Behavioral Health Care Providers Research Articles

Association between depression severity, mental health recovery and dropout from behavioral health care treatment

BackgroundUnderstanding the relationship between depression severity, patient recovery, and treatment continuity may help optimize the delivery of behavioral health services. MethodsUsing Cox proportional hazards regression, this study measures the association between treatment dropout and baseline depression severity, as measured by the Patient Health Questionnaire (PHQ-9), and the association between treatment dropout and baseline recovery, as measured by the Recovery Assessment Scale (RAS). The study also explores heterogeneity by service line (general mental health, substance use disorder, and eating disorder), residential versus intermediate level of care setting, age groups (adolescent and adult), and dropout factors. The data include 14,689 patients treated at a multi-state behavioral health care provider, discharged between 2021 and 2022. Premature dropout from behavioral health care treatment for any cause, patient factors and administrative factors were used as separate outcomes. FindingsA unit increase in baseline PHQ-9 was associated with a 1.2% reduced treatment dropout risk (hazard ratio (HR): 0.988; 95% confidence interval [0.983–0.992]). A unit increase in baseline RAS score was associated with 0.5% increased dropout likelihood (HR: 1.005; 95% CI [1.004, 1.007]). Subgroup analyses show associations are driven by general mental health, adolescent, and intermediate level of care subgroups. Patients with higher baseline suicidality and lower willigness to ask for helphad a reduced risk of dropout. InterpretationPatients with greater depression severity and lower recovery scores at admission were more likely to stay in behavioral health treatment, especially among adolescents, patients with general mental health issues, and outpatients.

Looking Toward the Future of Integrated Care: History, Developments, and Opportunities.

For almost five decades, the development and implementation of integrated care-the simultaneous combination of primary care with mental health and substance use care-has been a major challenge for the behavioral health care field. Integrated care is exceptionally important because many people with behavioral health conditions also have chronic physical health conditions. Early research findings in the mid-1980s showed that persons with mental illness are likely to develop chronic physical conditions earlier and more severely than other people. These findings precipitated efforts to understand this problem and to develop further appropriate integrated care solutions. Subsequently, the US Surgeon General made care integration a major focus of his landmark 1999 Report on Mental Health, as did the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Patient Protection and Affordable Care Act. However, it was not until 2014, and later, that integrated care actually began to be implemented more broadly. This article reviews these major developmental milestones, examines current activities, and explores likely developments over the next several years. Major current issues include the response to the COVID-19 pandemic, adjusting to its effects on the behavioral health care workforce, and the growing realization that behavioral health care must address the social determinants of life. Likely developments over the next several years will include devising ways to address our workforce crisis, developing effective community interventions, and implementing population health management strategies; implementing the CMS Innovation in Behavioral Health Model; improving reimbursement practices; and exploring the potential of AI for integrated care. Implications for future service organization and training of behavioral health care providers also are discussed. Granted the severity of the current workforce crisis in behavioral health care, urgent efforts are needed to advance the deployment of integrated care in the short-term future.

Care challenges and silver linings in HIV and behavioral health service delivery for individuals living with HIV and severe mental illness during the COVID-19 pandemic: a qualitative study

BackgroundThere has been a longstanding effort to integrate behavioral health and HIV care for people with comorbid HIV and behavioral health needs, including those with severe mental illness (SMI). As this population frequents both behavioral health and HIV care settings, they were likely to experience new obstacles to the quality and availability of care during the COVID-19 pandemic. This study aims to describe how clinics for HIV services or behavioral healthcare—as well as co-located sites providing both—sought to rapidly shift protocols to maintain a standard of patient care for people with comorbid HIV and SMI while adapting to the unprecedented circumstances of the pandemic.MethodsWe interviewed HIV and behavioral healthcare providers, clinic leaders, and support service agencies that served clients impacted by both HIV and SMI. Seventeen key informants across three settings (HIV care settings, behavioral health care settings, and integrated or co-located care settings) were interviewed in 2022. Interviews focused on changes in clinical services, protocols, and care provision strategies during and at the onset of the COVID-19 pandemic. Interviews were transcribed and coded using thematic analysis.ResultsCommonly endorsed themes included both positive and negative changes in care and care provision during the pandemic. Negative impacts of the pandemic included the loss of physical space, exacerbated mental health needs and disengagement in HIV care, patient barriers to telehealth and the digital divide, and increased healthcare workforce burnout. Positive changes included improved healthcare delivery and care engagement through telehealth, new opportunities to provide a wide range of social services, paradoxical increases in engagement in HIV care for certain patients, and broad institution of workforce wellness practices.ConclusionsThough COVID-19 presented several complex barriers to care for providers serving patients with comorbid HIV and SMI, the increased flexibility afforded by telehealth and a greater focus on collaborative approaches to patient care may benefit this patient population in the future. Additionally, the focus on workforce wellness may serve to increase retention and avoid burnout among providers. The strategies and lessons learned through adapting to COVID-19 may be invaluable moving forward as healthcare systems respond to future pandemics.

