Dentists' willingness to provide expanded HIV screening in oral health care settings: results from a nationally representative survey.

OBJECTIVES: Using a nationally representative survey, we determined dentists' willingness to provide oral rapid HIV screening in the oral health care setting. METHODS: From November 2010 through November 2011, a nationally representative survey of general dentists (sampling frame obtained from American Dental Association Survey Center) examined barriers and facilitators to offering oral HIV rapid testing (n = 1802; 70.7% response). Multiple logistic regression analysis examined dentists' willingness to conduct this screening and perceived compatibility with their professional role. RESULTS: Agreement with the importance of annual testing for high-risk persons and familiarity with the Centers for Disease Control and Prevention's recommendations regarding routine HIV testing were positively associated with willingness to conduct such screening. Respondents' agreement with patients' acceptance of HIV testing and colleagues' improved perception of them were also positively associated with willingness. CONCLUSIONS: Oral HIV rapid testing is potentially well suited to the dental setting. Although our analysis identified many predictors of dentists' willingness to offer screening, there are many barriers, including dentists' perceptions of patients' acceptance, that must be addressed before such screening is likely to be widely implemented.

Promoting smoking cessation in pregnancy with Video Doctor plus provider cueing: a randomized trial.

OBJECTIVE: This study examined the use of a Video Doctor plus provider cueing to promote provider advice and smoking cessation outcomes in pregnancy. DESIGN: A randomized clinical trial was conducted from 2006 to 2008. SETTING: Five community prenatal clinics in the San Francisco Bay Area of the United States. PARTICIPANTS: A total of 410 pregnant patients completed screening for behavioral risks including tobacco use in the past 30 days. Pregnant smokers (n = 42) were randomized regardless of their intention to quit smoking. METHODS: Participants were assigned to either usual care or intervention. Intervention participants received 15-minute Video Doctor sessions plus provider cueing, at baseline and one month, prior to their routine prenatal visit. The Video Doctor delivered interactive tailored messages, an educational worksheet for participants, and a cueing sheet for providers. MAIN OUTCOME MEASURES: Receipt of advice from the provider and 30-day smoking abstinence, both by self-report. RESULTS: Intervention participants were more likely to receive provider advice on tobacco use at both prenatal visits during the intervention period (60.9 vs. 15.8%, p = 0.003). The intervention yielded a significantly greater decrease in the number of days smoked and in cigarettes smoked per day. The 30-day abstinence rate at two months post baseline was 2.5 times greater in the intervention group; the difference was not significant (26.1 vs. 10.5%, p = 0.12). CONCLUSIONS: The Video Doctor plus provider cueing is an efficacious adjunct to routine prenatal care by promoting provider advice and smoking reduction among pregnant smokers.

Computer-assisted provision of emergency contraception a randomized controlled trial.

BACKGROUND: Emergency contraception (EC) can prevent unintended pregnancy. However, many women continue to lack information needed to use EC effectively and clinician time to counsel women about EC is limited. OBJECTIVE: To evaluate whether computer-assisted provision of EC can increase knowledge and use of EC among women able to access EC without a prescription. DESIGN: We conducted a randomized controlled trial in which the intervention group received a 15-minute computerized educational session and 1 pack of EC. The control group received education about periconception folate supplementation, but no information about EC. Participants were contacted 7 months after enrollment. PARTICIPANTS: Four hundred forty-six women recruited from 2 urgent care clinics in San Francisco in 2005. MEASUREMENTS: Knowledge of EC, use of EC, and self-reported pregnancy. RESULTS: At follow-up, women in the intervention group answered an average of 2 more questions about EC correctly than they had at baseline, whereas women in the control group answered only 1 more item correctly (2.0 vs 1.2, p < .001). There was a trend toward more use of EC during the study period in the intervention group (10% vs 4% of women followed, p = .06; 6% vs 3%, p = .09 of women enrolled). Fewer women in the intervention group were pregnant at the time of follow-up (0.8% vs 6.5%, p = .01 of women followed; 0.5% vs 4.0%, p = .01 of women enrolled). CONCLUSIONS: Computer-assisted provision of EC in urgent care waiting areas increased knowledge of EC in a state where EC had been available without a prescription for 3 years.

