy cases in managed care organizations.

The goal of this study was to develop an algorithm for detecting epilepsy cases in managed care organizations (MCOs). A data set of potential epilepsy cases was constructed from an MCO's administrative data system for all health plan members continuously enrolled in the MCO for at least 1 year within the study period of July 1, 1996 through June 30, 1998. Epilepsy status was determined using medical record review for a sample of 617 cases. The best algorithm for detecting epilepsy cases was developed by examining combinations of diagnosis, diagnostic procedures, and medication use. The best algorithm derived in the exploratory phase was then applied to a new set of data from the same MCO covering the period of July 1, 1998 through June 30, 2000. A stratified sample based on ethnicity and age was drawn from the preliminary algorithm-identified epilepsy cases and non-cases. Medical record review was completed for 644 cases to determine the accuracy of the algorithm. Data from both phases were combined to permit refinement of logistic regression models and to provide more stable estimates of the parameters. The best model used diagnoses and antiepileptic drugs as predictors and had a positive predictive value of 84% (sensitivity 82%, specificity 94%). The best model correctly classified 90% of the cases. A stable algorithm that can be used to identify epilepsy patients within MCOs was developed. Implications for use of the algorithm in other health care settings are discussed.

Developing a measure to assess attitudes toward epilepsy in the US population.

The aim of this study was to develop an instrument to measure the US public's attitudes toward people with epilepsy and to assess the initial reliability and validity of the instrument. A 46-item attitudinal instrument was developed and tested using a proportional, stratified, national, random-digit dial household telephone survey of adults aged > or = 18 (n=758). Exploratory factor analyses revealed four underlying constructs that accounted for 34.4% of the variance in the factor analysis: negative stereotypes (alpha=0.73); risk and safety concerns (alpha=0.85); work and role expectations (alpha=0.76); and personal fear and social avoidance (alpha=0.79). Knowledge was also assessed; participants with less knowledge about epilepsy had more negative attitudes. The results of these analyses provided evidence for reliability and construct validity of the instrument. Additional tests of the reliability, validity, and factor structure of the scales are necessary to refine the instrument.

Gender differences in patterns of risk factors among children receiving mental health services: latent class analyses.

Latent class analyses were used to analyze data from a sample of children participating in the national evaluation of the Comprehensive Communities Mental Health Services for Children and Their Families Program (N = 6786). Lifetime risk experiences of the child were analyzed to identify 4 classes of boys and girls with similar risk patterns. While low-risk, status-offense, abuse, and high-risk classes were identified for both boys and girls, there were nearly half the number of girls in the low-risk class, almost as many in the status-offense class, twice as many in the abuse class, and more than 3 three times as many in the high-risk class as there were boys. These findings suggest that there are specific groups of children entering services who differ as a function of their lifetime risk exposure. In addition, the relationship between class membership and child functioning, and class membership and family lifetime risk experiences. Understanding these differences provides critical information to the service planning process. In addition, it may result in immediate improvement in the triage of children into services and a better understanding of their behaviors during and after treatment.

Assessing the strengths of children referred for community-based mental health services.

This study investigated the relationship between child strengths and functional impairment, specifically whether youth with greater levels of functional impairment also exhibit strengths. The relationship was investigated for children (N = 1,838) of different genders, ages, race, and ethnic backgrounds and whose families were living at different income levels. A moderate relationship was found between child strengths and functional impairment. Those children with even the most severe functional impairment were rated as having average or near average strengths. With the exception of gender, the relationship between impairment and strengths did not differ as a function of demographic characteristics. These findings provide additional support for the construct validity of the Behavioral and Emotional Strengths Rating Scale (M. Epstein & J. Sharma, 1998) and they highlight the need for strength-based assessment and screening for youth entering mental health services. Child strengths as the foundation for service planning and implementation, and other implications are discussed.

Child functioning in rural and nonrural areas: how does it compare when using the service program site as the level of analysis?

The current study uses data from the national evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program to examine child functioning in rural (n = 8) as compared to nonrural (n = 18) system-of-care communities across the United States. In this study, the topic of rural versus nonrural differences is approached from a community-level perspective with aggregated functional impairment scores as the dependent variable of interest in weighted least squares regression. The demographic characteristics of children, particularly age, were more important predictors of functional impairment than geographic locale (i.e., rural vs nonrural). Specifically, while children served in nonrural communities were older than those served in rural communities, after controlling for this difference functional impairment levels were similar. It appears from these analyses that youth served in rural and nonrural communities with systems of care were more similar than they were different with regard to their level of functional impairment. This lack of aggregate functional difference between the rural and nonrural sites reminds policymakers and funding agents that youth in rural areas need equity in both access and resource for mental health services. As indicated by the findings in the current investigation youth in rural areas are not immune to the types of mental health challenges often publicized by researchers examining youth in nonrural areas.

Children with reported histories of sexual abuse: utilizing multiple perspectives to understand clinical and psychosocial profiles.

OBJECTIVE: The current study examines multiple empirically based perspectives (i.e., child, caregiver, and clinician) of behavior and functioning as they contribute to the clinical and psychosocial profile of children (aged 5 to 17.5 years) with reported histories of sexual abuse. METHOD: A large, multi-site data set of children referred into Comprehensive Community Mental Health Services both with and without reported histories of sexual abuse, was examined. Seven hundred and fifty-nine children with a reported history of sexual abuse were compared to 2722 without such a history on caregiver and child reported behavior, clinician rated functioning, diagnosis, demographic variables, and life challenges. RESULTS: The multiple perspectives contributed unique and specific information to regression models: caregiver-reported behavior contributed information about externalizing behavior while child-reported behavior added information about internalizing behavior and clinician ratings about self-harmful behavior. Children with reported histories of sexual abuse were also more likely to be female, Caucasian, and have reported histories of life challenges (e.g., physical abuse, substance use, running away). Child sexual abuse was associated with higher rates of depression and anxiety diagnoses, and lower rates of substance abuse, conduct, and attention deficit disorder diagnoses. CONCLUSIONS: The findings indicate that the profile of children entering into Comprehensive Community Mental Health Services with reported histories of sexual abuse, as compared to those without such histories, is complex and best understood via multiple perspectives. Caregiver, child and clinician rated information, when taken together, provide a comprehensive clinical and psychosocial profile around which to plan and implement individualized service plans.