Readiness to implement screening, brief intervention, and referral to treatment in school-based health centers.

The purpose of this study was to evaluate the readiness of a university-based school-based health center (SBHC) program to implement the screening, brief intervention, and referral to treatment (SBIRT) model. We completed preimplementation surveys and interviews with providers, staff, and administrators at participating SBHCs (N = 19) to measure current protocols for and barriers to addressing adolescent substance use and barriers and facilitators to implementing SBIRT. We used the R = MC2 heuristic (readiness equals motivation, general organizational capacity, and innovation-specific capacity) to interpret findings from the data. Using the R = MC2 heuristic, we identified factors that may aid implementation, including the prioritization of substance use and a supportive organizational culture, as well as potential barriers, including competing high-priority health issues and a lack of resources for innovation. This study contributes to the emerging literature on the implementation of the SBIRT model with adolescents and in SBHCs and demonstrates the practical applicability of the R = MC2 heuristic for assessing implementation readiness. SBHCs are ideal locations for addressing substance use but SBHC providers also face unique challenges when implementing the SBIRT model.

Virtual Intrauterine Device Placement Training Improves Clinician Comfort.

BACKGROUND AND OBJECTIVES: Virtual intrauterine device (IUD) training options can improve clinician continuing education and patient IUD access. Our objective was to evaluate a virtual, hands-on IUD training for primary care clinicians. METHODS: Training sessions occurred via video conferencing and included didactic instruction on IUD eligibility, counseling, placement, and removal. Trainers used pelvic models to demonstrate procedures for all Food and Drug Administration-approved IUDs and guided trainees during hands-on practice with IUDs. Surveys administered before and immediately after training assessed clinician satisfaction and evaluated pre-to-posttraining changes in self-rated comfort level with IUD procedures. We evaluated the changes using Wilcoxon signed-rank sum tests. RESULTS: Thirty-four New Mexico clinicians were trained during 29 sessions from January-June 2021. Trainees (n=32 responding to pre/postsurveys) included nurse practitioners and midwives (48%), physician assistants (28%), physicians (17%), and clinicians in training (7%). Approximately one-third (37%) had previous experience placing IUDs. Elements of training delivery were highly rated by clinicians, with all trainees successfully using the virtual platform and half indicating that they would potentially choose a virtual training over an in-person option in the future. After the training, clinicians reported significantly increased comfort with all aspects of IUD placement and removal (P≤.01). CONCLUSIONS: An interactive, virtual IUD training model was highly rated among practicing clinicians and increased their comfort with IUD placement and removal.

Associations Between Maternity Care Practices and 2-Month Breastfeeding Duration Vary by Race, Ethnicity, and Acculturation.

Objectives This study examines the associations between specific maternity care practices and breastfeeding duration for Spanish-speaking Hispanic, English-speaking Hispanic, non-Hispanic Native American, and non-Hispanic White women. Methods We analyzed data from the 2012-2014 New Mexico Pregnancy Risk Assessment Monitoring System. We used survey language as a proxy measure of acculturation and categorized women as Spanish-speaking Hispanic, English-speaking Hispanic, non-Hispanic Native American, and non-Hispanic White. We conducted bivariate analyses to compare rates of breastfeeding at 2 months and experiences of maternity care practices and logistic regression analysis to estimate the effects of these practices on breastfeeding duration for each group. Results Hispanic women were less likely than non-Hispanic women to breastfeed for at least 2 months (67.9% vs. 76.6%; p = 0.000); however, this varied significantly by acculturation level: 78.1% of Spanish-speaking Hispanic women compared to 66.1% of English-speaking Hispanic women breastfed for at least 2 months (p = 0.000). The effects of specific maternity care practices on duration varied across groups. Among non-Hispanic White, Native American, and English-speaking Hispanic women, breastfeeding while at the hospital had the strongest effect (AOR 2.09, 95% CI 1.67-2.61; AOR 2.71, 95% CI 2.08-3.52; and AOR 1.99, 95% CI 1.76-2.25, respectively). Among Spanish-speaking Hispanic women, being encouraged to breastfeed on demand had the strongest effect (AOR 5.179, 95% CI 3.86-6.94). Conclusions for Practice The effects of maternity care practices on breastfeeding duration vary by race, ethnicity, and acculturation level. Health care systems must acknowledge the diversity of their patient populations when seeking to develop and implement breastfeeding-friendly practices.

Missed Opportunities in the Outpatient Pediatric Setting to Support Breastfeeding: Results From a Mixed-Methods Study.

INTRODUCTION: Outpatient pediatric providers play a crucial role in the promotion of breastfeeding. We conducted a mixed methods study to measure provider knowledge, attitudes, and current practices around breastfeeding counseling. METHOD: In New Mexico in 2016 and 2017, we conducted a knowledge, attitudes, and practice survey of outpatient pediatric providers (i.e., nurse practitioners, physicians, and physician assistants) and conducted focus groups with outpatient pediatric providers. RESULTS: Seventy-seven providers responded to the survey, and 17 participated in three focus groups. Fewer than half of providers surveyed reported asking how long mothers plan to breastfeed at initial well-baby examinations. One quarter of participants (28.2%) erroneously reported that hepatitis C was an absolute contraindication to breastfeeding. Just half of respondents had received continuing education within the past 3 years about managing common breastfeeding problems. DISCUSSION: We identified missed opportunities for outpatient pediatric providers to support breastfeeding and a need for continuing provider education.

Measuring Unmet Needs for Anticipatory Guidance Among Adolescents at School-Based Health Centers.

