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The landscape of medical specialty choice is dynamic, undergoing significant changes as students' progress through undergraduate and graduate medical training. These shifts are influenced by various factors, with financial considerations becoming increasingly relevant among medical students' preferences. This study conducts a retrospective analysis of specialty match rates and physician compensation, suggesting a potential trend where primary care fields, though fundamental to healthcare, appear less competitive and often associated with less financial reward compared to other specialties. The existence of this disparity is not without consequences. It contributes significantly to the ongoing and anticipated primary care physician shortages. This situation requires a comprehensive approach to tackle the complex factors influencing medical students' career choices. Understanding these dynamics is critical for healthcare policy and planning. This paper investigates how financial considerations sway medical students' specialty choices, emphasizing the economic disparities between primary care and other specialties.

The capacity of the workforce lags behind the current demand for timely autism diagnostic assessment. Primary care providers (PCPs) are well-positioned to diagnose autism at earlier ages than providers from other disciplines. Thus, bolstering PCPs' diagnostic capabilities has been the focus of many recent capacity-building initiatives. Using data from the National Survey of Children's Health, this study aimed to evaluate whether diagnosis of autism in primary care has changed over time and whether diagnosis in primary care relates to age at autism diagnosis. Results indicated that the likelihood of being diagnosed with autism by a PCP decreased by about 2% with every passing year from 2004 to 2019 when controlling for demographic characteristics. PCPs diagnosed children approximately 1 year earlier than non-PCPs (e.g., psychiatrists and psychologists), which supports the critical role PCPs can play in timely diagnosis. Further research is needed to understand why the proportion of children diagnosed by PCPs has decreased over time; however, these findings suggest that capacity-building initiatives have not yet reached community practice. Future research should focus on the dissemination and implementation of training initiatives in community-based primary care practices.

This study examines how intellectual disability nurses employed in residential living services for persons with intellectual disabilities, in Norway, deal with medication management for these individuals. Using a qualitative study, a total of 18 intellectual disability nurses were interviewed as part of four focus groups. The results demonstrate six main challenges: First, Being alone with the responsibility of medication management - a challenge; Second, The need for further competence development; Third, Teaching and supervising unskilled colleagues in safe medication management; Fourth, Interpreting residents with little or only nonverbal communication; Fifth, The need to act as advocates when residents require hospitalization; Sixth, Deficient systems for medication management on several levels. The findings point to several major flaws in the system of medication management, which necessitates the need for highly qualified intellectual disability nurses. Managers must ensure that there is a secure system to mitigate errors and promote patient safety.

Developmental monitoring/screening predict early identified autism spectrum disorders (ASD), but studies have not yet robustly controlled for a key health care service impacting early identification: medical home. National Surveys of Children's Health (NSCH; 2016-2020) were used to determine the relationship between medical home, developmental monitoring/screening, and identified ASD. NSCH overall medical home variable had a minimal relationship with ASD (under 5 years of age, under 5 identified in last year, under 5 identified over a year prior). Usual source of care was positively, and care coordination negatively, associated with ASD identified in last year, suggesting the overall medical home variable may mask variance from subscales. Research is needed to determine how medical home relates to identification in applied settings.

Purpose: Many young children in need of early intervention are not identified in a timely manner. This preliminary study explored the emerging role of speech language pathologists (SLPs), providing training to improve the use of developmental screening in pediatric primary care. Method: A quantitative, descriptive methodology with a one-group pretest, posttest interventional design was utilized to assess the impact of an SLP-led educational intervention on the knowledge of 17 paraprofessional medical support personnel to administer a standardized developmental screening tool. Results: Data analysis revealed a significant increase on knowledge posttest scores from pretest scores. Conclusion: SLPs providing educational training in pediatric primary care is an important first step in identifying solutions to improving the early identification of children with developmental concerns.

Autistic people experience more co-occurring health conditions and, on average, die younger than non-autistic people. Despite growing awareness of health inequities, autistic people still report barriers to accessing healthcare. We aimed to explore the experiences of autistic people accessing healthcare, shining a light on the complex interplay of relevant factors and to explain, at least in part, the possible reasons underling health disparities and adverse health outcomes. This is a qualitative study from an autistic research team. Data were collected from 1248 autistic adults as part of a large, mixed-methods, international survey exploring barriers to primary healthcare. This article reports the qualitative findings, following a thematic analysis. Using our exploratory findings, we then constructed a model to explain the reported experiences. Respondents reported a variety of barriers. Here, our article gives voice to their stories, in their own words. Themes included: early barriers; communication mismatch; doubt -- in oneself and from doctors; helplessness and fear; and healthcare avoidance and serious adverse health outcomes. Our constructed model outlines a chronological journey through which healthcare access barriers may lead to adverse health outcomes. Our findings also build on the double empathy problem, situating this in a medical context, proposing a triple empathy problem.

Background: More than 20 million children in the United States lack access to primary health care. Practice Learning: Research shows that students with regular access to physical and mental health services have fewer absences, are more social, less likely to participate in risky behaviors, have improved focus and higher test scores. Implication For School Health Policy, Practice, And Equity: School-based health centers (SBHCs) can be an important, valuable and viable health care delivery option to meet the full-range of primary health care needs of students where they spend the majority of their wake hours, ie, in school. Children in rural and other underserved communities, as well as those underinsured, non-insured, economically challenged, underserved, and the most vulnerable among us are especially at risk. Conclusions: This paper discusses the history, value, and importance of SBHCs from myriad perspectives, including physical and emotional wellbeing, academic and social success, and the promotion of a positive transition to adulthood. In addition, the authors' experiences that resulted in building the first SBHC in the Mid-Hudson Valley Region of New York State are shared. These experiences form the foundation for creating an important roadmap for individuals and school leaders that are interested in bringing a SBHC to their school and district.