Perceptions and behaviors of healthcare providers towards rehabilitation support to children with severe malaria-related disability in Ethiopia: A qualitative descriptive study using the Theoretical Domains Framework.

Severe malaria often results in childhood disability. The prevalence of disability related to severe malaria is significant and is estimated to affect up to 53% of severe malaria survivors. In contrast, information is sparse about how healthcare providers in Africa think about or provide rehabilitation support in acute and post-acute phases respectively. Understanding the perceptions and behaviors of healthcare providers treating malaria could help inform malaria-related disability research, policy, and practice, aimed at the providers themselves. This study explored the perceptions and behaviors of healthcare providers towards rehabilitation for children with severe malaria-related disability. The Theoretical Domains Framework was used to describe the findings relative to wider literature on health provider behavior change. A qualitative descriptive approach was used to interview thirteen healthcare providers recruited purposively based on their clinical professions, roles, and settings. Data were analyzed using directed content analysis. We decided on the most prominent theoretical domains considering the frequency of specific perceptions and behaviors across the participants, the frequency of perceptions and behaviors in each domain, and evidence of strong perceptions and behaviors. Nine out of fourteen theoretical domains were identified. These domains were: Beliefs about consequences, environmental context and resources, goals, knowledge, skills, optimism, reinforcement, social influences, and social or professional role and identity. Healthcare providers' beliefs about their roles in screening for disability or referring to rehabilitation were less positive. The findings of this study suggest the need for interventions to support healthcare providers in acute phases (prevention and control of severe malaria) and post-acute phases (disability screening, referral, and rehabilitation care). Recommended interventions should focus on developing clinical guidelines, training clinicians, addressing institutional factors, and modifying external social influences such as socio-cultural factors.

Features and behaviours for weight loss in the Chilean cohort with obesity from the ACTION study.

In Latin America, obesity rates are among the highest in the world. Currently, people with obesity (PWO) receive suboptimal care due to several challenges and barriers. The international ACTION-IO study aimed to identify perceptions, attitudes and behaviours of PWO and healthcare providers (HCP), and to assess potential barriers to effective obesity care. The aim of this subanalysis of the Chilean cohort was to compare their characteristics, perceptions, attitudes and behaviours according to the percentage of weight loss (lower weight loss [LWL; ≤10%] or higher weight loss [HWL; >10%] of basal weight). The ACTION-IO survey was completed by 1000 Chilean PWO and 200 HCPs. Mean age of PWO was 38 years (range 18-75); 62% were female. The majority had class I obesity. HWL subgroup represented 17.2% of all Chilean subset. Specific characteristics of patients with HWL were identified (higher educational level, lower proportion of class III obesity, preference for consulting obesity specialists, considering conversations with HCP as very helpful). HWL patients reported higher rates of favourable outcomes following HCP advice and a higher probability of attending scheduled follow-up visits. Certain demographic and behavioural variables (educational level, consultation to obesity specialists, adherence to HCP advice, follow-up scheduled visits and becoming aware of the obesity state) may identify PWO with a higher probability of a greater weight loss.

