Countering Antivax Misinformation via Social Media: Message-Testing Randomized Experiment for Human Papillomavirus Vaccination Uptake.

BACKGROUND: Suboptimal adolescent human papillomavirus (HPV) vaccination rates have been attributed to parental perceptions of the HPV vaccine. The internet has been cited as a setting where misinformation and controversy about HPV vaccination have been amplified. OBJECTIVE: We aimed to test message effectiveness in changing parents' attitudes and behavioral intentions toward HPV vaccination. METHODS: We conducted a web-based message-testing experiment with 6 control messages and 25 experimental messages and 5 from each of the 5 salient themes about HPV vaccination (theme 1: safety, side effects, risk, and ingredient concerns and long-term or major adverse events; theme 2: distrust of the health care system; theme 3: HPV vaccine effectiveness concerns; theme 4: connection to sexual activity; and theme 5: misinformation about HPV or HPV vaccine). Themes were identified from previous web-based focus group research with parents, and specific messages were developed by the study team using content from credible scientific sources. Through an iterative process of message development, the messages were crafted to be appropriate for presentation on a social media platform. Among the 1713 participants recruited via social media and crowdsourcing sites, 1043 eligible parents completed a pretest survey questionnaire. Participants were then randomly assigned to 1 of the 31 messages and asked to complete a posttest survey questionnaire that assessed attitudes toward the vaccine and perceived effectiveness of the viewed message. A subgroup of participants (189/995, 19%) with unvaccinated children aged 9 to 14 years was also assessed for their behavioral intention to vaccinate their children against HPV. RESULTS: Parents in the experimental group had increased positive attitudes toward HPV vaccination compared with those in the control group (t969=3.03, P=.003), which was associated with increased intention to vaccinate among parents of unvaccinated children aged 9 to 14 years (r=1.14, P=.05). At the thematic level, we identified 4 themes (themes 2-5) that were relatively effective in increasing behavioral intentions by positively influencing attitudes toward the HPV vaccine (χ25=5.97, P=.31, root mean square error of approximation [RMSEA]=0.014, comparative fit index [CFI]=0.91, standardized root mean square residual [SRMR]=0.031). On the message level, messages that provided scientific evidence from government-related sources (eg, the Centers for Disease Control and Prevention) and corrected misinformation (eg, "vaccines like the HPV vaccine are simply a way for pharmaceutical companies to make money. That isn't true") were effective in forming positive perceptions toward the HPV vaccination messages. CONCLUSIONS: Evidence-based messages directly countering misinformation and promoting HPV vaccination in social media environments can positively influence parents' attitudes and behavioral intentions to vaccinate their children against HPV.

Pet Dogs and Children's Health: Opportunities for Chronic Disease Prevention?

INTRODUCTION: Positive associations between having a pet dog and adult health outcomes have been documented; however, little evidence exists regarding the benefits of pet dogs for young children. This study investigates the hypothesis that pet dogs are positively associated with healthy weight and mental health among children. METHODS: This cross-sectional study accrued a consecutive sample of children over 18 months in a pediatric primary care setting. The study enrolled 643 children (mean age, 6.7 years); 96% were white, 45% were female, 56% were privately insured, and 58% had pet dogs in the home. Before an annual visit, parents of children aged 4 to 10 years completed the DartScreen, a comprehensive Web-based health risk screener administered using an electronic tablet. The screener domains were child body mass index (BMI), physical activity, screen time, mental health, and pet-related questions. RESULTS: Children with and children without pet dogs did not differ in BMI (P = .80), screen time of 2 hours or less (P = 0.99), or physical activity (P = .07). A lower percentage of children with dogs (12%) met the clinical cut-off value of Screen for Child Anxiety and Related Disorders (SCARED-5) of 3 or more, compared with children without dogs (21%, P = .002). The mean SCARED-5 score was lower among children with dogs (1.13) compared with children without dogs (1.40; P = .01). This relationship was retained in multivariate analysis after controlling for several covariates. CONCLUSIONS: Having a pet dog in the home was associated with a decreased probability of childhood anxiety. Future studies need to establish whether this relationship is causal and, if so, how pet dogs alleviate childhood anxiety.

