A factor analytic approach to understanding health risk behaviors and resilience among multi-racial/ethnic adolescents in New Mexico.

OBJECTIVE: This study examined the factor validity of health risk behaviors and resilience indicators and their covariation across a large racially/ethnically diverse adolescent population. DESIGN: The study subsample (47% Hispanic, 31% White Non-Hispanic, 17% American Indian) was derived from the 2013 New Mexico Youth Risk Resilience Survey (YRRS; N-19,033). We conducted a confirmatory factor analysis on the 6 health risk domains identified by the CDC as contributing most to adolescent morbidity/mortality: (1) cigarette use, (2) alcohol and other illicit drug use, (3) marijuana use, (4) sexual activity, (5) nutrition habits, and (6) physical activity. RESULTS: A 4-factor CFA model of adolescent health risk behaviors was replicated, and a hypothesized 6-factor structure based on behaviors that contribute most to adolescent morbidity/mortality was confirmed. The pattern of covarying risk behaviors differed by Hispanic, Native American, and Non-Hispanic White groups. We also confirmed a single external resilience-interference factor (decreased parental support, low school/community engagement, negative peer associations) that positively correlated with all six risk behaviors. CONCLUSION: This study described the structure of adolescent health risk behaviors within a context of psychosocial resilience for American Indian and Hispanic adolescents in contrast to Non-Hispanic White adolescents. Our findings provided evidence for the construct validity of six health-risk behavior dimensions within a large racially/ethnically diverse adolescent sample, which reveal different patterns of loadings, degrees of model fit, and factor inter-correlations across the three racial/ethnic groups. Patterns of covarying risk behaviors differed in strength and direction by racial/ethnic group. Results suggest that interventions should target multiple behaviors and be tailored for different racial/ethnic groups. Targeting health risk and resilience indicators supports the use of multi-level health interventions at the individual, school, family, and community level by identifying individuals based on external resilience scores.

Developing the Minimum Dataset for the New Mexico Decedent Image Database.

BACKGROUND: A minimum dataset (MDS) can be determined ad hoc by an investigator or small team; by a metadata expert; or by using a consensus method to take advantage of the global knowledge and expertise of a large group of experts. The first method is the most commonly applied. OBJECTIVE: Here, we describe a use of the third approach using a modified Delphi method to determine the optimal MDS for a dataset of full body computed tomography scans. The scans are of decedents whose deaths were investigated at the New Mexico Office of the Medical Investigator and constitute the New Mexico Decedent Image Database (NMDID). METHODS: The authors initiated the consensus process by suggesting 50 original variables to elicit expert reactions. Experts were recruited from a variety of scientific disciplines and from around the world. Three rounds of variable selection showed high rates of consensus. RESULTS: In total, 59 variables were selected, only 52% of which the original resource authors selected. Using a snowball method, a second set of experts was recruited to validate the variables chosen in the design phase. During the validation phase, no variables were selected for deletion. CONCLUSION: NMDID is likely to remain more "future proof" than if a single metadata expert or only the original team of investigators designed the metadata.

Broad Consent for Research on Biospecimens: The Views of Actual Donors at Four U.S. Medical Centers.

Commentators are concerned that broad consent may not provide biospecimen donors with sufficient information regarding possible future research uses of their tissue. We surveyed with interviews 302 cancer patients who had recently provided broad consent at four diverse academic medical centers. The majority of donors believed that the consent form provided them with sufficient information regarding future possible uses of their biospecimens. Donors expressed very positive views regarding tissue donation in general and endorsed the use of their biospecimens in future research across a wide range of contexts. Concerns regarding future uses were limited to for-profit research and research by investigators in other countries. These results support the use of broad consent to store and use biological samples in future research.

Mental Health Effects of Stress over the Life Span of Refugees.

Information about the relative impact of stressful events across the lifespan on the mental health of refugees is needed. Cross-sectional data from a community sample of 135 Kurdish and 117 Vietnamese refugees were fit to a path model about the effects of non-war stress, war-related stress, and post-migration stress on mental health. Kurdish and Vietnamese data were generally consistent with the model. However, war-related stress produced no direct but a large indirect effect through post-migration stress on mental health in Kurds. Vietnamese data indicated a modest direct war-related stress effect but no indirect influence through post-migration stress. Different types of stressful events lead to adverse mental health of displaced refugees in a somewhat group-dependent manner. Implications for prevention and treatment are discussed.

