Objective: Medical and dental providers are not addressing prenatal oral health (POH) with patients despite knowledge of the risks. The objective of this study was to determine how training in dental schools and OB/Gyn residencies may contribute to this paradox.

Methods: We conducted a national survey of 60 dental school deans and 240 obstetrics and gynecology residency program directors. Questions assessed the number of hours of POH education, topics addressed, awareness of guidelines, and barriers to including more POH training.

Results: Response rates were 53% and 40% for dental schools and OB/Gyn residencies, respectively. 94% of dental schools provide some POH education, with 61% of schools offering 3+ hours. Only 39% of OB/Gyn residencies provide some POH education, most only 1-2 hours. 65% of dental programs and 45% of OB/Gyn residencies are aware of current POH evidence-based guidelines. Those OB/Gyn residency programs with POH training were three times as likely to expose their residents to these guidelines. A similar trend was observed for dental schools. Barriers to POH education include space in the curriculum and competing clinical priorities. 76% of OB/Gyn directors affirmed the importance of addressing oral health needs among prenatal patients; however, only 23% agreed that the ACGME should add POH competencies. The majority of respondents agreed they would add more POH education if the American College of Obstetrics and Gynecology issued a policy statement or practice bulletin.

Conclusions: The majority of dental schools teach POH but clinical exposure is limited. Less than half of OB/Gyn residencies include POH training. Future efforts should include distribution of POH guidelines/consensus statements to educators and learners, increasing exposure of dental students to pregnant patients, and developing faculty expertise in residencies.

METHODS: Family medicine residency directors completed a survey that asked how many hours of oral health teaching are included in their programs in addition to what topics are covered and the perceived barriers to this education. The response rate was 35%.

RESULTS: A total of 72% of respondents agreed that oral health is an important topic, but only 32% are satisfied with their residents' competency in oral health. Barriers to this education included competing priorities (85%), inadequate time (69%), and lack of faculty expertise (52%).

CONCLUSIONS: The findings suggest that programs are including more hours than in previous years, yet continued efforts are needed to cover core oral health topics and increase the competency of family medicine residents. Awareness of STFM's Smiles for Life and use of its modules were associated with increased hours of training.

METHODS: Eleven questions were embedded in the nationwide CERA survey to US family medicine residency directors regarding the processes, components, and barriers to early PGY-1 assessment. Responses are described, and bivariate analyses of the relationship between assessment variables and percentage of international medical graduates (IMGs), type of program, and barriers to implementation were performed using chi square testing.

RESULTS: Almost four of five (78.4%) responding programs conduct formal early assessments to establish baseline clinical skills (89.6%), provide PGY-1 residents with a guide to focus their learning goals (71.6%), and less often, in response to resident performance problems (34.3%). Barriers to implementing PGY-1 early assessment programs include cost of faculty time (56.3%), cost of tools (42.1%), and time for the assessment during the PGY-1 resident's schedule (41.0%). Cost of faculty time and time for assessment from the PGY-1 resident's schedule were statistically significant major/insurmountable barriers for community-based, non-university-affiliated programs.

CONCLUSIONS: Early PGY-1 assessments with locally developed tools for direct observation are commonly used in family medicine residency programs. Assessment program development should be targeted toward using existing, validated tools during the PGY-1 resident's patient care schedule.

Objectives: The purpose of this study was to determine how much oral health education is being provided to Family Medicine residents, if the program directors are aware of the importance of oral health, and if there are specific barriers to teaching oral health curricula in these programs.

Methods: 452 Family Medicine residency directors were surveyed about numbers of hours of OH teaching, topics covered, and perceived barriers to this education.

