Category Archives: Health Behavior News Service

Despite challenges, community health centers win high satisfaction rates


Doctor at deskBy Valerie DeBenedette
HBNS Contributing Writer

Low-income Americans are more likely to be satisfied with the care they receive at federally qualified health centers (FQHC) than at mainstream health care providers, reveals a new study in the Journal of Health Care for the Poor and Underserved.

The level of satisfaction shown by people who use the health centers was surprising, said lead author Leiyu Shi, DrPH, MBA, MPA, professor at the Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, M.D.

Because the centers treat a more vulnerable population, they often have a more difficult time addressing their patients’ needs, he noted. Yet, the study shows that health centers appear to be reducing gaps in both quality of service and accessibility, he said.

Federally funded health centers are usually located in medically underserved communities, making them more likely to be either in inner city or rural areas, explained Shi.

Patients using these centers are more racially and ethnically diverse than the national population and more likely to be uninsured (39 percent compared to 17 percent) or to receive Medicare or Medicaid (54 percent compared to 27 percent) and to be in fair to poor health than the general population.

But patients at FQHCs also reported better access to primary care and were more likely to be satisfied with the care they received (97.7 percent) than low-income Americans getting health care elsewhere (87.2 percent).

Patients at FQHCs also reported better access to primary care and were more likely to be satisfied with the care they received (97.7 percent) than low-income Americans getting health care elsewhere.

“This study tells us a lot about the role of a safety net system,” said Georges C. Benjamin, M.D., executive director of the American Public Health Association in Washington, D.C.

Federally qualified health centers have become like other health providers, but are more focused on primary care and preventive medicine, he noted.

They are based in the community, with one federal requirement being that 51 percent of the members of their board of directors be from the community. They can bill private health insurance, Medicare and Medicaid, he said.

“They have a range of ways for the completely uninsured to pay, usually on sliding fee scale,” he added. “They are much more sensitive to the individual who does not have any money or the ability to pay it back.”

Study authors suggest that there should be broader adoption of the FQHC model of care, which includes comprehensive and preventive primary care, a focus on vulnerable populations such as minorities and the uninsured, consumer participation, and cultural and linguistic sensitivity, among other features.


Shi L, LeBrun-Harris LA, Daly CA, et al.: Reducing disparities in access to primary care and patient satisfaction with care: The role of health centers. J Health Care Poor Underserved. 24 (2013): 56–66

Reach CFAH’s Health Behavior News Service at (202) 387-2829 or

<strong><em><a title=”HBNS” href=”” target=”_blank”>Health Behavior News Service</a> is part of the </em></strong><strong><em><a title=”Center for Advancing Health” href=”” target=”_blank”>Center for Advancing Health</a></em></strong></p>

<strong>The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.</strong>


Accidental poisonings leading cause of deaths at home

A jumble of pill bottles

Photo by Erin DeMay via Flickr

By Stephanie Stephens, HBNS Contributing Writer
Research Source: American Journal of Preventive Medicine

An increasing number of people are dying from unintentional injury at home, with more than 30,000 deaths occurring between 2000 and 2008, finds a new study in the American Journal of Preventive Medicine. Poisoning, falls and fire/burn injuries caused the most fatalities, respectively.

The study reveals that poisonings were the leading cause of unintentional home injury deaths for those ages 15 to 59 years, largely resulting from unintentional drug overdoses of narcotics, hallucinogens and other drugs.

Additionally, more men and boys died from home injury than women and girls did and adults 80 years and older had higher rates of injury-related in-home death than other ages.

“These injuries are predictable and preventable,” said lead author Karin Mack, Ph.D. of the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention.

Mack and her colleagues called for more research to develop effective interventions to modify the home like smoke alarms, limiting access to non-prescription drugs, and closer supervision of children.

Other helps would be broader dissemination of prevention messages to specific audiences including healthcare and education providers, law enforcement and policymakers, and media, they said.

The researchers used combined state-specific death certificate data from the National Vital Statistics System, an inter-governmental public health database. New Mexico had the highest rates of unintentional home injury death during the study period with the lowest in Massachusetts.

