健康教育应当实施标准化管理

当前我国健康教育与健康促进工作在立法条件尚未成熟的条件下,应在实施健康教育与健康促进工作中,探索具有法制效应的标准化管理方法,使健康教育与健康促进工作迈入卫生执法监督的视野,以利于进行监督、检查、指导、帮助,卓有成效的实现健康教育与健康促进工作目标。1 实施健康教育标准化管理,是社会进步的必然　2 1世纪是科学技术及科学管理迅速发展的时代。科学、技术、管理被人们称之现代经济发展的重要因素。国家振兴、经济繁荣,人民生活质量的提高,无不与之密切相关。健康教育现在的粗放经营和经验型管理方式与目前社会的发展和人们日…     

Variation of Behavioral Health Care by Behavioral Health Symptom Profile Among a Diverse Group of Pregnant and Parenting Mothers

The Journal of Behavioral Health Services & Research - This study examines the association between behavioral health symptoms and use of behavioral health care (BHC; i.e., past year counseling...     

Tobacco Use Among African-American Youth Receiving Behavioral Healthcare Services

African-American youth with behavioral health problems may be particularly vulnerable to tobacco use and dependence; however, little is known about overall prevalence and factors associated with tobacco use in this population. The present study compared rates of tobacco use for African-Americans (aged 13–17) receiving behavioral healthcare services to state and national prevalence rates. In addition, we examined whether tobacco use prevalence was related to treatment characteristics and services rendered. Retrospective chart reviews were conducted at an urban, public behavioral healthcare agency for youth admitted in 2009. Tobacco use rates among African-Americans receiving behavioral healthcare services were similar to, and in some cases, higher than statewide and national prevalence rates. While tobacco users were more likely to be enrolled in a substance abuse program than in a mental health program, only 2 of 55 youth reporting tobacco use had received documented tobacco cessation treatment. Future work should focus on implementing tobacco cessation prevention and treatment for these youth.     

健康教育不应有被遗忘的角落

健康教育是一种有计划、有目的、有系统、有组织的教育活动 ,其目的是促使人们自愿地采纳有利于健康的行为 ,消除或降低风险因素 ,降低发病率、伤残率和死亡率 ,提高生活质量 ,并评价教育的效果。健康教育的对象应是社会上的每一个人 ,包括残疾人。残疾人与健全人一样 ,都会受到各种能导致疾病的因素 (社会的、生物的、心理的 )的影响 ,同样是各种健康传播的受众。由于本身存在一定的生理缺陷 ,他们往往更容易受到致病因素的影响 ,在接受健康传播方面也可能感受到更多的困难。在上述各种意义上 ,他们是弱势人群。有肢体残疾者除行动有点障碍…     

Tobacco Retailer Proximity and Density and Nicotine Dependence Among Smokers With Serious Mental Illness