Results: 72% of respondents agreed that OH is an important topic, but only 32% were satisfied with their residents' competency in OH. All but 4% of programs address OH in their curricula; 52% reported 1-2 hours and 45% reported 3+ hours of OH teaching. Most commonly covered topics were prevention and care of caries (89%) and pediatric screening (85%); less covered topics included fluoride varnish (58%) and pregnancy and oral health (61%). Barriers to OH education included competing priorities (85%), inadequate time (69%), and lack of faculty expertise (52%). Awareness of the Society of Teachers of Family Medicine's Smiles for Life (SFL) curriculum and the use of SFL modules were associated with increased hours of training. Training in fluoride varnish, but not the application itself, was associated with more hours of OH curriculum. Residency directors who indicated competing priorities or lack of faculty expertise as barriers reported fewer hours of OH training.

Conclusion: Findings suggest that Family Medicine programs are including more hours than previously, yet continued efforts are needed to cover core OH topics and increase residents’ competence. Awareness of STFM's Smiles for Life and use of its modules were associated with increased hours of training.

METHODS: We surveyed Massachusetts family physicians about their screening practices of adult patients for a history of childhood abuse and found that 33.6% had some experience of personal trauma, with 42.4% of women and 24.3% of men reporting some kind of lifetime personal abuse, including witnessing violence between their parents. These rates are comparable to or higher than those reported in prior studies of physicians' histories of abuse.

RESULTS: Physicians with a past history of trauma were more likely to feel confident in screening and less likely to perceive time as a barrier to screening.

CONCLUSIONS: Given the high prevalence of prior childhood and victimization of both men and women physicians with the associated effects on their clinical work, we recommend that educational and training settings adopt specific competencies to provide safe and confidential environments where trainees can safely explore these issues and the potential impact on their clinical practice and well-being.

Purpose: To compare PACIC scores to hemoglobin A1C values in subjects with Type 2 Diabetes and to determine the correlation between patient-physician collaboration and glycemic control.

Methods: Participants were selected from the Diabetes Clinic at the University Hospital of the West Indies in Kingston, Jamaica, in August 2011. A total of 40 patients were screened, but only 19 met eligibility requirements and agreed to participate in the study. Informed consent was obtained. The patients were assigned a study number and then self-administered the Patient Assessment of Care for Chronic Illness (PACIC) questionnaire in a private examination room. The PACIC is a validated instrument consisting of a total of 20 multiple choice questions. It measures five subjective categories: 1) Patient activation; 2) Delivery system design and decision support; 3) Goal setting; 4) Problem solving/contextual counseling; and 5) Follow-up/ coordination. Each category can be averaged individually with scores ranging from 1-5. The overall PACIC score measures patient-physician collaboration with a score ranging from a low of 1.0 to a high of 5.0. Additional study data was collected by one of the authors (PD) for both characterization of the study population and for analysis of potential confounders. These additional independent variables included: patient age, type of treatment (i.e., lifestyle modification), and years diagnosed with diabetes mellitus.

Results: There were 19 subjects who were eligible for study and completed the PACIC questionnaire. There were more women than men (78.9%, 15 women and 4 men). The age range was 33-78 years with a mean age of 55. The range for years diagnosed with diabetes was 0.03 – 32 years with a mean of 14 years. Eight of the subjects (42.1%) were on combination therapy with insulin and oral hypoglycemic agents. Hemoglobin A1c values ranged from 5.4% – 15.5% with a mean of 10.8%. The PACIC scores ranged from 1.85 – 4.80 with a mean of 3.15. No statistically significant correlations were found between PACIC scores and HbA1c (r=.184). HbA1c did not significantly correlate with patient age (r=-.408), nor with years diagnosed with diabetes (r=-.244). Further statistical analysis using non-parametric correlation coefficients to take small sample sizes into account did not reveal any significant relationship either.

Conclusion: There was no statistically significant trends between our main variables of the patient-physician collaboration (PACIC score) and glycemic control (HbA1c). Analysis of potential confounders also failed to elicit any correlations with HbA1c. The major limitation in this study is the small sample size. An important next step would be to repeat this study with a larger clinic sample.

Objectives: The objective of this project was two-fold: 1) to evaluate the amount of information about basic health retained by VHWs who participated in a week-long training session; and 2) to follow-up with VHWs to see what changes they noticed in their communities and determine what challenges they face in disseminating health information in their villages.