Mack said that despite the uptick in home injury during the study period, she was encouraged by momentum occurring in the field of healthy homes, citing two publications that helped spark national interest in home safety: a 2009 report, “The Surgeon General’s Call to Action to Promote Healthy Homes,” and a 2011 report from the American Public Health Association, “Healthy & Safe Homes: Research, Practice, and Policy”.

Much more needs to be done, said Carol W. Runyan, M.P.H., Ph.D., a professor of epidemiology and community and behavioral health at the Colorado School of Public Health.

“The increases in poisoning, largely due to prescription pain medication, have been most dramatic over the past decade, signaling a need to rethink how pain medications are prescribed and used,” she said.

Falls continue to be the major source of fatal home injury in older adults and suffocation the leading cause for infants, Runyan said.

“As the authors note, most of these injuries are preventable through changes in the home environment and safety practices. Unfortunately, this enormous and costly public health problem has not received the national attention it deserves. Funding to understand and address the problem is a pittance compared to other health problems and many health professionals are poorly trained to address these challenges,” she said.

Runyan said the deaths are not inevitable results of uncontrollable or accidental circumstances. “Hopefully this paper will stimulate a shift in the national attention and support for prevention,” she said.
Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

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Blacks missing out on critical early treatment for strokes


clockBy Joan MacDonald, Contributing Writer
Health Behavior News Service
Research Source: Ethnicity & Disease

Getting to the emergency room within the first few hours of recognizing stroke symptoms can help prevent permanent brain damage, but a recent study in Ethnicity & Disease finds that Blacks are only half as likely as Whites to get timely treatment.

The study found that on average it took 339 minutes for Blacks to visit the emergency room for stroke treatment as opposed to 151 minutes for Whites. Delaying treatment can result in the death of vital brain cells.

“It has been estimated that nearly two million neurons die per minute during a stroke,” said Sheryl Martin-Schild, M.D., Ph.D., the study’s lead author. “Intravenous tissue plasminogen activator (IV tPA) is the only treatment during the acute phase of a stroke, the first 4.5 hours, proven to improve outcome in controlled clinical trials.”

Because IV tPA treatment breaks down the clots that obstruct blood flow inside the brain, delaying treatment within that narrow time frame puts patients at greater risk of permanent neurological damage.

The study, which followed 368 patients with a median age of 65 years, sought to identify racial disparities and the reasons for varying delays between symptom onset and emergency room treatment.

While the study found that Blacks and Whites received the same treatment once they arrived at the emergency room, reasons for the delay were not clear.

Socioeconomic standing did not seem to be a factor. Nor did the study find any bias in the way patients of different races were treated once they arrived in the emergency room.

There was no significant difference in the types of symptoms patients reported, with weakness being the most common symptom.

“Explanations for the delay could be numerous,” said Martin-Schild. They may include delayed symptom recognition, a lack of eagerness to call for help, fear of medical personnel and/or hospitals, social or environmental factors, a lack of local social support and/or longer transit time to hospital.

“Community education is vital in improving recognition of stroke symptoms,” said James McKinney, M.D., associate professor of neurology at Robert Wood Johnson Medical School in New Brunswick, New Jersey. “Unlike a heart attack, stroke is often painless, and many patients wait to see if their symptoms go away.”

McKinney suggests that further research is also needed to investigate the use of 911/EMS services, transport times and stroke center access. “All of these can decrease times from stroke onset to medical evaluation,” added McKinney.

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.


Do I have to go to the dentist?


By Kelly Malcom, HBNS Editor

Many of us have vivid memories of tying a thread to a loose tooth and wiggling it back and forth with our tongue all the time hoping for a profitable visit from the Tooth Fairy.

Facebook is full of school and family photos of kids with cute, gap-toothed smiles. But increasingly, children are losing their baby teeth not due to the budding of their permanent teeth but to the ravages of early decay and cavities.