Background: Integrated primary care (IPC) can address prevalent behavioral health concerns identified in pediatric office visits, but research on IPC consultation patterns is limited. Objective: This study investigated variation in consultation rates across presenting problems, patient sociodemographic factors, and IPC treatment duration. Method: Retrospective electronic health record data were extracted for 970 patients seen in 12 pediatric primary care sites and for whom behavioral health consultation was requested between June 2018 and December 2019. Logistic regressions were used to examine associations between sociodemographic variables, consultation reasons, and IPC visit type. We used multiple linear regression to assess the association between consultation reason and treatment duration. Results: Anxiety (36.2%) and disruptive behavior (29.7%) were the most common consultation reasons. Consultation requests for internalizing (anxiety, mood) problems were more prevalent in school-aged children and adolescents, whereas consultations for disruptive behavior (tantrums) and health-related issues (toileting, sleep concerns) were common in early childhood. Girls were less likely to receive consultation requests for attention deficit/hyperactivity disorder (ADHD) and autism/developmental concerns compared to boys, but more likely to receive consultation for internalizing problems. Consultation requests varied by patient race, ethnicity, visit type, and insurance type. Treatment duration after consultation was longer among patients with consultation requests for ADHD and for depression/mood concerns. Conclusions: Age-related behavioral health consultation patterns in IPC conform with expected developmental trends; however, sociodemographic findings suggest opportunities for enhancing care. Additional research is needed on IPC consultation given its promise for early identification, prevention, and treatment of pediatric mental health concerns.

The maldistribution of family physicians challenges equitable primary care access in Canada. The "Theory of Social Attachment" suggests that preferential selection and distributed training interventions have potential in influencing physician disposition. However, evaluations of these approaches have focused predominantly on rural underservedness, with little research considering physician disposition in other underserved communities. Accordingly, this study investigated the association between the locations from which medical graduates apply to medical school, their undergraduate preclerkship, clerkship, residency experiences, and practice as indexed across an array of markers of underservedness. We built association models concerning the practice location of 347 family physicians who graduated from McMaster University's MD Program between 2010 and 2015. Postal code data of medical graduates' residence during secondary school, pre-clerkship, clerkship, residency and eventual practice locations were coded according to five Statistics Canada indices related to primary care underservedness: relative rurality, employment rate, proportion of visible minorities, proportion of Indigenous peoples, and neighbourhood socioeconomic status. Univariate and multivariable logistic regression models were then developed for each dependent variable (i.e., practice location expressed in terms of each index). Residency training locations were significantly associated with practice locations across all indices. The place of secondary school education also yielded significant relationships to practice location when indexed by employment rate and relative rurality. Education interventions that leverage residency training locations may be particularly influential in promoting family physician practice location. The findings are interpreted with respect to how investment in education policies can promote physician practice in underserved communities.

HPV vaccination rates remain below target levels among adolescents in the United States, which is particularly concerning in safety-net populations with persistent disparities in HPV-associated cancer burden. Perspectives on evidence-based strategies (EBS) for HPV vaccination among key implementation participants, internal and external to clinics, can provide a better understanding of why these disparities persist. We conducted virtual interviews and focus groups, guided by the Practice Change Model, with clinic members (providers, clinic leaders, and clinic staff) and community members (advocates, parents, policy-level, and payers) in Los Angeles and New Jersey to understand common and divergent perspectives on and experiences with HPV vaccination in safety-net primary care settings. Fifty-eight interviews and seven focus groups were conducted (n = 65 total). Clinic members (clinic leaders n = 7, providers n = 12, and clinic staff n = 6) revealed conflicting HPV vaccine messaging, lack of shared motivation to reduce missed opportunities and improve workflows, and non-operability between clinic electronic health records and state immunization registries created barriers for implementing effective strategies. Community members (advocates n = 8, policy n = 11, payers n = 8, and parents n = 13) described lack of HPV vaccine prioritization among payers, a reliance on advocates to lead national agenda setting and facilitate local implementation, and opportunities to support and engage schools in HPV vaccine messaging and adolescents in HPV vaccine decision-making. Participants indicated the COVID-19 pandemic complicated prioritization of HPV vaccination but also created opportunities for change. These findings highlight design and selection criteria for identifying and implementing EBS (changing the intervention itself, or practice-level resources versus external motivators) that bring internal and external clinic partners together for targeted approaches that account for local needs in improving HPV vaccine uptake within safety-net settings.

Young adult refugees have suboptimal primary care use, including having a regular provider and engaging with a regular source of care for primary and preventive healthcare needs. Our purpose was to understand how young adult refugees (ages 18-29 years) resettled to the United States understand and experience primary care. We conducted 23 semi-structured interviews with young adult refugees and explored their ideas about and experiences of key characteristics of primary care. Emergent themes were synthesized. Young adult refugees reported a lack of an understanding of the idea of primary care. However, they also described the lack of accepted key components of primary care, such as being the first contact and providing continuity, coordination and comprehensiveness. The importance of developing an ability to ask questions, get answers and feel empowered was a facilitator of primary care successes. Young refugees lack access to healthcare that exemplifies quality primary care. Improving understanding of the primary care model and its value as well as increasing access and ease of engagement could improve primary care engagement for young adult refugees.

The purpose of this qualitative study was to identify and prioritize the mental health needs of rural communities in Texas Public Health Region 11 utilizing the Delphi method. Rural individuals face unique challenges when attempting to receive treatment for serious mental illness and mental health care. Stigma, a lack of privacy when seeking treatment, a shortage of mental health workforce professionals, a lack of culturally competent care, affordability, and transportation are all factors that complicate the need for treatment. This study utilized the Delphi method to engage rural community members in identifying and addressing critical issues related to mental healthcare delivery in their county. The sample for this study was selected from the population which comprise Texas Public Health Region 11 communities that were identified as rural communities within Health Professional Shortage Areas (HPSA) using an exponential nondiscriminatory snowball sampling method. Knowledge gained from the study will help to address challenges and critical issues in mental healthcare delivery in rural communities, such as workforce shortages, access issues, anonymity, stigma, integration of mental health services into primary care, and suicide prevention. The study's implications for refining, developing, and increasing rural mental health research, and implications for practice for mental health treatment providers in rural communities are discussed.

