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BMC Health Serv Res. 2016 Jan 22;15:584. doi: 10.1186/s12913-015-1237-x.

Using vignettes to assess contributions to the work of addressing child mental health problems in primary care.

Author information

1
Department of Health, Behavior, and Society, Johns Hopkins School of Public Health, 703 Hampton House, 624 N. Broadway, Baltimore, MD, USA. lwissow@jhmi.edu.
2
Department of Emergency Medicine, World Health Organization Collaborating Center for Emergency Medicine and Trauma Care, Aga Khan University, Karachi, Pakistan. waleed.zafar@aku.edu.
3
Department of Health, Behavior, and Society, Johns Hopkins School of Public Health, 703 Hampton House, 624 N. Broadway, Baltimore, MD, USA. katefothergill64@gmail.com.
4
Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA. aruble@jhmi.edu.
5
Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA. Eslade@psych.umaryland.edu.

Abstract

BACKGROUND:

To further efforts to integrate mental health and primary care, this study develops a novel approach to quantifying the amount and sources of work involved in shifting care for common mental health problems to pediatric primary care providers.

METHODS:

Email/web-based survey of a convenience sample (n = 58) of Maryland pediatricians (77% female, 58% at their site 10 or more years; 44% in private practice, 52 % urban, 48 % practicing with a co-located mental health provider). Participants were asked to review 11 vignettes, which described primary care management of child/youth mental health problems, and rate them on an integer-based ordinal scale for the overall amount of work involved compared to a 12th reference vignette describing an uncomplicated case of ADHD. Respondents were also asked to indicate factors (time, effort, stress) accounting for their ratings. Vignettes presented combinations of three diagnoses (ADHD, anxiety, and depression) and three factors (medical co-morbidity, psychiatric co-morbidity, and difficult families) reported to complicate mental health care. The reference case was pre-assigned a work value of 2. Estimates of the relationship of diagnosis and complicating factors with workload were obtained using linear regression, with random effects at the respondent level.

RESULTS:

The 58 pediatricians gave 593 vignette responses. Depression was associated with a 1.09 unit (about 50%) increase in work (95% CL .94, 1.25), while anxiety did not differ significantly from the reference case of uncomplicated ADHD (p = .28). Although all three complicating factors increased work ratings compared with the reference case, family complexity and psychiatric co-morbidity did so the most (.87 and 1.07 units, respectively, P < .001) while medical co-morbidity increased it the least (.44 units, p < .001). Factors most strongly associated with increased overall work were physician time, physician mental effort, and stress; those least strongly associated were staff time, physician physical effort, and malpractice risk. Pediatricians working with co-located mental health providers gave higher work ratings than did those without co-located staff.

CONCLUSIONS:

Both diagnosis and cross-diagnosis complicating factors contribute to the work involved in providing mental health services in primary care. Vignette studies may facilitate understanding which mental health services can be most readily incorporated into primary care as it is presently structured and help guide the design of training programs and other implementation strategies.

PMID:
26801906
PMCID:
PMC4722679
DOI:
10.1186/s12913-015-1237-x
[Indexed for MEDLINE]
Free PMC Article

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