“Pediatricians refer kids to us all the time who are underweight or malnourished. You look in their mouths and you can see why immediately: it’s because they have these extensive cavities and infection,” says Allison Cavenaugh Eggleston, DDS, a pediatric dentist in North Carolina.

“The parents who say to me that baby teeth aren’t important because they’re going to fall out anyway are the same parents who ask how their child will eat when I tell them I may need to extract all of their teeth.”

There are a number of reasons kids and adults don’t make it to the dentist regularly. For some parents, it’s a lack of understanding about the importance of oral health, even at an early age.

Eggleston tries to reach them early by educating pregnant women about the importance of seeing a dentist, not just for themselves but for their babies.

“There is hard evidence to show that reducing the cavity-causing bacteria in a mother’s and father’s mouth will reduce the cavity-causing bacteria in your child’s mouth. Many don’t think of it this way, but oral disease is an infectious disease that can be spread to your baby, even via something as simple as kissing them. That’s why it’s important to go to the dentist regularly, have your cleanings, and understand what you can do to help prevent these cavities.”

Barriers to Dental Care

For many people, just getting to a dentist can be difficult. This may be because the dentist is too far away. Eggleston will soon start her dental practice in an area of rural North Carolina where previously the closest dentist for many residents was 60 miles away. Roughly 47 million Americans live in areas that are recognized by the government as having a shortage of dentists.

Or it may be too difficult to get time off of work to take your child to the dentist.  “If you have someone who can take the kid to the dentist, that’s fine. But many families don’t have that caretaker,” says Jay Friedman, DDS, a dental consultant and author. To get around this, Friedman and many other experts suggest treating kids in schools using licensed dental therapists.

However, one of the greatest barriers to access to dental care is a lack of insurance and cost of care. “The most recent figures are that there are close to 130 million people without dental insurance, which is eye-popping,” said Shelly Gehshan, director of Pew Children’s Dental Campaign.

How to Pay for Dental Care

Dental care is essential but many people put it off because of cost. There are a few steps you can take to ease the pain of sticker shock:

  • Check to see if your employer offers dental insurance or flexible spending accounts for health care needs. You can use these to set aside a portion of your paycheck before taxes to help cover dental care.
  • Shop around if possible. Before agreeing to an expensive procedure, see whether another dentist will perform the same procedure for less.
  • Many dental offices will work with patients when it comes to bills. Offer to pay cash in exchange for a discount or ask about setting up a payment plan to stretch payments into smaller installments over time.

Local Resources:

Even for those with dental insurance, actually seeing a dentist can cause a big hit to one’s pocket book. Cait Goldberg is currently shopping around for an orthodontist for her daughter.

“We knew she’d eventually need braces because she’s sucked her thumb her whole life,” she explains. “The first dentist we saw is a Harvard grad and has this incredibly slick office, with iPads in the waiting room and everything. He told us he’d wait until she lost her last few baby teeth before applying braces at $8000 over the two or three years she’d wear them. In the meantime, we could purchase a $1,500 appliance to help her stop sucking her thumb.”

Another dentist had no iPads and zero bedside manner, but would cost $3000 less, she said. Her insurance would cover just $2000, either toward the appliance or the braces.

She’s going to keep looking but the extreme difference in price has made her skeptical. “I’m not even sure if one is better than the other or if it matters.”

Preventing Dental Problems

You can get your child off to a good start by beginning oral hygiene rituals early:

  • Wipe your infant’s gums after eating to get them used to you being in their mouths.
  • Brush your child’s baby teeth with a soft brush and a tiny amount-no larger than a grain of rice-of fluoride toothpaste.
  • Take your child to their first dental visit by age 1.
  • Ask about and consider sealants, which have been shown to reduce cavities.

The American Dental Association recommends that kids and adults:

  • Brush your teeth twice a day using fluoride toothpaste.
  • Use floss or an interdental tool to remove plaque and food particles from between the teeth.
  • Mouthwash can be used to reduce the amount of bacteria in the mouth and may cut down on tooth decay.
  • See a dentist once a year for a professional cleaning.