Rural providers' access to online resources: a randomized controlled trial.

OBJECTIVE: The research determined the usage and satisfaction levels with one of two point-of-care (PoC) resources among health care providers in a rural state. METHODS: In this randomized controlled trial, twenty-eight health care providers in rural areas were stratified by occupation and region, then randomized into either the DynaMed or the AccessMedicine study arm. Study participants were physicians, physician assistants, and nurses. A pre- and post-study survey measured participants' attitudes toward different information resources and their information-seeking activities. Medical student investigators provided training and technical support for participants. Data analyses consisted of analysis of variance (ANOVA), paired t tests, and Cohen's d statistic to compare pre- and post-study effects sizes. RESULTS: Participants in both the DynaMed and the AccessMedicine arms of the study reported increased satisfaction with their respective PoC resource, as expected. Participants in both arms also reported that they saved time in finding needed information. At baseline, both arms reported too little information available, which increased to "about right amounts of information" at the completion of the study. DynaMed users reported a Cohen's d increase of +1.50 compared to AccessMedicine users' reported use of 0.82. DynaMed users reported d2 satisfaction increases of 9.48 versus AccessMedicine satisfaction increases of 0.59 using a Cohen's d. CONCLUSION: Participants in the DynaMed arm of the study used this clinically oriented PoC more heavily than the users of the textbook-based AccessMedicine. In terms of user satisfaction, DynaMed users reported higher levels of satisfaction than the users of AccessMedicine.

Along the way to developing a theory of the program: a re-examination of the conceptual framework as an organizing strategy.

PURPOSE: Conceptual frameworks (CF) have historically been used to develop program theory. We re-examine the literature about the role of CF in this context, specifically how they can be used to create descriptive and prescriptive theories, as building blocks for a program theory. Using a case example of colorectal cancer screening intervention development, we describe the process of developing our initial CF, the methods used to explore the constructs in the framework and revise the framework for intervention development. METHODS: We present seven steps that guided the development of our CF: (1) assemble the "right" research team, (2) incorporate existing literature into the emerging CF, (3) construct the conceptual framework, (4) diagram the framework, (5) operationalize the framework: develop the research design and measures, (6) conduct the research, and (7) revise the framework. RESULTS: A revised conceptual framework depicted more complicated inter-relationships of the different predisposing, enabling, reinforcing, and system-based factors. The updated framework led us to generate program theory and serves as the basis for designing future intervention studies and outcome evaluations. CONCLUSIONS: A CF can build a foundation for program theory. We provide a set of concrete steps and lessons learned to assist practitioners in developing a CF.

Direct and indirect effects of childhood adversity on adult depression.

Exposure to adverse events in childhood is a predictor of subsequent exposure to adverse events in adulthood, and both are predictors of depression in adults. The degree to which adult depression has a direct effect of childhood adversity versus an indirect effect mediated by adult adversity has not previously been reported. We report data collected from 210 adult participants regarding childhood and adult adversity and current symptoms of depression. Mediation of the relationship between childhood adversity and adult depression by adult adversity was statistically assessed to evaluate the relative direct and indirect effects of childhood adversity on current depression levels in adults. Both the direct effect of childhood adversity on adult depression and the indirect effect, mediated by adulthood events, were significant. Therefore, partial mediation of the relationship between childhood adversity and adult symptoms of depression by adult adverse events was found in the sample. Implications for treatment are presented.

Expressions of machismo in colorectal cancer screening among New Mexico Hispanic subpopulations.

Although national colorectal cancer (CRC) incidence rates have steadily decreased, the rate for New Mexico Hispanics has been increasing, and screening rates are low. We conducted an exploratory qualitative study to determine barriers to CRC screening for New Mexico Hispanics. We found that machismo served as a dynamic influence on men's health-seeking behaviors; however, it was conceptualized differently by two distinct Hispanic subpopulations, and therefore appeared to play a different role in shaping their screening attitudes and behaviors. Machismo emerged as more of an influence for Mexican men, who expressed concern over colonoscopies being potentially transformative and/or stigmatizing, but was not as salient for Hispanos, who viewed the colonoscopy as "strictly medical," and were more concerned with discomfort and pain. Findings from the study highlight the importance of identifying varying characteristics among subpopulations to better understand screening barriers and provide optimal CRC screening counseling in primary care settings.