Cueing prenatal providers effects on discussions of intimate partner violence.

BACKGROUND: Intimate partner violence (IPV) during pregnancy poses a significant health risk to the mother and developing fetus. Practice guidelines recommend that prenatal providers screen for and counsel their patients about IPV, yet many physicians express reluctance or discomfort regarding such discussions. The Health in Pregnancy (HIP) computer program was designed to improve prenatal providers' counseling about behavioral risks. METHODS: English-speaking women 18 years or older, less than 26-weeks pregnant, and receiving prenatal care at one of the five participating clinics in the San Francisco area, were randomized in parallel groups in a controlled trial (June 2006-present; data analyzed June 2007). Participants reporting one or more risks were randomized to intervention or control in stratified blocks. Providers received summary "cueing sheets" alerting them to their patient's risk(s) and suggesting counseling statements. RESULTS: Thirteen percent (37/286) of the sample reported current IPV. Provider cueing resulted in 85% of the IPV-intervention group reporting discussions with their provider, compared to 23.5% of the control group (p<0.001). CONCLUSIONS: IPV discussions were influenced strongly by cueing providers. Provider cueing is an effective and appropriate adjunct to routine risk counseling in prenatal care.

Need for emergency contraception in urgent care settings.

BACKGROUND: Emergency contraceptive (EC) pills are safe and effective in preventing pregnancy up to 5 days after unprotected sex. OBJECTIVE: This study was conducted to determine the proportion and characteristics of women seeking urgent care who might benefit from receiving EC. METHODS: We used a computerized survey to assess desire for pregnancy and frequency of sex without contraception among 360 fertile women aged 18 to 45 years, who were seeking urgent care at two clinics in San Francisco, CA. Medical records were abstracted to assess whether clinicians discussed contraception. RESULTS: At both clinics, 11% (95% confidence interval, 8-15%) of women seeking urgent care might have benefited from immediately using EC. Few (8%) women reported a personal objection to EC, but few (7%) women had used EC in the prior 6 months. Chart review showed no evidence that any participants discussed EC with a clinician during their visit. CONCLUSIONS: Many women presenting for urgent care might benefit from EC.

Knowledge of and perceived access to emergency contraception at two urgent care clinics in California.

BACKGROUND: California allowed women access to emergency contraception (EC) without a physicians' prescription in 2002. METHODS: To assess knowledge of and perceived access to EC among California women outside of family planning settings, we administered a computerized survey to women, age 18-45 years, who could become pregnant, in the waiting areas of two urgent care clinics in San Francisco in 2005. RESULTS: Four hundred forty-six women were enrolled. Most women [87%; 95% confidence interval (95% CI), 83-89%] in this well-educated (48% had college degrees), ethnically diverse sample knew that a postcoital contraceptive exists. However, many women (32%; 95% CI, 28-37%) did not know EC is currently available in California. Only 49% of women knew that using EC will have no adverse effect on their future fertility and only 15% knew that EC will not cause a miscarriage or birth defects if used by a woman who is pregnant. Seven percent thought EC was not at all effective and 27% thought EC was somewhat or very unsafe. Eight percent had EC at home for future use. CONCLUSIONS: Functional knowledge of EC remains limited in California. Public education campaigns are needed to allow women to benefit from pharmacy direct access to EC.

Prevalence and correlates of ambivalence towards pregnancy among nonpregnant women.

