Predicting Clinical Practice Change: An Evaluation of Trainings on Sexually Transmitted Disease Knowledge, Diagnosis, and Treatment.

BACKGROUND: Sexually transmitted disease clinical training for working professionals requires substantial time and resources. Understanding the predictors of change in worksite practices and barriers to change will allow educators, learners, and clinical leadership to aid in ensuring learned practices are implemented and barriers are addressed. METHODS: Data for this analysis come from the first standardized national evaluation of a Centers for Disease Control and Prevention-funded clinical prevention training network, including precourse registration and responses to immediate postcourse (1-3 days) and 90-day postcourse evaluations from 187 courses. Univariate statistics describe the trainees and their workplace. Bivariate statistics describe their intention to change and actual change stratified by functional role and employment setting. Logistic regression identified predictors of self-reported changes in practice. RESULTS: The strongest predictors for practice change included an intention to change and attendance at a training lasting 4 hours or more. Functional role was a weaker predictor of change in practice; employment setting did not predict change. More than half of the trainees (65.9%; n = 912) stated their intention to make a change in their practice immediately after training. At 90 days after a course, 62.4% (n = 863) reported making a practice change. Trainees that took courses lasting 4 hours or more reported making a change more often (70%) compared with trainees from shorter courses (53%). We also report on trainees' barriers to practice change. CONCLUSIONS: Results suggest that longer trainings may result in more practice change than shorter trainings, recruitment of trainees should focus on those more likely to make a change in their practice, and future trainings should focus on organizational capacity building and assessing change at the organizational level.

Text Messaging, Teen Outreach Program, and Sexual Health Behavior: A Cluster Randomized Trial.

OBJECTIVES: To consider whether Youth All Engaged! (a text message intervention) intensified the effects of the adolescent pregnancy prevention Teen Outreach Program (control) for youths. METHODS: In this trial performed in Denver, Colorado, from 2011 to 2014, we randomized 8 Boys & Girls Clubs each of 4 years into 32 clubs per year combinations to ensure each club would serve as a treatment site for 2 years and a control site for 2 years. Control intervention consisted of the Teen Outreach Program only. We enrolled 852 youths (aged 14-18 years), and 632 were retained at follow-up, with analytic samples ranging from 50 to 624 across outcomes. We examined program costs, and whether the intervention increased condom and contraceptive use, access to care, and pregnancy prevention. RESULTS: Control program costs were $1184 per participant, and intervention costs were an additional $126 per participant (+10.6%). There were no statistically significant differences in primary outcomes for the full sample. Hispanic participants in the intervention condition had fewer pregnancies at follow-up (1.79%) than did those in the control group (6.72%; P = .02). CONCLUSIONS: Youth All Engaged is feasible, low cost, and could have potential benefits for Hispanic youths.

The Effectiveness of Cognitive Behavioral Therapy and Emotional Freedom Techniques in Reducing Depression and Anxiety Among Adults: A Pilot Study.

CONTEXT: The World Health Organization (WHO) places major depressive disorder (MDD), or depression, as the fourth leading cause of disability worldwide. Some studies have found that cognitive behavioral therapy (CBT) represents the most superior approach in treating mild to severe symptoms. Recent literature has indicated a number of limitations to this therapeutic approach. An approach that has received increasing attention within the literature is the emotional freedom technique (EFT). OBJECTIVE: The current pilot study aimed to evaluate the effectiveness of CBT and EFT in the treatment of depression and comorbid anxiety. DESIGN: The research team designed a pilot study structured as a randomized, controlled trial with 2 intervention arms. SETTING: The study took place at Bond University in Gold Coast, Queensland, Australia. PARTICIPANTS: Participants (n = 10) were local community members who had screened positive for a primary diagnosis of MDD. INTERVENTION: Participants were randomly assigned to an 8-wk CBT or EFT treatment program, the intervention groups. A sample of individuals from the community was assessed for comparative purposes (control group) (n = 57). OUTCOME MEASURES: Pre- and postintervention, all participants were interviewed using the Mini-International Neuropsychiatric Interview (MINI) 6.0, and they completed the following validated questionnaires: (1) the Beck Depression Inventory, second edition (BDI-2) and (2) the Depression, Anxiety, and Stress Scales (DASS-21). RESULTS: Findings revealed that both treatment approaches produced significant reductions in depressive symptoms, with the CBT group reporting a significant reduction postintervention, which was not maintained with time. The EFT group reported a delayed effect involving a significant reduction in symptoms at the 3- and 6-mo follow-ups only. Examination of the individual cases revealed clinically significant improvements in anxiety across both interventions. CONCLUSIONS: Overall, the findings provide evidence to suggest that EFT might be an effective treatment strategy worthy of further investigation.