The integration of behavioral health care within primary care settings, otherwise known as integrated care, has emerged as a treatment modality for counselors to reach a wide range of clients. However, previous counseling scholars have noted the lack of integrated care representation in counseling journals. In this scoping review, we identified 27 articles within counseling journals that provide integrated care implications. These articles appeared in 10 unique counseling journals, and the publication years ranged from 2004-2023. Articles were classified as: (a) conceptual, (b) empirical, or (c) meta-analyses and systematic reviews. The data extracted from the articles focused on the implications for integrated care training and practice for the next generation of counselors, evidence-based treatment approaches, and future research directions.

Objective: Examine differences in care patterns around adult ADHD between race (White/Non-White) and ethnic (Hispanic/Non-Hispanic) groups utilizing existing quality measures (QMs), concerning diagnosis, treatment, and medication prescribing. Methods: The AAFP National Research Network in partnership with SUNY Upstate Medical used an EHR dataset to evaluate achievement of 10 ADHD QMs. The dataset was obtained from DARTNet Institute and includes 4 million patients of 873 behavioral and primary care practices with at least 100 patients from 2010 to 2020. Patients 18-years or older with adult ADHD were included in this analysis. Results: White patients and Non-Hispanic/Latinx patients were more likely to achieve these QMs than Non-White patients and Hispanic/Latinx patients, respectively. Differences between groups concerning medication and monitoring demonstrate a disparity for Non-White and Hispanic/ Latinx populations. Conclusions: Using QMs in EHR data can help identify gaps in ADHD research. There is a need to continue investigating disparities of quality adult ADHD care. "(J. of Att. Dis. 2024; 28(5) 923-934)"

Multilevel service delivery frameworks are approaches to structuring and organizing a spectrum of evidence-based services and supports, focused on assessment, prevention, and intervention designed for the local context. Exemplar frameworks in child mental health include positive behavioral interventions and supports in education, collaborative care in primary care, and systems of care in community mental health settings. Yet, their high-quality implementation has lagged. This work proposes a conceptual foundation for multilevel service delivery frameworks spanning diverse mental health service settings that can inform development of strategic implementation supports. We draw upon the existing literature for three exemplar multilevel service delivery frameworks in different child mental health service settings to (1) identify core components common to each framework, and (2) to highlight prominent implementation determinants that interface with each core component. Six interrelated components of multilevel service delivery frameworks were identified, including, (1) a systems-level approach, (2) data-driven problem solving and decision-making, (3) multiple levels of service intensity using evidence-based practices, (4) cross-linking service sectors, (5) multiple providers working together, including in teams, and (6) built-in implementation strategies that facilitate delivery of the overall model. Implementation determinants that interface with core components were identified at each contextual level. The conceptual foundation provided in this paper has the potential to facilitate cross-sector knowledge sharing, promote generalization across service settings, and provide direction for researchers, system leaders, and implementation intermediaries/practitioners working to strategically support the high-quality implementation of these frameworks.

Background: Almost a third of college students experience significant mental health concerns, but many do not receive adequate services. This study investigated barriers to mental health services among college students screened in a student health center primary care service. Method: Students (N = 1662) presenting for primary care completed mental health screenings and a barrier measure in the student health center of a university. Latent class analysis created barrier profiles. Results: Three barrier profiles were identified (none, logistical, all barriers). Profiles related to gender (p < 0.001), with logistical/all barrier profiles more likely amongst female students. No significant difference found by race. Students with higher depression scores were more likely to report logistical barriers than no barriers (p < 0.001). Conclusion: Programs must address multiple barriers to successfully engage students in treatment. Tailored interventions, including in primary care, should assess and respond to individual barriers, not just common ones.

Purpose: This paper aims to generate a better understanding of how challenges and opportunities for sustainable change during digitalization relate to the organizing work of change agents mandated to facilitate technology adoption from within local work organizations. Design/methodology/approach: This study examines the work of welfare technology coordinators, health-care professionals who are mandated to facilitate the use of technologies in home-based services in a Norwegian city. Data comprise ethnographic observations of meetings and work practices, interviews and documents collected over one year. A practice-based approach was applied to analyze how the welfare technology coordinators go about integrating technologies with the work practices, and the forms of negotiations this work implies in their work community. Findings: The analysis identified four sets of practices in the coordinators' work: exploring and integrating new technologies into work practices, legitimizing aims and values, formalizing routines and responsibilities and critically considering existing and envisioned service practices. Through these practices, emerging problems and disconnections in the service organization were attended to in a continuous manner. Originality/value: The study contributes to the literature by examining the work of internal change agents mandated to facilitate multiple and simultaneous technology adoption and demonstrates the importance of recognizing the continuous efforts and negotiations of these agents as significant to sustainable organizing.

Background: The Australian Commission on Safety and Quality in Health Care recommends the development of reasonable adjustments to Comprehensive Care Standard to better suit the needs of people with intellectual disability. Method: An audit of adults with Down syndrome attending a mainstream internal medicine outpatient clinic was undertaken to describe their biopsychosocial profile, identify previously developed reasonable adjustments to clinical service and to consider their alignment with comprehensive care. Results: Of 54 adults, 31 (57%) male, average age 36 years (17.5-68 years), there were multiple syndromal and non-syndromal co-morbidities, 10 deaths (9 expected), from dementia. All had some degree of intellectual disability with all requiring disability supports to assist in their healthcare and an active health-disability interface in most cases. Conclusions: Reasonable adjustments to usual clinical content, process, knowledge, and organisation were identified, which appeared to facilitate application of comprehensive care. These were predominantly influenced by intellectual disability, disability supports, and the health-disability interface rather than the disease profile.

