Consultants' and referrers' perceived barriers to closing the cross-institutional referral loop, and perceived impact on clinical care.

BACKGROUND: Cross-institutional (external) referrals are prone to communication breakdowns, increasing patient safety risks, clinician burnout, and healthcare costs. To close these external referral loops, referring primary care physicians (PCPs) need to receive patient information from consultants at different healthcare institutions. Although existing studies investigated the early phases of external referral loops, we lack sufficient knowledge about the closing phases of these loops. This knowledge could allow health care institutions to improve care coordination and rates of closed referral loops by implementing socio-technical interventions for patient information exchange throughout a referral loop. Human factors engineering (HFE) provides a systematic approach to advance our understanding of barriers perceived by physicians. Using HFE, our objective was to characterize referring and consulting physicians' barriers to closing referral loops and implications for care. METHODS: This qualitative cross-sectional study included semi-structured interviews with referrers and external consultants. We used the Systems Engineering Initiative for Patient Safety 2.0 framework to conduct rapid qualitative analyses, determining perceived barriers and related implications. Main measures were consultants' and referrers' perceptions of, and experiences with, barriers to external referrals. RESULTS: Six referring PCPs and 12 consultants participated from two healthcare systems and four medical specialties. Physicians perceived three main barriers in external referrals: receipt of excessive and unnecessary faxed documents, missing or delayed documentation, and organizational policies regarding information privacy interfering with closing the loop. Compared to internal referrals, physicians reported increased staff burden, patient frustration, and delays in diagnosis with external referrals. Consultants reported the ability to provide the same level of care to patients with internal or external referrals. However, consultants described communication breakdowns that prohibited confirmation of follow-up plan retrieval, initiation, or effectiveness. CONCLUSION: Physicians reported technological and organizational barriers to closing cross-institutional referral loops. Promises of HIE technology for external referrals have not fully materialized. Among physicians and patients, retrieval and exchange of medical information increases perceived workload, burden, and frustration. These increases are not accurately captured by traditional organizational metrics. This study provides evidence that informs future human factors engineering research to address perceived barriers and guide future HIE design or implementation.

Caregiver and Juvenile Justice Personnel Perspectives on challenges and importance of caregiver engagement and the potential utility of a peer navigator program in the Juvenile Justice System.

BACKGROUND: For youth involved in the juvenile justice (JJ) system, caregiver involvement and engagement in the system is crucial for youth development and outcomes of JJ cases; however, there are challenges to establishing positive/productive partnerships between caregivers and JJ representatives. The current project examines perspectives of caregivers and JJ personnel regarding facilitators and barriers to establishing JJ-caregiver partnerships, as well as their perceptions of the use of a caregiver navigator program to support caregivers of system-involved youth. Results are used to inform development of a caregiver navigator program to support caregivers and help them navigate the JJ system. RESULTS: Semi-structured interviews were conducted with caregivers of youth involved in JJ (n = 15, 53% White, 93% female), JJ personnel (n = 7, 100% White, 50% female), and JJ family advisory board members (n = 5, 100% Black, 100% female). Caregivers reported varying experiences across intake/arrest, court, and probation processes. Positive experiences were characterized by effective communication and feeling supported by JJ. Negative experiences related to feeling blamed and punished for their child's system involvement and feeling unsupported. JJ interviews corroborated caregiver sentiments and also illustrated facilitators and barriers to JJ-caregiver partnerships. Both JJ personnel and caregivers endorsed potential benefits of a peer-based caregiver navigator program to provide social, informational, and emotional support. CONCLUSION: Continued work is needed to improve JJ-caregiver partnerships and use of a peer-based navigator program has the potential to address barriers to caregiver engagement in the JJ system.

Measures of self-reported identity associated with sex and gender: Relations with collegiate drinking.

