Area Health Education Center Research Articles

Delivery of Mobile Clinic Services to Migrant and Seasonal Farmworkers: A Review of Practice Models for Community-Academic Partnerships

Farmworkers in the US are a medically underserved group, who are largely uninsured, foreign-born, and working in a hazardous industry. This review addresses the challenges of providing health services for this priority population to study the numerous health access barriers that face migrant and seasonal farmworkers (MSFW), evaluates the services provided at mobile clinics, summarizes practice models for community-academic partnerships, and synthesizes the literature on effective partnership approaches to deliver these services. Because MSFW are a difficult group to reach and access, mobile farmworker clinics provide an opportunity for unique student training experiences, in addition to small survey and feasibility studies. A literature search was conducted to identify articles for the review. Out of 196 articles identified by the article databases and manual search techniques, 18 articles were finally selected for the review based on predetermined inclusion and exclusion criteria. Half of the articles were classified as case studies or descriptive studies with lessons learned. Only three articles were classified as research studies, and six articles were not classified as research studies, but rather descriptions of the clinics only. Many of the partnership models were structured with the lead agency as either the academic partner or an Area Health Education Center. The academic partner was usually a nursing school, and less frequently a medical school. Other service partners frequently mentioned were federally-qualified Community Health Centers, Migrant Health Centers, and health departments. The review found that service partnerships were characterized by collaboration between academic institutions and community organizations, with a lead agency driving sustainability efforts.

Engaging communities in education and research: PBRNs, AHEC, and CTSA.

Community engagement has become a prominent element in medical research and is an important component of the Clinical and Translational Science Awards program. Area Health Education Centers engage communities in education and workforce development. Engaging Communities in Education and Research (ECER) is a successful collaboration among the Colorado Area Health Education Center (AHEC), the Colorado Clinical Translational Science Institute, and Shared Network of Collaborative Ambulatory Practices and Partners--Colorado's practice-based research collaborative. The ECER Conference is an annual conference of community members, health care providers, clinical preceptors, AHEC board members, university faculty, primary care investigators, program administrators, and community organization leaders. Over 1,000 people have participated in the ECER Conference representing all regions of Colorado. Several projects from the "new ideas" breakout session have been developed and completed. Six-month follow-up provided evidence of numerous new collaborations, campus-community partnerships, and developing research projects. Several new collaborations highlight the long-term nature of building on relationships started at the ECER Conference. ECER has been a successful collaboration to develop and support campus-community collaborations in Colorado. Although seemingly just a simple 3-day conference, we have found that this event has lead to many important partnerships.

An Innovative Clerkship Module Focused on Patients With Disabilities

Lack of medical training results in physicians being unprepared to provide care to people with disabilities, which, in turn, contributes to the substantial health disparities that are evident in this population. Few medical schools or primary care residencies address the care of adults with disabilities. Competencies and guidelines to assist American physicians in caring for patients with physical or intellectual disabilities have yet to be established, thus making educational goals unclear. This article describes one novel training module regarding people with disabilities that was developed at the University of South Florida Health, Morsani College of Medicine (USF) and inserted into the primary care clerkship during a major curriculum redesign in 2005. Since then, all USF third-year medical students have been required to participate in this disability-related course component. The authors describe the module's development and integration into the primary care clerkship, as well as the specific elements of their curriculum. By using a variety of teaching modalities in the classroom and community, and especially by involving people with disabilities themselves, the medical students have a very comprehensive learning experience regarding people who have physical, sensory, or intellectual disabilities. The authors have been able to show that USF medical students, on completion of this module, demonstrate improved knowledge, attitudes, and comfort in caring for people with disabilities, which the authors believe will lead to improved health and health care access for this underserved population. Suggestions for program replication, including common challenges, are also discussed.

