Bloom's taxonomy-Can evidence-based teaching improve junior medical officers' knowledge of the mental health and guardianship acts?

OBJECTIVE: To determine whether a brief educational intervention for Junior Medical Officers (JMOs), using teaching methods aimed at achieving higher outcomes on Bloom's Taxonomy, significantly improved participant confidence and knowledge in decision making about restrictive care. METHOD: JMOs received a teaching session on restrictive medical and mental health care. Groups were randomly assigned to either sessions including a component of modern pedagogical interventions (Think-Pair-Share and SNAPPS), or sessions including a control period focusing on reviewing a condensed summary of relevant information. Pre- and post-intervention measures were recorded for subjective self-ratings of confidence and scores on standardized clinically relevant extended matching questions (EMQs). RESULTS: There was no difference in subjective confidence improvement between groups; however, the group receiving the modern pedagogical intervention demonstrated significantly greater objective performance on knowledge-based EMQs. CONCLUSIONS: A brief modern pedagogical intervention using interactive teaching methods shows promise for improving knowledge of restrictive care and the Mental Health and Guardianship Acts. In the control group, similarly increased confidence in knowledge did not equate to increased competence on a knowledge assessment. Refurbishing educational interventions presents opportunities for improving clinical outcomes and engaging junior doctors in psychiatry.

Evaluation of General and Musculoskeletal Health Literacy Disparities in Pediatric Sports Injury Patient and Guardian Populations.

BACKGROUND: Increased participation of adolescents in organized sports has led to an increase in pediatric sports injury. Limited health literacy puts patients at risk for worse outcomes through decreased compliance. We aim to evaluate the extent of health literacy disparities in pediatric sports medicine populations. METHODS: Patients aged 10 to 17 years and their consenting guardians visiting clinic for treatment of a sports-related injury completed a unique questionnaire including self-reported health literacy measures and direct assessment of knowledge regarding care for musculoskeletal injuries. Statistical analysis based on socioeconomic factors and demographics was performed using t tests. RESULTS: A total of 268 patient surveys (14.37±1.94 y) and 251 guardian surveys (43.62±9.08 y) were collected. In self-reported general health literacy scores for guardians, all categories except ethnicity played a statistically significant role, with higher health literacy scores associated with higher education, use of English as the primary language at home, private insurance, and female guardians (P<0.001, <0.001, <0.001, 0.011). In contrast, age was the only factor affecting scores in the patient population (P=0.015). Among self-reported musculoskeletal health literacy and directly measured musculoskeletal literacy scores, there were significant differences in groups by age, primary language, and level of education (P=0.020, 0.003). CONCLUSIONS: Significant disparities in general and musculoskeletal health literacy exist within pediatric sports medicine populations, most notably between guardian groups. Improving disparities in health literacy for these populations may best be aimed at guardians, using medical education through verbal/written instruction in multiple languages. LEVEL OF EVIDENCE: Level IV.

Parental anxiety in pediatric surgery consultations: the role of health literacy and need for information.

INTRODUCTION: Although important, parental anxiety, health literacy and need-for-information in pediatric surgery outpatient clinics have not been extensively studied. Lower educational attainments, minorities and lower socioeconomic status have been associated with limited health literacy. Parental anxiety has been related to health literacy, sex, education and information needs. The aim of this study is to investigate health literacy and need-for-information and their association to parental anxiety in consultations of pediatric surgery. MATERIALS & METHODS: We conducted an observational, cross-sectional study in the outpatient pediatric surgery clinic from December 2016 to October 2017. Health literacy, anxiety and need-for-information of parents/guardians of children waiting for pediatric surgical consultation were evaluated. Multivariate regression analysis was used to examine the impact of health literacy and need-for-information on parental/guardian anxiety considering sociodemographic and clinical characteristics of the participants. RESULTS: Almost half (46.1%) of the 664 parents/guardians recruited had limited or problematic health literacy and 79.8% of the sample was classified as being anxious. Parental/guardian anxiety was associated at the multiple regression analysis with parental health literacy level (ß = -0.282, p < 0.001), need-for-information preoperatively (ß = 0.907, p < 0.001), educational level (ß = -0.716, p = 0.001), sex (ß = 1.563, p < 0.001), and severity of the condition of the child (ß = 0.379, p < 0.001). CONCLUSION: Parents/guardians experience high levels of anxiety, which is associated to health literacy and need-for-information. These factors should be considered in pediatric surgical consultations, aiming to reduce parental anxiety. TYPE OF STUDY: Retrospective Study. LEVEL OF EVIDENCE: Level II.

Parental knowledge gaps and barriers for children receiving human papillomavirus vaccine in the Rio Grande Valley of Texas.