Are doctors who have been ill more compassionate? Attitudes of resident physicians regarding personal health issues and the expression of compassion in clinical care.

BACKGROUND: Compassion is an attribute central to professionalism and modern clinical care, yet little is known about how compassion is acquired and preserved in medical training. We sought to understand whether personal illness experiences are thought by residents to foster compassion. METHODS: The authors surveyed 155 (71% response rate) second- and third-year residents at the University of New Mexico School of Medicine regarding their views of the relationship of personal life experience with illness to compassion and empathy for patients. RESULTS: Residents believe that experience with personal health issues enhances physician compassion for patients. Residents who report more personal health concerns, such as physical or mental health problems and family health problems, endorse the connection between direct experience with illness and empathy. CONCLUSION: Health care trainees' own illness experiences may increase compassionate patient care practices and foster empathy.

Medical students as patients: implications of their dual role as explored in a vignette-based survey study of 1027 medical students at nine medical schools.

OBJECTIVE: Medical students experience a range of mental and physical illnesses during training and may encounter significant barriers in seeking health care. Little is known about the issues surrounding the dual role as both learner and patient when a medical student seeks care at his or her training institution. METHOD: A confidential survey examining medical students' health care needs, practices, and concerns was administered at 9 US medical schools. One part of the survey focused on responses to 4 medical student-patient vignettes. The vignettes systematically varied preexisting student vs preexisting patient status before assuming a medical student-patient role, and the vignettes also varied illness situations that were more vs less stigmatizing. Responses were analyzed using χ(2) and multivariate analysis of variance tests. RESULTS: A total of 1027 students participated. We found that students were more likely to accept the dual role as medical student-patient in vignettes depicting a preexisting patient role than a preexisting student role. Students sought to avoid the dual role as student-patient in the context of stigmatizing health concerns. Women students were more likely than men to reject the dual role in all cases. CONCLUSION: Medical students appear to be sensitive to the conflicts that may be associated with the dual role as both medical student and patient when seeking care at their training institution. Our data suggest the importance of substantive efforts to promote the health, interests, and well-being of medical student-patients.

Barriers to colorectal cancer screening: physician and general population perspectives, New Mexico, 2006.

INTRODUCTION: Colorectal cancer (CRC) screening rates are low in New Mexico. We used statewide surveys of primary care physicians and the general population to characterize CRC screening practices and compare perceptions about screening barriers. METHODS: In 2006, we surveyed 714 primary care physicians in New Mexico about their CRC screening practices, beliefs, and perceptions of patient, provider, and system barriers. A 2004 state-specific CRC screening module for the Behavioral Risk Factor Surveillance System (BRFSS) survey asked 3,355 participants aged 50 years or older why they had not ever or had not recently completed a fecal occult blood test (FOBT) or lower endoscopy. RESULTS: The 216 physicians (30% response rate) reported offering screening to a median 80% of their average-risk patients in the past year and estimated that a median 50% were current with screening. They attributed low screening proportions mainly to patient factors (embarrassment, fear of pain, lack of insurance). However, just 51% of physician respondents used health maintenance flow sheets, and only 13% used electronic medical records to identify patients due for CRC screening. The BRFSS respondents most often reported that lack of physician discussion was responsible for not being current with screening (45% FOBT, 34% endoscopy); being asymptomatic was also often cited as an explanation for lack of screening (22% FOBT, 36% endoscopy). CONCLUSION: Physicians and adults in the general population had markedly different perspectives on barriers to CRC screening. Increasing screening may require system supports to help physicians readily identify patients due for CRC testing and interventions to educate patients about the rationale for screening.

"If only someone had told me ": lessons from rural providers.