Methods to assess youth engagement in a text messaging supplement to an effective teen pregnancy program.

Youth are prolific users of cell phone minutes and text messaging. Numerous programs using short message service text messaging (SMS) have been employed to help improve health behaviors and health outcomes. However, we lack information on whether and what type of interaction or engagement with SMS program content is required to realize any benefit. We explored youth engagement with an automated SMS program designed to supplement a 25-session youth development program with demonstrated efficacy for reductions in teen pregnancy. Using two years of program data, we report on youth participation in design of message content and response frequency to messages among youth enrolled in the intervention arm of a randomized controlled trial (RCT) as one indicator of engagement. There were 221 youth between the ages of 14-18 enrolled over two years in the intervention arm of the RCT. Just over half (51%) were female; 56% were Hispanic; and 27% African American. Youth were sent 40,006 messages of which 16,501 were considered bi-directional where youth were asked to text a response. Four-fifths (82%) responded at least once to a text. We found variations in response frequency by gender, age, and ethnicity. The most popular types of messages youth responded to include questions and quizzes. The first two months of the program in each year had the highest response frequency. An important next step is to assess whether higher response to SMS results in greater efficacy. This future work can facilitate greater attention to message design and content to ensure messages are engaging for the intended audience.

Understanding distress in posttreatment adult leukemia and lymphoma survivors: a lifespan perspective.

Using in-depth interviews, this paper explores the nature and sources of cancer-specific distress among 51 posttreatment adult leukemia and lymphoma survivors (LLS), focusing on the role of lifespan stage in shaping reported stressors. LLS (all ages) reported physical aftereffects of cancer treatment, with reported sources of emotional and financial distress varying by lifespan stage. Young adult survivors (18-39) reported a greater number of distress sources. Distress may persist up to 4 years posttreatment, particularly among younger LLS, who appear to be at greater risk of distress in multiple domains.

Prevalence and predictors of distress in posttreatment adult leukemia and lymphoma survivors.

This paper examines predictors of cancer-specific distress among posttreatment adult leukemia and lymphoma survivors (LLS). Using a survey mailed to LLS in the Colorado Central Cancer Registry (N = 477), the authors developed a multivariable risk profile for distress. Thirty one percent of LLS reported indicators of distress. Significantly higher distress was associated with younger age (p < 0.001) in bivariate analyses. The risk profile included fear of recurrence, financial burden, and younger age. Distress did not attenuate based on time since treatment completion and may persist up to 4 years posttreatment, suggesting a need for intervention, particularly among high-risk LLS.

Enhancing a Teen Pregnancy Prevention Program with text messaging: engaging minority youth to develop TOP ® Plus Text.

PURPOSE: To develop and pilot a theory-based, mobile phone texting component attractive to minority youth as a supplement to the Teen Outreach Program(®), a youth development program for reducing teen pregnancy and school dropout. METHODS: We conducted iterative formative research with minority youth in multiple focus groups to explore interest in texting and reaction to text messages. We piloted a month-long version of TOP(®) Plus Text with 96 teens at four sites and conducted a computer-based survey immediately after enrollment and at the end of the pilot that collected information about teens' values, social support, self-efficacy, and behaviors relating to school performance, trouble with the law, and sexual activity. After each of the first three weekly sessions we collected satisfaction measures. Upon completion of the pilot we conducted exit interviews with twelve purposively selected pilot participants. RESULTS: We successfully recruited and enrolled minority youth into the pilot. Teens were enthusiastic about text messages complementing TOP(®). Results also revealed barriers: access to text-capable mobile phones, retention as measured by completion of the post-pilot survey, and a need to be attentive to teen literacy. CONCLUSIONS: Piloting helped identify improvements for implementation including offering text messages through multiple platforms so youth without access to a mobile phone could receive messages; rewording texts to allow youth to express opinions without feeling judged; and collecting multiple types of contact information to improve follow-up. Thoughtful attention to social and behavioral theory and investment in iterative formative research with extensive consultation with teens can lead to an engaging texting curriculum that enhances and complements TOP(®).

Integration of family planning services into a sexually transmitted disease clinic setting.

