Lawrence S. Wissow

The Impact of Barriers and Self-Efficacy on Self-Care Behaviors in Type 2 Diabetes

PURPOSE this cross-sectional, correlational study examined the relationships of diabetes-specific treatment barriers and self-efficacy with self-care behaviors. METHODS A total of 309 people with type 2 diabetes participated in this study. All of the factors were assessed by selfreport questionnaires. Self-care behaviors included exercise, diet, skipping medication, testing blood for glucose, adjusting insulin to avoid or correct hyperglycemia, and adjusting diet to avoid or correct hypoglycemia. RESULTS Perceived barriers to carrying out self-care behaviors were associated with worse diet and exercise behavior. Greater selfefficacy predicted more frequent blood glucose testing, less frequent skipping of medication and binge eating, and closer adherence to an ideal diet. Nontraditional dimensions of selfefficacy were associated with worse self-care. Self-efficacy explained 4% to 10% of the variance in diabetes self-care behaviors beyond that accounted for by patient characteristics and health beliefs about barriers. CONCLUSIONS The findings of this study provided support for Rosenstocks proposal that a persons self-perceived capability to carry out a behavior should be incorporated into an expanded health belief model.

Use of an innovative video feedback technique to enhance communication skills training

Context  Despite growing interest in medical communication by certification bodies, significant methodological and logistic challenges are evident in experiential methods of instruction.

Ethnicity, Income, and Parenting Contexts of Physical Punishment in a National Sample of Families with Young Children

Nearly half of U.S. parents use physical punishment for child discipline. Although some studies relate physical punishment and later dysfunction, others suggest that its effects depend on the context in which it is used. The authors analyzed data from the Commonwealth Fund Survey of Parents With Young Children, a national sample of 2,017 parents with children younger than 3. Parents reported their use of spanking, five other disciplinary practices, and four nurturing interactions. The authors used cluster analysis to define four groups of parents with distinct patterns of discipline and nurturing. Two groups with above-average use of spanking shared a high prevalence of parent depressive symptoms and a low level of nurturing but had markedly different demographic profiles and use of nonphysical punishment. Parents who used average levels of spanking made frequent use of nonphysical disciplinary strategies and had high levels of nurturing interactions. Parents who reported below-average spanking had relatively low levels of both disciplinary and nurturing interactions.

Improving Child and Parent Mental Health in Primary Care: A Cluster-Randomized Trial of Communication Skills Training

OBJECTIVE. We examined child and parent outcomes of training providers to engage families efficiently and to reduce common symptoms of a range of mental health problems and disorders. METHODS. Training involved three 1-hour discussions structured around video examples of family/provider communication skills, each followed by practice with standardized patients and self-evaluation. Skills targeted eliciting parent and child concerns, partnering with families, and increasing expectations that treatment would be helpful. We tested the training with providers at 13 sites in rural New York, urban Maryland, and Washington, DC. Children (5–16 years of age) making routine visits were enrolled if they screened “possible” or “probable” for mental disorders with the Strengths and Difficulties Questionnaire or if their provider said they were likely to have an emotional or behavioral problem. Children and their parents were then monitored for 6 months, to assess changes in parent-rated symptoms and impairment and parent symptoms. RESULTS. Fifty-eight providers (31 trained and 27 control) and 418 children (248 patients of trained providers and 170 patients of control providers) participated. Among the children, 72% were in the possible or probable categories. Approximately one half (54%) were white, 30% black, 12% Latino, and 4% other ethnicities. Eighty-eight percent (367 children) completed follow-up monitoring. At 6 months, minority children cared for by trained providers had greater reduction in impairment (−0.91 points) than did those cared for by control providers but no greater reduction in symptoms. Seeing a trained provider did not have an impact on symptoms or impairment among white children. Parents of children cared for by trained providers experienced greater reduction in symptoms (−1.7 points) than did those cared for by control providers. CONCLUSION. Brief provider communication training had a positive impact on parent mental health symptoms and reduced minority childrens impairment across a range of problems.