BACKGROUND: Ambivalence towards pregnancy is rarely acknowledged in policy discussions. METHODS: We surveyed 441 nonpregnant women who consecutively presented to two urgent care clinics in California about their current intentions to conceive using a five-point scale. We examined the association between ambivalence towards pregnancy, sociodemographic characteristics and use of contraception. RESULTS: Almost one third of women (29.0%; 95% CI=25-33%) expressed ambivalence about their intentions to become pregnant. In multivariable modeling, being older than 30, being nonwhite and having a personal or religious objection to abortion were significantly associated with ambivalence towards pregnancy. Compared with women who stated they were trying to avoid pregnancy, women who expressed ambivalence were significantly less likely to have used a barrier or hormonal form of contraception at last intercourse (OR=0.36, 95% CI=0.23-0.57) and more likely to use the natural family planning (NFP) method (OR=3.31, 95% CI=1.39-7.90) or withdrawal (OR=1.61, 95% CI=0.98-2.65). CONCLUSION: Ambivalence towards pregnancy is common and is associated with use of less effective contraceptive methods.

Dental students' knowledge, attitudes, and intended behaviors regarding caries risk assessment: impact of years of education and patient age.

Dental caries remains the single most common chronic childhood disease; without intervention, the prevalence and severity of caries increase into adulthood. Dental schools have begun to integrate caries risk assessment (CRA) and prevention counseling into the curriculum. We sought to assess the knowledge, attitudes, and intended behaviors of dental students regarding CRA and prevention counseling with children and adults. We also examined the extent to which these findings were influenced by the years of instruction that students received on these topics. We conducted a cross-sectional survey of dental students at the University of California, San Francisco. All first-year (D1) through fourth-year (D4) students were eligible to participate. Of the 322 eligible students, 290 (90 percent) participated. D4 students correctly answered a mean of 70.4 percent of the knowledge-based questions on CRA; the mean score among D1 students was 50.4 percent. Whereas 95 percent of D4 students identified themselves as confident in their ability to assess adult patients for caries risk, only 68 percent had such confidence with patients less than five years. To effectively prevent early childhood caries, dental schools should provide students with the skills necessary to be confident and willing to perform CRA and prevention counseling for all age groups.

Seizing the 9-month moment: addressing behavioral risks in prenatal patients.

OBJECTIVE: Our qualitative study explored prenatal care providers' methods for identifying and counseling pregnant women to reduce or stop smoking, alcohol use, illicit drug use, and the risk of domestic violence. METHODS: We conducted six focus groups (five with OB/Gyn physicians, one with nurse practitioners and certified nurse midwives), total N=49, using open-ended questions. Investigators analyzed transcripts to identify and describe themes. RESULTS: Three major themes emerged: (1) specific risk-prevention tactics or strategies exist that are useful during pregnancy; (2) some providers address patients' isolation or depression; and (3) providers can adopt a policy of "just chipping away" at risks. Specific tactics included normalizing risk prevention, using specific assessment techniques and counseling strategies, employing a patient-centered style of smoking reduction, and involving the family. CONCLUSIONS: Providers generally agreed that addressing behavioral risks in pregnant patients is challenging. Patient-centered techniques and awareness of patients' social contexts help patients disclose and discuss risks. PRACTICE IMPLICATIONS: Brief but routine assessment and risk reduction messages require little time of the provider, but can make a big difference to the patient, who may make changes later.

Reframing "prevention with positives": incorporating counseling techniques that improve the health of HIV-positive patients.

Federal HIV prevention strategy seeks to increase efforts by health care providers to identify and reduce their HIV-positive patients' transmission-related behaviors. Implementation of these recommendations will be hindered if providers perceive these efforts have the potential to harm their relationships with patients. Because transmission-related behaviors (unsafe sex and sharing needles) and the related issues of drug and alcohol use also jeopardize the health of HIV-positive patients, providers can use patient-centered counseling when addressing those behaviors. We suggest efforts to increase provider-delivered transmission-prevention counseling be reframed so that "prevention with positives" includes the goal of protecting HIV-positive patients' health. We review the specific consequences of these risky behaviors on HIV-positive patients' health and review brief counseling strategies appropriate for HIV care providers.