PURPOSE: Health care providers face challenges in rural service delivery due to the unique circumstances of rural living. The intersection of rural living and health care challenges can create barriers to care that providers may not be trained to navigate, resulting in burnout and high turnover. Through the exploration of experienced rural providers' knowledge and lessons learned, this study sought to inform future practitioners, educators, and policy makers in avenues through which to enhance training, recruiting, and maintaining a rural workforce across multiple health care domains. METHODS: Using a qualitative study design, 18 focus groups were conducted, with a total of 127 health care providers from Alaska and New Mexico. Transcribed responses from the question, "What are the 3 things you wish someone would have told you about delivering health care in rural areas?" were thematically coded. FINDINGS: Emergent themes coalesced into 3 overarching themes addressing practice-related factors surrounding the challenges, adaptations, and rewards of being a rural practitioner. CONCLUSION: Based on the themes, a series of recommendations are offered to future rural practitioners related to community engagement, service delivery, and burnout prevention. The recommendations offered may help practitioners enter communities more respectfully and competently. They can also be used by training programs and communities to develop supportive programs for new practitioners, enabling them to retain their services, and help practitioners integrate into the community. Moving toward an integrative paradigm of health care delivery wherein practitioners and communities collaborate in service delivery will be the key to enhancing rural health care and reducing disparities.

Is torture reliably assessed and a valid indicator of poor mental health?

Torture is thought to confer worse mental health than other war-related traumatic events. However, reliability of torture assessment and validity of torture constructs as indicators of poor mental health have not been systematically evaluated. Study aims were to assess the psychometric properties of 2 common torture constructs. Refugees were assessed for having experienced torture by 1 subjective and 1 objective criterion. A subset was interviewed about definitions and effects of torture. Reliability and validity of torture constructs were assessed with general linear models. Interview data were analyzed for consistency of themes. Reliability of torture constructs was moderate, which paralleled inconsistencies in interview themes. Both torture criteria had similar dose-dependent relationships to mental health. Multivariate analyses showed that torture was not an independent predictor of poor mental health when controlling for the number of war-related events. Further work is needed to define torture from distinct medical and legal perspectives to improve reliability and validity.

The range of symptoms in refugees of war: the New Mexico Refugee Symptom Checklist-121.

The range of symptoms experienced by refugees of war has not been empirically assessed. The New Mexico Refugee Symptom Checklist-121 (NMRSCL-121) was developed utilizing established guidelines and evaluated for its psychometric properties. Community-dwelling Kurdish and Vietnamese refugees reported 48 (SD = 31) persistent and bothersome somatic and psychological symptoms on the NMRSCL-121. Internal consistency and test-retest reliability for the total scale and for most subscales were acceptable, and construct and concurrent validity for the NMRSCL-121 data was shown. There were modest ethnic group differences on symptom severity and psychometric properties of NMRSCL-121 subscales. The NMRSCL-121 produces reliable and valid assessments of a wide range of symptoms in 2 broad community samples of displaced adult refugees.

When providers and patients come from different backgrounds: perceived value of additional training on ethical care practices.

Fostering the therapeutic alliance, safeguarding confidentiality, gaining informed consent, and enhancing treatment adherence are critical aspects of patient care. We examined whether multidisciplinary health care providers perceive additional training on these areas as helpful in their work with patients from different ethnic backgrounds than the provider. Data are drawn from a National Institute on Drug Abuse-funded survey of 1555 providers in 8 disciplines in New Mexico and Alaska. Clinicians viewed additional training as moderately helpful for ensuring treatment adherence, establishing the therapeutic alliance, safeguarding confidentiality, and engaging in informed consent processes, in that order. Women were more receptive than men to additional training. Modest differences were detected between behavioral and physical health providers and between minority and majority providers. Implications of providers' only modest interest in such training are discussed.

Mexican immigrant women's perceptions of health care access for stigmatizing illnesses: a focus group study in Albuquerque, New Mexico.

This study examines attitudes of Mexican female immigrants to Albuquerque, New Mexico, regarding barriers to health care access in the United States and Mexico for stigmatizing and non-stigmatizing illnesses and moderating effects of social support. Native Spanish speakers conducted three focus groups (in Spanish) lasting two hours with seven to eight participants. Focus groups were transcribed, translated, and coded. Frequency data were calculated by number of times concepts or themes were raised. Comparisons of barriers to health care access were made between U.S. and Mexican cultures. The majority (86%) of comments on barriers for non-stigmatizing illnesses implicated U.S. culture; the majority (90%) for stigmatizing illnesses implicated Mexican culture. Social support for stigmatizing illnesses was discussed. Participants discussed important issues of health care access for stigmatizing illnesses that may have implications for this population's health status. Greater attention should be paid to stigma and social support in future empirical studies.