Informed consent for enrolling minors in genetic susceptibility research: a qualitative study of at-risk children’s and parents’ views about children’s role in decision-making

PURPOSE To better understand the process by which families at increased risk of disease would decide to enroll their children in genetic susceptibility research in order to develop recommendations regarding the informed consent process by which at-risk children are enrolled in such research in the future [corrected]. METHODS Parents and children (ages 10-17 years) from families at increased risk for heart disease (n = 21 dyads) or breast cancer (n = 16 dyads) participated in two face-to-face, audio-taped, semi-structured interviews: Initial interviews were conducted with parents and children separately, and follow-up family interviews were conducted 1 year later. Interview transcripts were coded based on common themes. RESULTS Families vary in the stage at which, and degree to which, children would be involved in decision-making about research participation. In general, the older/more mature the child, the less risky the research and the more open the communication style, the greater the likelihood that decisions would be made jointly. Most children wanted some parental input, but still thought the final decision should be theirs. Most parents would want to make the initial decision about whether it would be reasonable to consider enrolling their child in the research being proposed, but none opposed the child having some time alone with the researcher. All parents and children in our study placed extreme importance on not forcing children to participate in nontherapeutic research if they do not want to. CONCLUSIONS Decision-making about enrolling children in genetic susceptibility research should be based on an informed consent process that (a) gives parents and children sufficient opportunity to ask questions of the researcher(s) and to communicate with one another, and (b) gives children the opportunity to exercise their right to refuse participation without parental influence. This process should be tailored to the childs maturity level and style of communication in the family.

Discussion of sensitive health topics with youth during primary care visits: relationship to youth perceptions of care.

PURPOSE Youth have concerns about sensitive health topics, such as drugs, sex, and mental health, and many wish to discuss those concerns with a primary care provider. Research has not determined whether the discussion of sensitive health topics during primary care visits is independently associated with youth perceptions of care. This study examined whether the discussion of sensitive health topics during primary care visits was associated with youths perceptions of the provider and of participation in treatment. METHODS Directly after visits to 54 primary care providers in 13 geographically diverse offices and clinics, youth age 11-16 years old (N = 358) reported whether the visit included the discussion of mood, behavior, getting along with others, drugs, tobacco, alcohol, sexuality, birth control, parent mood, or family problems. Youth also reported whether the provider understood their problems, eased their worries, allowed them to make decisions about treatment, gave them some control over treatment, and asked them to take some responsibility for treatment. Providers reported confidence in their ability to offer counseling for nonmedical concerns and their beliefs and attitudes toward treating nonmedical concerns. RESULTS Youth had more positive perceptions of the provider and were more likely to report taking an active role in treatment when the visit included the discussion of a sensitive health topic. Results from multivariate random effects logistic regression suggested that youth were more likely to report that the provider understood their problems (OR = 3.62, CI = 1.57-8.31), eased their worries (OR = 2.13, CI = 1.06-3.92), allowed them to make decisions about treatment (OR = 2.71, CI = 1.44-5.10), gave them some control over treatment (OR = 2.51, CI = 1.32-4.71), and asked them to take some responsibility for treatment (OR = 2.00, CI = 1.04-3.86) when the visit included the discussion of one or more sensitive health topics. The odds of each of these outcomes were also higher when the visit included the discussion of a greater number of sensitive topics. Youth also had more positive perceptions of female providers. Youth demographics, mental health status, and other provider characteristics were unrelated to youth perceptions of care. CONCLUSIONS The discussion of sensitive health topics during primary care visits may have a positive impact on youth perceptions of care. Future research is needed to understand the relationship between the discussion of sensitive health topics and health outcomes among youth.

Promoting Advance Directives Among Elderly Primary Care Patients

OBJECTIVE: To determine efficient ways of promoting advance directives among heterogeneous populations of elderly ambulatory patients.DESIGN: One-year quasi-experimental trial.SETTING: Five suburban and urban health centers in one region of a large managed care organization. One additional suburban center served as a control site.PARTICIPANTS: Individuals ages 65 and older (N=2,120) who were continuously enrolled and had a health maintenance visit with their primary care provider during the study year.INTERVENTION: Physician education (oral and written) and physician and patient prompts to discuss advance directives.MAIN RESULTS: Sixty-six (7.8%) of patients at the intervention centers completed new advance directives, versus 9 of 1,277 (<1%) at the comparison center (P<.001). Patients 75 and older were twice as likely (odds ratio [OR], 2.0; 95% confidence limits [CL], 1.2 to 3.3) as those 65 to 74 to file a new advance directive, and the odds were twice as great (OR, 2.6; 95% CL, 1.4 to 4.6) at centers serving communities with median household income over the state median. Gender, recent hospitalization, emergency room visits, and number of chronic conditions were not related to making new directives nor was predominant ethnicity of the center community (African-American versus white). Adjusted for these factors, the intervention resulted in a 20-fold increase (95% CL, 10.4 to 47.8) in the odds of creating a new advance directive. Doctors reported barriers of time and unwillingness to press discussions with patients.CONCLUSIONS: A replicable intervention largely targeting doctors achieved a modest increase in advance directives among elderly ambulatory patients. Future interventions may need to target lower-income patients, “younger” elderly, and more specifically address doctors’ attitudes and comfort discussing advance directives.

