Does Immediate Access to Birth Control Help Prevent Pregnancy? A Comparison of Onsite Provision Versus Off Campus Referral for Contraception at Two School-Based Clinics

PURPOSE: The purpose of this study was to assess the impact of different policies on access to hormonal contraception and pregnancy rates at two high school-based clinics. METHODS: Two clinics in high schools (Schools A and B), located in a large urban district in the southwest US, provide primary medical care to enrolled students with parental consent; the majority of whom have no health insurance coverage. The hormonal contraceptive dispensing policy of at School clinic A involves providing barrier, hormonal and emergency contraceptive services on site. School clinic B uses a referral policy that directs students to obtain contraception at an off-campus affiliated family planning clinic. Baseline data (age, race and history of prior pregnancy) on female students seeking hormonal contraception at the two clinics between 9/2008-12/2009 were extracted from an electronic administrative database (AHLERS Integrated System). Data on birth control use and pregnancy tests for each student was then tracked electronically through 3/31/2010. The outcomes measures were accessing hormonal contraception and positive pregnancy tests at any point during or after birth control use were started through 12/2009. The appointment keeping rate for contraceptive services and the overall pregnancy rates were compared between the two schools. In addition the pregnancy rates were compared between the two schools for students with and without a prior history of pregnancy. RESULTS: School clinic A: 79 students sought hormonal contraception; mean age 17.5 years; 68% were > 18 years; 77% were Hispanic; and 20% reported prior pregnancy. The mean duration of the observation period was 13 months (4-19 months). All 79 students received hormonal contraception (65% pill and 35% long acting progestin injection) onsite. During the observation period, the overall pregnancy rate was 6% (5/79); 4.7% (3/63) among students with no prior pregnancy. School clinic B: 40 students sought hormonal contraception; mean age 17.5 years; 52% > 18 years; 88 % were Hispanic; and 7.5% reported prior pregnancy. All 40 students were referred to the affiliated clinic. The mean duration of the observation period was 11.9 months (4-19 months). 50% (20) kept their appointment. Pills were dispensed to 85% (17/20) and 15% (3/20) received long acting progestin injection. The overall pregnancy rate was 20% (8/40); 21.6% (8/37) among students with no prior pregnancy. A significantly higher frequency of students seeking hormonal contraception kept their initial appointment for birth control at the school dispensing onsite contraception compared to the school with a referral policy for contraception (p<0.05). The pregnancy rate was significantly higher for the school with a referral policy for contraception compared to the school with onsite contraceptive services (p< 0.05). The pregnancy rate was also significantly higher for students without a prior history of pregnancy in the school with a referral policy for contraception (21.6%) versus the school with onsite contraceptive services (4.7%) (p< 0.05). CONCLUSION: This preliminary study showed that School clinic B with a referral policy had a lower appointment keeping rate for contraceptive services and a higher pregnancy rate than School clinic A with on-site contraceptive services. An on-site dispensing policy for hormonal contraceptives at high school-based health clinics may be a convenient and effective approach to prevent unintended first and repeat pregnancies among adolescents who seek hormonal contraception. This study has strong implications for reproductive health policy, especially as directed toward high-risk teenage populations.

Psychiatric severity and behavior change in alcoholism

Individuals who are diagnosed with a chronic mental illness and an alcohol use disorder comprise a high risk population that challenges the mental health care system. Effective treatment for the dually diagnosed, who are characterized by heterogeneity in their psychiatric diagnoses, their substance use patterns, and their current degree of dysfunction, presents a challenge. Several integrated treatment models have been developed that attempt to concurrently treat patients' psychiatric and substance abuse problems. At this point in the development of these "dual diagnosis" programs, treatment planning is hindered by a lack of knowledge about the relation of psychiatric severity to the process of recovery from alcohol abuse and dependence.^ The present study sought to advance the field's understanding of the relation between psychiatric severity and the process of behavior change through an examination of the relation between dimensions of psychiatric severity and Prochaska and DiClemente's Transtheoretical Model (TTM) constructs. The TTM, which focuses on identifying the processes of change that appear to underlie the modification of addictive behaviors, provides a way of conceptualizing and measuring specific elements relevant to the desired behavior change. Knowledge of the relation between these constructs and psychiatric severity will enable treatment planners to develop dual diagnosis programs which target clients' needs with a much higher level of specificity.^ One hundred-thirty two alcohol dependent patients in a dual diagnosis treatment program were assessed on psychiatric severity (defined as number of symptoms and level of distress resulting from symptoms) and the Transtheoretical Model constructs. The constructs include stages and processes of change for alcohol use, alcohol decisional balance, and alcohol abstinence self-efficacy. Results indicate that the TTM variable of "temptation to drink" is most strongly related to psychiatric severity: the more psychiatric distress a person is experiencing, the more he or she is tempted to drink. The "cons" of drinking were also related to psychiatric severity, indicating that participants who were experiencing more psychiatric distress also endorsed as important a higher number of the negative aspects of drinking.^ Additional aims of this investigation were to determine whether participants' scores on the Transtheoretical Model variables were associated with their: (a) severity of drinking, defined as frequency, quantity and consequences of use, (b) previous psychiatric and substance abuse treatment episodes, and (c) functional impairment. Associations were found among these variables and each of the key constructs of the Transtheoretical Model. Each association is explored in detail and implications for treatment programming are discussed. ^