Changing dentists' knowledge, attitudes and behavior regarding domestic violence through an interactive multimedia tutorial.

BACKGROUND: Dentists have a unique opportunity to address the problem of domestic violence (DV). The authors tested the effectiveness of a tutorial designed to educate dentists in identifying and responding to DV. METHODS: The authors developed a brief interactive multimedia tutorial for dentists and recruited practicing dentists (N = 174) for a randomized, controlled trial. A 24-question instrument assessed participants' knowledge, attitudes and practice behaviors regarding DV at two time points. The control group took the tutorial before completing a posttest. The authors also administered a 20-question empathy scale. RESULTS: The experimental group demonstrated significantly greater improvement in scores on most items, including knowledge, attitudes and behaviors, relative to control subjects (P < .01). Empathy scores did not show significant correlation with change scores on the DV assessment instrument. CONCLUSIONS: The tutorial is effective in helping dentists learn how to identify and help patients who are experiencing abuse. CLINICAL IMPLICATIONS: Broad dissemination of the tutorial about DV would introduce dentists to simple strategies for responding to patients who experience DV.

Domestic violence compared to other health risks: a survey of physicians' beliefs and behaviors.

BACKGROUND: Physicians routinely confront patient risk behaviors once considered private, including tobacco use, alcohol abuse, and HIV/STD-risk behavior. We compared physicians' behaviors and beliefs on screening and intervention for domestic violence with each other risk. METHODS: Survey of nationwide, random sample of 610 primary care physicians from the American Medical Association Physician Masterfile. RESULTS: Fewer primary care physicians screened for domestic violence than for other risks (p <0.001); once domestic violence was identified, however, physicians intervened with equal or greater frequency than for other risks. Fewer believed that they knew how to screen or intervene for domestic violence compared with other risks, and significantly fewer believed that domestic violence interventions were successful compared with interventions for tobacco and HIV/STD risks (Bonferroni adjusted p<0.001). CONCLUSIONS: Lower domestic violence screening rates may reflect physicians' beliefs that they do not know how to screen or intervene, and that interventions are less successful for domestic violence than for other risks. We may improve screening rates by educating physicians that a simplified role, as for other risks, can be effective for domestic violence.

Preparing dental students to recognize and respond to domestic violence: the impact of a brief tutorial.

BACKGROUND: The purpose of this study was to evaluate the impact of a brief, interactive multimedia tutorial designed to prepare dentists to recognize and respond to domestic violence. METHODS: The authors randomly assigned dentists and dental students to one of three groups: a control group or one of two experimental groups in a modified Solomon four-group design. RESULTS: One hundred sixty-one dental students and 13 dentists completed the multimedia tutorial. At the posttest, subjects in both experimental groups demonstrated significantly better scores than did subjects in the control group on most items. The two experimental groups (pretest and posttest, posttest only) did not differ significantly from each other. CONCLUSION: An engaging, interactive tutorial presenting a simplified model for ways in which dental professionals can recognize and respond to domestic violence significantly improved dental students' knowledge of, and attitudes toward, the topic. CLINICAL IMPLICATIONS: Clinicians may improve the care they provide to patients by accessing this brief tutorial and following the lessons contained in it.

Using innovative video doctor technology in primary care to deliver brief smoking and alcohol intervention.

Given physicians' increased responsibilities and time constraints, it is increasingly difficult for primary care physicians to assume a major role in delivering smoking and alcohol assessment and intervention. The authors developed an innovative use of computer technology in the form of a "video doctor" to support physicians with this. In this article, two brief interventions, delivered by an interactive, multimedia video doctor, that reduce primary care patients' smoking and alcohol use are detailed: (a) a patient-centered advice message and (b) a brief motivational intervention. The authors are testing the use of the video doctor to deliver these interventions in a randomized, controlled study, Project Choice. A pilot study testing the feasibility and acceptability of the video doctor suggests it was well received and accepted by patients (n = 52) and potentially provides an innovative, cost-effective, and practical way to support providers' efforts to reduce smoking and alcohol use in primary care populations.

