Integrating primary care and behavioral health with four special populations: Children with special needs, people with serious mental illness, refugees, and deaf people.

Special patient populations can present unique opportunities and challenges to integrating primary care and behavioral health services. This article focuses on four special populations: children with special needs, persons with severe and persistent mental illness, refugees, and deaf people who communicate via sign language. The current state of primary care and behavioral health collaboration regarding each of these four populations is examined via Doherty, McDaniel, and Baird's (1996) five-level collaboration model. The section on children with special needs offers contrasting case studies that highlight the consequences of effective versus ineffective service integration. The challenges and potential benefits of service integration for the severely mentally ill are examined via description of PRICARe (Promoting Resources for Integrated Care and Recovery), a model program in Colorado. The discussion regarding a refugee population focuses on service integration needs and emerging collaborative models as well as ways in which refugee mental health research can be improved. The section on deaf individuals examines how sign language users are typically marginalized in health care settings and offers suggestions for improving the health care experiences and outcomes of deaf persons. A well-integrated model program for deaf persons in Austria is described. All four of these special populations will benefit from further integration of primary care and mental health services.

The role of anxiolytic premedication in reducing preoperative anxiety.

Prevention of preoperative anxiety with anxiolytic premedication is associated with improved preoperative outcomes in surgical patients. The objective of the authors' study was to evaluate the percentage of surgical patients that are prescribed premedication for preoperative anxiety before their anticipated surgical procedure. A prospective study was carried out by theatre nursing staff in the theatre reception bay of a university teaching hospital. A questionnaire was designed to record the number of patients that described symptoms consistent with preoperative anxiety. The number of patients that had been offered anxiolytic premedication for preoperative anxiety was also recorded. Consent was obtained from 115 consecutive surgical patients (male, n=52; female, n=63). Of these, 66% (n=76) reported anxiety before their surgical procedure (male: n=27, female: n=49). Premedication with a low-dose benzodiazepine was prescribed by an anaesthetist in 4% of cases (n=5). Patients that received premedication preoperatively reported effective relief of their anxiety symptoms This study demonstrates that preoperative patient anxiety is highly prevalent. The authors' findings suggest that premedication with anxiolytic pharmacological therapy may be an underused therapeutic resource for managing preoperative patient anxiety.

Health-related quality of life and biomarkers in breast cancer survivors participating in tai chi chuan.

INTRODUCTION: Breast cancer survivors experience diminished health-related quality of life (HRQOL). We report on the influence of tai chi chuan exercise (TCC) on HRQOL and explore associations between changes in HRQOL and biomarkers. METHODS: Breast cancer survivors (N = 21) were randomly assigned to TCC or standard support therapy (SST) for 12 weeks (three times/week; 60 min/session). Interleukin-6, interleukin-8 (IL-8), insulin-like growth factor-1 (IGF-1), insulin-like growth factor-binding protein (IBFBP)-1, IGFBP-3, glucose, insulin, and cortisol were measured pre- and postintervention. Overall HRQOL and subdomains were assessed at preintervention (T1), midintervention (T2) and postintervention (T3) and biomarkers at T1 and T3. RESULTS: The TCC group improved in total HRQOL (T1-T2:CS = 8.54, P = 0.045), physical functioning (T1-T2:CS = 1.89, P = 0.030), physical role limitations (T1-T2 CS = 1.55, P = 0.023), social functioning (T1-T3:CS = 1.50, P = 0.020), and general mental health (T1-T2:CS = 2.67, P = 0.014; T1-T3:CS = 2.44, P = 0.019). The SST improved in social functioning (T1-T2:CS = 0.64, P = 0.043) and vitality (T1-T2:CS = 0.90, P = 0.01). There were relationships between changes in IGF-1 and overall HRQOL (r = -0.56; P < 0.05), physical role limitation (r = -0.68; P < 0.05), and social functioning (r = -0.56; P < 0.05). IGFBP-1 changes were associated with physical role limitations changes (r = 0.60; P < 0.05). IGFBP-3 changes were associated with physical functioning changes (r = 0.46; P ≤ 0.05). Cortisol changes were associated with changes in physical role limitations (r = 0.74; P < 0.05) and health perceptions (r = 0.46; P < 0.05). Glucose changes were associated with emotional role limitation changes (r = -0.70; P < 0.001). IL-8 changes were associated with emotional role limitation changes (r = 0.59; P < 0.05). DISCUSSION/CONCLUSIONS: TCC may improve HRQOL by regulating inflammatory responses and other biomarkers associated with side effects from cancer and its treatments. IMPLICATIONS FOR CANCER SURVIVORS: TCC may be an intervention capable of improving HRQOL in breast cancer survivors.