A-I-D for Cascades: Designing a theory-informed intervention for addressing prescribing cascades in primary care

Abstract Introduction Prescribing cascades, which occur when a medication is used to treat the side effect of another medication, are important contributors to polypharmacy. There is an absence of studies that evaluate the implementation or impact of existing interventions to address prescribing cascades in practice. Aim To design theory-informed options for interventions to address prescribing cascades within interprofessional primary care teams. Methods The Behaviour Change Wheel (BCW) framework, and its eight steps, were applied to guide intervention development by the research team. Three target behaviours were drafted and prioritised for intervention development based on data collected as part of two qualitative studies exploring why and how cascades occur across practice settings.[1,2] A target behaviour was selected and the COM-B (capability, opportunity, motivation-behaviour) model was then applied to identify the relevant factors for interprofessional primary care teams. The BCW was used to determine the relevant intervention types and policy options for the behaviour. Next, corresponding behaviour change techniques (BCTs) were identified and intervention options drafted. Prioritisation of behaviours and intervention examples were guided by the APEASE criteria (Affordability, Practicability, Effectiveness/cost-effectiveness, Acceptability, Side-effects/safety, Equity). Results The three target behaviours involved supporting: 1) healthcare providers to ask about, investigate and manage cascades (often through deprescribing), 2) the public to ask about prescribing cascades, and 3) the public to share medication histories and experiences with healthcare providers. The team selected the healthcare provider behaviour, called A-I-D (ask, investigate, deprescribe), for intervention development. Psychological capability and physical opportunity were determined to be the most relevant COM-B components, corresponding to education, training, environmental restructuring, and enablement intervention types and the guidelines, communications and marketing, and service provision policy options within the BCW model. Ultimately, 10 intervention options comprised of BCTs were developed by the team, which are ready for further prioritisation by stakeholders. These can be grouped into three categories: provision of educational content or materials for use by clinicians, provision of consultation or training to support clinicians, and knowledge mobilisation strategies. Through the process, the team identified that development of a practice guidance tool, which assists healthcare providers to investigate and manage prescribing cascades, is needed to support further intervention development. Conclusion The BCW framework guided the design of intervention options that will support primary care clinicians practising in interprofessional teams to address prescribing cascades. A limitation of this work is that applying the BCW framework required several judgements by the team, comprised of scientists, pharmacists, and nurses but not a general practitioner physician. Many but not all have practised with primary care interprofessional teams. When identifying interventions for future consultation, it was determined that the development of a practice guidance tool (i.e., which assists with identifying, investigating, and managing prescribing cascades) underpinned all the proposed interventions for addressing prescribing cascades in practice. Further research is needed to determine what primary care clinicians will need in this practice guidance tool and how it will be used in practice, to support its development.

The Role of Trust as a Driver of Private-Provider Participation in Disease Surveillance: Cross-Sectional Survey From Nigeria.

Recognition of the importance of valid, real-time knowledge of infectious disease risk has renewed scrutiny into private providers' intentions, motives, and obstacles to comply with an Integrated Disease Surveillance Response (IDSR) framework. Appreciation of how private providers' attitudes shape their tuberculosis (TB) notification behaviors can yield lessons for the surveillance of emerging pathogens, antibiotic stewardship, and other crucial public health functions. Reciprocal trust among actors and institutions is an understudied part of the "software" of surveillance. We aimed to assess the self-reported knowledge, motivation, barriers, and TB case notification behavior of private health care providers to public health authorities in Lagos, Nigeria. We measured the concordance between self-reported notification, TB cases found in facility records, and actual notifications received. A representative, stratified sample of 278 private health care workers was surveyed on TB notification attitudes, behavior, and perceptions of public health authorities using validated scales. Record reviews were conducted to identify the TB treatment provided and facility case counts were abstracted from the records. Self-reports were triangulated against actual notification behavior for 2016. The complex health system framework was used to identify potential predictors of notification behavior. Noncompliance with the legal obligations to notify infectious diseases was not attributable to a lack of knowledge. Private providers who were uncomfortable notifying TB cases via the IDSR system scored lower on the perceived benevolence subscale of trust. Health care workers who affirmed "always" notifying via IDSR monthly reported higher median trust in the state's public disease control capacity. Although self-reported notification behavior was predicted by age, gender, and positive interaction with public health bodies, the self-report numbers did not tally with actual TB notifications. Providers perceived both risks and benefits to recording and reporting TB cases. To improve private providers' public health behaviors, policy makers need to transcend instrumental and transactional approaches to surveillance to include building trust in public health, simplifying the task, and enhancing the link to improved health. Renewed attention to the "software" of health systems (eg, norms, values, and relationships) is vital to address pandemic threats. Surveys with private providers may overestimate their actual participation in public health surveillance.