We have observed that as the theoretical landscape in behavioral science continues to proliferate and diversify, it is not uncommon that distance between subspecialties emerge, artificially accentuating differences between camps. This may occur at the risk of losing sight of the common ground, and worsening communication between subspecialties. In this paper, we propose conceptual "crosswalking" as a means to preserve interdisciplinary communication within the behavioral sciences. This is illustrated using Bronfenbrenner's Person-Process-Context-Time (PPCT) Model, mapped onto therapeutic modalities with a focus on ecological systems. Recommendations for future crosswalking are made.

Autistic adults often experience health problems and a range of healthcare barriers. Therefore, the aim of this study was to evaluate barriers and explore how primary care providers and autistic adults want to improve their primary healthcare. Semi-structured interviews with three autistic adults, two parents of autistic children and six care providers, were performed to evaluate barriers in Dutch healthcare. Next, in a three-round Delphi-study, 21 autistic adults and 20 primary care providers rated barriers in primary healthcare and assessed recommendations based on usefulness and feasibility. In the thematically analysed interviews, 20 barriers in Dutch healthcare for autistic people were identified. In the Delphi-study, the primary care providers rated the negative impact of most barriers lower than the autistic adults. The Delphi-study resulted in 22 recommendations to improve primary healthcare for autistic adults, focused on: primary care providers (i.e. education in collaboration with autistic people), autistic adults (i.e. improvement of preparation for general practitioner-appointments) and organization of general practice (i.e. enhancement of continuity in care). In conclusion, primary care providers seem to assess healthcare barriers as less impactful than autistic adults. With the use of the Delphi-method, useful and feasible recommendations to improve primary healthcare for autistic adults were identified, based on the needs of autistic adults and primary care providers.

Background: Rates of mental health conditions are high among adults with learning disabilities relative to the general population, however research suggests mental health conditions may be missed or under-identified in this population group. This review considers factors associated with the identification of mental health conditions among adults with learning disabilities in primary care. Methods: A scoping review was conducted and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance extension for scoping reviews (PRISMA-ScR) We searched electronic databases (Cinahl, PsychINfo and Medline) for articles published between the years 2000 and 2022. Data were extracted, tabulated and themes were identified. Findings: The searches identified 3262 articles and 34 met inclusion criteria and were included in the review. Six broad themes were identified including (i) mental health screening in primary care, (ii) education, training and awareness raising for primary care staff, (iii) increasing access to psychological therapies (IAPT) through improved mental health condition case recognition in primary care and IAPT practitioner confidence, (iv) health checks and continuity of care, (v) specialist support for primary care providers, and (vi) awareness raising among adults with learning disabilities. Conclusions: There should be efforts to increase availability in primary care of mental health screening measures suitable for people with learning disabilities. Training opportunities for providers across different sectors of health and social care pathways, on the mental health needs of people with a learning disability are also required. The findings can be used to guide the development of services, for adults with learning disabilities and symptoms of mental health conditions in primary care.

Background: Although the Canadian Consensus Guidelines for Primary Care of Adults with Intellectual and Developmental Disabilities recommends conducting periodic health checks in primary care, uptake is lacking. This study seeks to understand factors influencing the conduct of periodic health checks and identify what needs to change to increase them. Method: Qualitative data from five stakeholder groups (adults with intellectual and developmental disabilities, primary care providers, administrative staff, family, disability support workers) was guided by the Behaviour Change Wheel and the Theoretical Domains Framework to identify barriers and 'what needs to change' to support periodic health checks. Results: Stakeholders (n = 41) voiced multiple barriers. A total of 31 common and 2 unique themes were identified plus 33 items 'needing to change'. Conclusion: Despite barriers, stakeholders saw merit in periodic health checks as a preventative and equitable healthcare offering for adults with intellectual and developmental disabilities. Results will inform future intervention development steps.

Primary care health checks, screenings and GP consultations are often the gateway for people with intellectual disabilities to access their physical and mental healthcare. For a population who experience greater levels of health difficulties alongside significant health inequality, improving care quality and access is of major importance. This meta-ethnographic, qualitative review aims to explore people with intellectual disabilities experiences of health checks, screenings and GP visits, while assessing the quality of the current literature and synthesising findings to consider clinical and research recommendations based on third order constructs. A systematic search identified 20 studies that met inclusion criteria. Quality assessment of each paper was conducted. Meta-ethnography methods were used to analyse and synthesis findings. One overarching concept was identified: Include Me, along with seven core concepts; Empowerment and Disempowerment, Communication and Interpersonal Factors, Access and Adaptations and Biased Narratives and Shifting Perspectives. Implications for practice and future direction are discussed.

To date, little research has focused on transgender and gender diverse (TGD) college students' experiences with health services; most of the literature around TGD health focuses on barriers to care. During the 2021-22 academic year, a collective of researchers, university health service providers, and transgender/gender diverse community members collaborated to conduct a pilot study of TGD students (undergraduate and graduate) at the University of Michigan, on topics related to health, wellness, and their campus experience. This mixed-methods analysis investigates participants' (N = 121) overall health, mental health, and access to trans-inclusive primary care providers, as well as self-reported qualitative responses regarding both how they take care of their health, and positive experiences in accessing beneficial and affirming health care. Students noted positive practices that we themed into concrete actions -- at the interpersonal, organizational, and institutional levels -- and recognizing humanity/agency. The students also reported a range of practices for taking care of themselves and staying healthy, which we organized into three themes: traditional, self-reflective, and connective methods. We conclude by sharing implications for campus health centers and related organizations.