Purpose: Despite its availability for more than a decade, the human papillomavirus (HPV) vaccine has low uptake in Texas (49%). The objective of this study was to understand parental knowledge and attitudes about HPV and the HPV vaccine as well as child experience with the HPV vaccine among a medically underserved, economically disadvantaged population. Methods: As part of a Cancer Prevention Research Institute of Texas-funded project to improve HPV vaccination rates, we surveyed parents / guardians of 4th-12th graders (ages 9-17) in the Rio Grande City Consolidated Independent School District (RGCCISD). Descriptive statistics were used to describe parents' knowledge and attitude and children's vaccine experience. Results: Of the 7,055 surveys distributed, 622 (8.8%) were returned. About 84% of the respondents were female. About 57.1% of the parents /guardians had female RGCCISD students with a mean age of 11.7 ± 1.8 years. Overall, 43.9% reported receiving a healthcare provider recommendation and 32.5% had their child vaccinated. Higher percentages were reported if the respondent was female and had a female child aged ≥15 years old. Among survey respondents, 28.2% reported their child initiated the HPV vaccine and 18.8% completed the series. Barriers of uptake included work / school schedule conflicts and no healthcare provider recommendation. Conclusions: There are still prominent gaps in parents' and students' complete understanding of HPV vaccination, gender preferences for vaccination, and provider recommendations. Future interventions must target men and minority populations in order to increase knowledge and awareness about HPV, the HPV vaccine, and HPV-associated cancers.

Informed decision-making with and for people with dementia - efficacy of the PRODECIDE education program for legal representatives: protocol of a randomized controlled trial (PRODECIDE-RCT).

BACKGROUND: In Germany, the guardianship system provides adults who are no longer able to handle their own affairs a court-appointed legal representative, for support without restriction of legal capacity. Although these representatives only rarely are qualified in healthcare, they nevertheless play decisive roles in the decision-making processes for people with dementia. Previously, we developed an education program (PRODECIDE) to address this shortcoming and tested it for feasibility. Typical, autonomy-restricting decisions in the care of people with dementia-namely, using percutaneous endoscopic gastrostomy (PEG) or physical restrains (PR), or the prescription of antipsychotic drugs (AP)-were the subject areas trained. The training course aims to enhance the competency of legal representatives in informed decision-making. In this study, we will evaluate the efficacy of the PRODECIDE education program. METHODS: A randomized controlled trial with a six-month follow-up will be conducted to compare the PRODECIDE education program with standard care, enrolling legal representatives (N = 216). The education program lasts 10 h and comprises four modules: A, decision-making processes and methods; and B, C and D, evidence-based knowledge about PEG, PR and AP, respectively. The primary outcome measure is knowledge, which is operationalized as the understanding of decision-making processes in healthcare affairs and in setting realistic expectations about benefits and harms of PEG, PR and AP in people with dementia. Secondary outcomes are sufficient and sustainable knowledge and percentage of persons concerned affected by PEG, FEM or AP. A qualitative process evaluation will be performed. Additionally, to support implementation, a concept for translating the educational contents into e-learning modules will be developed. DISCUSSION: The study results will show whether the efficacy of the education program could justify its implementation into the regular training curricula for legal representatives. Additionally, it will determine whether an e-learning course provides a valuable backup or even alternative learning strategy. TRIAL REGISTRATION: TRN: ISRCTN17960111 , Date: 01/06/2017.

Treating maladaptive grief and posttraumatic stress symptoms in orphaned children in Tanzania: group-based trauma-focused cognitive-behavioral therapy.

This study was designed to test the feasibility and child clinical outcomes for group-based trauma-focused cognitive behavior therapy (TF-CBT) for orphaned children in Tanzania. There were 64 children with at least mild symptoms of grief and/or traumatic stress and their guardians who participated in this open trial. The TF-CBT for Child Traumatic Grief protocol was adapted for use with a group, resulting in 12 weekly sessions for children and guardians separately with conjoint activities and 3 individual visits with child and guardian. Using a task-sharing approach, the intervention was delivered by lay counselors with no prior mental health experience. Primary child outcomes assessed were symptoms of grief and posttraumatic stress (PTS); secondary outcomes included symptoms of depression and overall behavioral adjustment. All assessments were conducted pretreatment, posttreatment, and 3 and 12 months after the end of treatment. Results showed improved scores on all outcomes posttreatment, sustained at 3 and 12 months. Effect sizes (Cohen's d) for baseline to posttreatment were 1.36 for child reported grief symptoms, 1.87 for child-reported PTS, and 1.15 for guardian report of child PTS.

Wishard Volunteer Advocates Program: an intervention for at-risk, incapacitated, unbefriended adults.