TXT me I'm only sleeping: adolescents with mobile phones in their bedroom.

The purpose of this study was to determine if mobile phones interfere with adolescent sleep. We conducted a pilot test in a pediatric primary care practice of 454 patients, half female (51.2%), 12 to 20 years old (mean = 15) attending a well-child visit. Adolescents completed paper-and-pencil surveys in the waiting room. More than half took their mobile phone to bed (62.9%) and kept it turned on while sleeping (56.8%). Almost half used their phone as their alarm (45.7%). More than one-third texted after going to bed (36.7%). Two or more times per week, 7.9% were awakened by a text after going to sleep.

Community variation in adolescent access to indoor tanning facilities.

Melanoma rates among younger women in New Hampshire (NH) are rising. In urban studies, youth proximity to tanning facilities has been linked to indoor tanning, a proven cause of melanoma. Youth access has not been examined in rural settings. To determine on a statewide basis the influence of rurality and community income level on female students' ease of access to tanning facilities, all NH tanning facilities (N = 261) and high schools (N = 77) in 2011 were spatially and statistically analyzed to determine schools with more facilities within 2 miles of the school and greater capacity (fewer female students per facility), for indoor tanning. Schools above the state-wide average for both measures were classified as "Easy Access" to indoor tanning. Among NH high schools, 74 % have 1 or more tanning facility within two miles and 22 % have "Easy Access" to tanning facilities. Ease of access did not differ by rurality. Lower-income school status was an independent predictor of both greater capacity and "Easy Access". While urban and rural teens have similar access to indoor tanning, female students in lower-income communities have easier access. Variations in access by community size and income must be considered in planning interventions to address youth indoor tanning.

Workshop on Implementation Science and Digital Therapeutics for Behavioral Health.

Digital therapeutics can overcome many of the barriers to translation of evidence-based treatment for substance use, mental health, and other behavioral health conditions. Delivered via nearly ubiquitous platforms such as the web, smartphone applications, text messaging, and videoconferencing, digital therapeutics can transcend the time and geographic boundaries of traditional clinical settings so that individuals can access care when and where they need it. There is strong empirical support for digital therapeutic approaches for behavioral health, yet implementation science with regard to scaling use of digital therapeutics for behavioral health is still in its early stages. In this paper, we summarize the proceedings of a day-long workshop, "Implementation Science and Digital Therapeutics," sponsored and hosted by the Center for Technology and Behavioral Health at Dartmouth College. The Center for Technology and Behavioral Health is an interdisciplinary P30 Center of Excellence funded by the National Institute on Drug Abuse, with the mission of promoting state-of-the-technology and state-of-the-science for the development, evaluation, and sustainable implementation of digital therapeutic approaches for substance use and related conditions. Workshop presentations were grounded in current models of implementation science. Directions and opportunities for collaborative implementation science research to promote broad adoption of digital therapeutics for behavioral health are offered.

Private well water testing promotion in pediatric preventive care: A randomized intervention study.

Over 43 million U.S. residents rely on private unregulated wells for their drinking water, raising public health concerns, particularly in regions like northern New England where widespread groundwater arsenic contamination is now recognized. Children are particularly vulnerable to adverse health effects from arsenic exposure. Despite AAP Guidelines, approaches to engage pediatric clinicians in promoting private well testing have not been previously described. We sought to determine the most effective practice approaches to achieve successful well water testing in routine pediatric care. 12 primary care clinics were block randomized to one of four study arms. Two intervention variables were assessed: (1) test results access (parent only vs. parent and clinic) and (2) follow up approaches (yes/no). Parents of children under 12 months using a private well were eligible. Prepaid water tests were provided. Primary outcome was parental water test completion. Eleven clinics successfully implemented processes identifying well users. 240 testing kits were dispensed. Completion rates averaged 29% (range 10 to 61%). The study arm with both clinic results access and staff follow up system was 2.3 times more likely to achieve test completion than other arms (95% CI 1.12-4.86, p = .03). Kit distribution by clinicians versus nursing staff, irrespective of study arm, had 2.4 times greater completion (95% CI 1.13-5.11, p = .02). Systematic drinking water source screening can be improved in pediatric care. Higher testing completion was found in practices randomized to reminders and structured follow up versus single visit discussion, but clinician involvement was the most predictive factor.