Methods: The study sample consisted of 110 participants who were asked to complete the pre- and post-tests. The pre- and post-training test consisted of 49 multiple choice questions, written in Luganda, with a total possible score of 105. The pre-test was distributed to the participants on the first day of the training session. Participants were administered post-tests on the last day of the training session. The questions and the delivery of the exams were the same at both points in time. The grading of the tests was as follows: each correct answer received one point, incorrect answers received no points, and questions with more than one answer received no points. We compared the percentage of correct answers of the pre- and post-tests to determine any changes in knowledge as a result of the training session.

A total of 99 trainees were recruited to participate in focus groups. Focus groups were conducted three and six months after the original training session and involved five to ten VHWs per session. Questionnaires were distributed to the groups and questions were read aloud with discussion about each topic. We asked the VHWs: 1) Have you noticed healthy changes in your community?; 2) What changes have you noticed; 3) How does the community view a VHW?; and 4) What support could you use as a VHW?

Results: The VHWs selected from the communities were aged 25-40, were more likely to be female than male, and generally had a non-health related occupation. One hundred and two participants completed both the pre- and post-tests. The average difference between test scores at the two points in time was an improvement of 20.25 points, or 19.3%. The range of differences between the scores was -5 to +61. Given that the VHWs were not previously educated about basic health, this was viewed a marginal improvement. However, the data from the focus groups indicates that the VHWs were enacting changes in their community. The participants in the focus group were also aged 25-40 and 43 were males and 56 were females.

The focus groups demonstrated that 86% of the VHWs noticed positive changes in the community; including the creation of latrines (34%), more drying racks (16%), more hand-washing (11%), increased usage of boiled water (9%) and the newfound creation and usage of “tippy-taps” (8%). When asked if the community viewed the VHWs as a positive asset, 81% answered yes. Lastly, when queried as to what support VHWs could use to facilitate their work, the majority answered some type of transport (51%); while other popular answers were gumboots and raingear, more training, cell phones or a stipend to compensate them for their work.

Conclusion: The increased mean score of the post-tests indicates that the VHWs did learn basic health information during the training session. However, the improvement in score was not as notable as one would expect given the intense nature of the trainings and the baseline level of knowledge being somewhat low. The data from the focus groups, however, indicated that VHWs are creating positive change in their communities. This could mean that the simple act of appointing one person to educate their community imbues in them a responsibility to spread the knowledge that they do possess; however basic it may be. It also could indicate that the VHWs learned more at the training sessions than the test scores reveal. This could be due to a multitude of factors, including difficulty with reading, the advanced nature of the test questions, difficulty with multiple choice questions, or difficulty applying knowledge to the test, especially considering that most of the VHWs were adults many years out of school. In light of this information, one could consider a different method of evaluation, and more focus on the follow-up to assess what the VHWs are actually able to do in their communities. Moving forward, it would be ideal to evaluate the villages themselves via a system of door-to-door surveys that ask the villagers about changes they have or have not made and if they have seen any improvement in their health. This information will provide further evidence as to whether VHWs are an ideal model in the field of health education.

OBJECTIVE: We sought to determine if the sequential appearance of wanting, craving and needing provides an indication of the intensity of other markers of tobacco addiction including psychological and behavioral indicators.

METHODS: A web-based survey was completed by 422 smokers ages 18-78 years. Subjects were assigned to one of four qualitatively distinct stages of physical addiction based on their most advanced symptom: 1-none, 2-wanting, 3-craving, or 4-needing. Using linear Chi square and ANOVA, we determined if higher stages were associated with higher levels of tobacco addiction on more than a dozen measures.