Examining State Licensing Requirements for Select Master's-Level Behavioral Health Providers for Children.

The authors examined licensing requirements for select children's behavioral health care providers. Statutes and regulations as of October 2021 were reviewed for licensed clinical social workers, licensed professional counselors, and licensed marriage and family therapists for all 50 U.S. states and the District of Columbia. All jurisdictions had laws regarding postgraduate training and license portability. No jurisdiction included language about specialized postgraduate training related to serving children and families or cultural competence. Other policies that related to the structure, composition, and authority of licensing boards varied across states and licensure types. In their efforts to address barriers to licensure, expand the workforce, and ensure that children have access to high-quality and culturally responsive care, states could consider their statutes and regulations.

The Importance of Autonomy and Performance Goals in Perceived Workload Among Behavioral Health Providers.

The authors sought to assess workplace characteristics associated with perceived reasonable workload among behavioral health care providers in the Veterans Health Administration. The authors evaluated perceived reasonable workload and workplace characteristics from the 2019 All Employee Survey (AES; N=14,824) and 2019 Mental Health Provider Survey (MHPS; N=10,490) and facility-level staffing ratios from Mental Health Onboard Clinical Dashboard data. Nine AES and 15 MHPS workplace predictors of perceived reasonable workload, 11 AES and six MHPS demographic predictors, and facility-level staffing ratios were included in mixed-effects logistic regression models. In total, 8,874 (59.9%) AES respondents and 5,915 (56.4%) MHPS respondents reported having a reasonable workload. The characteristics most strongly associated with perceived reasonable workload were having attainable performance goals (average marginal effect [AME]=0.10) in the AES and ability to schedule patients as frequently as indicated (AME=0.09) in the MHPS. Other AES characteristics significantly associated with reasonable workload included having appropriate resources, support for personal life, skill building, performance recognition, concerns being addressed, and no supervisor favoritism. MHPS characteristics included not having collateral duties that reduce care time, staffing levels not affecting care, support staff taking over some responsibilities, having spirit of teamwork, primary care-mental health integration, participation in performance discussions, well-coordinated mental health care, effective veteran programs, working at the top of licensure, and feeling involved in improving access. Facility-level staffing ratios were not significantly associated with perceived reasonable workload. Leadership may consider focusing resources on initiatives that support behavioral health providers' autonomy to schedule patients as clinically indicated and develop attainable performance goals.

Development of an evidence-informed governance and stewardship framework for elderly healthcare in Iran: A qualitative study

BackgroundThe ageing population poses significant challenges to healthcare systems, necessitating the establishment of high-functioning, integrated frameworks for elderly healthcare. This study aimed to explore the key challenges associated with the stewardship of elderly care in Iran and to develop a holistic stewardship framework. MethodsFor this qualitative study, thirty semi-structured interviews were conducted with key Iranian healthcare stakeholders, utilizing purposive and snowball sampling during 2021–2022. Inductive open coding was utilized to generate new concepts related to key stewardship challenges. The World Health Organization's conceptual framework, outlining the three stewardship tasks, served as the basis for crafting a tailored framework for elderly healthcare stewardship in Iran. ResultsFourteen main challenges and 38 sub-challenges were identified for elderly healthcare stewardship in Iran, categorized according to the WHO framework's three stewardship tasks. Challenges related to WHO stewardship task 1, involving health policy formulation and vision definition, included challenges in vision definition, planning, policymaking, and intergovernmental institutional superiority. Challenges related to WHO stewardship task 2, delineating governance and stewardship through control and regulation, encompassed issues such as support for the elderly, system responsiveness, behavior of healthcare providers, organizational structure, and cross-sectoral leadership challenges. Challenges associated with WHO stewardship task 3, about the use of collective intelligence, explored stakeholder collaboration, information for decision-making, and challenges within the elderly information system, covering data documentation, reporting, analysis, accessibility, distribution, and circulation. Subsequently, a framework was developed, covering areas like defining the vision and direction of health policy, managing information systems, evidence-informed policymaking, and delivering elderly health services with a holistic approach. ConclusionThe present framework shows how a management information system, guided by evidenced-informed policymaking and the formulation of customized health policies, can facilitate the provision of elderly health services based on identified needs. It presents a governance and stewardship pathway that can be adopted by Iranian health policymakers and similar middle-income countries facing analogous challenges in ageing and aged care system stewardship, serving as a model for developing their own frameworks.

