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Thesis (Ph.D.) - University of Glasgow, 2004. / Ph.D thesis submitted to the Departments of Public Health and Palliative Medicine, Faculty of Medicine, University of Glasgow, 2004. Includes bibliographical references (p. 272-293). Print version also available. Mode of access : World Wide Web. System requirements : Adobe Acrobat reader required to view PDF document.

Obesity is highly prevalent and results in poor health outcomes and increased morbidity and mortality. Mentally ill patients are at increased risk for obesity and other health disparities that result in significantly reduced life expectancy. Primary care providers (PCP’s) are first line defense in the obesity epidemic. A brief education intervention on obesity management in patients with mental illness was presented to PCP’s at a community clinic to educate them on obesity management in patients with mental illness. A pre-and posttest was devised to assess current practice and intent to utilize knowledge. Results indicate that post intervention all provider agreed or strongly agreed that they felt more confident treating obesity indicating success of the presentation. Short-term implications of this project are better treatment for a high-risk population. More broadly, this project further adds to the current literature another example that brief educational interventions are beneficial for healthcare providers to help enable best evidence based practice.

Purpose: With the obesity epidemic ever increasing, the purpose of this quality improvement project is to assess if Veteran’s Administration (VA) primary care providers have knowledge of and/or application barriers of the Veteran’s Administration/Department of Defense Clinical Practice Guideline for Screening and Management of Overweight and Obesity (SMOOG) in the VA primary care clinic in southern Arizona. Background: The prevalence of obesity seen in adults in the U.S. escalated from 15% to 34%, which is more than double from 1980 to 2008. Active military and Veterans obesity rates rose in similar fashion. The implementation of practice guidelines is critical to effective treatment to counteract the rising rates of overweight and obesity. Adherence to clinical practice guidelines often remains low causing an omission of therapies recommended in the guidelines. Methods: This quality improvement project used a descriptive methodology. Initially, SMOOG was evaluated using the AGREE II instrument. Next, a survey was administered to primary care providers to identify provider knowledge of and barriers to utilization of the SMOOG guidelines. Inclusion criteria for this study are: VA employed primary care provider and practicing primary care for at least 1 year. The 20-question survey measured providers’ knowledge and perceptions of their use of the VA/DoD SMOOG. Results: Evaluation using the AGREE II tool revealed the lowest possible quality scores observed in the Applicability domain. Based upon the results of the evaluation SMOOG is recommended for use with modifications specifically improving its applicability. Fifteen primary care providers participated in the survey. The results revealed that few primary care providers use SMOOG in clinical practice and barriers exist to implementation of SMOOG. Conclusions: Assessing providers’ knowledge, perceptions, and barriers to SMOOG provides insight towards the next steps in addressing the rising prevalence of obesity among U.S. Veterans. An appraisal of SMOOG revealed that the guideline was developed with a high quality in the areas of evidence and clear presentation, but is clearly deficient in its applicability of implementation of the recommendations. The data obtained serves as an initial step to inform future research into synthesizing and guiding an implementation strategy.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine.

To conduct a pilot survey to assess acceptance of mobile teledermoscopy (MTD) by primary care nurse practitioners (NPs) working in Arizona.