Screening for anemia in Red Cross blood donor clinics

Accurate screening for anemia at Red Cross blood donor clinics is essential to maintain a safe national blood supply. Despite the importance of identifying anemia correctly by measurement of hemoglobin or hematocrit (hemoglobin/hematocrit) there is no consensus regarding the efficacy of the current two stage screening method which uses the Readacrit$\sp{\rm tm}$ microhematocrit in conjunction with copper sulfate.^ A cross-sectional study was implemented in which hemoglobin/hematocrit was measured, with the present method and four new devices, on 504 prospective blood donors at a Canadian Red Cross permanent blood donor clinic in London, Canada. Concurrently gathered, venous and capillary blood samples were tested by each device and compared to Coulter S IV$\sp{\rm tm}$ determined venous standard readings. Instrument hemoglobin/hematocrit means were statistically calibrated to the standard ones in order to appraise systematic deviations from the standard. Classification analysis was employed to assess concordance between each instrument and the standard when classifying prospective donors as anemic or non-anemic. This was done both when each instrument was used alone (single stage) and when copper sulfate was used as a preliminary screen (two stage) and simulated over a range of anemia prevalences. The Hemoximeter$\sp{\rm tm}$ and Compur M1000$\sp{\rm tm}$ devices had the highest correlations of hemoglobin measurements with the standard ones for both capillary (n.s.) and venous blood (p $<$.05). Analysis of variance (anova) also showed them to be the most accurate (p $<$.05), as did both single and two stage classification analysis, therefore, they are both recommended. There was a smaller difference between instruments for two stage than for single stage screening; therefore instrument choice is less crucial for the former. The present method was adequate for two stage screening as tested but simulations showed that it would discriminate poorly in populations with a higher prevalence of anemia. The Stat-crit and Readacrit, which measure hematocrit, became less accurate at crucial low hematocrit levels. In light of this finding and the introduction of new, effective and easy to use hemoglobin measuring instruments, the continued use of hematocrit as a surrogate for hemoglobin, is not recommended. ^

The impact of traditional psychiatric services and case management services on the functioning of people with schizophrenia: A cross-national study in Nova Scotia and Texas

The purpose of this study was to determine the impact of traditional psychiatric services with case management services on the functioning of people with schizophrenia. Traditional services were defined as routine clinic services consisting of medication follow-along, psychotherapy, and support services. Case management consisted of activities involved in linking, planning, and monitoring services for the outpatient client who has schizophrenia. The target population was adult schizophrenics who had been receiving outpatient clinic services for a minimum of six months. Structured interviews were conducted using standardized scales (e.g., Quality of Life, Self-Efficacy, and Brief Symptom Inventory) with 78 outpatient client volunteers from two sites: Nova Scotia (Canada) and Texas (USA). The researcher tested for differences in psychiatric symptomatology, recidivism, and quality of life for persons with schizophrenia receiving traditional psychiatric services in Nova Scotia and traditional plus case management services in Texas. Data were collected from the structured interviews and medical records review forms. Types of services were blocked into low and high levels of Intensity (frequency x minutes) and compared to determine the relative contribution of each. Finally, the role of clients' self-efficacy was tested as an intervening variable. Although the findings did not support the hypotheses in the direction anticipated, there were some interesting and useful results. From the Nova Scotia site, clients who received low levels of services were hospitalized less compared to the Texas site. The more psychotic a patient was the higher their involvement in medication follow-along and the more monitoring they received. The more psychotherapy received, the lower the reported satisfaction with social relationships. Of particular interest is the role that self-efficacy played in improved client outcomes. Although self-efficacy scores were related to improved functioning, the mechanism for this still needs to be clarified through subsequent research. ^

