Discussing Depression with Vietnamese American Patients

Background Asian patients preferentially seek mental health care from their primary care providers but are unlikely to receive it. Primary care providers need culturally-informed strategies for addressing stigmatizing illnesses. Methods 11 Vietnamese American community members participated in semi-structured interviews. Interviews were audio-taped and transcribed. The grounded theory approach was used for qualitative coding and thematic analysis. Results Vietnamese community members describe experiences with depression under four themes: (1) Stigma and face; (2) Social functioning and the role of the family; (3) Traditional healing and beliefs about medications; and (4) Language and culture. Based on this data, we offer suggestions for improving culturally-informed care for Vietnamese Americans. Disucssion Our study adds to the research aimed at improving communication and health care relationships between physicians and Vietnamese American patients. Physicians should learn to tailor their interviewing style to the increasingly diverse patient population

Organizing for Quality Improvement in Health Care: An Example From Childhood Obesity Prevention.

Children in rural areas face higher rates of obesity than children in urban areas, and their clinicians face challenges with preventing and managing obesity and translation of evidence into practice. We evaluated how the quality improvement (QI) intervention, Healthy Eating Active Living TeleHealth Community of Practice (HEALTH COP), at 7 rural California clinics addressed these challenges. Focus group interviews with QI team members assessed their experiences and factors related to adoption of key changes. Key challenges were clinician and staff buy-in, changing ingrained clinical practices, and motivating patient and families. Facilitators were top-down organizational requirements for QI, linkages to local QI resources, involvement of clinical champions, alignment with existing practices, incorporating a learning system connecting similar clinics, and clear and consistent communication channels. Evaluations of QI interventions should include not only measurement of effectiveness but also identification of factors associated with change and interactions with organizational processes and contexts

Provider Recommendations in the Face of Scientific Uncertainty: An Analysis of Audio-Recorded Discussions about Vitamin D

BackgroundLittle is known about how providers communicate recommendations when scientific uncertainty exists.ObjectivesTo compare provider recommendations to those in the scientific literature, with a focus on whether uncertainty was communicated.DesignQualitative (inductive systematic content analysis) and quantitative analysis of previously collected audio-recorded provider-patient office visits.ParticipantsSixty-one providers and a socio-economically diverse convenience sample of 603 of their patients from outpatient community- and academic-based primary care, integrative medicine, and complementary and alternative medicine provider offices in Southern California.Main measuresComparison of provider information-giving about vitamin D to professional guidelines and scientific information for which conflicting recommendations or insufficient scientific evidence exists; certainty with which information was conveyed.ResultsNinety-two (15.3 %) of 603 visit discussions touched upon issues related to vitamin D testing, management and benefits. Vitamin D deficiency screening was discussed with 23 (25 %) patients, the definition of vitamin D deficiency with 21 (22.8 %), the optimal range for vitamin D levels with 26 (28.3 %), vitamin D supplementation dosing with 50 (54.3 %), and benefits of supplementation with 46 (50 %). For each of the professional guidelines/scientific information examined, providers conveyed information that deviated from professional guidelines and the existing scientific evidence. Of 166 statements made about vitamin D in this study, providers conveyed 160 (96.4 %) with certainty, without mention of any equivocal or contradictory evidence in the scientific literature. No uncertainty was mentioned when vitamin D dosing was discussed, even when recommended dosing was higher than guideline recommendations.Conclusions and relevanceProviders convey the vast majority of information and recommendations about vitamin D with certainty, even though the scientific literature contains inconsistent recommendations and declarations of inadequate evidence. Not communicating uncertainty blurs the contrast between evidence-based recommendations and those without evidence. Providers should explore best practices for involving patients in decision-making by acknowledging the uncertainty behind their recommendations

Factors Related to Disclosure and Nondisclosure of Dietary Supplements in Primary Care, Integrative Medicine, and Naturopathic Medicine.

Patients infrequently disclose use of dietary supplements to providers. Little is known about factors that motivate patients to disclose supplement use. The study aimed to identify reported factors motivating patients' disclosure and nondisclosure of dietary supplement use and explore differences based on type of supplement and provider practice. Mixed methods study combining qualitative content analysis of semi-structured interviews with statistical analyses to assess differences in identified factors by provider practice type and supplement type. Seventy-eight English-speaking patients who reported taking 466 dietary supplements in the previous 30 days were recruited from primary care and Complementary and Alternative Medicine (CAM), and Integrative Medicine (IM) offices in Southern California. We identified nine themes related to disclosure and nine related to nondisclosure of dietary supplement use. Major themes were features of the office visit, circumstances in patient health and medical care, and provider/patient characteristics. The most commonly raised theme promoting disclosure of supplement use was provider inquiry. Patients associate disclosure with having concerns about a supplement but also with annual physical exams and some routine topics of discussion, including self-care, lab results, and new medication prescriptions. Themes related to nondisclosure included lack of provider inquiry, features of the office visit, such as supplements being unrelated to the visit purpose, and patients' convictions that supplements are safe or not important to discuss. Themes did not vary by supplement type. Primary care patients were more likely than CAM/IM patients to attribute nondisclosure to convictions that supplements were beneficial, not worth mentioning, or equivalent to food (p ≤ 0.001). When providers fail to ask directly about dietary supplement use, disclosure is often an impromptu decision that is driven by the content of provider-patient interactions. Ensuring disclosure of dietary supplement use to prevent potential drug-supplement interactions or adverse health outcomes likely requires consistent, proactive provider queries about supplement use