The Relative Geographic Immobility Of New Registered Nurses Calls For New Strategies To Augment That Workforce

Little is known about registered nurses' geographic mobility after they earn their first professional degree and become licensed to practice. Through a cross-sectional mailed survey of newly licensed registered nurses in fifteen states, we found that 52.5 percent work within forty miles of where they attended high school. Our complementary analysis of Census Bureau data shows that next to teaching, nursing is one of the least mobile professions for women, for reasons that remain unclear. To ensure that underserved areas have an adequate workforce of registered nurses, policy makers should expand the number of educational programs in these areas; fund programs that provide incentives to young people from these areas to attend nursing programs; consider supporting extension programs from accredited nursing schools; and review admission policies for nursing programs and the financial aid they offer. If states find it difficult to retain out-of-state graduates, giving preference to in-state applicants may make sense. Finally, programs and policies that offer financial incentives to attract registered nurses to underserved areas, such as the National Health Service Corps and the Area Health Education Centers, are critically important. When sufficiently funded, such programs could serve to offset the low mobility of new registered nurses that we observed.

Sidebar: Hospital-Based Self-Management of Diabetes

Mission Hospital is an 800-bed, not-for-profit, independent community hospital system located in Asheville, North Carolina. The Health Education Center, an outpatient program of Mission, includes the Diabetes Center, which is accredited through the American Diabetes Association. The Diabetes Center has a sister diabetes program at McDowell Hospital, in Marion, North Carolina, that provides diabetes education for adults in that region. For patients with or at risk for diabetes, one of the advantages conferred by the Diabetes Center’s relationship with Mission Hospital is that the center shares the hospital’s mission of serving all individuals in western North Carolina and the surrounding region. A second advantage is that the Health Education Center has the financial backing to conduct yearly community programs to reach underserved and minority populations, with no charge to the participants. The events serve 100-300 people each year and include screening for hyperglycemia, measurement of high blood pressure, and calculation of body mass index. Education in the areas of basic diabetes pathophysiology, nutrition, and exercise is provided by certified diabetes educators and physicians. Participants also receive healthy snacks and recipes and are given blood glucose meters and taught how to use them. Mission sees value in educating health professionals about diabetes. Since 2000, Mission, along with the Mountain Area Health Education Center and other community and regional organizations, has planned and held an annual professional diabetes clinical workshop for medical, nursing, pharmacy, and nutrition professionals. This workshop reaches 180-250 health professionals per year and covers the most up-to-date research and trends in diabetes care. Twenty-four percent of inpatients discharged from Mission have a diagnosis of diabetes or hyperglycemia. Two years ago, Mission started a diabetes-resource program for nurses. This is a comprehensive diabetes education program for bedside nurses, who, by expanding their knowledge base, are thus better equipped to provide education about diabetes-associated survival skills to inpatients with diabetes. Part of this training is to reinforce the importance of ensuring that patients receive a referral to outpatient diabetes selfmanagement training at the time of discharge, either at one of Mission’s diabetes centers or at another outpatient education center in the region. Another advantage of being based in a hospital system is that patients can receive care and services from a multidisciplinary team of professionals. Our outpatient diabetes education team includes an endocrinologist, who serves as our medical director, and 10 certified diabetes educators from the nursing, nutrition, and pharmacy professions. Our team also includes an exercise specialist and a clinical social worker. The ability to refer patients for multiple types of services within the same program is convenient for both patients and clinicians. Also, having professionals with multiple backgrounds available to discuss issues such as treatments, disease cases, and patient-related challenges is a tremendous advantage for the clinicians/educators. Having such a large team also enables us to offer comprehensive services, including diabetes self-care classes, an insulin pump course, a gestational diabetes course, medical nutrition therapy, initiation of continuous glucose monitoring, a program on pediatric diabetes, individual consultations for diabetes and nutrition education, diabetes support groups, and employersponsored disease management programs. Of note, patients participating in the disease management programs undergo long-term follow-up by our clinicians and are seen quarterly for clinical assessment, goal setting, monitoring, and drug therapy review. In this population, we have seen significant improvements in hemoglobin A1c and lipid levels, decreased per-patient medical costs, and reduced numbers of sick days. These services are not a significant source of revenue for Mission. Their value is instead found in the community-level health and wellness benefits they yield, as well as in the satisfaction exhibited by the patients who visit us and by the team of professionals available to care for them.