School health has been identified as a neglected aspect of primary health care in Ghana, leading to compromised health, well-being and life satisfaction among students. To address this concern, this study identified the barriers hindering the implementation of school-based health programs in Ghana. It employed a qualitative approach, including 116 respondents who participated in interviews. The collected data were analyzed using thematic analysis with the aid of NVivo software. In line with the research objective, findings show that the implementation of school-based health programs faces several teething challenges that serve as barriers to the success and sustainability of the programs. These barriers included resource constraints; a lack of adequate parental and community participation and a lack of adequate collaboration between stakeholders' management and leadership issues, governance issues and political issues. The findings from the study have a relevant and innovative contribution to achieving good health and well-being and quality education as part of the 2030 Agenda for Sustainable Development Goals and shaping primary healthcare management in the context of a developing country. It recommends that policymakers and health practitioners pay special attention to school-based health programs as a key strategy for primary health care management in developing countries.

Introduction: Motivational interviewing (MI) is an evidence-based counseling approach within primary care. However, MI rarely translates to practice following introductory training programs, and a lack of evidence regarding its implementation persists today. This study describes primary care clinicians' professional transformation in implementing MI through interprofessional communities of practice (ICP-MI). Method: Qualitative data collection involved the research journal, participant observation of four ICP-MIs (76 hours/16 clinicians), and focus groups. A general inductive approach was used for data analysis. Results were conceptualized based on the Consolidated Framework for Implementation Research. Results: Four processes of MI implementation in primary care are presented as a motivational endeavor: ambivalence, introspection, experimentation, and mobilization. The clinicians were initially ambivalent, taking into consideration the significant challenges involved. After introspecting actual practices, they realized the limits of their previous clinician-centered approaches. The experimentation of MI in the workplace followed and enabled clinicians to witness MI feasibility and its added value. Finally, they were mobilized to ensure MI sustainability in their practices/organization. Intrinsic factors of influence included the clinicians' personal traits and their perception about MI as a clinical priority. Organizational support was also a crucial extrinsic factor in encouraging the clinicians' efforts. Conclusion: As described in a fragmented manner in previous studies, MI implementation processes and influencing factors are presented as integrated findings. Incorporating engaging educational activities to provide clinicians with motivational support and collaborating with health care organizations to plan appropriate resources should be considered in the development of MI implementation programs from the onset.

Motivational interviewing is an evidence-based counseling approach. However, its learning processes and their influencing factors are understudied, failing to address the suboptimal use of motivational interviewing in clinical practice. A participatory action research was conducted in collaboration with 16 primary care clinicians, who encountered similar challenges through their previous counseling approaches. The study aimed to facilitate and describe the clinicians' professional transformation through interprofessional communities of practice on motivational interviewing (ICP-MI). Data were collected using the principal investigator's research journal and participant observation of four independent ICP-MIs (76 h) followed by focus groups (8 h). The co-participants performed inductive qualitative data analysis. Results report that learning motivational interviewing requires a paradigm shift from health experts to health guides. The learning processes were initiated by the creation of an openness to the MI spirit and rapidly evolved into iterative processes of MI spirit embodiment and MI skill building. The intrinsic influencing factors involved the clinician's personal traits and professional background; the extrinsic influencing factor was the shared culture disseminating the expert care model. Previously described in a fragmented manner, motivational interviewing learning processes, and its influencing factors were presented as integrated findings. Considerations in elaborating effective MI training/implementation programs are discussed for clinicians, trainers, and decision-makers. Future areas of investigation are also highlighted calling forth the research community to contribute to knowledge advancement on health education in primary care.

Primary care providers (PCPs) are increasingly called upon to screen for and treat depression. However, PCPs often lack the training to diagnose and treat depression. We designed an innovative 12-month evidence and mentorship-based primary care psychiatric training program entitled the University of California, Irvine (UCI) School of Medicine Train New Trainers Primary Care Psychiatry (TNT PCP) Fellowship and examined whether this training impacted clinician prescription rates for antidepressants. We retrieved information on 18,844 patients and 192 PCPs from a publicly insured health program in Southern California receiving care between 2017 and 2021. Of the 192 PCPs, 42 received TNT training and 150 did not. We considered a patient as exposed to the provider's TNT treatment if they received care from a provider after the provider completed the 1-year fellowship. We utilized the number of antidepressant prescriptions per patient, per quarter-year as the dependent variable. Linear regression models controlled for provider characteristics and time trends. Robustness checks included clustering patients by provider identification. After PCPs completed TNT training, "exposed" patients received 0.154 more antidepressant prescriptions per quarter-year relative to expected levels (p < 0.01). Clustering of standard errors by provider characteristics reduced precision of the estimate (p < 0.10) but the direction and magnitude of the results were unchanged. Early results from the UCI TNT PCP Fellowship demonstrate enhanced antidepressant prescription behavior in PCPs who have undergone TNT training. A novel, and relatively low-cost, clinician training program holds the potential to empower PCPs to optimally deliver depression treatment.

The Massachusetts Multi-City Young Children's System of Care Project was a federally funded program to provide integrated early childhood mental health (ECMH) services in primary care for families of very young children (birth-six years old) with Serious Emotional Disturbances across three cities in Massachusetts, U.S.A. This study describes lessons learned from the implementation of this program and makes recommendations for best practices to improve the delivery and efficacy of ECMH services in primary care settings. Staff and leadership (n = 35) from 11 agencies (primary care practices, community service agencies, and local health departments) that co-implemented this program participated in focus groups and semi-structured key informant interviews. Thematic analysis was used to characterize specific facilitators and barriers to successfully implementing system-wide programming for ECMH. Four main themes were identified: (1) Strong multilevel working relationships are critical for integration, (2) Capacity-building activities can be leveraged to improve implementation, (3) Financial challenges are a primary barrier to building efficacious systems of care, and (4) Flexibility and resourcefulness can help overcome logistical challenges in integration. Implementation lessons learned may serve as guidance for other states and institutions in the U.S. seeking to improve the integration of ECMH services into primary care. They may also provide strategies to adapt and scale these interventions to improve the mental health and well-being of young children and their families.