THE EFFECT OF PERSON-ENVIRONMENT FIT ON THE PSYCHOLOGICAL WELL-BEING OF PSYCHIATRIC AIDES WORKING IN A STATE HOSPITAL (COPING RESOURCES, SOCIAL SUPPORT, OCCUPATIONAL STRESS, LOCUS-OF-CONTROL)

This study addressed two purposes: (1) to determine the effect of person-environment fit on the psychological well-being of psychiatric aides and (2) to determine what role the coping resources of social support and control have on the above relationship. Two hundred and ten psychiatric aides working in a state hospital in Texas responded to a questionnaire pertaining to these issues.^ Person-environment fit, as a measure of occupational stress, was assessed through a modified version of the Work Environment Scale (WES). The WES subscales used in this study were: involvement, autonomy, job pressure, job clarity, and physical comfort. Psychological well-being was measured with the General Well-Being Schedule which was developed by the National Center for Health Statistics. Co-worker and supervisor support were measured through the WES and finally, control was assessed through Rotter's Locus of Control Scale.^ The results of this study were as follows: (1) all person-environment (p-e) dimensions appeared to have linear relationships with psychological well-being; (2) the p-e fit - well-being relationship did not appear to be confounded by demographic factors; (3) all p-e fit dimensions were significantly related to well-being except for autonomy; (4) p-e fit was more strongly related to well-being than the environmental measure alone; (5) supervisor support and non-work related support were found to have additive effects on the relationship between p-e fit and well-being, however no interaction or buffering effects were observed; (6) locus of control was found to have additive effects in the prediction of well-being and showed interactive effects with work pressure, involvement and physical comfort; and (7) the testing of the overall study model which included many of the components mentioned above yielded an R('2) = .27.^ Implications of these findings are discussed, future research suggested and applications proposed. ^

THE DISCHARGED PSYCHIATRIC PATIENT: POST-HOSPITAL ADJUSTMENT AND FACTORS AFFECTING REHOSPITALIZATION

Discharged psychiatric patients were studied six months post-discharge to determine those demographic, social and clinical characteristics affecting positive or negative adjustment and the degree to which the use of mental health services and medication compliance mediated the effects. With the exception of those with primary or secondary diagnoses of OBS, substance abuse or mental retardation, sixty-three psychiatric subjects between the ages of eighteen and sixty-four were chosen from all admissions into the hospital and interviewed six months after discharge using a specially designed questionnaire.^ The subjects' adjustment to community living was found to be marginal. Although not engaged in destructive activities, over half were living with their family members who supported them financially and emotionally. Most were unemployed and had been so for a long time. Others worked sporadically and frequently changed residences. Most did have substantial social ties with extended family and with friends with whom they interacted regularly, but one-fourth were socially isolated. Almost three-quarters continued to obtain regular mental health services after discharge and followed medication instructions under the supervision of their physician. The use of mental health services after discharge and the use of medication did not appear to affect the subjects' community adaption or their rate of rehospitalization.^ Forty percent of those discharged were rehospitalized by the end of the follow-up period. Four levels of risk of rehospitalization emerged. The highest risk was associated with a history of five or more prior hospitalizations, living alone, and social isolation. One third or more of the subjects expressed a need for more counseling, leisure time activities, case-manager assistance, vocational guidance, supervised housing, and placement into a transitional residential treatment program.^ Recommendations were made to enhance the ability to predict recidivism, to develop interorganizational casework management programs linking the patient and family to the community mental health system and to create computerized tracking and monitoring programs that systematically report patient treatment regimen and progress cross-sectionally and longitudinally. ^

Is obesity associated with increased symptoms of psychiatric morbidity among Indian adolescents?