RESULTS: 16.8% of subjects were in stage 1, 26.1% in stage 2, 17.1% in stage 3 and 40.0% in stage 4. Each step up in stage was associated with higher levels of addiction as measured by the Fagerstrom Test for Nicotine Dependence, the Hooked on Nicotine Checklist, the Autonomy over Tobacco Scale, and higher levels of psychological dependence, duration of tobacco use, frequency of tobacco use, daily cigarette consumption, and 10 additional measures.

CONCLUSIONS: In this cross-sectional study, each sequential stage of physical addiction was associated with higher levels of every indicator of addiction. The data suggest that the stages of progression of physical addiction provide a global indication of the severity of tobacco addiction.

STUDY DESIGN: An anonymous survey was administered to 349 tobacco users in grades 9 through 12 in Florida. The combinations of withdrawal symptoms reported were examined to determine whether they were consistent with the developmental sequence described by case reports (wanting, then craving, then needing). Dependence was measured by several validated measures, including the Hooked on Nicotine Checklist, the Autonomy Over Tobacco Scale, and the modified Fagerstrom Tolerance Questionnaire.

RESULTS: The combinations of withdrawal symptoms reported by 99.4% of subjects were consistent with case reports stating that wanting, craving, and needing develop in that sequence. Across the stages, from wanting to needing, higher stages were associated with significant increases in the strength of addiction as measured by the Hooked on Nicotine Checklist, the Autonomy Over Tobacco Scale, the modified Fagerstrom Tolerance Questionnaire, and all other measures.

CONCLUSIONS: Our data confirmed that withdrawal symptoms develop in an orderly sequence, as proposed, and indicate that each progressive step along the sequence of wanting, craving, and needing represents a substantial increase in tobacco addiction. This provides the foundation for a clinical approach to staging the progression of tobacco addiction.

Methods: In 2010, an anonymous self-completed paper survey was administered to 1541 students of mixed race and ethnicity in grades 9-12 (mean age 15.9 years) in a Florida high school where students used cigarettes and smokeless tobacco.

Results: The reliability (Cronbach's alpha) for the HONC was 0.90 for smokers (n=139) and 0.91 for dippers (n=85), and for the AUTOS was 0.94 for smokers and dippers. Dippers and smokers did not differ significantly in relation to scores on the HONC, AUTOS, latency to withdrawal onset or pleasure derived from smoking. One or more symptoms on the HONC were reported by 56% of dippers and 57% of smokers with product, and by 91% of dippers and 91% of smokers with >/=100 lifetime uses (not significant). Greater lifetime use was associated with a significantly shorter latency to withdrawal for smokers and dippers.

Conclusions: The HONC and AUTOS are highly reliable measures of dependence for adolescent users of cigarettes and smokeless tobacco. Using these measures and other indicators, no meaningful differences in dependence were found between dippers and smokers at comparable levels of lifetime use.

Data Source. Survey of a sample of primary care physicians in MA.

Study Design. Cross-sectional survey of a sample of physicians who provide care to MassHealth (MA Medicaid) enrolled-children. Dependent variables: history of completed preventive dental skills training, and FV provision. Independent variables: oral health knowledge, FV-attitudes, and physician and practice characteristics.

Principal Findings. Overall, 19 percent of respondents had completed the training required to be eligible to bill for FV provision. Only 5 percent of physicians were providing FV. Most respondents (63 percent) were not familiar with the new policy, and only 25 percent felt that FV should be provided during well-child visits. Most physicians (60 percent) did not feel that the reimbursement rate of U.S.$26/application was sufficient; 17 percent said that they would not provide FV, regardless of payment. Most common barriers to FV provision were a lack of time and logistical challenges.

Conclusions. Our findings suggest that simply reimbursing physicians for FV provision is insufficient to ensure provider participation. Success of this policy will likely require addressing several barriers identified.

Objective: This study was designed to examine student and facilitator perceptions of effective case-based small group teaching in the pre-clinical years and compare results in order to identify similarities and differences and identify key areas of disconnect so that the small group learning experience can be improved.