Video study of physician selection: preferences in the face of diversity.

OBJECTIVES: To determine whether a diverse group of people would predominantly choose a white male physician regardless of group member's sex and ethnicity when given a choice among 6 actor-portrayed video doctors (males and females of Latino, European, and African descent) and whether further exposure would alter initial selections. STUDY DESIGN: Participants selected a video doctor after viewing a brief introduction and again after viewing the delivery of a prevention message. POPULATION: Three hundred ninety-five participants recruited at a shopping mall in the San Francisco Bay Area (61% female, 39% male; 30% Asian American, 29% European American, 26% Latino, 8% African American, and 7% other). OUTCOMES MEASURED: Initial and final video doctor selections; ratings of video doctors on interpersonal qualities. RESULTS: Most participants (85% of females and 63% of males) initially chose a female video doctor (P<.001) and even more did so at final selection. Approximately half initially chose a same-race video doctor (66% of European Americans, 51% of Latinos, and 50% of African Americans), but fewer did so at final selection (56% of European Americans, 44% of Latinos, and 52% of African Americans). In addition, at final selection 57% of Asian Americans and other-ethnicity participants chose a non-European American video doctor. CONCLUSIONS: Many healthcare consumers will accept physicians of both sexes and of different races. After observing the video doctors demonstrate a professional and warm affect, participants became even more receptive to choosing a video doctor of a different race. Video doctor technology holds promise for increasing our understanding of patients' preferences.

Tweeting about pain: comparing self-reported toothache experiences with those of backaches, earaches and headaches.

BACKGROUND: The authors conducted a study of tweets posted on Twitter to compare self-reported toothache experiences with those of backache, earache and headache in regard to pain intensity, action taken, perceived cause and effect of pain. METHODS: From a total of 508,591 relevant tweets collected on seven nonconsecutive days, the authors randomly selected 1,204 tweets (301 per pain type) and conducted content analyses of each tweet. RESULTS: Toothaches were described as having higher pain intensity than were earaches or headaches but pain intensity comparable with that of backaches. Despite people who experience toothache being more likely to seek health care than those experiencing backaches (odds ratio [OR], 3.91; 95 percent confidence interval [CI], 1.57-9.71) or headaches (OR, 6.11; 95 percent CI, 2.16-17.25), only one in 10 people with toothaches mentioned seeking health care for their pain. People with toothaches were less likely to report an effect on daily functioning compared with those with backaches (OR, 0.13; 95 percent CI, 0.03-0.56) or earaches (OR, 0.19; 95 percent CI, 0.05-0.77). CONCLUSIONS: Using unsolicited self-reported data from Twitter, the authors found similarities and differences in the experiences of people with toothaches compared with those of people with other common pains. These findings offer insights into understanding dental pain and dental care utilization. PRACTICAL IMPLICATIONS: The use of social media, such as Twitter, to discuss health issues provides opportunities for dental professionals to better understand dental care experiences from the patients' perspective. Furthermore, social media such as Twitter offer providers the opportunity to share information with the public and to facilitate provider-patient communication.

Counseling patients on preventing prenatal environmental exposures--a mixed-methods study of obstetricians.

OBJECTIVE: Describe the attitudes, beliefs, and practices of U.S. obstetricians on the topic of prenatal environmental exposures. STUDY DESIGN: A national online survey of American Congress of Obstetricians and Gynecologists (ACOG) fellows and 3 focus groups of obstetricians. RESULTS: We received 2,514 eligible survey responses, for a response rate of 14%. The majority (78%) of obstetricians agreed that they can reduce patient exposures to environmental health hazards by counseling patients; but 50% reported that they rarely take an environmental health history; less than 20% reported routinely asking about environmental exposures commonly found in pregnant women in the U.S.; and only 1 in 15 reported any training on the topic. Barriers to counseling included: a lack of knowledge of and uncertainty about the evidence; concerns that patients lack the capacity to reduce harmful exposures; and fear of causing anxiety among patients. CONCLUSION: U.S. obstetricians in our study recognized the potential impact of the environment on reproductive health, and the role that physicians could play in prevention, but reported numerous barriers to counseling patients. Medical education and training, evidence-based guidelines, and tools for communicating risks to patients are needed to support the clinical role in preventing environmental exposures that threaten patient health.