Introduction to the Special Section: Rural Health Issues in Pediatric Psychology

The difficulties of meeting the medical and psychological needs of individuals living in rural areas have long been recognized. In Pre-Colonial days, a network of native healers attempted to meet the needs of rural populations, and when the Colonists arrived from England, the first formally trained physicians arrived in America as well. As the colonists moved westward, physicians followed, facing difficulties and hardships they had not encountered previously. In 1910, the Flexner report was released, which suggested revamping medical education and moving toward a formalized 4-year medical education system. Less than 20 years after this report was implemented, publications started to appear in the literature discussing the lack of healthcare providers in rural areas—an unintended consequence of the Flexner report. Recognizing this problem, in the 1960s and 1970s, the federal government established Area Health Education Centers (AHECs) primarily to directly serve the medical and behavioral needs of rural individuals. Although the office of Rural Health Policy at the U.S. Department of Health and Human Services was not formally established until 1987, it was seen as a final major step forward in improving the health of rural Americans. Data indicate, however, that even with all of these impressive steps forward, the health of rural populations is still lacking when compared to urban populations. Recent data released by the National Center for Health Statistics (2010) indicate that 14.8% of individuals in urban areas ‘‘did not get medical care due to cost,’’ and yet this rate is even higher (17.1%) among rural residents. The same is true for the items querying ‘‘did not get prescription drugs due to cost’’ (10.8% urban, 13.6% rural) and ‘‘did not get dental care due to cost’’ (16.4% urban, 19.2% rural). Specific to children, 10.2% of the children aged <18 years who live in urban areas had no visit to a physician in the past 12 months; the rate for rural children was higher at 12.0%. Finally, the percentage of children aged 18 years with one or more visits to an emergency room was higher for rural children (24.2%) than for urban children (20.2%). Though these differences may seem small, they equate to tens of thousands of rural children not receiving adequate medical care. Looking at specific diseases, data from the National Survey of Children’s Health (U.S. Department of Health and Human Services, 2005) indicate that rural children are more likely to be overweight (17.1% large rural, 17.4% small rural) than urban children (14.2%). Unintentional injury rates are also higher among rural children (9.4% large rural, 10.0% small rural) compared to urban children (9.3%). Chronic physical or mental health problems are also more prevalent among rural children (9.0% large rural, 8.1% small rural) than among urban children (7.7%). Our nation has long recognized the problems faced in meeting the medical and behavioral needs of rural populations, and has taken dramatic and positive steps to ameliorate these differences. Despite this, taken together, data overwhelmingly indicate that children and adults living in rural areas still experience greater medical and behavioral issues and are less likely to receive treatment for these issues relative to their nonrural counterparts.

Integration of pharmacists into a patient-centered medical home

To define the joint principles of the patient-centered medical home (PCMH) and describe the integration of pharmacists into a PCMH. Family medicine residency training program in North Carolina from 2001 to 2011. Mountain Area Health Education Family Health Center is a family medicine residency training program that is part of the North Carolina Area Health Education Center system. The goal of the organization is to train and retain health care students and residents. The practice is recognized as a level III PCMH by the National Committee for Quality Assurance (NCQA) and seeks to provide quality, safe, patient-centered care according to the joint principles of PCMH. Pharmacists, nurses, nutritionists, care managers, Spanish translators, and behavioral medicine specialists work collaboratively with physicians to provide seamless, comprehensive care. The Department of Pharmacotherapy is embedded in the family medicine clinic. Three pharmacists and two pharmacy residents are involved in providing direct patient care services, ensuring access to community resources, assisting patients with transitions of care, providing interprofessional education, and participating in continuous quality improvement initiatives. The pharmacists serve as clinical pharmacist practitioners and provide medication therapy management services in a pharmacotherapy clinic, anticoagulation clinics, and an osteoporosis clinic and via an inpatient family medicine service. Multiple learners such as student pharmacists, pharmacy residents, and family medicine residents rotate through the various pharmacy clinics to learn about pharmacotherapeutic principles and the role of the pharmacist in PCMH. PCMH is a comprehensive, patient-centered, team-based approach to population management in the primary care setting. Pharmacists play a vital role in PCMH and make fundamental contributions to patient care across health care settings. Such innovations in the ambulatory care setting create a unique niche for pharmacists to use their skills.