Assessing Mental Health Concerns of Spanish-Speaking Dairy Farm Workers.

Background: Hispanic dairy farm workers have risk factors for mental health concerns. There is insufficient study of their mental health needs.Methods: We conducted focus groups at five farms. We quantified the burden of depressive symptoms with Patient Health Questionnaires (PHQ-2 and PHQ-9) during three seasons of mobile clinics on farm sites.Results: Focus groups revealed that sources of stress included working conditions, language barriers, fear of deportation, and distance from family. Depression screening found that the rate of mild depressive symptoms ranged from 0% to 3.2%. No individual scored higher than mild depression.Discussion: Rates of depressive symptoms were substantially lower than in the general US population, which may be explained by a population that self-selects for resilience. Our mixed qualitative and quantitative data acquisition provided us a more robust and comprehensive understanding of our population's mental health concerns than using one method alone.

Increasing collaboration on substance use disorder research with primary care practices through the National Drug Abuse Treatment Clinical Trials Network.

BACKGROUND: The National Drug Abuse Treatment Clinical Trials Network (CTN) called for its national nodes to promote the translation of evidence-based interventions from substance use disorder (SUD) research into clinical practices. This collaborative demonstration project engaged CTN-affiliated practice-based research networks (PBRNs) in research that describes aspects of opioid prescribing in primary care. METHODS: Six PBRNs queried electronic health records from a convenience sample of 134 practices (84 participants) to identify the percent of adult patients with an office visit who were prescribed an opioid medication from October 1, 2015, to September 30, 2016, and, of those, the percent also prescribed a sedative in that year. Seven PBRNs sent an e-mail survey to a convenience sample of 108 practices (58 participants) about their opioid management policies and procedures during the project year. RESULTS: Of 561,017 adult patients with a visit to one of the 84 clinics in the project year, 22.9% (PBRN range 3.1%-25.4%) were prescribed opioid medications, and 52.1% (PBRN range 8.5%-60.6%) of those were prescribed a sedative in the same year. Of the 58 practices returning a survey (45.3% response rate), 98.1% had formal written treatment agreements for chronic opioid therapy, 68.5% had written opioid prescribing policies, and 43.4% provided reports to providers with feedback on opioid management. Only 24.1% were providing buprenorphine for OUD. CONCLUSION: CTN-affiliated PBRNs demonstrated their ability to collaborate on a project related to opioid management; results highlight the important role for PBRNs in OUD treatment, research, and the need for interventions and additional policies addressing opioid prescribing in primary care practice.

Smoke-Free Moms: Financial Rewards for Smoking Cessation by Low-Income Rural Pregnant Women.