The purpose of this project was to improve primary care provider knowledge, attitude and behaviors related to the current HIV-screening and PrEP implementation guidelines. Surveys were conducted among five primary care providers at a Midwest VA Healthcare System before and after an HIV and PrEP-related education. The surveys were anonymous, and participation was voluntary. Each participant received a survey by pen and paper to self-assess their HIV-screening and PrEP prescribing intention, comfort-level with HIV prevention practices, and knowledge before and after the presentation by using Likert scales, true/false, and correct answer recall questions. Of the eligible 11 providers in attendance of the presentation, six of the 11 (54.5%) participated in the surveys. One participant was excluded as he/she did not submit his/her completed presurvey, which rendered the survey incomplete for data analysis. The included participants (n=5) worked in General/Primary Care, were either a MD (2 of 5) or NP (3 of 5), who have practiced as their current clinical title for less than 5 years to greater than 25 years. Responses were measured based on the FREQ procedure as the sample size was small. Following the intervention, there was no overall increase in intent to follow the current CDC HIV screening guidelines however intention prior to the intervention was already high. Following education, the providers’ ability to identify those at risk for HIV increased by 60% (3 of 5), and comfort-level in identifying those at risk for HIV whom are PrEP eligible increased by 80% (4 of 5). Of these providers, there was an 80% (4 of 5) increase in provider self-rated comfort-level in discussing PrEP with high risk patients post-education. Each provider rated their intention to prescribe PrEP after the intervention on a Likert scale, as “Probably” or “Very Probable,” which was a 60% (3 of 5) provider improvement. Overall, responses indicated an improvement of provider knowledge, attitudes, and behavior after receiving HIV screening and PrEP education. Findings of this project are comparable with previous research, this project, however, did not evaluate actual provider change in practice following education.

Youth depression is a serious mental health disorder that may have detrimental consequences. Half of all lifetime cases of mental illness begin before the age of 14 (Hagan, Shaw, & Duncan, 2008). Depression in youth is linked to increased morbidity and mortality, along with high-risk behaviors. Mental health and mood disorders are the leading cause of illness and burden among youth (Patel, 2013). Nationally, suicide is the third leading cause of death for individuals aged 15 to 24. In North Dakota, suicide is the first leading cause of death for individuals aged 15 to 24 (American Foundation for Suicide Prevention, 2016). Unfortunately, depression remains largely underdiagnosed and undertreated; only about 50 percent of youth with depression are diagnosed before they reach adulthood (Zuckerbrot, Cheung, Jensen, Stein, & Laraque, 2007). The purpose of this project was to improve the mental health of youth through increasing universal screening in the primary care setting, and improve the confidence and ability of the primary care provider to diagnose and treat youth depression. Primary care provider education was launched through collaboration with Essentia Health, providing education regarding youth depression focused on universal screening, identification of youth depression, and treatment modalities. To evaluate primary care provider education, a pretest/posttest was completed, along with key stakeholder interviews. Surveys demonstrated an increased intent to screen and increased confidence in identifying and managing youth depression. The interview with key stakeholders was used to determine the effectiveness and feasibility of universal screening and management of youth depression in the primary care setting.

There are many barriers present to keeping elderly in the home . One of these barriers is lack of identifying and supporting caregivers of these patients . Informal caregivers provide the majority of care for elderly patients residing in the community . Being able to identify and support these caregivers in the primary care setting may prevent caregiver burden, with a primary goal of keeping the care recipient in the home . This interactive presentation objectives include; exploring the influences of the caregiver role and the elderly’s ability to stay in the home, critiquing the existing evidence for identifying caregivers of elderly patients and introducing and describing ongoing research within a Tennessee Primary Care Practice .

Primary care providers have become the front line of treatment for mental health in the United States. Group interventions have been argued to be an effective way to treat more patients with fewer resources, which could reduce the burden of psychopathology on primary care settings. Group therapy faces many barriers to successful implementation in primary care, including site constraints, provider perceptions, population needs, and recruiting difficulties. A survey was developed to assess primary care providers’ perspectives on these areas and distributed via online survey to practitioners in Appalachia; 28 providers responded. No hypotheses were supported, likely a result of the small sample size. Analysis of quantitative and quantitative data elucidated some potential areas for future exploration. Respondents held generally favorable views of group therapy in primary care, and may be more responsive to the peer support and learning elements of group interventions than time or cost benefits. Respondents reported scheduling and a lack of mental health providers with group expertise to be a significant barrier to group interventions in primary care. Billing may not be a significant concern for primary care providers, as is typically reported. Discrepancies between psychopathology frequently seen in primary care settings and the demand on provider time and attention are also discussed.