BACKGROUND: Sexually transmitted diseases (STDs) and unintended pregnancy are significant and costly public health concerns. Integrating family planning services (FPS) into STD visits provides an opportunity to address both concerns simultaneously. Our objectives were to create an electronic eligibility reminder to identify male and female patients eligible for FPS during an STD clinic visit and measure FPS use, additional cost of integrated services, and patient/provider satisfaction and to explore the impact on incident pregnancy and STDs. METHODS: Quasi-experimental design compared enrollment and patient/provider satisfaction before (2008) and after implementation (2010). Incident pregnancy and STD 12 months after the initial visit before and after were explored. Time and cost were calculated. Quantitative and qualitative analyses were performed. RESULTS: A total of 9695 clients (male, 5842; female, 3853) in 2008 and 10,021 clients (male, 5852; female, 4169) in 2010 were eligible for FPS. Enrollment in FPS increased (2008: 51.6%, 2010: 95.3%; P < 0.01). Total additional cost was US$29.25/visit, and additional staff time was 4.01 minutes for integrated visits. Staff satisfaction increased and client satisfaction remained high. Among women returning within 12 months (39.6% in 2008, 37.1% in 2010), pregnancies were lower among enrolled versus nonenrolled women for 2008 (7.7% vs. 19.5%, P < 0.01) and 2010 (13.1% vs. 25.9%, P = 0.05). Incident STDs did not differ. DISCUSSION: An electronic eligibility reminder of FPS increased FPS use. Integration of FPS with STD services is feasible, is well accepted, and increases costs minimally. Integration may reduce pregnancy rates without increasing STD rates.

Can experiential-didactic training improve clinical STD practices?

BACKGROUND: High rates of sexually transmitted diseases (STDs) present an ongoing costly public health challenge. One approach to reduce STD transmission is to increase the number of clinicians adopting the Centers for Disease Control and Prevention's STD Treatment Guidelines. This evaluation assesses the effectiveness of a 3-day experiential and didactic training to translate recommendations into practice by increasing clinician knowledge and skills and helping participants anticipate and overcome barriers to implementation. METHODS: Between 2001 and 2004, 110 direct care clinicians from 10 states participated in one of 27 standardized 3-day interactive trainings offered by the Denver STD/human immunodeficiency virus (HIV) Prevention Training Center. STD/HIV knowledge and clinical skills were measured before, immediately after, and 6 months after training. Practice patterns were assessed before training and after 6 months. Structural barriers to implementation were identified 6 months post-training. RESULTS: Trainees demonstrated significant post-training gains in mean knowledge scores immediately post-training (P < 0.001) and 6 months post-training (P = 0.002). After 6 months, self-reported mean skill levels remained significantly improved compared to precourse (P < 0.05) for each of 27 skills including STD risk assessment, clinical examination, diagnosis, and treatment. Self-reported improvement in practice patterns was significant for 23 of 35 practices (P < 0.05) 6 months post-training. Participants indicated that inadequate time (52.9%), facilities/equipment (51.5%), and staffing (47.1%) interfered with implementation of recommended practices. CONCLUSIONS: Experiential-didactic STD/HIV training can modestly improve knowledge, clinical skills, and implementation of STD recommended practices 6 months after training. Further research is needed to identify the impact of improved clinical practices on STD/HIV transmission.

Collection of the BD SurePath Pap Test with a broom device plus endocervical brush improves disease detection when compared to the broom device alone or the spatula plus endocervical brush combination.

OBJECTIVE: Here we examine the diagnostic utility of the US Food And Drug Administration (FDA) approved Spatula + endocervical brush combination for the BD SurePath Pap Test (SPPT) and compare it to SPPT collection with the broom alone or to an off-label combination of broom + EC brush. This question is important due to lingering concerns over the value of EC detection to a satisfactory Pap test. METHODS: 20,125 SPPT vials were examined for the collection devices contained. The SPPT collection device combinations allowed were: Rovers Cervex-Brush (broom, FDA approved), Medscand Pap Perfect Spatula + Medscand CytoBrush Plus GT (spatula + GT brush, FDA approved) or Rovers Cervex-Brush + Surgipath C-E Brush (broom + CE brush, off label). RESULTS: Examination of SPPT vials revealed 11,130 collected with the broom, 4,687 collected with the spatula + GT brush and 2,921 collected with the broom + CE brush. Absence of an endocervical/transformation zone was seen in 22.86% of broom cases, 13.10% of spatula + GT brush cases (p= 0.00005 vs broom) and 10.17% of broom + CE brush cases (p= 0.00005 vs broom, p= 0.00005 vs spatula + GT brush). Importantly, LSIL detection was: broom 2.99%; spatula + GT brush 2.45% (p= 0.053 vs broom); broom + CE brush 4.18% (p= 0.034 vs broom, p= 0.0001 vs spatula + GT brush). CONCLUSION: When broom + brush combination is compared to broom alone or to spatula + GT brush, the broom + CE brush combination better sampled the endocervical/transformation zone and increased LSIL detection.