INTRODUCTION: Maternal smoking places the child at risk during pregnancy and postpartum. Most women who quit smoking do so early when they first learn of pregnancy. Few low-income women quit once they enter prenatal care. The purpose of this study is to test in a clinical prenatal care setting the effectiveness of the Smoke-Free Moms intervention, which provides pregnant women a series of financial incentives for smoking cessation. STUDY DESIGN: A prospective nonrandomized controlled trial that collected control population data of smoking-cessation rates at each clincal visit during pregnancy and postpartum with usual smoking counseling in 2013-2014. In 2015-2016, the same data were collected during the implementation of the Smoke-Free Moms intervention of financial incentives. Data analysis occurred in 2017. SETTING/PARTICIPANTS: Women who were smoking at the first prenatal visit at four federally qualified health centers in rural New Hampshire. INTERVENTION: All women received 5A's smoking counseling from clinic staff. At each clinic visit, with point-of-care confirmed negative urinary cotinine, intervention women received gift cards. MAIN OUTCOME MEASURES: Cotinine confirmed smoking cessation without relapse: (1) during pregnancy and (2) smoking cessation in both pregnancy and postpartum. RESULTS: Of 175 eligible pregnant women enrolled, 134 women were followed to the postpartum visit (Intervention n=66, Control n=68). The quit rates during pregnancy did not differ between groups (Intervention 36.4%, Control 29.4%, p=0.46). However, significantly more intervention mothers quit and continued as nonsmokers postpartum (Intervention 31.8%, Control 16.2%, p=0.04). In a logistic regression model including baseline sociodemographic, depressed mood, stress, and readiness to quit items, confidence in being able to quit predicted both cessation outcomes. The financial incentive intervention was an independent predictor of cessation in pregnancy through postpartum. CONCLUSIONS: Financial incentives with existing smoking-cessation counseling by staff in low-income clinical prenatal programs led to cessation that continued during the postpartum period. Further study in larger populations is indicated.

Part II: A Qualitative Study of Social Risk Screening Acceptability in Patients and Caregivers.

INTRODUCTION: This study aimed to better understand patient and caregiver perspectives on social risk screening across different healthcare settings. METHODS: As part of a mixed-methods multisite study, the authors conducted semistructured interviews with a subset of adult patients and adult caregivers of pediatric patients who had completed the Center for Medicare and Medicaid Innovation Accountable Health Communities social risk screening tool between July 2018 and February 2019. Interviews, conducted in English or Spanish, asked about reactions to screening, screening acceptability, preferences for administration, prior screening experiences that informed perspectives, and expectations for social assistance. Basic thematic analysis and constant comparative methods were used to code and develop themes. RESULTS: Fifty interviews were conducted across 10 study sites in 9 states, including 6 primary care clinics and 4 emergency departments. There was broad consensus among interviewees across all sites that social risk screening was acceptable. The following 4 main themes emerged: (1) participants believed screening for social risks is important; (2) participants expressed insight into the connections between social risks and overall health; (3) participants emphasized the importance of patient-centered implementation of social risk screening; and (4) participants recognized limits to the healthcare sector's capacity to address or resolve social risks. CONCLUSIONS: Despite gaps in the availability of social risk-related interventions in healthcare settings, patient-centered social risk screening, including empathy and attention to privacy, may strengthen relationships between patients and healthcare teams. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Part I: A Quantitative Study of Social Risk Screening Acceptability in Patients and Caregivers.

INTRODUCTION: Despite recent growth in healthcare delivery-based social risk screening, little is known about patient perspectives on these activities. This study evaluates patient and caregiver acceptability of social risk screening. METHODS: This was a cross-sectional survey of 969 adult patients and adult caregivers of pediatric patients recruited from 6 primary care clinics and 4 emergency departments across 9 states. Survey items included the Center for Medicare and Medicaid Innovation Accountable Health Communities' social risk screening tool and questions about appropriateness of screening and comfort with including social risk data in electronic health records. Logistic regressions evaluated covariate associations with acceptability measures. Data collection occurred from July 2018 to February 2019; data analyses were conducted in February‒March 2019. RESULTS: Screening was reported as appropriate by 79% of participants; 65% reported comfort including social risks in electronic health records. In adjusted models, higher perceived screening appropriateness was associated with previous exposure to healthcare-based social risk screening (AOR=1.82, 95% CI=1.16, 2.88), trust in clinicians (AOR=1.55, 95% CI=1.00, 2.40), and recruitment from a primary care setting (AOR=1.70, 95% CI=1.23, 2.38). Lower appropriateness was associated with previous experience of healthcare discrimination (AOR=0.66, 95% CI=0.45, 0.95). Higher comfort with electronic health record documentation was associated with previously receiving assistance with social risks in a healthcare setting (AOR=1.47, 95% CI=1.04, 2.07). CONCLUSIONS: A strong majority of adult patients and caregivers of pediatric patients reported that social risk screening was appropriate. Most also felt comfortable including social risk data in electronic health records. Although multiple factors influenced acceptability, the effects were moderate to small. These findings suggest that lack of patient acceptability is unlikely to be a major implementation barrier. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Longitudinal retention of families in the assessment of a prevention program targeting adolescent alcohol and tobacco use: the utility of an ecological systems framework.