The Rockcastle Project: A Case Study of Interprofessional Clinical Education and Practice in a Rural Medical Center

The purpose of this pilot project was to provide an interprofessional, evidence-based learning experience for students in three disciplines during a four-week period in a rural hospital. Methods: This project is described as a case study and included students and faculty from two universities, personnel from an Area Health Education Center, and hospital practitioners in three health care disciplines. Project planners designed and carried out an interprofessional clinical course, which included one student in each of three disciplines: occupational therapy, physical therapy and communication sciences and disorders. Planning included establishing a course description, objectives, course requirements, and outcome measures. Results: During a four week period, the students met regularly, performed a patient examination together, and presented results of the examination in the form of a plan of care, mentored by supervisors in corresponding disciplines. The Interdisciplinary Education Perception Scale (IEPS) was completed by students prior to and at the conclusion of the four weeks to assess attitudes toward interprofessional education. Scores on the IEPS increased for all three students and an overall increase of positive perceptions of the other disciplines was noted.Conclusion: Opportunities such as the Rockcastle Project foster university, clinical, and organizational partnerships within rural communities and promote interprofessional teamwork.

Sidebar: Challenges to Providing Services to North Carolina Veterans Who Have Traumatic Brain Injury

ncmedicaljournal.com NCMJ vol. 72, no. 1 ncmedicaljournal.com 51 CareLine and with the North Carolina National Guard. The goal of promoting the behavioral and physical health of military families will be addressed with programs and evidence-based practices that support the families’ resilience and emotional health. The DMHDDSAS Practice Improvement Collaborative, managed by the Governor’s Institute on Alcohol and Drug Abuse, reviews and catalogues evidence-based practices designed to address the health care needs of this special group. The historic collaboration between LMEs and state hospitals has been expanded to include the VA, the University of North Carolina system, Area Health Education Centers and Community Care of North Carolina (CCNC), and the Center of Excellence for Integrated Care (CEIC). The DMHDDSAS will continue to work with SAMHSA’s national technical-assistance center to improve the quality of service delivered in North Carolina. CCNC provides managed primary care for Medicaideligible patients, under the guidance of the North Carolina Division of Medical Assistance. According to Michael Lancaster, director of behavioral health at CCNC, care managers help coordinate health care for military members, veterans, or family members who have Medicaid coverage. The CCNC case manager works cooperatively with the LME care coordinator to ensure that appropriate services are secured. North Carolina has worked to improve care for all of its citizens, including those who served the nation as a member of the military. One avenue of improvement is being investigated by the CEIC, whose work addresses the disconnection between mental health and physical health, a by-product of the US health-care system’s payment system. This disconnection has made access to timely mental health services and coordinated care difficult for residents in North Carolina and the United States and has exacerbated the stigma many patients may feel about seeking mental health services. While the VA has led the way in integrating mental health care and physical health care at VA facilities, the public and private health systems have lagged in efforts to help patients who have mental and physical conditions. In 2006, professional organizations, state agencies, consumer groups, and others joined together to create the training program, clinical tools, and practice-based demonstration projects to enable primary care practices to integrate a mental health or substance abuse provider into the practice. This integration could be as minimal as an agreement to share patient care between a primary care practice and a mental health or substance abuse provider in the same region, or it could be as complex as the full integration of the behavioral health or primary care provider into the practice’s teams of Challenges to Providing Services to North Carolina Veterans Who Have Traumatic Brain Injury

Development and Assessment of a Physical Activity Guidebook for the Colon Health and Life-Long Exercise Change (CHALLENGE) Trial (NCIC CO.21)

We report the development and assessment of a physical activity (PA) guidebook called Step Up to the Challenge that is being used to support a PA behavior change intervention in a randomized trial examining PA and disease-free survival in colon cancer survivors. Content for the PA guidebook was constructed based on the Theory of Planned Behavior (TPB). Expert judges (N = 51) included oncologists, rehabilitation practitioners, colon cancer survivors, and TPB researchers. All expert judges completed the Maine Area Health Education Center checklist for evaluating written health information. A subset of TPB expert judges (n = 11) also assessed the degree of match between the guidebook content and TPB constructs. Expert judges indicated that the PA guidebook achieved desirable attributes for organization, writing style, appearance, appeal, feasibility, and appropriateness. For the TPB assessment, all mean item-content relevance ratings indicated at least a "very good match" between the PA guidebook content and the TPB constructs. Our guidebook successfully targets the TPB constructs known to influence PA behavior change and contains suitable and appropriate written health information. This guidebook will be an integral component of the behavioral support program designed to determine the effects of PA on disease-free survival in colon cancer survivors.