Managing Medications During “Sick Days” in Patients With Diabetes, Kidney, and Cardiovascular Conditions: A Theory-informed Approach to Intervention Design and Implementation

ObjectivesOur aim in this work was to 1) explore barriers and enablers to patient and health-care provider (HCP) behaviours related to sick-day medication guidance (SDMG), 2) identify theory-informed strategies to advise SDMG intervention design, and 3) obtain perspectives on an eHealth tool for this purpose. MethodsA qualitative descriptive study using qualitative conventional content analysis was undertaken. Interviews and focus groups were held with patients and HCPs from January 2021 to April 2022. Data were analyzed using the Behaviour Change Wheel and Theoretical Domains Framework to inform intervention design. ResultsForty-eight people (20 patients, 13 pharmacists, 12 family physicians, and 3 nurse practitioners) participated in this study. Three interventions were designed to address the identified barriers and enablers: 1) prescriptions provided by a community-based care provider, 2) pharmacists adding a label to at-risk medications, and 3) built-in prompts for prescribing and dispensing software. Most participants accepted the concept of an eHealth tool and identified pharmacists as the ideal point-of-care provider. Challenges for an eHealth tool were raised, including credibility, privacy of data, medical liability, clinician remuneration and workload impact, and equitable access to use of the tool. ConclusionsPatients and HCPs endorsed non-technology and eHealth innovations as strategies to aid in the delivery of SDMG. These findings can guide the design of future theory-informed SDMG interventions.

Reasons for scaphoid non-union: Analysis of behavior of health care providers and patients

To assess factors related to health-system and patient behavior in scaphoid fracture non-union, a retrospective analysis of 134 patients treated by scaphoid reconstruction was performed. Mean age at the accident was 26 years (range, 9–75 years), and the mean age at surgery was 28 years (range, 13–75 years). Mean time to first consultation was 233 days (range, 0–12,136 days), and time to surgery 740 days (range, 19−12,362 days). The physician was mainly a general practitioner (52.2%), or an orthopedist/traumatologist (17.9%), general surgeon (12.7%), or hand surgeon (17.2%). The initial diagnostic procedure was X-ray in 76.9% of cases, computed tomography (CT) in 20.9%, magnetic resonance imaging (MRI) in 13.4%, and none in 11.2%. A fracture was diagnosed in 32.8% of cases, and non-union in 14.9%. Patients mainly presented late: 63% within 3 weeks, and a minority on the day of the accident (39%). In 11% of cases, healthcare providers performed either no or inadequate imaging (77%) and missed correct diagnosis in 52% of cases. 128 patients had a second consultation, and 77 a third, with the same or different physicians, before surgery, leading to increased healthcare costs due to delayed diagnosis and treatment. Delayed presentation and lack of suspicion by attending physicians were the main reasons. Speeding up diagnosis and improving physician training are vital and could significantly reduce health care costs. CT or MRI should be performed if scaphoid fracture is suspected.

'I had to Educate Myself': A thematic analysis of online stillbirth stories to improve obstetric care.

To examine which met and unmet needs are discussed in stillbirth stories shared on YouTube with the aim to improve obstetric care. Inductive thematic analysis of 19 English-language stillbirth stories uploaded to YouTube. Online setting, YouTube video content. Women who experienced stillbirth and shared a video on YouTube talking about their experience. We conducted a thorough textual reading of the transcripts following Braun and Clarke's guidelines for thematic analysis. Codes were developed and grouped into themes. Although some women actively used their birth videos to call out shortcomings in their care, most others used their platform for other purposes such as destigmatisation, awareness and support, and rather unintentionally provided insight into their met and unmet needs. When analysing their birth stories, three major themes emerged: choice and decision-making, education and information, and behaviour of healthcare providers. This study demonstrates the value of birth stories in research. We identified three major opportunities for improvement of obstetric care: being provided with options and being able to make choices in the decision-making process are clearly valued, but there are some caveats: women and other childbearing individuals need timely and continuous information, and more attention is needed for emotional intelligence training of healthcare providers.