This study examined the association between ecological context (extrafamilial, familial, child factors) at baseline and longitudinal retention of families in the 36-month assessment of an adolescent alcohol and tobacco use prevention program that was conducted within a pediatric primary care setting. A total of 1,780 families were enrolled at baseline when the youth were in the fifth and sixth grades, and 1,220 of these families participated in the 36-month assessment. Findings indicated that familial and child, but not extrafamilial, factors were associated with the participation of families in the 36-month assessment. Clinical implications and future research directions are discussed.

Choctaw Nation Youth Sun Exposure Survey.

The incidence of skin cancer is rising among American Indians (AI) but the prevalence of harmful ultraviolet light (UVL) exposures among AI youth is unknown. In 2013, UVL exposures, protective behaviors, and attitudes toward tanning were assessed among 129 AI and Non-Hispanic (NHW) students in grades 8-12 in Southeastern Oklahoma. Sunburn was reported by more than half the AI students and most of the NHW students. One-third of AI students reported never using sunscreen, compared to less than one-fifth of NHW students, but racial differences were mitigated by propensity to burn. Less than 10% of students never covered their shoulders when outside. Girls, regardless of race, wore hats much less often than boys. Regardless of race or sex, more than one-fourth of students never stayed in the shade, and more than one-tenth never wore sunglasses. The prevalence of outdoor tanning did not differ by race, but more than three-fourths of girls engaged in this activity compared to less than half the boys. Indoor tanning was reported by 45% of the girls, compared to 20% of girls nationwide, with no difference by race. Nearly 10% of boys tanned indoors. Among girls, 18% reported more than ten indoor tanning sessions. Over one-quarter of participants agreed that tanning makes people look more attractive, with no significant difference by race or sex. Investigations of UVL exposures should include AI youth, who have not been represented in previous studies but whose harmful UVL exposures, including indoor tanning, may place them at risk of skin cancer.

Right For Me: protocol for a cluster randomised trial of two interventions for facilitating shared decision-making about contraceptive methods.

INTRODUCTION: Despite the observed and theoretical advantages of shared decision-making in a range of clinical contexts, including contraceptive care, there remains a paucity of evidence on how to facilitate its adoption. This paper describes the protocol for a study to assess the comparative effectiveness of patient-targeted and provider-targeted interventions for facilitating shared decision-making about contraceptive methods. METHODS AND ANALYSIS: We will conduct a 2×2 factorial cluster randomised controlled trial with four arms: (1) video+prompt card, (2) decision aids+training, (3) video+prompt card and decision aids+training and (4) usual care. The clusters will be clinics in USA that deliver contraceptive care. The participants will be people who have completed a healthcare visit at a participating clinic, were assigned female sex at birth, are aged 15-49 years, are able to read and write English or Spanish and have not previously participated in the study. The primary outcome will be shared decision-making about contraceptive methods. Secondary outcomes will be the occurrence of a conversation about contraception in the healthcare visit, satisfaction with the conversation about contraception, intended contraceptive method(s), intention to use a highly effective method, values concordance of the intended method(s), decision regret, contraceptive method(s) used, use of a highly effective method, use of the intended method(s), adherence, satisfaction with the method(s) used, unintended pregnancy and unwelcome pregnancy. We will collect study data via longitudinal patient surveys administered immediately after the healthcare visit, four weeks later and six months later. ETHICS AND DISSEMINATION: We will disseminate results via presentations at scientific and professional conferences, papers published in peer-reviewed, open-access journals and scientific and lay reports. We will also make an anonymised copy of the final participant-level dataset available to others for research purposes. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT02759939.