Abstract B105: Addressing colorectal cancer disparities in rural Appalachia

Abstract Colorectal cancer, a disease that is both preventable and detectable in early stages, is currently the third leading cause of cancer death in the U.S. In Kentucky, this disease is the second leading cause of cancer death. The elevated rates of colorectal cancer are a concern because they have increased in recent decades and because of low rates of use of available screening modalities. Low screening rates are particularly concerning for rural populations because of limited access to colonoscopy as well as diagnostic and treatment facilities for colorectal cancer. This concern is particularly acute in Appalachia, a region with a long history of pronounced cancer health disparities. This NCI-funded study is designed to increase colorectal cancer screening by providing outreach and education to primary care physicians practicing in rural, medically underserved areas in Appalachian Kentucky. The intervention is delivered using academic detailing in partnership with Area Health Education Centers (AHEC). General practice, family medicine, and general internal medicine practices in Appalachian Kentucky were identified and invited to participate. A practice representative, usually the lead health care provider, completed a survey describing the practice characteristics and the colorectal cancer screening testing that they provided and/or recommended. Medical record reviews of a sample of 60 asymptomatic patients age 50 and older were conducted to establish baseline screening rates. Practices were then randomized to early or delayed intervention groups. The intervention was delivered at the practices. After an introductory visit, the academic detailer made up to four subsequent visits to the practices to present information on screening efficacy, patient counseling, reimbursement, and practice management. Evaluation data were collected through medical record reviews at 6 and 18 months after the final intervention visit. Medical record reviews collected data on screening recommended and/or provided (fecal occult blood testing (FOBT) in the past year, flexible sigmoidoscopy in the past 5 years, and colonoscopy in the past 10 years). A total of 66 practices we enrolled. Baseline data from 3906 patient records indicated that health care providers had recommended screening by FOBT in the past year for 18.5% of the eligible patients seen during the period covered by the medical record review. The review also showed that 10.5% of records included documentation of results of FOBT. For flexible sigmoidoscopy in the past 5 years 0.4% had a recommendation and 0.3% results. For colonoscopy in the past 10 years, rates of recommendation and results documentation were 43.7% and 29.7%, respectively. Data from medical record review conducted 6 months after the intervention revealed small changes in FOBT, and a substantial increase in documentation of results from colonoscopy, (p&amp;lt;.05). Medical record review at 18 months post intervention revealed a sharp decline in FOBT and slight increases in colonoscopy. Qualitative interviews with project personnel and participants suggest that a pattern of rapid abandonment of FOBT as a screening modality and increased emphasis on colonoscopy may be competing explanations for intervention effects. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B105.

Satisfaction with a Distance Continuing Education Program for Health Professionals

This study assessed differences in program satisfaction among health professionals participating in a distance continuing education program by gender, ethnicity, discipline, and community size. A one-group posttest design was used with a sample of 45,996 participants in the University of Arkansas for Medical Sciences, Rural Hospital, Distance Continuing Medical Education Program during 1995-2007. This program provided 2,219 continuing education programs for physicians (n = 7,047), nurses (n = 21,264), allied health (n = 3,230) and dental (n = 305) professionals, pharmacists (n = 4,088), administrators (n = 1,211), and marketing/finance/human resources professionals (n = 343). These programs were provided in Arkansas hospitals, clinics, and area health education centers. Interactive video technology and the Internet were used to deliver these programs. The program satisfaction instrument demonstrated adequate internal consistency reliability (Cronbach's alpha = 0.91) and construct validity. Participants had high levels of satisfaction regarding knowledge and skills, use of information to enhance patient care, program quality, and convenience of the technology (mean total satisfaction score = 4.44, range: 1-5). Results from the t-test for independent samples and one-way analysis of variance indicated that men (p = 0.01), African-Americans and Hispanics (p < 0.01), dental professionals (p < 0.01), and participants in larger urban communities (population of 75,001-185,000) (p < 0.01) had significantly greater satisfaction. Nurses and physicians had significantly greater satisfaction regarding the use of information in practice to enhance patient care (p < 0.01). Results suggest that socioeconomic and demographic factors can affect satisfaction with distance continuing education programs.