Adolescent, Parent, and Provider Perceptions of a Predictive Algorithm to Identify Adolescent Suicide Risk in Primary Care

ObjectiveTo understand adolescent, parent, and provider perceptions of a machine learning algorithm for detecting adolescent suicide risk prior to its implementation primary care. MethodsWe conducted semi-structured, qualitative interviews with adolescents (n = 9), parents (n = 12), and providers (n = 10; mixture of behavioral health and primary care providers) across two major health systems. Interviews were audio recorded and transcribed with analyses supported by use of NVivo. A codebook was developed combining codes derived inductively from interview transcripts and deductively from implementation science frameworks for content analysis. ResultsReactions to the algorithm were mixed. While many participants expressed privacy concerns, they believed the algorithm could be clinically useful for identifying adolescents at risk for suicide and facilitating follow-up. Parents’ past experiences with their adolescents’ suicidal thoughts and behaviors contributed to their openness to the algorithm. Results also aligned with several key Consolidated Framework for Implementation Research domains. For example, providers mentioned barriers inherent to the primary care setting such as time and resource constraints likely to impact algorithm implementation. Participants also cited a climate of mistrust of science and healthcare as potential barriers. ConclusionsFindings shed light on factors that warrant consideration to promote successful implementation of suicide predictive algorithms in pediatric primary care. By attending to perspectives of potential end users prior to the development and testing of the algorithm, we can ensure that the risk prediction methods will be well-suited to the providers who would be interacting with them and the families who could benefit.

Implementing an integrated care pathway for Somatic Symptoms and Related Disorders (SSRDs) in paediatric population

Introduction: Somatic symptom and related disorders (SSRDs) are commonly encountered in pediatric hospital settings. These children and youth, who present with physical symptoms (e.g., headache, abdominal pain, dizziness) of emotional distress (e.g., anxiety, stress) are diagnostically and psychosocially complex, posing significant challenges for medical and behavioral health care providers. Children and adolescents with SSRDs have high health system utilization and costs and present in multiple clinical settings, have high school absenteeism, and are at elevated risk of iatrogenic harm and missed diagnoses. Patients and their caregivers present with variable readiness to engage in mental health assessment and treatment, with only 40% receiving physician-based mental health care within a year of diagnosis. There is a lack of standardization of care across and within institutions for youth with these disorders. As part of the hospital’s broader strategic direction to integrate physical and mental health care, a SSRD pathway, was developed to address care needs of one of the highest resource intensive populations at a tertiary care hospital. 
 Methods: In 2021, a survey was conducted by our hospital’s implementation team to understand hospital stakeholder priorities when considering the many areas where new integrated care project could be launched. Stakeholders engaged in the survey included physician and operational leaders, clinical staff across the spectrum of disciplines, and a youth and family advisory panel. Focus groups (n = 57) were also conducted to solicit input and feedback. The results highlighted the need to develop a specialized care pathway for children and youth with SSRD focused on integrating physical and mental health care and support with system navigation. Using a logic model with iterative presentations to key stakeholders, the design phase included an interdisciplinary team approach with project management and operational resources to support project implementation and evaluation. Care pathways were developed based on a patient’s readiness to engage in mental health treatment and where they we along their diagnostic odyssey and care journey and intensity of resources required to support their care needs.
 Integrated Care Pathway: As part of the pilot pathway, a patient’s care journey will be planned in accordance with their level of readiness to accept both a somatization diagnosis and a need for mental health treatment. Patients who are partially or non-receptive to mental health supports will have access to a care manager with both physical and mental health expertise. The care manager will engage with families in shifting their focus and understanding about the mind-body connection and provide extended support with care navigation. Patients who are receptive to mental health treatments, will be referred to a group treatment program led by psychiatry and psychology with a focus on psychoeducation relating to the mind-body connection. Patients in this pathway will also have access to occupational therapy and physiotherapy resources to support with restoring function and improving school attendance, when needed. Pilot evaluation will include process and outcome measures such as number of children engaged in this pathway, time to return to functioning, completion of various mental health measures, and health resource utilization."

