Children's Oral Health Initiative: workers' perspectives on its impact in First Nations communities. / Initiative en santé buccodentaire des enfants : le point de vue des intervenants quant à ses effets dans les communautés des Premières Nations.

INTRODUCTION: Since 2004, the Children's Oral Health Initiative (COHI) has been working in many First Nations and Inuit communities in Canada to address oral health disparities, specifically early childhood caries (ECC). The COHI community-based approach improves early childhood oral health (ECOH) by balancing prevention with minimally invasive dentistry. The goal is to reduce the burden of oral disease, mainly by minimizing the need for surgery. We investigated program success in First Nations communities in the province of Manitoba, from the perspective of COHI staff. METHODS: First Nations community-based dental therapists and dental worker aides participated in three focus groups and an in-depth semistructured interview. The collected data were thematically analyzed. RESULTS: Data from 22 participants yielded converging and practitioner-specific themes. Participants reported that dental therapists and dental worker aides provide access to basic oral care in their communities including oral health assessments, teeth cleaning, fluoride varnish applications and sealants. The participants agreed that education, information sharing and culturally appropriate parental engagement are crucial for continuous support and capacity building in the community programs. Low enrolment, difficulty accessing homes and getting consent, limited human resources as well as lack of educational opportunities for dental worker aides were identified challenges. CONCLUSION: Overall, the participants reported that the COHI program positively contributes to ECOH in First Nations communities. However, increased community-based training for dental workers, community awareness about the program, and engagement of parents to facilitate culturally appropriate programming and consent processes are critical to improving program outcomes.

Promoting benzodiazepine cessation through an electronically-delivered patient self-management intervention (EMPOWER-ED): Randomized controlled trial protocol.

Background: Long-term benzodiazepine dependence carries significant health risks which might be reduced with low-cost patient self-management interventions. A booklet version of one such intervention (Eliminating Medications Through Patient Ownership of End Results; EMPOWER) proved effective in a Canadian clinical trial with older adults. Digitizing such an intervention for electronic delivery and tailoring it to different populations could expand its reach. Accordingly, this article describes the protocol for a randomized controlled trial to test the effectiveness of an electronically-delivered, direct-to-patient benzodiazepine cessation intervention tailored to U.S. military veterans. Methods: Design: Two-arm individually randomized controlled trial. Setting: US Veterans Health Administration primary care clinics. Participants: Primary care patients taking benzodiazepines for three or more months and having access to a smartphone, tablet or desktop computer. Intervention and comparator: Participants will be randomized to receive either the electronically-delivered EMPOWER (EMPOWER-ED) protocol or asked to continue to follow provider recommendations regarding their benzodiazepine use (treatment-as-usual). Measurements: The primary outcomes are complete benzodiazepine cessation and 25% dose reduction, assessed using administrative and self-report data, between baseline and six-month follow-up. Secondary outcomes are self-reported anxiety symptoms, sleep quality, and overall health and quality of life, measured at baseline and 6-month follow-up, and benzodiazepine cessation at 12-month follow-up. Comments: This randomized controlled trial will evaluate whether the accessibility and effectiveness of a promising intervention for benzodiazepine cessation can be improved through digitization and population tailoring.

Adapting the Eliminating Medications Through Patient Ownership of End Results Protocol to Promote Benzodiazepine Cessation Among US Military Veterans: Focus Group Study With US Military Veterans and National Veterans Health Administration Leaders.

BACKGROUND: Long-term dependence on prescribed benzodiazepines is a public health problem. Eliminating Medications Through Patient Ownership of End Results (EMPOWER) is a promising self-management intervention, delivered directly to patients as a printed booklet, that is effective in promoting benzodiazepine reduction and cessation in older adults. EMPOWER has high potential to benefit large health care systems such as the US Veterans Health Administration (VHA), which cares for many veterans who use benzodiazepines for extended periods. OBJECTIVE: We aimed to adapt the original EMPOWER booklet materials for electronic delivery and for use among US military veterans receiving VHA care who were long-term benzodiazepine users. METHODS: We used elements of Analysis, Design, Development, Implementation, and Evaluation, a framework commonly used in the field of instructional design, to guide a qualitative approach to iteratively adapting EMPOWER Electronic Delivery (EMPOWER-ED). We conducted 3 waves of focus groups with the same 2 groups of VHA stakeholders. Stakeholders were VHA-enrolled veterans (n=16) with medical chart evidence of long-term benzodiazepine use and national VHA leaders (n=7) with expertise in setting VHA policy for prescription benzodiazepine use and developing electronically delivered educational tools for veterans. Qualitative data collected from each wave of focus groups were analyzed using template analysis. RESULTS: Themes that emerged from the initial focus groups included veterans' anxiety about self-tapering from benzodiazepines and prior negative experiences attempting to self-taper without support. Participants also provided feedback on the protocol's look and feel, educational content, the tapering protocol, and website functionality; for example, feedback from policy leaders included listing, on the cover page, the most commonly prescribed benzodiazepines to ensure that veterans were aware of medications that qualify for self-taper using the EMPOWER-ED protocol. Both groups of stakeholders identified the importance of having access to supportive resources to help veterans manage sleep and anxiety in the absence of taking benzodiazepines. Both groups also emphasized the importance of ensuring that the self-taper could be personalized and that the taper instructions were clear. The policy leaders emphasized the importance of encouraging veterans to notify their provider of their decision to self-taper to help facilitate provider assistance, if needed, with the taper process and to help prevent medication stockpiling. CONCLUSIONS: EMPOWER-ED is the first direct-to-patient electronically delivered protocol designed to help US military veterans self-taper from long-term benzodiazepine use. We used the Analysis, Design, Development, Implementation, and Evaluation framework to guide the successful adaption of the original EMPOWER booklet for use with this population and for electronic delivery. The next step in this line of research is to evaluate EMPOWER-ED in a randomized controlled trial.