University of Pittsburgh School of Medicine

University of Pittsburgh School of Medicine

Kids Into Health Careers: A Rural Initiative

To describe a project that introduces middle school and high school students living in Pennsylvania's rural geographic regions to nursing careers through outreach extended to students regardless of gender, ethnicity, or socioeconomic status. The authors employed many strategies to inform students about careers in nursing. The methods included: working with guidance counselors, participating in community health fairs, taking part in school health career fairs, collaborating with Area Health Education Centers, serving on volunteer local education advisory boards, developing a health careers resource guide, and establishing a rural health advisory board. Developing developmentally appropriate programs may have the potential to pique interest in nursing careers in children of all ages, preschool through high school. Publicity is needed to alert the community of kids into health care career programs. Timing is essential when planning visits to discuss health care professions opportunities with middle and high school students. It is important to increase the number of high school student contacts during the fall months. Targeting high school seniors is particularly important as they begin the college applications process and determine which school will best meet their educational goals. Outcome measures to determine the success of health career programs for students in preschool through high school are needed. Evaluation methods will be continued over the coming years to assess effectiveness.

A national view of rural health workforce issues in the USA

Regional or state studies in the USA have documented shortages of rural physicians and other healthcare professionals that can impact on access to health services. The purpose of this study was to determine whether rural hospital chief executive officers (CEOs) in the USA report shortages of health professions and to obtain perceptions about factors influencing recruiting and retention. A nationwide US survey was conducted of 1031 rural hospital CEOs identified by regional/state Area Health Education Centers. A three-page survey was sent containing questions about whether or not physician shortages were present in the CEO's community and asking about physician needs by specialty. The CEOs were also asked to assess whether other health professionals were needed in their town or within a 48 km (30 mile) radius. Analyses from 335 respondents (34.4%) representative of rural hospital CEOs in the USA are presented. Primary care shortages based on survey responses were very similar to the pattern for all rural areas in the USA (49% vs 52%, respectively). The location of respondents according to ZIP code rurality status was similar to all rural areas in the USA (moderately rural, 29.3% vs 27.6%, respectively), and 69.1% were located in highly rural ZIP codes (vs 72.4% of highly rural ZIP codes for all USA). Physician shortages were reported by 75.4% of the rural CEOs, and 70.3% indicated shortages of two or more primary care specialties. The most frequently reported shortage was family medicine (FM, 58.3%) followed by general internal medicine (IM, 53.1%). Other reported shortages were: psychiatry (46.6%); general surgery (39.9%); neurology (36.4%); pediatrics (PEDS, 36.2%); cardiology (35%); and obstetrics-gynecology (34.4%). The three most commonly needed allied health professions were registered nurses (73.5%), physical therapists (61.2%) and pharmacists (51%). The percentage of CEOs reporting shortages of two or more primary care specialties (FM, IM or PEDS) was 70.3% nationally, with no statistically significant regional variation (p = .394), while higher for the New England through Virginia region (83.9%) than for all other regions. The CEOs reported the highest specialty care shortages for psychiatry (46.6%) followed by general surgery (39.9%), neurology (36.4%), cardiology (35.0%) and obstetrics-gynecology (34.4%). Major specialty shortages varied among regions and only for neurology and cardiology were regional differences statistically significant (p < .05). Marked variation between need for healthcare professionals were reported ranging from approximately 73% for registered nurses (RNs) to 16% for health educators. Reporting of need for RNs in rural areas was nearly 74% nationally and 35% reported a need for nurse practitioners. Differences for both RNs and nurse practitioners were not statistically significant among regions. Nationally, approximately 30% of CEOs reported a shortage of licensed practical nurses, which differed significantly among regions (p = .006). There was variation in physical therapist shortages among regions (p = .001), with 61.2% of CEOs reporting shortages nationally. Regional variation pattern was observed for pharmacists (p = .004) with approximately 50% of rural CEOs reporting a need for pharmacists nationally. The association between CEOs' reported shortages of two or more primary care doctors and their indication of the need for other health professionals was statistically significant for nurse practitioners, physician assistants, pharmacists, and dentists. The recruitment and retention attributes deemed to be of greatest importance were: (1) healthcare is a major part of the local economy; (2) community is a good place for family; (3) doctors are well-respected and supported; and (4) people in the community are friendly and supportive of each other. These were remarkably similar across 6 US geographic regions. Similarities in shortages and attributes influencing recruitment across regions suggest that major policy and program interventions are needed to develop a rural health professions workforce that will enable the benefits of recent US health reform insurance coverage to be realized. Substantial and targeted programs to increase rural healthcare professionals are needed.