Do navigators' estimates of navigation intensity predict navigation time for cancer care?

Patient navigation requires that patient load be equitably distributed. We examined whether navigators could predict the relative amount of time needed by different patients for navigation. Analysis of 139 breast and colorectal cancer patients randomized to the navigation arm of a trial evaluating the effectiveness of navigation. Navigators completed a one-item scale estimating how much navigation time patients were likely to require. Participants were mostly females (89.2%) with breast cancer (83.4%); barriers to cancer care were insurance difficulties (26.6%), social support (18.0%), and transportation (14.4%). Navigator baseline estimates of navigation intensity predicted total navigation time, independent of patient characteristics. The total number of barriers, rather than any specific type of barrier, predicted increased navigator time, with a 16% increase for each barrier. Navigators' estimate of intensity independently predicts navigation time for cancer patients. Findings have implications for assigning navigator case loads.

Patient navigation from the paired perspectives of cancer patients and navigators: a qualitative analysis.

OBJECTIVE: Patient navigation for cancer care assesses and alleviates barriers to health care services. We examined paired perspectives of cancer patients and their navigators to examine the process of patient navigation. We explored the strengths, limitations, and our own lessons learned about adopting the novel methodology of multiperspective analysis. METHODS: As part of a larger RCT, patients and navigators were interviewed separately. We reviewed interviews with 18 patient-navigator dyads. Dyad summaries were created that explicitly incorporated both patient and navigator perspectives. Emerging themes and verbatim quotations were reflected in the summaries. RESULTS: Paired perspectives were valuable in identifying struggles that arose during navigation. These were represented as imbalanced investment and relational amelioration. Patients and navigators had general consensus about important patient needs for cancer care, but characterized these needs differently. CONCLUSION: Our experience with multiperspective analysis revealed a methodology that delivers novel relational findings, but is best conducted de novo rather than as part of a larger study. PRACTICE IMPLICATIONS: Multiperspective analysis should be more widely adopted with clear aims and analytic strategy that strengthen the ability to reveal relational dynamics. Navigation training programs should anticipate navigator struggles and provide navigators with tools to manage them.

Patients' experiences with navigation for cancer care.

OBJECTIVE: We examined how navigation, defined as the assessment and alleviation of barriers to adequate health care, influences patients' perspectives on the quality of their cancer care. METHODS: We conducted post-study patient interviews from a randomized controlled trial (usual care vs. patient navigation services) from cancer diagnosis through treatment completion. Patients were recruited from 11 primary care, hospital and community oncology practices in New York. We interviewed patients about their expectations and experience of patient navigation or, for non-navigated patients, other sources of assistance. RESULTS: Thirty-five patients newly diagnosed with breast or colorectal cancer. Valued aspects of navigation included emotional support, assistance with information needs and problem-solving, and logistical coordination of cancer care. Unmet cancer care needs expressed by patients randomized to usual care consisted of lack of assistance or support with childcare, household responsibilities, coordination of care, and emotional support. CONCLUSION: Cancer patients value navigation. Instrumental benefits were the most important expectations for navigation from navigated and non-navigated patients. Navigated patients received emotional support and assistance with information needs, problem-solving, and logistical aspects of cancer care coordination. PRACTICE IMPLICATIONS: Navigation services may help improve cancer care outcomes important to patients by addressing fragmented, confusing, uncoordinated, or inefficient care.

Integrative nonpharmacologic behavioral interventions for the management of cancer-related fatigue.