Unbefriended, incapacitated individuals who lack surrogates to make medical decisions present a complex problem to the healthcare providers who treat them. Adults without surrogates are among the most vulnerable in the community and are often alone and estranged from family, neglected and abused, and at risk of receiving inappropriate medical treatment. This article describes the program model and outcomes for the first 2 years of the Wishard Volunteer Advocates Program (WVAP), a guardianship program using trained, supervised volunteers as surrogates for unbefriended, incapacitated individuals. Of the 50 individuals enrolled during the study period, 20 were female, and 39 were Caucasian and 11 African American. Their average age was 67. Nineteen were insured with Medicare as primary and Medicaid as supplementary insurance. Ninety-eight percent had four or more comorbid conditions at the time of the index hospitalization. Before program referral, many lived alone in unsafe conditions. Adult Protective Services was involved in almost half of the cases at the time of the index hospitalization. Approximately half of the participants required some type of property management. Healthcare usage data demonstrated that most were not receiving medical care before WVAP enrollment; the data indicated a decrease in emergency department visits and hospitalization after WVAP enrollment. The WVAP completed Medicaid applications for 12 participants, resulting in $297,481.62 in reimbursement for the index hospitalization and a payer source for subsequent hospitalization and long-term care. The volunteer advocate model provides an efficient and quality mechanism for providing unbefriended individuals with surrogates.

[Confirmatory study on the regression equation for children dental behavior in Beijing].

OBJECTIVE: To test and verify the regression equation got before for children's dental behavior management problems(BMP). METHODS: The study group included 279 children aged 2- < 8 years who received dental treatment by 16 pediatric dentists in the Department of Pediatric Dentistry, Peking University School of and Hospital of Stomatology. Interviews were conducted with accompanying guardians and children's dental behavior was rated by a modified Venham's clinical anxiety scale and a cooperative behavior rating scale. The variables were put into the regression equation and the results were compared with their dental behavior scale. RESULTS: The accuracy rate of regression equation reached 84.2% (235/279) , sensitivity was 0.613 (95%CI:0.514-0.712) and specificity was 0.957 (95%CI:0.928-0.986). CONCLUSIONS: The regression equation is characterized by its accuracy rate at a good level. Younger age, negative guardian expectations of the child's behavior during treatment, anxiety or shyness around strangers, and presence of toothache were four risk factors for children's dental BMP.

[Effect of pretreatment education of the guardians of children's behavior during dental treatment].

OBJECTIVE: To assess the effect of the pretreatment education of the guardians on the children's and guardian's behavior during dental treatment. METHODS: The study group included 235 children aged 2-8 years who received dental treatment in the Department of Pediatric Dentistry, Peking University School and Hospital of Stomatology. Interviews were conducted with accompanying guardians to collect information of children and their guardians, including parent's Corah Dental Anxiety Scale. The guardians were randomly divided into two groups. Group I was control group in which the guardians received a pamphlet about how to clean children's teeth, group II was the education group in which the guardians received a pamphlet about how to help a child to cooperate with the dentist during dental treatment. Children's heart rate was recorded at different time points: before the treatment, at local anesthesia (LA), during the treatment and at the end of the treatment. Children's dental behavior was rated by a modified Venham's clinical anxiety scale and a cooperative behavior rating scale. The guardian's tension was sorted into four levels and the characteristics of their language were recorded. RESULTS: Among the 235 children, 131 were boys and 104 were girls with mean age of 4.35 years, and 165 children were treated under LA. The group I included 129 children and 95 children were treated with LA. The group II included 106 children and 70 children were treated with LA. The children's behavior in group II was better than that in group I(χ(2)=4.56, P=0.033). The guardians in group II were more relaxed than in group I at all the four times points: Beginning (Z=-2.581, P=0.01), LA (Z=-3.613, P=0.002), Treatment (Z=-3.096, P=0.002), Whole (Z=-3.042, P=0.002); and more positive language were used in group II at three times points: LA (χ(2)=15.57, P<0.001), Treatment (χ(2)=6.52, P =0.011) and Whole (χ(2)=15.99, P<0.001). CONCLUSION: An education for guardians before dental treatment may improve children's dental behavior and guardians' tension in dental treatment.

A Lipskian analysis of child protection failures from Victoria Climbié to "Baby P": a street-level re-evaluation of joined-up governance.