Test performance comparison of inform HPV and hybrid capture 2 high-risk HPV DNA tests using the SurePath liquid-based Pap test as the collection method.

No US Food and Drug Administration-approved method is available to test for human papillomavirus (HPV) DNA in the SurePath liquid-based Papanicolaou (Pap) test (TriPath Care Technologies, Burlington, NC). We compared the performance characteristics of Inform HPV (Ventana Medical Systems, Tucson, AZ) and Hybrid Capture 2 (HC2; Digene, Gaithersburg, MD) using SurePath for collection. The study included samples from 102 women, aged 18 to 60 years, who underwent a SurePath Pap test immediately before colposcopy and cervical biopsy. Each SurePath specimen was processed additionally for Inform HPV and HC2. Performance characteristics were determined by using the cervical biopsy as the "gold standard." The SurePath, Inform HPV, and HC2 correctly identified high-grade squamous intraepithelial lesions (HSILs) in 15 (94%) of 16, 6 (38%) of 16, and 14 (93%) of 15 cases, respectively. When only SurePath samples with a diagnosis of atypical glandular and/or squamous cells were examined, Inform HPV and HC2 correctly identified HSIL in 19 (43%) of 44 and 45 (100%) of 45 cases, respectively. When SurePath is used for collection, Inform HPV lacks sufficient sensitivity to detect HSIL reliably.

Effectiveness of the SurePath liquid-based Pap test in automated screening and in detection of HSIL.

We have shown that SurePath when compared to conventional Paps fails to increase HSIL detection. In this study, assessment of test performance characteristics for the FocalPoint showed that sensitivity was 96% when manual screening was used as the "gold standard." When cervical biopsy, however, was used as the "gold standard" FocalPoint sensitivity decreased to 93%, which was the same as manual screening. Examination of the FocalPoint "no further review" cases showed that 4/296 were SIL. To understand better the implication of an SIL diagnosis, cervical biopsies generated from SurePath and conventional Paps were compared. Conventional Paps diagnosed as LSIL had a biopsy LSIL:HSIL ratio of 3.1/1, while SurePath Paps had a biopsy LSIL:HSIL ratio of 1.5/1. These results indicate that when cervical biopsy is used as the "gold standard," FocalPoint and manual screening of SurePath Paps have similar test performance but that the FocalPoint can fail to detect LSIL. Importantly, LSIL in a SurePath Pap is 1.6 times more likely to be HSIL on biopsy than LSIL in a conventional Pap.

New red blood cell lysing fixative for use in fine needle aspiration and fluid cytology.

OBJECTIVE: To describe a new red blood cell (RBC) lysing fixative, Devine's lysing solution (DLS), that increases the diagnostic utility of fine needle aspiration (FNA) and fluid cytology. STUDY DESIGN: Twenty bloody FNA cases were fixed with either DLS or 95% ethanol, and the ability to render a diagnosis on these materials was analyzed. DLS was compared to the red cell lysing fixative CytoRich Red (CRR) (TriPath Care Technologies, Burlington, North Carolina, U.S.A.) in its ability to lyse RBCs by mixing human RBCs with the U266 multiple myeloma cell line. DLS was compared to CRR in its ability to suitably preserve materials for Papanicolaou and immunocytochemical analysis. RESULTS: Comparison of DLS with 95% ethanol fixation in 20 bloody FNA cases prepared in duplicate showed that DLS reduced from 17 to 3 the number of cases that had RBCs obscuring > or = 25% of the diagnostic material. In 3 cases, DLS enabled the rendering of a definitive diagnosis of malignancy, which could not be made on the ethanol-fixed material. DLS was compared to CRR, and both fixatives were similarly effective at lysing RBCs, preserving the cellular morphology of diagnostic cells in FNA and fluid cytology, and preserving cells for use in immunocytochemistry. CONCLUSIONS: DLS increases the visualization of diagnostic cellular material when compared to ethanol fixation. DLS is comparable to CRR in RBC lysing ability, diagnostic cell preservation and preservation of materials for immunocytochemistry.