A randomized controlled trial comparing a manual and computer version of CALM in VA community-based outpatient clinics.

BACKGROUND: This study compared a computer and manual version of a tailored Coordinated Anxiety Learning and Management (VA CALM) protocol on provider fidelity to CBT and patient outcomes. METHODS: This study was a cluster randomized controlled trial. Providers (N = 32) were randomized to deliver VA CALM by computer or manual. Veteran patients (N = 135), treated by study providers, were recruited. The primary outcome was CBT fidelity, measured by rating audiotaped sessions. Secondary outcomes were Veterans' general (BSI-18 GSI, SF-12) and disorder-specific (GAD-7, PCL-5, PHQ-9) outcomes assessed at baseline, three and six month follow-up. RESULTS: We found a large (d = 0.88) but not statistically significant difference in mean fidelity rating scores between conditions. Compared with the manual, participants with generalized anxiety disorder receiving VA CALM by computer reported lower GAD-7 scores at three (-5.88; 95% CI=-11.37, -0.39) and six month (-5.25; 95% CI=-10.29, -0.22) follow-ups (d = 0.37 to 0.55). Participants in the computer and manual conditions reported lower PHQ-9 (-3.11; 95% CI=-5.51, -0.71; -4.06; 95% CI=-7.22, -0.90, respectively) and BSI-18 GSI (0.78; 95% CI=0.68,0.90; 0.71; 95% CI=0.58, 0.87, respectively) scores from baseline to six month follow-up. We did not find statistically significant differences over time or between conditions on SF-12 or PCL-5 scores. LIMITATIONS: This study was underpowered to test the primary outcome. Small samples sizes in the disorder-specific subgroup analysis may limit the generalizability of findings. CONCLUSIONS: Neither modality proved to be superior on VA CALM fidelity. The computer version of VA CALM, compared to the manual, may provide modest benefit to Veterans with GAD.

Feasibility and acceptability of shared decision-making to promote alcohol behavior change among women Veterans: Results from focus groups.

BACKGROUND: Although rates of unhealthy drinking are high among women Veterans with mental health comorbidities, most women Veterans with mental comorbidities who present to primary care with unhealthy drinking do not receive alcohol-related care. Barriers to alcohol-related treatment could be reduced through patient-centered approaches to care, such as shared decision-making. AIMS: We assessed the feasibility and acceptability of a telephone-delivered shared decision-making intervention for promoting alcohol behavior change in women Veterans with unhealthy drinking and co-morbid depression and/or probable post-traumatic stress disorder. METHODS: We used 3, 2-hour focus group discussions with 19 women Veterans to identify barriers and solicit recommendations for using the intervention with women Veterans who present to primary care with unhealthy drinking and mental health comorbidities. Transcripts from the focus groups were qualitatively analyzed using template analysis. RESULTS: Although participants perceived that the intervention was feasible and acceptable for the targeted patient population, they identified the treatment delivery modality, length of telephone sessions, and some of the option grid content as potential barriers. Facilitators included strategies for enhancing the telephone-delivered shared decision-making sessions and diversifying the treatment options contained in the option grids. Focus group feedback resulted in preliminary adaptations to the intervention that are mindful of women Veterans' individual preferences for care and realistic in the everyday context of their busy lives.

Long-term functional outcomes in surgically treated patients with oropharyngeal cancer.

OBJECTIVES/HYPOTHESIS: As survival rates in oropharyngeal cancer improve, long-term functional outcomes are increasingly important to understand. We report long-term functional outcomes in a cohort of surviving patients with oropharyngeal squamous cell carcinoma treated with primary surgery ± radiotherapy. STUDY DESIGN: Cross-sectional study. METHODS: Patients undergoing primary surgery for oropharyngeal cancer in Oxford, United Kingdom, between 2000 and 2010 were identified. The University of Washington Quality-of- Life and MD Anderson Dysphagia Inventory questionnaires were sent to all patients. Multivariate analysis was performed to determine the relationship between clinical factors and swallowing outcomes. RESULTS: Twenty percent of patients required gastrostomy-tube placement (mean feed duration, 114 days). On multivariate analysis, increased age, advanced T stage, and an open surgical approach were associated with significantly reduced quality-of-life scores. CONCLUSIONS: Mean functional scores were comparable to previously published series of patients treated with primary surgery. Gastrostomy insertion rate was lower than in many previously published studies. Furthermore, specific variables have been identified that are associated with adverse functional outcome.

Building partnerships with rural Arkansas faith communities to promote veterans' mental health: lessons learned.

BACKGROUND: The Mental Health-Clergy Partnership Program established partnerships between institutional (Department of Veterans' Affairs [VA] chaplains, mental health providers) and community (local clergy, parishioners) groups to develop programs to assist rural veterans with mental health needs. OBJECTIVES: Describe the development, challenges, and lessons learned from the Mental Health-Clergy Partnership Program in three Arkansas towns between 2009 and 2012. METHODS: Researchers identified three rural Arkansas sites, established local advisory boards, and obtained quantitative ratings of the extent to which partnerships were participatory. RESULTS: Partnerships seemed to become more participatory over time. Each site developed distinctive programs with variation in fidelity to original program goals. Challenges included developing trust and maintaining racial diversity in local program leadership. CONCLUSIONS: Academics can partner with local faith communities to create unique programs that benefit the mental health of returning veterans. Research is needed to determine the effectiveness of community based programs, especially relative to typical "top-down" outreach approaches.