Smoking Cessation in Family Medicine: Effects of an Area Health Education Center Training Program

Many clinicians have not received adequate training in smoking cessation. We examined the effects of a tobacco training program on clinician behavior, attitudes, knowledge, and comfort related to smoking cessation. In a prospective cohort study, family medicine residents and faculty completed a pretest, followed by an educational intervention that encompassed presentations on smoking cessation resources, motivational interviewing, and the neurobiology of addiction and pharmacotherapy. After 3months, participants completed a postintervention survey. Results were analyzed using chi-square tests to examine the effects of training. Thirty-three residents and faculty completed the pretraining survey and 25 completed the posttraining survey. Following training, participants were more familiar and comfortable with Public Health Service Clinical Practice Guidelines (P < .0001). No significant differences were found in performance of the 5 As (Ask, Advise, Assess, Assist, and Arrange) or other behaviors, including providing assistance with counseling, cessation plans, resources, or pharmacotherapy. There were no improvements in knowledge of specific intervention plans or attitudes related to identifying and counseling smokers. A multidisciplinary tobacco training program increases clinician familiarity and comfort with practice guidelines, and may contribute to improving care activities that promote a healthy lifestyle. Future research should explore other interventions that have the potential of changing practice patterns on a larger scale. Future studies should also assess the effect of training programs on patient-oriented outcomes.

Exercises in Emergency Preparedness for Health Professionals in Community Clinics

Health professionals in community settings are generally unprepared for disasters. From 2006 to 2008 the California Statewide Area Health Education Center (AHEC) program conducted 90 table top exercises in community practice sites in 18 counties. The exercises arranged and facilitated by AHEC trained local coordinators and trainers were designed to assist health professionals in developing and applying their practice site emergency plans using simulated events about pandemic influenza or other emergencies. Of the 1,496 multidisciplinary health professionals and staff participating in the exercises, 1,176 (79%) completed learner evaluation forms with 92–98% of participants rating the training experiences as good to excellent. A few reported helpful effects when applying their training to a real time local disaster. Assessments of the status of clinic emergency plans using 15 criteria were conducted at three intervals: when the exercises were scheduled, immediately before the exercises, and for one-third of sites, three months after the exercise. All sites made improvements in their emergency plans with some or all of the plan criteria. Of the sites having follow up, most (N = 23) were community health centers that made statistically significant changes in two-thirds of the plan criteria (P = .001–.046). Following the exercises, after action reports were completed for 88 sites and noted strengths, weaknesses, and plans for improvements in their emergency plans Most sites (72–90%) showed improvements in how to activate their plans, the roles of their staff, and how to participate in a coordinated response. Challenges in scheduling exercises included time constraints and lack of resources among busy health professionals. Technical assistance and considerations of clinic schedules mitigated these issues. The multidisciplinary table top exercises proved to be an effective means to develop or improve clinic emergency plans and enhance the dialogue and coordination among health professionals before an emergency happens.