Methods: An 18-item survey was emailed to all 388 students who had started the second year of medical school at the University of Massachusetts between August 2008 and August 2010 and to 146 of 161 facilitators who had facilitated a case-based small group session during that same time. Chi-square tests of equality of proportions were used to compare the answers of students and small group facilitators.

Results: 79 (54%) small group facilitators and 195 (50%) students responded. Student and facilitator responses were similar in the areas regarding goals of small group sessions and responsibilities of the facilitator. Significant difference was noted between cohorts about the most important roles of the facilitator, whether facilitators and/or students should attend training prior to sessions, whether groups should follow a consistent format, how students should be expected to prepare for small groups, how student knowledge and performance should be assessed, and whether the small group leader should be a skilled facilitator or content expert.

Conclusions: This study demonstrates that there are areas where perceptions of effectiveness differ between students and facilitators. Identifying these areas presents an opportunity to make small group sessions more effective by allowing for more informed facilitator development and better communication of session expectations to students. The lack of a substantive body of literature on this important trend in medical education, coupled with our findings, suggests that further study is needed to identify characteristics of case-based small group learning that are mutually valued by students and facilitators. This will encourage the development of small group sessions that are deemed effective and maximize learning and teaching time.

Objectives: The objectives of this study were to evaluate if prenatal patient satisfaction and knowledge about pregnancy improves if a structured prenatal education plan is implemented throughout a family medicine health center. Also, we sought to evaluate if a structured prenatal education plan for expectant mothers will improve specific clinical outcomes.

Methods: Focus groups were held in which prenatal patients were asked about their level of satisfaction with current prenatal care practices at the Hahnemann Family Health Center. Advice for improvement was also elicited. The data gathered from the focus group, the input of physicians at the health center, and information gathered from a review of current prenatal education materials around the country was used to create a new prenatal health education plan.

In addition, data collection tools (three surveys) were specifically created for this study (partially based on previously validated tools). Surveys were specific for the first trimester, third trimester, and postnatal period. Currently in year one, pregnant women have been, and will continue to be, surveyed regarding their prenatal knowledge and satisfaction given the current state of prenatal care at the health center. During this year approximately 50 patients in their first trimester will be enrolled and surveyed throughout the pre and postnatal period. At the beginning of year two, the new prenatal education plan will be implemented. A new cohort of about 50 patients at the health center, who receive the new prenatal health education, will be assessed on their level of prenatal knowledge and satisfaction using the same survey tools. Knowledge/satisfaction will be compared between the two groups. In addition, clinical measures (such as number of phone calls regarding prenatal issues between scheduled visits, number of trips to the emergency room, preterm labor, smoking cessation rates, and breast feeding) will be compared, via a chart review, between the two groups.

Results: Focus groups, with women who currently receive prenatal care at the health center, revealed that women were inconsistently counseled about ways to combat stress during pregnancy, expectations for the mother and baby while in the hospital during labor and delivery, the reason the health center collects a urine sample during each prenatal visit, as well as dental care and preterm labor precautions. In addition, at least one woman reported never discussing with her physician topics such as nutrition during pregnancy, weight gain, breastfeeding, stages of pregnancy, and development of the baby.

Initial survey results indicate that women in their first trimester of pregnancy most often feel they have “some knowledge” about pregnancy and prenatal-related issues but patients vary widely on their confidence in making decisions regarding basic pregnancy issues without having to talk to a doctor. About 50% believe they have added stress in their life due to pregnancy. Worries regarding pregnancy and child care topics vary widely. About 78% of the time, women answered knowledge-based questions concerning pregnancy-related topics correctly.

Conclusion: Initial results indicate that there are currently gaps in prenatal education and knowledge throughout prenatal care at the health center. Based on our findings and those of previously published studies, it can be hypothesized that by closing these gaps, as with a structured health education plan, clinical outcomes will improve. We will be better able to assess this hypothesis after year two of this study. While patient satisfaction cannot be assessed at this time, our early survey results indicate that first trimester women seem to subjectively and objectively have some accurate prenatal knowledge.