The challenge of intentional tanning in teens and young adults.

Changing UV exposure in adolescents and young adults has the potential to prevent years of excess exposure and subsequent skin cancer. Initial expectations were that an individual or media campaign informational approach would change this behavior. It is being recognized that current efforts have failed. Changing UV behaviors is challenging and has much in common with changing other health risk behaviors. The tanning industry benefits from recruiting new participants in this risky behavior. Research is just beginning to show some promising approaches, and will benefit from our experience attempting to change other risky behaviors.

A longitudinal examination of the link between parent alcohol problems and youth drinking: the moderating roles of parent and child gender.

The unique and interactive effects of paternal and maternal alcohol problems on the drinking behavior of adolescent girls and boys were investigated. A prospective design was employed to examine changes in youth drinking behavior over a 3-year period in a community-based sample of 695 families. Results revealed that, as maternal alcohol problems increased, the likelihood of adolescent alcohol use increased. Paternal alcohol problems were associated with an increased likelihood of alcohol use for girls only. Findings point to the need for future research to investigate both maternal and paternal alcohol problems in community samples and with a sample size large enough to examine both parent and adolescent gender. Implications for preventive and interventive efforts are considered.

Screening for Adverse Childhood Experiences in a Family Medicine Setting: A Feasibility Study.

INTRODUCTION: The role of adverse childhood experiences (ACEs) in predicting later adverse adult health outcomes is being widely recognized by makers of public policy. ACE questionnaires have the potential to identify in clinical practice unaddressed key social issues that can influence current health risks, morbidity, and early mortality. This study seeks to explore the feasibility of implementing the ACE screening of adults during routine family medicine office visits. METHODS: At 3 rural clinical practices, the 10-question ACE screen was used before visits with 111 consecutive patients of 7 clinicians. Clinician surveys about the use of the results and the effect on the visits were completed immediately after the visits. The presence of any ACE risk and "high-risk" ACE scores (≥4) were compared with clinician survey responses. RESULTS: A risk of ACEs was present in 62% of patients; 22% had scores ≥4. Clinicians were more likely to have discussed ACE issues for high-risk patients (score 0-3, 36.8%; score ≥4, 83.3%; P =. 00). Clinicians also perceived that they gained new information (score 0-3, 35.6%; score ≥4, 83.3%; P = .00). Clinical care changed for a small proportion of high-risk patients, with no change in immediate referrals or plan for follow-up. In 91% of visits where a risk of ACEs was present, visit length increased by ≤5 minutes. CONCLUSIONS: Incorporation of ACE screening during routine care is feasible and merits further study. ACE screening offers clinicians a more complete picture of important social determinants of health. Primary care-specific interventions that incorporate treatment of early life trauma are needed.

Multi-institutional development and utilization of a computer-assisted learning program for the pediatrics clerkship: the CLIPP Project.

Computer-assisted instruction (CAI) holds significant promise for meeting the current challenges of medical education by providing consistent and quality teaching materials regardless of training site. The Computer-assisted Learning in Pediatrics Project (CLIPP) was created over three years (2000-2003) to meet this potential through multi-institutional development of interactive Internet-based patient simulations that comprehensively teach the North American core pediatrics clerkship curriculum. Project development adhered to four objectives: (1) comprehensive coverage of the core curriculum; (2) uniform approach to CAI pedagogy; (3) multi-institutional development by educators; and (4) extensive evaluation by users. Pediatrics clerkship directors from 30 institutions worked in teams to develop a series of 31 patient case simulations. An iterative process of case content and pedagogy development, case authoring, peer review, and pilot-testing ensured that the needs of clerkship directors and medical students were met. Fifty medical schools in the United States and Canada are presently using CLIPP. More than 8,000 students have completed over 98,000 case sessions, with an average of 2,000 case sessions completed per week at this time. Each CLIPP case has been completed by more than 3,000 students. The current cost of CLIPP development is approximately $70 per student user, or $6 per case session. The project's success demonstrates that multi-institutional development and implementation of a peer-reviewed comprehensive CAI learning program by medical educators is feasible and provides a useful model for other organizations to develop similar programs. Although CAI development is both time-consuming and costly, the initial investment decreases significantly with broad use over time.