PURPOSE: Our previously validated Youth Engagement with Health Services survey measures adolescent health care quality. The survey response format allows adolescents to indicate whether their needs for anticipatory guidance were met. Here, we describe the unmet needs for anticipatory guidance reported by adolescents and identify adolescent characteristics related to unmet needs for guidance. METHODS: We administered the survey in 2013-2014 to 540 adolescents who used school-based health centers in Colorado and New Mexico. A participant was considered to have unmet needs for anticipatory guidance if they indicated that guidance was needed on a given topic but not received or guidance was received that did not meet their needs. We calculated proportions of students with unmet needs for guidance and examined associations between unmet needs for guidance and participant characteristics using the chi-square test and logistic regression. RESULTS: Among participants, 47.4% reported at least one unmet need for guidance from a health care provider in the past year. Topics with the highest proportions of adolescents reporting unmet needs included healthy diet (19.5%), stress (18.0%), and body image (17.0%). In logistic regression modeling, adolescents at risk for depression and those with minority or immigrant status had increased unmet needs for guidance. Adolescents reporting receipt of patient-centered care were less likely to report unmet needs for guidance. CONCLUSIONS: The Youth Engagement with Health Services survey provides needs-based measurement of anticipatory guidance received that may support targeted improvements in the delivery of adolescent preventive counseling. Interventions to improve patient-centered care and preventive counseling for vulnerable youth populations may be warranted.

Adolescent substance use: Assessing the knowledge, attitudes, and practices of a school-based health center workforce.

BACKGROUND: Recent attention has focused on the potential for school-based health centers (SBHCs) to provide access points for adolescent substance use care. In 2015, the University of New Mexico began screening, brief intervention, and referral to treatment (SBIRT) training for providers at New Mexico Department of Health (NMDOH)-funded SBHCs across the state. This study assesses baseline knowledge, attitudes, and practices of the New Mexico SBHC provider workforce regarding adolescent substance use and provision of services. METHODS: In early 2015, the NMDOH administered an SBHC provider workforce survey (N = 118) and achieved a 44.9% response rate. This descriptive analysis includes all survey respondents who self-identified as a primary care or behavioral health provider in an SBHC serving middle or high school students (n = 52). RESULTS: Among respondents, the majority (57.7%) were primary care providers, including nurse practitioners, physicians, and physician assistants. The remaining 42.3% of respondents were master's-level behavioral health providers. Only 44.2% of providers reported practicing the full SBIRT model at their SBHC, and 21.2% reported having received continuing education on SBIRT within the previous 3 years. Most respondents, 84.6%, agreed that it is the responsibility of SBHC providers to screen students for substance use using a standardized tool, and 96.2% agreed that it is the responsibility of the SBHC provider to assess for students' readiness to change. A majority reported self-efficacy in helping students achieve change in their alcohol use, illicit drug use, and prescription drug misuse: 73.1%, 65.4%, and 63.5%, respectively. CONCLUSIONS: These results suggest that SBIRT training for New Mexico SBHC providers is timely. The authors identified gaps between recommended SBIRT practices and SBIRT delivery as well as discrepancies between reported provider self-efficacy and actual implementation of the SBIRT model. Further study will determine the effectiveness of efforts to address substance use and implement SBIRT in SBHCs.

Measuring youth health engagement: development of the youth engagement with health services survey.

PURPOSE: The purpose of this study was to create and validate a survey instrument designed to measure Youth Engagement with Health Services (YEHS!). METHODS: A 61-item YEHS! survey was created through a multistaged process, which included literature review, subject matter expert opinion, review of existing validated measures, and cognitive interviewing with 41 adolescents in Colorado and New Mexico. The YEHS! was then pilot tested with a diverse group of high school students (n = 354) accessing health services at one of eight school-based health centers in Colorado and New Mexico. We conducted psychometric analyses and examined correlations between the youth health engagement scales and measures of quality of care. RESULTS: We created scales to measure two domains of youth health engagement: health access literacy and health self-efficacy. The youth health engagement scales demonstrated strong reliability (Cronbach's α .76 and .82) and construct validity (mean factor loading .71 and .76). Youth health engagement scores predicted higher experiences of care scores (p < .001) and receipt of more anticipatory guidance (p < .01). CONCLUSIONS: This study supports the YEHS! as a valid and reliable measure of youth health engagement among adolescents using school-based health centers. We demonstrate an association between youth health engagement and two quality of care measures. Additional testing is needed to ensure the reliability and validity of the instrument in diverse adolescent populations.

Reporting on continuity of coverage for children in Medicaid and CHIP: what states can learn from monitoring continuity and duration of coverage.

OBJECTIVE: The Children's Health Insurance Program Reauthorization Act (CHIPRA) requires states to measure and report on coverage stability in Medicaid and the Children's Health Insurance Program (CHIP). States generally have not done this in the past. This study proposes strategies for both measuring stability and targeting policies to improve retention of Medicaid coverage, using Ohio as an example. METHODS: A cohort of newly enrolled children was constructed for the 1-year time period between July 2007 and June 2008 and followed for 18 months. Hazard ratios were estimated after 18 months to predict the likelihood of maintaining continuous enrollment in Medicaid, adjusting for income eligibility group, age, race, gender, county type, and change in unemployment. Children dropping from the program at the renewal period (12-16 months) were followed for 12 months to determine their rate of return. RESULTS: Approximately 26% of children aged <1 year and 35% of children aged 1 to 16 years dropped from Medicaid by 18 months, with the steepest drop occurring after 12 months, the point of renewal. Likelihood of dropping was associated with the higher income eligibility groups, older children, and Hispanic ethnicity. Approximately 40% of children who were dropped at renewal re-enrolled within 12 months. Children in the lowest income group returned sooner and in higher proportions than other children. CONCLUSIONS: A substantial number of children lose Medicaid coverage only to re-enroll within a short time. Income eligibility group appears to be a strong indicator of stability. Effective monitoring of coverage stability is important for developing policies to increase retention of eligible children.