Objectives. We examined the density and proximity of tobacco retailers and associations with smoking behavior and mental health in a diverse sample of 1061 smokers with serious mental illness (SMI) residing in the San Francisco Bay Area of California.Methods. Participants’ addresses were geocoded and linked with retailer licensing data to determine the distance between participants’ residence and the nearest retailer (proximity) and the number of retailers within 500-meter and 1-kilometer service areas (density).Results. More than half of the sample lived within 250 meters of a tobacco retailer. A median of 3 retailers were within 500 meters of participants’ residences, and a median of 12 were within 1 kilometer. Among smokers with SMI, tobacco retailer densities were 2-fold greater than for the general population and were associated with poorer mental health, greater nicotine dependence, and lower self-efficacy for quitting.Conclusions. Our findings provide further evidence of the tobacco retail environment as a potential vector contributing to tobacco-related disparities among individuals with SMI and suggest that this group may benefit from progressive environmental protections that restrict tobacco retail licenses and reduce aggressive point-of-sale marketing.Tobacco use among people with serious mental illness (SMI) is common and has serious health and financial costs.1 Nationally, individuals with psychiatric or addictive disorders consume 44% to 46% of cigarettes purchased and are more likely than those in the general population to be daily and heavy smokers.2,3 In one study, it was estimated that smokers with SMI spend, on average, 27% of their income on tobacco.4 Individuals with SMI suffer disproportionately from tobacco-related diseases and, as a group, have a 25-year premature mortality rate.5 Increasingly, researchers and practitioners highlight the need for more targeted prevention and intervention strategies to reduce the burden of smoking-related diseases in this vulnerable group.6,7Cigarette smoking among people with SMI reflects a complex interplay of genetic, neurobiological, cultural, and psychosocial factors.6 Studies have examined shared genetic effects between smoking and SMI,8–11 as well as associations with attention and cognition, stress and mood, and reductions in the side effects of psychotropic medications.6 In addition to individual-level risk factors, a complete understanding of smoking disparities among individuals with SMI requires examination of “upstream” social determinants of health, including social, political, and economic contexts. Accordingly, research on the etiology and maintenance of cigarette use in this disproportionately affected group has increasingly focused on systemic factors outside of an individual’s control, such as tobacco industry targeting, reduced access to smoking cessation services, and tobacco control policies.7,12 Notably, smokers with SMI are responsive to tobacco control policies that have been effective in the general population, such as smoking bans and cigarette tax increases.13–16The built environment is another important social determinant of health that has the potential to affect smoking among people with SMI. In the general population, retail availability of tobacco, which includes the number of retailers per area or population (i.e., density) and the distance to the nearest retailer (i.e., proximity) from one’s home or school, is associated with earlier smoking initiation,17,18 increased current smoking19–22 and cigarette purchases,23 and reduced smoking cessation over time.24,25 Smokers who live in neighborhoods with higher densities of tobacco retailers have greater exposure to retail advertisements and promotions, which can obstruct quit attempts by increasing cues to smoke, provoking cravings, and triggering impulse purchases.26–29 Smokers are price sensitive,30,31 and the financial costs of smoking are lower in communities with more convenient tobacco access and reduced travel time to purchase.22 Moreover, retailers and point-of-sale tobacco advertisements are more prevalent in socially and economically disadvantaged neighborhoods.19,22,32–36The effects of increased tobacco availability may be particularly strong among smokers with SMI given that factors such as unreliable transportation and limited resources37 in this population may lead to a greater reliance on readily obtainable consumer goods. Furthermore, people with SMI have been targeted by the tobacco industry,12,38 and they may be especially sensitive to aggressive tobacco advertisements and promotions. Surprisingly, in spite of the public health relevance, to our knowledge no studies of the retail availability of tobacco have involved clinical samples of individuals with SMI.Our goals in this study, which included a diverse sample of adults with SMI, were to characterize the proximity (roadway distance to the nearest retailer) and density (number of retailers per acre) of tobacco retailers within 500 meters and 1 kilometer of participants’ residences and to assess whether retail availability of tobacco is associated with severity of mental illness, nicotine dependence, and readiness to quit smoking. We also evaluated whether these associations vary according to gender.We hypothesized that smokers with SMI would reside in neighborhoods with greater than average tobacco retailer density for their county area and that this neighborhood characteristic would be associated with greater severity of mental illness. Furthermore, we predicted that increased retail availability of tobacco would be associated with greater nicotine dependence and lower readiness to quit, regardless of severity of mental illness. We also examined gender differences given calls to assess such differences in tobacco control research, policy, and practice39 and recent evidence that proximity to a tobacco retailer is associated with a lower likelihood of smoking cessation among men but not women who are moderate to heavy smokers.24     

Tobacco Use Prevention and Health Facilitator Effectiveness

Tobacco prevention programs often use peers to teach refusal skills to other adolescents. College undergraduate health facilitators delivered a tobacco prevention intervention to sixth and seventh grade students in six schools. Outside observers evaluated facilitators in seven categories: being prepared, maintaining class control, keeping students' attention, encouraging participation, communication, relating to students, and working well in a team. Facilitators were rated highly in all categories. Higher rated health facilitators had more effect in reducing tobacco use than poorly rated facilitators. Facilitators who worked well in a team, related well to students, and were well-prepared were especially effective in positively influencing program outcomes.     

Quality Improvement With Pay-for-Performance Incentives in Integrated Behavioral Health Care