THE USE, QUALITY AND EFFECTIVENESS OF PELVIC EXAMINATION IN PRIMARY CARE FOR THE DETECTION OF GYNAECOLOGICAL CANCER

Introduction: Pelvic examinations are vital for timely detection of gynecological cancers in primary care, yet discomfort can deter some women from seeking them. General practitioners face challenges in managing intimacy during exams, impacting their skills and confidence. Understanding these complexities using behavior change models like COM-B can aid in developing interventions to enhance pelvic examination uptake and address barriers in primary care settings for early cancer detection. A systematic review aims to consolidate qualitative studies on GPs' perceptions and experiences regarding pelvic exams, focusing on their role, barriers, and factors influencing GP behavior. Methods: The researchers in this study followed the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines to ensure that their work met the required standards. This was done to ensure the precision and reliability of the conclusions derived from the research. Result: The search produced 18 results. After looking at the titles and summaries, we found 10 papers that fit our criteria. At first, we excluded several articles because they were written in review style. But after reading the full papers carefully, we included five papers in our final analysis. These papers included a cross sectional study, randomized control trial, and several guidelines. Conclusion: Understanding and predicting healthcare provider behavior in gynecological examinations is complex. The Theory of Planned Behavior provided some insights into intentions but didn't fully explain actual behaviors, which were influenced by external factors like workload. Recommendations suggest tailored approaches for high-risk groups and aligning pelvic exams with cervical screening intervals. However, concerns arise from potential overuse of exams and the impact of fee-for-service payments. More comprehensive research is needed to guide noncervical malignancy screenings and comprehend the various factors influencing healthcare provider behavior in these clinical practices.

Design, implementation, and evaluation of a training on culturally sensitive care for nursing students: A pilot study

There is a need for culturally sensitive care for people with a migration background because of the increasing ethnocultural diversity in Western countries. Consequently, more and more training programs for health care providers are starting to implement these topics in curricula. However, while the content of culturally competent care is widely debated in nursing literature, a description of how students are and should be taught is lacking. Even more, studies have shown that merely increasing knowledge on ethnicity, culture or migration does not help to increase culturally sensitive behaviour of (future) healthcare providers. On the contrary it even leads to more stereotypical thinking. More critical self-awareness is needed among caregivers to overcome barriers such as othering (i.e., micro-racism by defining the other in an inferior way).
 
 In response to abovementioned shortcomings, we developed, implemented and evaluated a course on culturally sensitive care in the curriculum of nursing students. Nursing students and caregivers were involved in the development of the course. This program (4h) aimed to increase self-awareness among caregivers about othering, racism and exclusion in society and in healthcare. The paper will describe the content of the program (building on the Johari Window model developed to increase awareness in interpersonal relations (Luft & Ingham, 1961), the pilot implementation and evaluation among 34 students. The program was well received by the participants. Success factors (i.e. profile of the teacher, self-awareness positionality) and working points (i.e. ethnic/minority-matching) were detected. This program will be adapted and further implemented in the curriculum based on the feedback.

Examining multiple funding flows to public healthcare providers inlow- andmiddle-income countries - results from case studies inBurkina Faso, Kenya, Morocco, Nigeria, Tunisia andVietnam.

Provider payment methods are traditionally examined by appraising the incentive signals inherent in individual payment mechanisms. However, mixed payment arrangements, which result in multiple funding flows from purchasers to providers, could be better understood by applying a systems approach that assesses the combined effects of multiple payment streams on healthcare providers. Guided by the framework developed by Barasa etal. (2021) (Barasa E, Mathauer I, Kabia E etal. 2021. How do healthcare providers respond to multiple funding flows? A conceptual framework and options to align them. Health Policy and Planning 36: 861-8.), this paper synthesizes the findings from six country case studies that examined multiple funding flows and describes the potential effect of multiple payment streams on healthcare provider behaviour in low- and middle-income countries. The qualitative findings from this study reveal the extent of undesirable provider behaviour occurring due to the receipt of multiple funding flows and explain how certain characteristics of funding flows can drive the occurrence of undesirable behaviours. Service and resource shifting occurred in most of the study countries; however, the occurrence of cost shifting was less evident. The perceived adequacy of payment rates was found to be the strongest driver of provider behaviour in the countries examined. The study results indicate that undesirable provider behaviours can have negative impacts on efficiency, equity and quality in healthcare service provision. Further empirical studies are required to add to the evidence on this link. In addition, future research could explore how governance arrangements can be used to coordinate multiple funding flows, mitigate unfavourable consequences and identify issues associated with the implementation of relevant governance measures.