This paper explores the issue of joined-up governance by considering child protection failures, firstly, the case of Victoria Climbié who was killed by her guardians despite being known as an at risk child by various public agencies. The seeming inability of the child protection system to prevent Victoria Climbié's death resulted in a public inquiry under the chairmanship of Lord Laming. The Laming report of 2003 looked, in part, to the lack of joined-up working between agencies to explain this failure to intervene and made a number of recommendations to improve joined-up governance. Using evidence from detailed testimonies given by key personnel during the Laming Inquiry, the argument of this paper is that we cannot focus exclusively on formal structures or decision-making processes but must also consider the normal, daily and informal routines of professional workers. These very same routines may inadvertently culminate in the sort of systemic failures that lead to child protection tragedies. Analysis of the micro-world inhabited by professional workers would benefit most, it is argued here, from the policy-based concept of street-level bureaucracy developed by Michael Lipsky some 30 years ago. The latter half of the paper considers child protection failures that emerged after the Laming-inspired reforms. In particular, the case of 'Baby P' highlights, once again, how the working practices of street-level professionals, rather than a lack of joined-up systems, may possibly complement an analysis of, and help us to explain, failures in the child protection system. A Lipskian analysis generally offers, although there are some caveats, only pessimistic conclusions about the prospects of governing authorities being able to avoid future child protection disasters. These conclusions are not wholeheartedly accepted. There exists a glimmer of optimism because street-level bureaucrats still remain accountable, but not necessarily in terms of top-down relations of authority rather, in terms of interpersonal forms of accountability ­ accountability to professionals and citizen consumers of services.

African American parents'/guardians' health literacy and self-efficacy and their child's level of asthma control.

Nearly 1 of 10 American children has asthma. Asthma is addressed in Healthy People 2010 as a public health problem. This study examined the relationship between parents'/guardians' health literacy levels and their perceived self-efficacy to manage their child's asthma. A four-page asthma questionnaire was developed to assess the self-efficacy of parents/guardians of African American children with asthma. There was a statistically significant relationship among the parents'/guardians health literacy levels and their perceived efficacy expectations to manage their child's asthma. There is evidence that high parental/guardian self-efficacy and successful asthma management contribute to a child with well-controlled asthma. It is necessary for patient educators to capitalize on physician/nurse visits and use the time for asthma education, particularly to increase the efficacy expectations of parents/guardians with limited health literacy skills.

A guide for health care practitioners in the assessment of young people's capacity to consent to treatment.

The Health Care Consent Act, 1996, states that every person in Ontario, regardless of age, is presumed to be capable of consenting to or refusing medical treatment unless he or she is found incapable with respect to a specific treatment or plan of treatment. Health care practitioners may find it especially challenging to apply the legal test of capacity to young people. As an aid to assessment, a guide incorporating both legal and medical perspectives has been developed. This article describes the background and context of the development of the guide and explains how it helps practitioners to conduct a simpler, more focused evaluation of capacity in youth. The guide, along with an introduction and comments for parents, is included in an appendix.

Are physicians' recommendations to limit life support beneficial or burdensome? Bringing empirical data to the debate.

RATIONALE: Although there is a growing belief that physicians should routinely provide a recommendation to surrogates during deliberations about withdrawing life support, there is a paucity of empirical data on surrogates' perspectives on this topic. OBJECTIVES: To understand the attitudes of surrogate decision-makers toward receiving a physician's recommendation during deliberations about whether to limit life support for an incapacitated patient. METHODS: We conducted a prospective, mixed methods study among 169 surrogate decision-makers for critically ill patients. Surrogates sequentially viewed two videos of simulated physician-surrogate discussions about whether to limit life support, which varied only by whether the physician gave a recommendation. MEASUREMENTS AND MAIN RESULTS: The main quantitative outcome was whether surrogates preferred to receive a physicians' recommendation. Surrogates also participated in an in-depth, semistructured interview to explore the reasons for their preference. Fifty-six percent (95/169) of surrogates preferred to receive a recommendation, 42% (70/169) preferred not to receive a recommendation, and 2% (4/169) felt that both approaches were equally acceptable. We identified four main themes that explained surrogates' preferences, including surrogates' perceptions of physicians' appropriate role in life or death decisions and their perceptions of the positive or negative consequences of a recommendation on the physician-surrogate relationship, on the decision-making process, and on long-term regret for the family. CONCLUSIONS: There is no consensus among surrogates about whether physicians should routinely provide a recommendation regarding life support decisions for incapacitated patients. These findings suggest that physicians should ask surrogates whether they wish to receive a recommendation regarding life support decisions and should be flexible in their approach to decision-making.

Randomized controlled trial of a brief intervention for increasing participation in parent management training.

Evidence-based treatments exist for a range of child and adolescent behavior problems; however, effects are often limited by poor treatment attendance and adherence. The authors developed and evaluated the efficacy of a brief (5 to 45 min) intervention designed to increase treatment attendance and adherence in a sample of 76 parents referred for treatment of their child's oppositional, aggressive, and antisocial behavior. The results of this randomized controlled trial showed that parents who received this brief intervention had greater treatment motivation, attended significantly more treatment sessions, and had greater adherence to treatment according to both parent and therapist report. This study provides researchers and clinicians with a brief and efficacious method of increasing motivation, attendance, and adherence for treatment.