Adaptations to health care barriers as reported by rural and urban providers.

Barriers to ethical and effective health care in rural communities have been well-documented; however, less is known about strategies rural providers use to overcome such barriers. This study compared adaptations by rural and urban health care providers. Physical and behavioral health care providers were randomly selected from licensure lists for eight groups to complete a survey; 1,546 (52%) responded. Replies indicated that health care providers from small rural and rural communities were more likely to integrate community resources, individualize treatment recommendations, safeguard client confidentiality, seek out additional expertise, and adjust treatment styles than were providers from small urban and urban communities. Behavioral health care providers were more likely than physical health care providers to integrate community resources, individualize treatment recommendations, safeguard client confidentiality, and adjust their treatment styles; physical health care providers were more likely than behavioral health care providers to make attempts or have options to seek out additional expertise.

Informed consent in gynecologic surgery.

OBJECTIVE: The objective of the study was to describe surgeon self-reported behaviors and descriptions of information given to patients when obtaining surgical consent. STUDY DESIGN: This was a survey of 330 gynecological surgeons. Surgeons rated descriptions of information given to patients as well as behaviors for confirming patient understanding during surgical consent. Mean ratings are compared with repeated-measures multivariate analysis of variance. RESULTS: Forty-four percent of surveys (145 of 330) were returned. Most respondents were male (56%), Caucasian (86%), in academic practices settings (55%), with more than 10 years of experience after residency (53%). Surgeons give very detailed descriptions of risks and alternatives to surgery. Less detailed descriptions are given of the postoperative course, expected benefits of surgery, or functional and anatomic changes after surgery. Surgeons confirm patient understanding most often by asking patients whether they have any questions and rarely evaluate patient literacy. CONCLUSION: Surgeons provide widely varying attention to various issues and topics related to communicating with their patients preoperatively.

Acupuncture for posttraumatic stress disorder: a randomized controlled pilot trial.

The purpose of the study was to evaluate the potential efficacy and acceptability of accupuncture for posttraumatic stress disorder (PTSD). People diagnosed with PTSD were randomized to either an empirically developed accupuncture treatment (ACU), a group cognitive-behavioral therapy (CBT), or a wait-list control (WLC). The primary outcome measure was self-reported PTSD symptoms at baseline, end treatment, and 3-month follow-up. Repeated measures MANOVA was used to detect predicted Group X Time effects in both intent-to-treat (ITT) and treatment completion models. Compared with the WLC condition in the ITT model, accupuncture provided large treatment effects for PTSD (F [1, 46] = 12.60; p < 0.01; Cohen's d = 1.29), similar in magnitude to group CBT (F [1, 47] = 12.45; p < 0.01; d = 1.42) (ACU vs. CBT, d = 0.29). Symptom reductions at end treatment were maintained at 3-month follow-up for both interventions. Accupuncture may be an efficacious and acceptable nonexposure treatment option for PTSD. Larger trials with additional controls and methods are warranted to replicate and extend these findings.

Ethical disparities: challenges encountered by multidisciplinary providers in fulfilling ethical standards in the care of rural and minority people.

CONTEXT: Health care disparities are well documented for people living in rural areas and for people who are members of ethnic minorities. PURPOSE: Our goal was to determine whether providers report greater difficulty in providing care for rural than urban residents and for ethnic minorities than patients/clients in general in 4 practice areas of ethical relevance: attaining treatment adherence, assuring confidentiality, establishing therapeutic alliance, and engaging in informed consent processes. METHODS: We received survey responses from 1,558 multidisciplinary medical and behavioral providers across rural and non-rural areas of New Mexico and Alaska in 2004 to assess a wide range of issues in providing health care. FINDINGS: Providers reported some difficulties in fulfilling various ethical practices for all types of patients, but not more difficulty when caring for minority compared to nonminority patients/clients. However, they do report more frequent additional problems related to the practice issues of treatment adherence, therapeutic alliance, informed consent, and confidentiality with minority patients than others. Difficulties and more frequent additional problems are greater for providers in rural than in non-rural areas. Results generalize across both Alaska and New Mexico with few differences. CONCLUSIONS: We obtained evidence for disparity in care for patients/ clients who were minority group members, and clear evidence of disparity for people residing in rural compared to non-rural areas of 2 states with large rural areas.