Background: People with learning disabilities are at increased risk of physical health conditions and mortality compared to the general population. Initiatives to address these health inequalities include the introduction of learning disability registers, through which people with learning disabilities can be identified and offered annual health checks and reasonable adjustments in their healthcare provision. A barrier to offering such initiatives to people with learning disabilities is that practitioners/providers may be unaware of the presence of a learning disability, and people who meet criteria may not be entered onto general practice learning disability registers. Screening tools can be used to help identify people with learning disabilities in order that they can be offered appropriate health services and reasonable adjustments. This study aimed to explore the awareness and views of UK primary care staff about the existence and role of screening tools for learning disability in their services. Methods: A qualitative approach was used; semistructured online interviews were conducted with a purposive sample of primary care staff recruited via a regional professional network of primary care practitioners. Five general practitioners and one nurse practitioner, representing five primary care practices in the North-East of England, participated. Interview transcripts were analysed using thematic analysis. Findings: Two themes and associated subthemes were identified. Within Theme 1 ('I haven't had anything much to do with them') two subthemes related to reasons why screening tools were not routinely used. Theme 2 ('I think they're great that they exist') comprised two subthemes that explored the benefits of screening tools, for example, for those practitioners less experienced with people with learning disabilities, and also explored potential reluctance to use them. The study found that most practitioners had some knowledge of screening tools and the general consensus was that they are beneficial. However, the tendency of participants was not to use screening tools in a consistent and/or systematic way, instead relying on informal approaches or other services for identifying the presence of learning disabilities. Conclusions: The study findings highlight the need for changes in practice to support primary care staff to access and systematically use evidence-based effective and efficient screening tools for learning disability.

Background: School nurses are rarely integrated into primary care teams to their full potential. We aimed to characterize school nurses' perceptions related to current and optimal collaboration with primary care providers (PCPs) and identify actionable solutions to improve efficiency, quality, and coordination of pediatric care. Methods: We conducted and qualitatively analyzed interviews with school nurses to characterize structures, processes, and perceived benefits of optimized school nurse-PCP collaboration. Results: School nurse interviewees (n = 23) identified factors important to school nurse-PCP collaboration within 2 domains: information sharing and relationship building. Information sharing themes included health information sharing laws, data sharing systems, and technology-based communication systems. Relationship building themes included health care sector understanding of the school nurse role, PCP knowledge of school health requirements, shared professional development opportunities, and time and personnel. Perceived benefits of optimized PCP-school nurse collaboration were identified for children, PCPs, school nurses, and parents. Implications for School Health Policy, Practice, and Equity: Needs assessments and action plans guided by the domains of information sharing and relationship building can inform local improvements to optimize school nurse-PCP collaboration. Conclusions: School nurses highlighted cross-sector solutions to enhance school nurse-PCP collaboration including integrated information sharing systems and intentional relationship building.

Background: Mental health literacy is important for awareness of mental illnesses in adolescence, which is the initial period of mental disorders. Determining the levels of mental health literacy guides studies in activities promoting mental health. This study aimed to determine the mental health literacy levels of high school students and teachers and related factors. Methods: Our study is a cross-sectional study. A total of 1051 people (students and teachers) were included in the Fatih District of Istanbul were included in our study. The mental health literacy levels of the participants were evaluated with the Mental Health Literacy Questionnaire. This questionnaire includes scenarios about mental problems called "vignettes" and questions about them. Results: Students' recognition percentages of depression, schizophrenia, and social phobia vignettes were found to be 28.1%, 46.5%, and 5.9%, respectively. For the person who was described in the vignettes, the "family physician" was chosen as the least by students and teachers. A statistically significant relationship was found between students' mental health literacy levels and sex, grade, father education levels, and experiencing vignette similar issues (p < 0.005). Additionally, teachers who were not school administrators and experienced vignette similar issues levels were higher (p < 0.005). Conclusions: These results showed us that mental health literacy levels are low in high schools. School-based intervention studies on this issue are of critical importance. In addition, it is seen that individuals do not consider asking for help with mental health problems from primary care services. This shows the inadequacy of the integration of primary health care services and mental health services.

In this retrospective cohort study using data from an integrated primary care and subspecialty network, we examined medical records of children seen in primary care at eligible autism spectrum disorder (ASD) screening ages and followed through at least 4 years of age. We examined the prevalence of ASD; age of first documented ASD diagnosis; and whether the prevalence and age of documented diagnosis varied by race, ethnicity, socio-economic status (SES) and site of care (urban versus suburban/rural). The prevalence of ASD across the cohort was 3.2%, with a median age of diagnosis of 3.93 years. ASD prevalence was unexpectedly higher among Asian children, non-Hispanic Black children, children with higher Social Vulnerability Index scores (a neighborhood-level proxy of socio-economic risk), and children who received care in urban primary care sites. There were no statistically significant differences in age at which ASD diagnosis was documented across socio-demographic groups. Receiving primary care at an urban site accounted for most other socio-demographic differences in ASD prevalence rates, except among Asian children, who were found to have higher adjusted odds of ASD diagnosis compared to White children (aOR = 1.82, p < 0.001). Determining what clinical-, individual- or systems-level factors contribute to ASD diagnosis remains important to improve equity.

Autistic people experience more health conditions and earlier mortality. This study investigated views about a primary care health check for autistic adults to inform its design. Fifty-one people participated in consultation groups and interviews, comprising autistic adults (some with co-occurring intellectual disabilities), adults with intellectual disabilities, supporters and health professionals. Participants wanted the health check to cover physical and mental health and social functioning. They emphasised the importance of sharing information about individual needs and associated adjustments before the health check. They highlighted the need to change the way healthcare services communicate with autistic people, such as reducing phone contact and booking appointments online. They wanted individual choice in how the health check was completed, with video call or email offered alongside face-to-face. Participants raised the need for further training of primary care staff on autism, to highlight the diversity of experiences of autistic people and ways in which difficulties, such as pain, may present differently. Clinicians raised questions about the capacity of mental health and social care services to meet the additional needs potentially identified through the health check. This study represents a key step in the development and co-design of a UK primary care health check for autistic people.