The relationship between obesity and mental health disorders has not been explored among adolescents in India. Although evidence from western countries has failed to demonstrate conclusive associations, a tremendous increase in the prevalence of obesity and overweight among urban adolescents in India, along with an absolute lack of studies into mental health of Indian adolescents, necessitate the need for research in this population. This present study used data collected from 861 urban 6th and 8th graders from Delhi, India and tested for the associations of weight status with psychiatric symptomatology and other weight related behaviors. The Strengths and Difficulties questionnaire (SDQ) was used to collect data on psychiatric symptoms. Falling into the overweight or obese category was hypothesized to be associated with borderline or abnormal scores on the SDQ scales. Results indicated a high prevalence for overweight/obesity among the population (>30%). No significant associations were demonstrated between weight status and borderline/abnormal SDQ scores on all the scales. However, significant associations were found between sedentary behaviors (screen time >2 hrs daily), positive and negative weight-control behaviors and borderline/abnormal SDQ scores on various scales. In light of these new findings, a further exploration of the relationship in this population is indicated.^

A descriptive analysis of the consumers at farm stands outside WIC clinics

Because fruit and vegetable intake remains low in low-income populations, the attention of public health researchers has focused on different strategies to reach this population. One possible method of reaching low income populations is through government food assistance programs like the WIC's Farmers Market Nutrition Program (FMNP). This program provides vouchers to WIC recipients that are redeemable only at farmers' markets. In the summer of 2010, two farm stands near WIC clinics in Austin were surveyed in order to establish socio-demographic characteristics of the clientele of the markets. The overall purpose of this pilot study was to describe the clientele of the markets and to examine associations between food insecurity, acculturation, socio-demographic factors, and farmers' market participants' fruit and vegetable intake. The sample was a convenience sample of farmers' market customers. One hundred study participants completed self-administered surveys. Independent t-tests were used to explore the differences in means of fruit and vegetable intake according to acculturation and food insecurity levels. The overall mean (SD) of daily fruit and vegetable intake was 4.20±2.69 for customers of both markets. Significant differences were reported between the two markets in overall fruit and vegetable intake and specifically in the following: 100% juice (P=.023), fruit consumption (P=.028), green salad (P=.003), and salsa (P=.044). The differences showed that customers at the market in a more busy location were on average reporting eating more fruits and vegetables than customers at another market that was located in a more secluded location. When examined by level of food security, individuals who were more food secure consumed more fruit (P=.016). When examined by level of acculturation, the overall fruit and vegetable intake was not significantly different between levels of acculturation. The overall findings in this report suggest that the population at these markets consists of individuals who are food insecure and on government assistance programs. While there were no significant differences between fruit and vegetable intake, acculturation and food insecurity, this report suggests the need for culturally tailored interventions that serve the Hispanic population and would assist this population to become more food secure.^

Costs and quality of medication reconciliation practice in primary care clinics

Medication reconciliation, with the aim to resolve medication discrepancy, is one of the Joint Commission patient safety goals. Medication errors and adverse drug events that could result from medication discrepancy affect a large population. At least 1.5 million adverse drug events and $3.5 billion of financial burden yearly associated with medication errors could be prevented by interventions such as medication reconciliation. This research was conducted to answer the following research questions: (1a) What are the frequency range and type of measures used to report outpatient medication discrepancy? (1b) Which effective and efficient strategies for medication reconciliation in the outpatient setting have been reported? (2) What are the costs associated with medication reconciliation practice in primary care clinics? (3) What is the quality of medication reconciliation practice in primary care clinics? (4) Is medication reconciliation practice in primary care clinics cost-effective from the clinic perspective? Study designs used to answer these questions included a systematic review, cost analysis, quality assessments, and cost-effectiveness analysis. Data sources were published articles in the medical literature and data from a prospective workflow study, which included 150 patients and 1,238 medications. The systematic review confirmed that the prevalence of medication discrepancy was high in ambulatory care and higher in primary care settings. Effective strategies for medication reconciliation included the use of pharmacists, letters, a standardized practice approach, and partnership between providers and patients. Our cost analysis showed that costs associated with medication reconciliation practice were not substantially different between primary care clinics using or not using electronic medical records (EMR) ($0.95 per patient per medication in EMR clinics vs. $0.96 per patient per medication in non-EMR clinics, p=0.78). Even though medication reconciliation was frequently practiced (97-98%), the quality of such practice was poor (0-33% of process completeness measured by concordance of medication numbers and 29-33% of accuracy measured by concordance of medication names) and negatively (though not significantly) associated with medication regimen complexity. The incremental cost-effectiveness ratios for concordance of medication number per patient per medication and concordance of medication names per patient per medication were both 0.08, favoring EMR. Future studies including potential cost-savings from medication features of the EMR and potential benefits to minimize severity of harm to patients from medication discrepancy are warranted. ^