PRE-VIEW: Development and Pilot Testing of An Interactive Video Doctor Plus Provider Alert to Increase Cancer Screening.

BACKGROUND: Interventions to increase recommended cancer screening tests and discussions are needed. METHODS: We developed PRE-VIEW (The PREventive VIdeo Education in Waiting Rooms Program), a multimedia cancer prevention intervention for primary care clinics based on the Transtheoretical Model of Behavior Change We pilot tested PRE-VIEW An Interactive Video Doctor plus Provider Alert for feasibility and acceptability in primary care clinic settings in the San Francisco Bay Area, California in 2009-2010. RESULTS: Eighty participants (33 men and 47 women; more than half non-white) at 5 primary care clinics were included. After PRE-VIEW, 87% of women were definitely interested in mammography when due and 77% were definitely interested in a Pap test. 73% of participants were definitely interested in colorectal cancer screening when due, and 79% of men were definitely interested in a discussion about the PSA test. The majority indicated that they received an appropriate amount of information from PRE-VIEW and that the information presented helped them decide whether or not to be screened. CONCLUSIONS: PRE-VIEW was well received and accepted and potentially provides an innovative and practical way to support physicians' efforts to increase cancer screening.

The impact of an oral health program on domestic violence survivors within community shelters.

BACKGROUND: The authors conducted a study to evaluate the impact of an oral health treatment program on oral health-related quality of life (OHRQoL) for women who were domestic violence (DV) survivors living in community shelters. METHODS: After completing DV education, dental residents provided treatment to female survivors of DV (n = 37) at on-site clinics. They administered pretest and posttest surveys to participants to assess their OHRQoL in terms of pain, impact of oral health on functioning and discomfort, embarrassment and quality of life overall to the participants. The authors also administered patient satisfaction surveys to participants to assess their satisfaction with treatment and the program. RESULTS: Participants reported significantly improved OHRQoL for seven of the eight items assessed (P < .05). They were satisfied with their treatment and with dental residents' performance. CONCLUSIONS: The program was effective and well received. Practical Implications. By participating in a one-day DV education program and using portable dental equipment installed in community shelters, dental residents and dentists can provide much needed dental treatment to a population of women who otherwise may not seek or have access to oral health care. Treatment can play an important role in DV survivors' self-esteem and reintegration into normal social and workplace activities.

Oral health education for pediatric nurse practitioner students.

The aim of this study was to evaluate whether an interdisciplinary, multifaceted oral health education program delivered to pediatric nurse practitioner students at the University of California, San Francisco, would improve their knowledge, confidence, attitudes, and behaviors regarding the provision of oral health assessments, consultations, referrals, and services to young children during well-child visits. Thirty pediatric nurse practitioner students were included in the study. Participants completed a written survey before and after receiving an interdisciplinary educational intervention that included didactic education, simulation exercises, and clinical observation by a pediatric dental resident. Between pre-intervention and post-intervention, a significant improvement was seen in the pediatric nurse practitioners' knowledge of oral health topics (p<0.001), confidence when providing oral health counseling (p<0.001), and attitudes about including oral health counseling in their examinations (p=0.006). In the post-intervention survey, 83 percent of the subjects reported having incorporated oral examinations into their well-child visits. Our study suggests that providing an interdisciplinary oral health educational program for pediatric nurse practitioner students can improve their knowledge, confidence, attitudes, and behaviors regarding the incorporation of oral health care services during routine well-child visits.