Drug information-seeking behaviour among Jordanian physicians: a cross-sectional study.

Background: Due to the huge number of drugs available and the rapid growth and change in drug information, healthcare professionals, especially physicians, frequently require reliable, easily accessible, rapid, and accurate reference sources to obtain the necessary drug information. Several sources of information are available for physicians to use and select from; however, the information-seeking behaviour of healthcare providers is varied, and this process can be challenging. Objectives: In this study, Jordanian physicians were approached to evaluate the drug information they require, the sources of information they use, the perceived credibility of the sources, and the challenges they face when searching for the most accurate and current information about drugs. Methods: This is an observational, cross-sectional study. A self-administered questionnaire was distributed to practising physicians in Jordan using a convenience sampling method (purposive sampling followed by snowball sampling) regardless of their speciality, age, gender, seniority, or place of employment. Results: Three hundred and eighty physicians participated in the study. Most participants responded that they performed drug information searches on a weekly (155, 40.8%) or a daily basis (150, 39.5%). The drug-related information that physicians most frequently searched for concerned dosage regimens and adverse drug events. The majority of surveyed doctors (97.9%) reported using online websites to acquire drug information; UpToDate®, Medscape and Drugs.com were the most frequently used online databases, although many participants did not consider online sources to be the most reliable source. The most prevalent and recurrent challenges encountered concerned an inability to access subscription-only journals and websites (56.6%), difficulty identifying trusted and credible sources (41.8%) and the enormous number of available sources (35.3%). However, these challenges were less of a problem for physicians who currently work or have previously worked in academia (p < 0.001). Conclusion: This study demonstrated that Jordanian physicians frequently use online websites to look for drug information and all doctors face challenges throughout this process particularly those with no experience in academia. This suggests that being in academia makes the process of information-seeking easier which highlights the need for academics to transfer their knowledge and experience to their non-academic colleagues and the upcoming generations of physicians.

'I wasn't made to feel like a nut case after all': A qualitative story completion study exploring healthcare recipient and carer perceptions of good professional caregiving relationships.

Professional caregiving relationships are central to quality healthcare but are not always developed to a consistently high standard in clinical practice. Existing literature on what constitutes high-quality relationships and how they should be developed is plagued by dyadic conceptualisations; discipline, context and condition-specific research; and the absence of healthcare recipient and informal carer voices. This study aimed to address these issues by exploring how healthcare recipients and carers conceptualise good professional caregiving relationships regardless of discipline, care setting and clinical condition. A qualitative story completion approach was used. Participants completed a story in response to a hypothetical stem that described a healthcare recipient (and, in some instances, carer) developing a good relationship with a new healthcare provider. Stories were analysed using reflexive thematic analysis. Participants were 35 healthcare recipients and 37 carers (n = 72 total). Participants' stories were shaped by an overarching discourse that seeking help from new providers can elicit a range of unwanted emotions for both recipients and carers (e.g., anxiety, fear, dread). These unwanted emotions were experienced in relation to recipients' presenting health problems as well as their anticipated interactions with providers. Specifically, recipient and carer characters were fearful that providers would dismiss their concerns and judge them for deciding to seek help. Good relationships were seen to develop when healthcare providers worked to relieve or minimise these unwanted emotions, ensuring healthcare recipients and carers felt comfortable and at ease with the provider and the encounter. Participants positioned healthcare providers as primarily responsible for relieving recipients' and carers' unwanted emotions, which was achieved via four approaches: (1) easing into the encounter, (2) demonstrating interest in and understanding of recipients' presenting problems, (3) validating recipients' presenting problems and (4) enabling and respecting recipient choice. Participants' stories also routinely oriented to temporality, positioning relationships within recipients' and carers' wider care networks and biographical and temporal contexts. The findings expand our understanding of professional caregiving relationships beyond dyadic, static conceptualisations. Specifically, the findings suggest that high-quality relationships might be achieved via a set of core healthcare provider behaviours that can be employed across disciplinary, context and condition-specific boundaries. In turn, this provides a basis to support interprofessional education and multidisciplinary healthcare delivery, enabling different healthcare disciplines, specialties, and teams to work from the same understanding of what is required to develop high-quality relationships. The findings are based on stories from 72 healthcare recipient and carer participants, providing rich insight into their conceptualisations of high-quality professional caregiving relationships.