Virtual visits are a telehealth service where patients and providers communicate in real-time using audio and/or video technology. Setting up a virtual visit is complex and may pose challenges for some autistic adults. We conducted semi-structured interviews with autistic adults (n = 7), family members of autistic adults (n = 12), and clinic personnel (n = 6) from one US-based clinic and used thematic analysis to identify factors affecting usability of virtual visits. We found virtual visit preparation involves multiple contacts between clinic personnel and patients or family members via a variety of channels and usability was affected by technology considerations, logistical considerations, and expectations for visits. Participants said technological experience and using the patient portal enhanced usability, but technological issues could increase anxiety. Clinic personnel reported time constraints created logistical barriers to virtual visits; streamlining the process before the visit via the patient portal may improve the usability of virtual visits for autistic adults, family members, and clinic personnel. Participants also reported unclear expectations for virtual visits reduced usability and recommended reminders, instructional videos, and estimated wait-times to clarify expectations. While our findings are based on a single clinic, they may help inform usability improvement efforts in other clinics offering virtual visits for autistic adults.

Transitioning autistic youth from pediatric to adult healthcare requires coordination of multiple stakeholders, including youth, caregivers, and pediatric and adult care providers, whose interests at times overlap but often differ. To understand barriers and facilitators to inclusive transition experiences, we conducted thematic analysis of interviews with 39 stakeholders from the same large, integrated healthcare system. We identified three major themes: (1) Navigating the healthcare transition without guidance, (2) Health consequences of a passive healthcare transition, and (3) Strategies for inclusion and continuous engagement. Facilitators included gradual transition planning, a warm handoff between providers, and support of shared healthcare decision-making. Providers also sought clinical tools and logistical supports such as care coordinators and longer transition-specific visit types to enhance patient-centered care.

Attention-deficit hyperactivity disorder (ADHD) is among the most commonly diagnosed disorders of children and youth. Young people receive their ADHD diagnoses and medical treatment in primary health care settings and can experience a range of behavioral and educational disabilities treated in the clinic, at home, and at school. We propose a team-based collaborative care model (TBCCM) to foster communication and collaboration among health care and education teams, embedding implementation science methods to promote and sustain evidence-based practices for youth with ADHD. Key features of the model include (a) effective leadership and teamwork within the two universal systems of education and health care, (b) use of data from multiple informants who describe and monitor student behavior within and across contexts, and (c) adoption and adaptation of evidence-based practices. We expect that these efforts to embed implementation science methods within a collaborative team structure will improve the uptake of evidence by intervention teams in the two systems, and thus optimize outcomes for children and youth with ADHD.

The integration of behavioral health services in primary care has become increasingly popular in pediatric settings in recent years. While there are various models of integrated behavioral health (IBH), the aim is constant: to increase access to behavioral and mental health care through collaboration between behavioral health providers and physicians. Prior to the pandemic, only 20%-50% of children and adolescents received mental health care from a professional. Since COVID-19, access to care has only worsened. Given this reality, the use of IBH has promising benefits, including: (1) positive outcomes for patients and providers; (2) improved screening, identification, and intervention; (3) improved mental health outcomes; and (4) reduction of provider burnout. Given these aims and outcomes, a major opportunity exists for school psychologists to bring unique, but highly transferable, knowledge and skills to an emerging field. In this article, the authors share the real-life experiences of a licensed school psychologist and advanced practicum student to highlight how the comprehensive training of school psychologists prepares us to perform well in an integrated setting. The authors also call attention to the numerous possibilities available for those looking for an alternative setting or expansion of their current practice.

Background: Despite extensive literature on school-based health center (SBHC) characteristics and outcomes, their quality of care has not been examined nationally. Standardized quality metrics can inform health care delivery and improvement. Methods: SBHC national performance measures (NPMs) were developed by reviewing measures from national child health quality initiatives and engaging stakeholders in a consensus-building process. NPMs were pilot-tested with 73 SBHCs and SBHCs nationally subsequently reported data. Results: Five NPMs were selected including the percentage of clients annually who received at least one--(1) well-child visit, whether administered in the SBHC or elsewhere; (2) risk assessment; (3) body mass index screen with nutrition and physical activity counseling; and, if age-appropriate, (4) depression screening with follow-up treatment plan; and (5) chlamydia screening among sexually active clients. SBHCs experienced challenges with reporting during pilot-testing, particularly related to extracting data from electronic health records, and identified strategies to address challenges. Approximately 20% of SBHCs nationally voluntarily reported data during the initial year. Implications for School Health: Standardized performance measures can help SBHCs monitor and improve care delivery and demonstrate effectiveness compared to other child health delivery systems. Conclusion: Ongoing data collection will help examine whether measure adoption drives quality improvement for SBHCs nationwide.

The purpose of this study was to examine the frequency and quality of primary care physician (PCP) recommendations to investigate the management of young children with delays and self-injury (SIB; e.g., head banging) from the time of initial SIB concern to specialty referral as recommended by the American Academy of Pediatrics (AAP). Via a structured electronic health record review, PCP referrals and recommendations were examined for a cohort of 250 children (10-59 months old) with delays and SIB. Only a small portion of cohort charts reviewed (8.0%) received AAP recommended intervention via referral to subspecialty providers by their PCP. Further, only 37.5% received SIB-specific care recommendations. Findings suggest that future targeted education is needed to improve primary care access to AAP recommended intervention for young children with delays and early SIB.