Cancer-related fatigue (CRF) is a debilitating, multi-faceted biopsychosocial symptom experienced by the majority of cancer survivors during and after treatment. CRF begins after diagnosis and frequently persists long after treatments end, even when the cancer is in remission. The etiological pathopsychophysiology underlying CRF is multifactorial and not well delineated. Mechanisms may include abnormal accumulation of muscle metabolites, dysregulation of the homeostatic status of cytokines, irregularities in neuromuscular function, abnormal gene expression, inadequate ATP synthesis, serotonin dysregulation, abnormal vagal afferent nerve activation, as well as an array of psychosocial mechanisms, including self-efficacy, causal attributions, expectancy, coping, and social support. An important first step in the management of CRF is the identification and treatment of associated comorbidities, such as anemia, hypothyroidism, pain, emotional distress, insomnia, malnutrition, and other comorbid conditions. However, even effective clinical management of these conditions will not necessarily alleviate CRF for a significant proportion of cancer survivors. For these individuals, intervention with additional therapeutic modalities may be required. The National Comprehensive Cancer Network guidelines recommend that integrative nonpharmacologic behavioral interventions be implemented for the effective management of CRF. These types of interventions may include exercise, psychosocial support, stress management, energy conservation, nutritional therapy, sleep therapy, and restorative therapy. A growing body of scientific evidence supports the use of exercise and psychosocial interventions for the management of CRF. Research on these interventions has yielded positive outcomes in cancer survivors with different diagnoses undergoing a variety of cancer treatments. The data from trials investigating the efficacy of other types of integrative nonpharmacologic behavioral therapies for the management of CRF, though limited, are also encouraging. This article provides an overview of current research on the relative merits of integrative nonpharmacologic behavioral interventions for the effective clinical management of CRF and makes recommendations for future research. Disclosure of potential conflicts of interest is found at the end of this article.

Knowledge and beliefs about health promotion and preventive health care among somali women in the United States.

We explored conceptualizations of health promotion and experiences with preventive health services among African refugee women. We asked 34 resettled Somali refugee women about their beliefs and experiences regarding health promotion and common preventive health care services in the United States. Interviews were audiotaped, transcribed, and analyzed using a grounded theory approach. Key themes were the importance of good hygiene, an adequate source of food and water, access to a regular source of health care, spirituality, traditional practices, and functioning well at home. All participants were familiar with the process and rationale for immunizations and routine medical examinations; few understood cancer screening services.

Behavioral interventions in treating anticipatory nausea and vomiting.

Anticipatory nausea and vomiting (ANV) is associated with a significant reduction in the quality of life for many chemotherapy patients. The use of 5-hydroxytryptamine type 3 receptor antagonists provides some relief for chemotherapy-induced nausea and vomiting, but does not seem to control ANV. Nonpharmacologic approaches, which include behavioral interventions, may provide the greatest promise in relieving symptoms. Little evidence supports the use of complementary and alternative methods, such as acupuncture and acupressure, in relieving ANV. Behavioral interventions, especially progressive muscle relaxation training and systematic desensitization, should be considered important methods for preventing and treating ANV.

Attention-deficit/hyperactivity disorder: presentation and management in the Haitian American child.

A case study of a young Haitian American is presented that is illustrative of cultural issues that influence care of those with attention-deficit/hyperactivity disorder (ADHD). Medications are the preferred treatment for ADHD and can be combined with psychological intervention. However, many Haitians and Haitian Americans see psychoactive medications as leading to substance abuse or mental illness. Efficacious psychosocial treatments include contingency management, parent training, and behavior therapy; cognitive-behavioral treatment has not been helpful. Complementary and alternative medicine might have appeal; primary care physicians can help families to assess such treatments and not to be enticed by expensive ones of little benefit. A determinant of the treatment a family pursues is their perception of the cause of the ADHD behaviors. While there is no term for ADHD in the Haitian-Creole language, in the Haitian culture the behaviors consistent with the diagnosis might be interpreted as indicating a poorly raised child whose behavior could be modified by parental discipline, an intentionally bad child, or a psychically victimized child suffering from an "unnatural" condition. "Natural" ailments are attributed to natural forces (e.g., wind, temperature), while "unnatural" ones are attributed to bad spirits or punishment by God. Families may "lift their feet" (Leve pye nou: to see a Hougan or voodoo priest) to determine the unnatural cause. Haitian Americans often combine therapeutic foods that are considered cold in nature, natural sedatives and purgatives from herbal medicine, religious treatments, and Western medicine. Immigrants often lack support of extended families in an environment not supportive of their interpretation of child behaviors and traditionally accepted parental disciplinary style. Stigma, language, cultural conceptions, concerns about governmental agencies, and physician bias can all be barriers to care for immigrant families. Primary care and behavioral integration are useful in managing families from other cultures.