OBJECTIVE: Quantitative research has typically relied on categorical measures of sex assigned at birth (SAAB) and gender, with heterogeneous findings in terms of their associations with alcohol-related behavior. This investigation examined continuous indices of self-identification as an alternative to categorical operationalizations in alcohol research. METHOD: Eight hundred ninety-three undergraduate students (74.6% cisgender women, 20.3% cisgender men, 3.9% nonbinary, and 1.2% transgender), recruited from the Midwest and Pacific Northwest of the United States, completed online measures of SAAB (male/female), gender (categorical), continuous indices of identification (femaleness, maleness, and bidirectional), and alcohol consumption (Cahalan Indices; Daily Drinking Questionnaire-Revised; Alcohol Use Disorders Identification Test [AUDIT]). RESULTS: Novel continuous measures of identification were associated with categorical indices of SAAB and gender as predicted. While none of the self-identification indices (continuous or categorical) predicted current drinking (consumption in the past 30 days), they evidenced relatively consistent, albeit small effects, across quantity-frequency of drinking and AUDIT scores for current drinkers. Higher scores on maleness and bidirectional indices of identification were associated with greater consumption, while greater endorsement of femaleness and being a cisgender woman (vs. a cisgender man) were related to less drinking. CONCLUSIONS: Continuous self-reported identification items performed well when describing drinking behavior in college students. The inclusion of dimensional scales of identity broadens our ability to capture differing self-conceptualizations in research.

Examining the unique and additive effect of trauma and racial microaggressions on substance use risk among Black young adults.

OBJECTIVE: Exposure to traumatic events is linked to adverse health outcomes, including substance use. Contemporary models have conceptualized racism, including racial microaggressions, as a form of trauma. However, few studies have been conducted examining the unique and additive effect of racial microaggressions within models that include exposure to traditional forms of trauma on substance use outcomes, as well as whether effects vary by gender. METHOD: Three hundred and ninety-nine Black young adults between 18 and 29 (61% female, mean age 20.7) completed measures on problem alcohol and cannabis use, and experiences of trauma and racial microaggressions. RESULTS: Controlling for age, gender, income, race (i.e., monoracial vs. multiracial), and recruitment source, regression analyses showed that racial microaggressions predicted problem substance use above the effect of trauma exposure. Moreover, exoticization/assumptions of similarity and workplace/school microaggressions primarily accounted for the effect of racial microaggressions on substance use risk. One gender effect was found, with trauma exposure associated with lower cannabis use for Black males and a nonsignificant effect found for Black females. CONCLUSIONS: Racial microaggressions provide unique and additive understanding in risk for substance use outcomes among Black young adults above effects observed from exposure to traditional forms of trauma. This finding highlights the significance of racial microaggression on health outcomes for Black young adults and can inform future research in the area of trauma exposure and substance use risk among this population of young people. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The relationship between racial discrimination and substance use: Does locus of control help explain risk?

Introduction: Exposure to racial discrimination has been consistently linked with risk for substance use. However, outside of externalizing and affect-based factors, few other mechanisms have been examined. One potential candidate is locus of control, a learning processes that involves the degree to which one attributes rewards as resulting from their own control (internal locus of control) versus outside control (external locus of control). There is evidence that exposure to stressors is associated with locus of control, with a separate body of literature linking locus of control with substance use. Thus, it is plausible that locus of control may be a mechanism underlying the relationship between racial discrimination and substance use. Methods: The current study investigated this pathway among 503 racial/ethnic minority adults aged 18-35 who completed an online questionnaire including measures on racial discrimination related stress, locus of control, and substance use. Results: Results indicated a significant indirect effect between racial discrimination related stress, two external domains of locus of control (i.e., powerful others and chance), and substance use. A significant indirect effect was not found for internal locus of control. Conclusion: These findings expand our understanding on potential mechanisms that underlie the racial discrimination-substance use risk pathway among racial/ethnic minority adults, which may in turn provide important targets for substance use intervention programming.

Implementation of a Brief Dialectical Behavioral Therapy Skills Group in High Schools for At-Risk Youth: Protocol for a Mixed Methods Study.

BACKGROUND: Adolescence is a developmental period marked by engagement in risk-taking behaviors, especially among impulsive or emotionally dysregulated youth. Thus, interventions that teach skills to reduce the risk of negative outcomes associated with emotional dysregulation are required. Social and emotional learning (SEL) programs have been developed to address both adolescent emotional dysregulation and risk-taking behaviors; however, current programs have mostly been implemented among younger youth and are used as a tier 1 universal intervention rather than a targeted tier 2 intervention for youth identified with emotional regulation difficulties. OBJECTIVE: This study aimed to address the need for SEL programming that can be delivered in schools, particularly for older youth who have difficulties with emotional or behavioral dysregulation, to reduce the risk of health-risk behaviors among this population. METHODS: Here, we outline the implementation of an SEL intervention titled Going 4 Goals, a 9-session adaptation of the Dialectical Behavioral Therapy for Adolescents (DBT-A) program delivered to at-risk high school students in a school setting. The primary objectives of the study are to test whether participating in the skills group intervention produces significant increases in the core DBT-A skills of mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness, while also producing significant decreases in substance use and risky behaviors. These primary outcomes are based on changes in participant scores between baseline and after the intervention and follow-ups at 1, 3, and 6 months compared with a control group of youth participating in the school's health curriculum at the same time points. Qualitative interviews will also be conducted with intervention participants and school staff to examine acceptability and facilitators of and barriers to the intervention. RESULTS: A total of 171 participants across 13 groups had been enrolled in the intervention, with data collection ending December 2021. Data analysis will begin in the spring of 2022, with expected results to be published in the spring of 2023. CONCLUSIONS: This paper describes the protocol of the 9-session school-based adaptation of the DBT-A intervention and discusses the strengths and limitations of the study and future directions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/32490.