Objectives. We evaluated a quality improvement program with a pay-for-performance (P4P) incentive in a population-focused, integrated care program for safety-net patients in 29 community health clinics.Methods. We used a quasi-experimental design with 1673 depressed adults before and 6304 adults after the implementation of the P4P program. Survival analyses examined the time to improvement in depression before and after implementation of the P4P program, with adjustments for patient characteristics and clustering by health care organization.Results. Program participants had high levels of depression, other psychiatric and substance abuse problems, and social adversity. After implementation of the P4P incentive program, participants were more likely to experience timely follow-up, and the time to depression improvement was significantly reduced. The hazard ratio for achieving treatment response was 1.73 (95% confidence interval = 1.39, 2.14) after the P4P program implementation compared with pre-program implementation.Conclusions. Although this quasi-experiment cannot prove that the P4P initiative directly caused improved patient outcomes, our analyses strongly suggest that when key quality indicators are tracked and a substantial portion of payment is tied to such quality indicators, the effectiveness of care for safety-net populations can be substantially improved.Behavioral health problems are among the most common and disabling health conditions worldwide.1 They often co-occur with chronic medical diseases and can substantially worsen associated health outcomes.1 When these problems are not effectively treated, they can impair self-care and adherence to medical and mental health treatments and are associated with increased mortality and increased overall health care costs.2National surveys have consistently demonstrated that more Americans receive mental health care from primary care providers than from mental health specialists.3 Most patients prefer an integrated approach in which primary care and mental health providers work together to address medical and behavioral health needs. In reality, however, medical, mental health, and substance abuse services are fragmented and delivered in separate “silos” with little to no effective collaboration. In a recent survey, two thirds of primary care providers (PCPs) reported that they could not access effective mental health services for their patients.4Currently, the most robust research evidence for improving mental health outcomes in primary care comes from studies of collaborative care programs for common mental disorders, such as depression.5 In such programs, PCPs are part of a collaborative care team that may include nurses, clinical social workers, psychologists, and psychiatrists who can support medication management prescribed by PCPs and provide evidence-based mental health treatments in primary care. Core components of successful programs include the concepts of measurement-based care and stepped care in which treatments are systematically changed or intensified if patients do not show substantial improvement in target clinical outcomes.6 In the largest trial of collaborative care to date, participants were more than twice as likely as those in usual care to experience a substantial improvement in their depression over 12 months.7 They also had less physical pain,8 better social and physical functioning, and better overall quality of life than did patients in usual care settings.9Although there was compelling research evidence supporting collaborative care for depression in primary care by the year 2000,5 large-scale implementations of this approach have only started to emerge over the past few years, and there remain few reports of the effectiveness of such programs when implemented outside of research trials. Examples include the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) program in Minnesota10 and the Washington State Mental Health Integration Program (MHIP; http://integratedcare-nw.org) in which over 100 community health clinics and 30 community mental health centers partner to provide integrated care for safety-net patients with medical and behavioral health needs.Funded by the State of Washington and administered by the Community Health Plan of Washington (CHPW), a nonprofit managed care plan, in collaboration with Public Health–Seattle & King County, MHIP provides medical and mental health services for low-income adults who are temporarily disabled due to a physical or mental health condition and expected to be unemployed for at least 90 days (adults covered in the State of Washington''s Disability Lifeline Program), veterans and family members of veterans, the uninsured, low-income mothers and their children, and low-income older adults. Behavioral health care is provided in the primary care clinic through a collaborative approach including a PCP and a care coordinator, a consulting psychiatrist assigned to each of the primary care–based teams, and other behavioral health providers, if available. Each care coordinator receives weekly caseload consultation with a consulting psychiatrist to review cases and develop a treatment plan, which might include medication recommendations, psychosocial support and brief psychotherapeutic interventions by the care coordinator, and referrals to other services that are clinically indicated (e.g., substance abuse counseling). Patients who are too challenging to be cared for in primary care are referred to a partnering community mental health center for additional treatment.MHIP was initiated in 29 community health clinics in the 2 most populous counties in Washington State representing the metropolitan Seattle–Tacoma area in late 2007. In 2010, the program was expanded to over 100 community health clinics and 30 community mental health centers statewide. Expert faculty from the AIMS (Advancing Integrated Mental Health Solutions) Center at the University of Washington provided training, technical assistance, and a web-based tracking system11 to help support systematic outcome tracking and quality improvement. All program participants are tracked in this registry, which captures clinical diagnoses assigned by clinicians working with patients and clinical outcomes using validated clinical rating scales such as the PHQ-9 (Patient Health Questionnaire) for depression.12 This information is gathered for all participants at an initial assessment and at each subsequent contact with a care coordinator.Initial experience with MHIP suggested substantial variation in the quality and outcomes of care provided across the participating community health clinics. To reduce this variation and improve the overall effectiveness of the program, the program sponsors instituted a quality improvement program with a pay-for-performance (P4P) incentive. Before 2009, participating clinics received full payment for the cost of the care coordinators deployed in the participating primary care clinics. Outcomes were monitored by MHIP staff, and technical assistance was provided to support struggling sites, but no financial incentives were tied to performance. After the P4P incentive program went into effect on January 1, 2009, 25% of the annual program funding to participating clinics was contingent on meeting several quality indicators, including timely follow-up of patients in the program (2 or more contacts per month for at least half of the active caseload), psychiatric consultation for patients who do not show clinical improvement, and regular tracking of psychotropic medications used. Participating clinics and providers received regular feedback on their quality indicators through the web-based clinical tracking system and training and technical assistance to help improvement on these indicators through an all-day in-person training workshop for care coordinators (http://chpw.org/gau) and monthly webinars provided by the University of Washington AIMS Center.There is very limited experience with P4P incentives in behavioral health care,13 and we know of no published studies of such incentives in the context of population-focused, primary care–based collaborative care programs. In this article, we take advantage of this real-world experiment and examine changes in quality of care and patient outcomes observed among MHIP participants before and after implementation of the P4P incentive program.     

Use of Small Group With Chronically Ill Children

The authors describe the use of small groups with chronically ill elementary students as a way to facilitate acceptance of their diseases. Specific techniques that proved helpful are described.     

高校心理健康教育应关注大学生的自我和谐

关注大学生自我和谐是建设和谐社会的时代需要,是顺应心理健康教育观念新变革的需要。开展发展性心理咨询、心理素质拓展训练、心理健康教育课程等是促进大学生自我和谐的有效途径。     

新形势下部队进行心理健康教育的思考

为探讨新形势下部队进行心理健康教育实施方法，本阐述了心理健康教育实施方案和心理健康教育需要把握的问题，为在新形势下部队开展心理健康教育提供经验。