LGBT youth experience disproportionate rates of mental health diagnoses, including depression and anxiety. Using qualitative interviews of LGBT youth (n = 14) and primary care providers (n = 12), we sought to identify whether mental health discussions with a primary care provider were perceived as overall beneficial. Most LGBT youth felt comfortable being asked about depression, anxiety, or other mental health conditions by their primary care provider. All felt it appropriate to provide this information by survey or tablet. However, youth participants' comfort depended on feeling connected with and accepted by their provider. Those that did feel comfortable, perceived a benefit when these conversations did happen. Providers unanimously described wanting to address mental health needs in LGBT youth, either in terms of societal advancement, or clinic-based changes. Both LGBT youth and primary care providers appeared to want more mental health discussions during visits. However, more connectedness may be needed to improve willingness to engage in care; and providers may require specific support to successfully fill this need.

Objective: First, to examine general health care attitudes and health care utilization of a University Health Service (UHS) at a large university. Second, to identify differences between LGBT and non-LBGT students. Participants: 2,943 university students were surveyed in Spring 2013; 7.8% LGBT, 67% undergraduate and 65% female. Methods: A cross-sectional mixed-methods online survey to assess health care utilization and attitudes. Results: A majority had utilized UHS and held positive attitudes in general. LGBT students were more likely to: use UHS for ongoing care, mental health, and preventive care; report concerns about utilization (e.g. confidentiality, sensitivity, and discrimination issues); report provider discomfort discussing sexuality; and hold positive attitudes toward the health care needs of LGBT students. Conclusions: University health centers have an important role in student health. Barriers to care should be removed, including perceived discrimination. Student health center staff should be trained on LGBT health issues.

Purpose: To meet future healthcare needs, primary care is undergoing a transformation in which innovations and new ways of working play an important role. However, successful innovations depend on joint learning and rewarding collaborations between healthcare and other stakeholders. This study aims to explore how learning develops when entrepreneurs, healthcare professionals and older people collaborate in a primary care living lab. Design/methodology/approach: The study had an action research design and was conducted at a clinically embedded living lab at a primary care centre on the west coast of Sweden. Data consisted of e-mail conversations, recordings from design meetings and three group interviews with each party (entrepreneurs, healthcare professionals and older people). Data were analysed with inductive qualitative content analysis. Findings: An overarching theme, "To share each other's worlds in an arranged space for learning", was found, followed by three categories, "Prerequisites for learning", "Strategies to achieve learning" and "To learn from and with each other". These three categories comprise eight subcategories. Originality/value: This research contributes to knowledge regarding the need for arranged spaces for learning and innovation in primary care and how collaborative learning can contribute to the development of practice.

This study investigates the effect of an instructional design for medical Chinese, which incorporates research findings from Conversation Analysis (CA) and uses authentic doctor-patient consultations in primary-care visits as teaching materials. The goal of the instruction is to develop students' interpersonal communicative competence in medical settings, especially doctor-patient consultations. Twelve pre-med college students in the course "Chinese for Healthcare Professions" participated in this study. They first participated in five 50-min classes using a chapter from a medical Chinese textbook. Then, they participated in an additional set of five 50-min instructional sessions introducing CA-informed instruction using authentic consultations. The pedagogical effects were measured with paired roleplays administered at three different times: at the beginning of the course, after the regular instruction sessions, and, finally, after the CA-informed instructional period. The results show that the CA-informed instruction for using authentic doctor-patient consultations has a positive effect on improving students' communicative performance in simulated medical settings.

Modern communication between health care professionals and patients increasingly relies upon secure messages (SMs) exchanged through an electronic patient portal. Despite the convenience of secure messaging, challenges include gaps between physician and patient expertise along with the asynchronous nature of such communication. Importantly, less readable SMs from physicians (e.g., too complicated) may result in patient confusion, non-adherence, and ultimately poorer health outcomes. The current simulation trial synthesizes work on patient physician electronic communication, message readability assessments, and feedback to explore the potential for automated strategy feedback to improve the readability of physicians' SMs to patients. Within a simulated secure messaging portal featuring multiple simulated patient scenarios, computational algorithms assessed the complexity of SMs written by 67 participating physicians to patients. The messaging portal provided strategy feedback for how physician responses might be improved (e.g., adding details and information to reduce complexity). Analyses of changes in SM complexity revealed that automated strategy feedback indeed helped physicians compose and refine more readable messages. Although the effects for any individual SM were slight, the "cumulative" effects within and across patient scenarios showed trends of decreasing complexity. Physicians appeared to learn how to craft more readable SMs via interactions with the feedback system. Implications for secure messaging systems and physician training are discussed, along with considerations for further investigation of broader physician populations and effects on patient experience.

Interprofessional education (IPE) is championed as an innovative approach to prepare the future health workforce to address the complex needs of consumers and tackle a range of contemporary healthcare challenges worldwide. An interprofessional work-integrated learning experience (WIL), whereby students were immersed in international and rural settings and worked in teams to deliver primary healthcare project outcomes, was developed, implemented, and evaluated with undergraduate health students. Qualitative evaluation of the IPE program aimed to investigate the experiences and perceptions of 62 students through focus group interviews, is reported. Students regarded the placement as a rich learning environment and reported positive experiences in interprofessional collaborative competencies. Major themes included: overall perceptions and attitudes, scope of practice, improved teamwork skills, future practice, and placement preparation. Students strengthened their learning with, from and about other professional groups and identified challenges and implementation issues. Findings from this study will inform future implementation of interprofessional WIL experiences.

The coordination of primary and behavioral health care that holistically targets clients' physical and mental needs is known as "integrated care." Primary care is increasingly becoming a de facto mental health system because of behavioral health care shortages and patient preferences. Primary care behavioral health (PCBH) is a gold standard model used to assist in the integration process. Although counselor training addresses some aspects of integrated care, best practices for counselor education and supervision within the PCBH framework are underdeveloped. This article provides an overview of the Program for the Integrated Training of Counselors in Behavioral Health (PITCH). The authors discuss challenges in implementation; solutions; and implications for counselor training, clinical practice, and behavioral health workforce development.