Dieting and substance use among White and Black adolescent girls.

OBJECTIVE: Previous research has found an increasing co-occurrence of dieting and substance use behavior among adolescent girls. However, to date few studies have examined the temporal ordering of these behaviors. Further, limited research has been conducted to explore whether the pathways are similar among both White and Black girls. METHOD: For the current study 1580 girls (grade 6-11; 78.2% White; 21.8% Black) provided data on their dieting behavior and substance use. A cross-lagged panel design was used to examine the concurrent and prospective relationship between dieting behavior and substance use across one year, then by race. RESULTS: Among the full sample of girls, there was a significant concurrent relationship. Additionally, dieting behavior predicted substance use one year later, but the inverse relationship was not found. For the stratified analysis, dieting behavior and substance use were not correlated among Black girls at either time point, however concurrent relationships were found for White girls. For the prospective pathways non-significant effects were found for both groups. DISCUSSION: These findings provide support for a temporal relationship between dieting behavior and substance use, such that the former predicts risk for the latter. However, when examined by race, some pathways of the full sample were found for White girls, whereas Black girls did not report an association between study variables. Thus, future studies should consider the impact of race within risk pathways.

Discrimination and Substance Use: Examining the Moderating Role of Impulsivity among Racial-Ethnic Minority Adolescents.

BACKGROUND: Research on substance use among racial-ethnic minority populations notes that discrimination experiences predict substance use outcomes. Individual-level factors, such as impulsivity, are also known risk factors for substance use. However, little is known about the direct and interaction effects between discrimination experiences and impulsivity among racial-ethnic minority youth. The current study examines the effects of perceived experiences of discrimination on alcohol and marijuana use among racial-ethnic minority youth, and whether individual differences in impulsivity traits help to further understand potential risk for substance use. METHODS: Participants were 112 racial-ethnic minority adolescents (Mage = 15.27; African American, Hispanic, Multiracial, Native American/Alaskan Native, or Other). Adolescents completed self-report measures of perceived experiences of discrimination, alcohol and marijuana use (past year occurrence and problematic use), and five impulsivity traits (i.e., sensation seeking, lack of planning, lack of perseverance, negative urgency, and positive urgency). RESULTS: A significant main effect of perceived discrimination on problem marijuana use was found, as well as a significant main effect of lack of premeditation on current marijuana use. Several marginally significant main effects emerged for alcohol use and problem alcohol use (i.e., positive urgency and sensation seeking, respectively). CONCLUSION: While no significant moderation effects emerged, marginal findings suggest a potential interactive effect of discrimination and impulsivity traits on problem alcohol and marijuana use among racial-ethnic minority youth. Further research is needed in this area to replicate findings, which is critical to informing effective intervention and prevention efforts for this population of youth.

The Changing Face of Treatment: Mental Health Concerns and Integrated Care in an HIV Clinic.

Though advances in medical treatment have increased lifespans for those living with HIV, quality of life concerns often remain under-treated by health care providers. The integration of mental health services within the HIV medical setting can provide comprehensive care for patients, including brief screening, intervention, and appropriate follow-up. In this study, investigators examined mental health concerns identified during behavioral health screens at appointments in an Infectious Disease Clinic and compared them with previously published data from the same setting to assess changes in patient-reported problems. Results indicated shifts in identified problems, as well as demographic changes in the patient population from the previous study. Analyses suggested anger and goal-setting problems significantly contribute to reports of psychiatric symptoms, and suggested that adjustment to diagnosis, depression, and sleep concerns significantly contribute to the likelihood of engaging in a mental health consultation. Our findings highlight the importance of behavioral health screening to identify psychosocial concerns in integrated HIV care settings.