Promoting Optimal Development: Screening for Behavioral and Emotional Problems

By current estimates, at any given time, approximately 11% to 20% of children in the United States have a behavioral or emotional disorder, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Between 37% and 39% of children will have a behavioral or emotional disorder diagnosed by 16 years of age, regardless of geographic location in the United States. Behavioral and emotional problems and concerns in children and adolescents are not being reliably identified or treated in the US health system. This clinical report focuses on the need to increase behavioral screening and offers potential changes in practice and the health system, as well as the research needed to accomplish this. This report also (1) reviews the prevalence of behavioral and emotional disorders, (2) describes factors affecting the emergence of behavioral and emotional problems, (3) articulates the current state of detection of these problems in pediatric primary care, (4) describes barriers to screening and means to overcome those barriers, and (5) discusses potential changes at a practice and systems level that are needed to facilitate successful behavioral and emotional screening. Highlighted and discussed are the many factors at the level of the pediatric practice, health system, and society contributing to these behavioral and emotional problems.

Mid-life suicide: an increasing problem in U.S. Whites, 1999-2005.

BACKGROUND The overall suicide rate in the U.S. increased by 6% between 1981 and 1986 and declined by 18% between 1986 and 1999. Detailed descriptions of recent trends in suicide are lacking, especially with regard to the method of suicide. Information is needed on the major changes in rates of suicide in specific population groups in recent years (1999-2005). METHODS Mortality data came from the Web-based Injury Statistics Query and Reporting System. Suicide trends during 1981-2005 were analyzed by age, race, gender, and method, with an emphasis on increases between 1999 and 2005. Linear regression was used to examine the significance of trends in suicide mortality. The annual percentage change in rates was employed to measure the linear trend in suicide mortality. RESULTS The suicide rate increased after 1999, due primarily to an increase in suicide among whites aged 40-64 years, whose rate of completed suicide between 1999 and 2005 rose by 2.7% annually for men and by 3.9% annually for women,with increases of 6.3% and 2.3% for poisoning, 2.8% and 19.3% for hanging/suffocation, and 1.5% and 1.9% for firearms for men and women, respectively. Rates did not increase for other age or racial groups [corrected]. CONCLUSIONS The differential increases by age, race, gender, and method underscore a change in the epidemiology of suicide.Whites aged 40-64 years have recently emerged as a new high-risk group for suicide. Although firearms remain the most common method of suicide, the notable increases in suicide by poisoning in men and hanging/suffocation in women deserve prevention attention [corrected].

Identification of youth psychosocial problems during pediatric primary care visits.

This investigation applied the Gateway Provider Model (GPM) of child mental health services to investigate whether characteristics of the child, family, visit, and provider were related to the identification of youth psychosocial problems during primary care visits. Data were gathered during 774 visits to 54 primary care providers (PCPs) at 13 clinics. Similar to previous investigations in primary care settings, 42% of youth demonstrated at least a sub-threshold clinical mental health problem. Most PCPs reported high job satisfaction and control, but reported varying access to mental health specialists. PCPs generally had positive attitudes and beliefs about treating psychosocial problems but many reported that doing so was burdensome. Identification was more likely when the visit was for a mental health problem, when issues related to psychosocial problems were discussed during the visit, when the youth demonstrated mental health symptoms, impairment, or burden to the family, and when the youth was older, uninsured, or received Medicaid. Identification was less likely when the PCP reported greater burden associated with treating psychosocial problems and when the PCP reported greater accessibility to mental health specialists. These results suggest that identification is associated with the interaction of multilevel factors and that the GPM is a useful model to investigate points of intervention for improving the identification of children’s mental health problems in primary care settings.