Two approaches to maternal depression screening during well child visits.

The US Preventive Services Task Force (USPSTF) has recommended depression screening for adults. Screening mothers has special importance to pediatricians because of the impact of maternal depression on children. The two screening questions endorsed by the USPSTF may allow pediatricians to screen mothers during routine well child care. This study explores the feasibility and yield of interview- and paper-based pediatric screening for maternal depression during well child visits. A structured interview script was developed to inquire about maternal depression. It included the two-question screen and required less than 1 minute to administer. An alternative paper-based screen asked the two questions after a brief written introduction providing the rationale. Four community pediatric practices in New Hampshire and Maine were trained in both screening approaches and developed plans on how to respond to positive screens (either question positive). The 11 providers at these sites tested the two approaches on two different series of mothers at well child visits. The pediatricians also reported barriers to the screening inquiries, maternal responses, and subsequent clinician actions and referrals. The pediatricians screened 250 mothers via the scripted interview. In a second trial, 223 women had paper-based depression screening. Yields from the paper-based screen were 22.9% versus 5.7% for the interview-based screener. Pediatricians also took on the new role of discussion of possible depression in about two thirds of cases. Subsequently, 7.6% of all women with paper-based screening were referred to mental health versus 1.6% with the interview-based screening. With the interview, mothers of children younger than 1 year of age were less likely to screen positive than those with older children (1.9% vs. 8.5%, p = .04). With the paper-based screener, no age differences in positive screen rates occurred. While both approaches to screening were feasible in primary care, the yield from the two different approaches differed substantially. This finding deserves exploration in future studies. With either of these screening approaches, pediatricians could enhance their detection of mothers at risk of depression. The outcomes of pediatrician screening and the best approach to follow-up care still need to be determined.

Integrating mental health into adolescent annual visits: impact of previsit comprehensive screening on within-visit processes.

PURPOSE: To evaluate how a comprehensive, computerized, self-administered adolescent screener, the DartScreen, affects within-visit patient-doctor interactions such as data gathering, advice giving, counseling, and discussion of mental health issues. METHODS: Patient-doctor interaction was compared between visits without screening and those with the DartScreen completed before the visit. Teens, aged 15-19 years scheduled for an annual visit, were recruited at one urban and one rural pediatric primary care clinic. The doctor acted as his/her own control, first using his/her usual routine for five to six adolescent annual visits. Then, the DartScreen was introduced for five visits where at the beginning of the visit, the doctor received a summary report of the screening results. All visits were audio recorded and analyzed using the Roter interaction analysis system. Doctor and teen dialogue and topics discussed were compared between the two groups. RESULTS: Seven midcareer doctors and 72 adolescents participated; 37 visits without DartScreen and 35 with DartScreen were audio recorded. The Roter interaction analysis system defined medically related data gathering (mean, 36.8 vs. 32.7 statements; p = .03) and counseling (mean, 36.8 vs. 32.7 statements; p = .01) decreased with DartScreen; however, doctor responsiveness and engagement improved with DartScreen (mean, 4.8 vs. 5.1 statements; p = .00). Teens completing the DartScreen offered more psychosocial information (mean, 18.5 vs. 10.6 statements; p = .01), and mental health was discussed more after the DartScreen (mean, 93.7 vs. 43.5 statements; p = .03). Discussion of somatic and substance abuse topics did not change. Doctors reported that screening improved visit organization and efficiency. CONCLUSIONS: Use of the screener increased discussion of mental health but not at the expense of other adolescent health topics.