Teachers Can Be Trained to Help Students With Complex Trauma

Back to table of contents Previous article Next article Professional NewsFull AccessTeachers Can Be Trained to Help Students With Complex TraumaAaron LevinAaron LevinSearch for more papers by this authorPublished Online:7 Aug 2009https://doi.org/10.1176/pn.44.15.0009Children who experience chronic, complex trauma are vulnerable to a host of behavioral and educational problems, yet educators often feel frustrated with their attempts to respond. Natalie Turner, M.S., L.M.H.C., of Washington State University says schools have alternatives to punishing “bad” behavior by children affected by trauma.Credit: Aaron LevinFrequently those problems are treated—ineffectively—as disciplinary issues, but a more helpful way of dealing with them might involve some eye-opening training for teachers, said Natalie Turner, M.S., L.M.H.C., program director at the Area Health Education Center for Eastern Washington at Washington State University in Spokane.“Too often educators focus on punishing these children, when what is needed is accountability balanced with empathy,” said Turner at the National Association for Rural Mental Health annual meeting in Albuquerque in June.Complex trauma is pervasive, episodic trauma that persists over time and often co-occurs with poverty, family violence, substance abuse, or community violence, said Turner. “These children grow up in an unsafe, chaotic, unpredictable world where they see things as threatening even when they are not, because that is what their experience has taught them.”Constant stress induced by complex trauma appears to cause changes in the brain, leading to difficulties with motor skills, language, social behavior, and self-control.“It's hard for them to stay in their seats, to listen, and to process and retain information,” she said. It also takes time and perhaps some teacher retraining so that the children can be helped to overcome those neuropsychiatric effects.Although many of these children will not develop problems, the ones who do are often punished in the expectation that it will change their behavior.The child may respond to a teacher's request for quiet or control by looking away, putting his or her head down on the desk, or simply ignoring the teacher. This may result in the child's being sent to the principal's office for punishment for acting “disrespectful,” the leading reason for such referrals.The behavior can resemble symptoms for ADHD, anxiety, or bipolar disorder, and children are eventually so diagnosed, often because it is the only way they can get treatment, said Turner.“Teachers personalize this behavior, although 99 percent of the time it has nothing to do with them,” said Turner. This behavior is a response to the trauma laying unseen by the teacher in a child's home or neighborhood environment.The teacher's reaction makes things only worse. It publicly shames the students, removes them from the learning setting in class, and doesn't change their behavior. Even though the process rarely works, educators continue to do what they've always done because they haven't developed alternatives.Counseling or medications may help many of these children, but more might be done to lessen the apparent conflict in the classroom before it escalates.Changing both students' and educators' behavior isn't easy.“Teachers may need more child-development training,” she said.“ They don't need to know if a child is traumatized; they just need to be trauma sensitive.”It can take a long time to create a sense of safety in the classroom and rebuild lost attachment. Teachers have to play a consistent, safe, and predictable role over a long period, building relationships that may not exist elsewhere in the children's lives. Students need help with skills to regulate their emotional responses and cope in healthy ways with threatening environments.“All children have the potential to overcome adversity,” she said.Parents need support, too. Many have grown up in households where they were traumatized and so may need help breaking the cycle that is harming their children.Turner and her colleagues have begun pilot programs in Washington state using a model that calls for restructuring the classroom and professional environments and helping teachers recognize, understand, and control their own responses to children's behavior without having to send them to the principal's office. They also have commitments from four school superintendents to try out the program in a clinical trial randomized on the building level. ▪ ISSUES NewArchived

An Innovative Faculty Toolkit

Author Affiliation: Assistant Director, Charlotte Area Health Education Center, North Carolina.Mary R. WebsterCorrespondence: Charlotte Area Health Education Center, 5039 Airport Center Parkway, Bldg K, Charlotte, NC 28208 ([email protected]).

South Carolina Area Health Education Consortium Disaster Preparedness and Response Training Network

The South Carolina Area Health Education Consortium (SC AHEC) was funded in 2003 to train healthcare professionals in disaster preparedness and response. During the 5 years of funding, its Disaster Preparedness and Response Training Network evolved from disaster awareness training to competency-based instruction and performance assessment. With funding from the assistant secretary for preparedness and response (ASPR), a project with implications for national dissemination was developed to evaluate 2 aspects of preparedness training for community-based healthcare professionals. The SC AHEC designed disaster preparedness curricula and lesson plans, using a consensus-building technique, and then (1) distributed sample curricula and resources through the national Area Health Education Center system to assess an approach for providing preparedness training and (2) delivered a standardized preparedness curriculum to key influential thought leaders from 4 states to evaluate the effectiveness and acceptability of the curriculum. As a result of this project, the SC AHEC recommends that preparedness training for community-based practitioners needs to be concise and professionally relevant. It should be integrated into existing healthcare professions education programs and continuing education offerings. The project also demonstrated that although AHECs may be interested and well suited to incorporate preparedness training as part of their mission, more work needs to be done if they are to assume a prominent role in disaster preparedness training.