Asking Questions

One of the best things anyone can do is ask questions about treatment recommendations. Like medical care, dental care costs have been rising partly due to the use of unnecessary tests and procedures. In fact, Dr. Friedman spearheaded a campaign against the prophylactic removal of wisdom teeth, of which, he says up to 70 percent are unnecessary. (See below)

Do You Need Your Wisdom Teeth Out?

Many people believe having your wisdom teeth taken out is a rite of passage. Yet, if they aren’t causing pain or other problems, you may be able to leave them alone.

Dr. Jay Friedman, DDS, a dental consultant, estimates that up to 70 percent of wisdom teeth extractions are unnecessary-a big deal considering the procedure can cost thousands of dollars plus recovery time.

A recent review from The Cochrane Library, considered the gold standard for determining the relative effectiveness of different interventions, found no evidence to support the prophylactic removal of impacted wisdom teeth (impacted meaning the tooth is wedged between another tooth and the jaw).

Talk to your dentist about the risks of watching and waiting versus removing them to prevent potential future problems.


Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

Percent Percentage Groups Pawns

Women and minorities face barriers to clinical trials


Photo: Sanja Gjenero

Physicians have great influence over whether minorities and women participate in cancer clinical trials, according to a new literature review.

Women and minorities experience disproportionately high rates of cancer in the United States, yet they are typically under-represented in clinical trials, according to the review in the latest issue of Ethnicity & Disease.

Reversing this trend is an important goal of the National Cancer Institute, because study participation is associated with increased survival time and appears to provide both psychological and emotional benefits.

In the report, author Geri L. Schmotzer, Ph.D., of New Mexico State University’s School of Nursing reviewed 22 studies focusing on clinical trial participation and recruitment in under-represented groups including women, ethnic and racial minorities, elderly and/or rural patients, and individuals of low socioeconomic status.

Key Points:

  • Minorities and women face disproportionately high rates of cancer in the United States, yet they are under-represented in clinical trials.
  • The time demands, the cost of clinical trials and a distrust of researchers and their sponsoring institutions influence low participation rates of women and minorities.
  • Lack of physician knowledge about available clinical trials and a tendency for physicians to exclude some patients based on assumptions about their ability to participate affects participation.

She discovered that there are more barriers to participation, both related to the patients themselves and to their physicians, than facilitators.

Among the patient-related barriers for women and minority patients was a reported mistrust of medical researchers and their sponsoring agencies.

Other significant barriers include logistical issues such as the time, transportation and expense required for extra study-related clinic visits.

“If there were times other than 8 to 5 that people could go to the office and be a part of a research study, that would encourage more participation,” said Schmotzer.

“A lot of times the physician makes the decision for the patient prior to even asking the patient.”

“We need to be more cognizant of the importance of practical barriers and find ways to address and reduce them,” agrees David S. Wendler, Ph.D., an expert on research ethics at the National Institutes of Health Clinical Center. “These likely are more significant than the often-discussed issues of trust and historic abuses.”

Among the reasons offered by physicians for not recruiting more patients for clinical trials was a lack of awareness about available trials.

A more troubling finding was that many physicians engage in a form of “triage,” in which they offer study participation to some patients but not to others. They may base this selection process — perhaps unintentionally — on their beliefs regarding the patient’s preferences, anticipated logistical problems, or assumptions about the patient’s ability to understand or comply with study requirements.

“A lot of times the physician makes the decision for the patient prior to even asking the patient,” says Schmotzer. “The failure of a physician to offer a trial due to prior patient triage is inappropriate,” she states in the report.

These findings suggest that more research is needed to understand why physicians may refrain from offering research participation to women and minorities.

Photo courtesy of Sanja Gjenero

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

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Illustration of the lungs in blue

People with asthma get the green light for exercise


Illustration of the lungs in blueBy Christen Brownlee, Contributing Writer
Health Behavior News Service

Not only is it safe for people with asthma to exercise, but doing so could reduce their risk of asthma symptoms or attacks, according to a new evidence review in The Cochrane Library.

Many people with asthma report avoiding exercise because they’re afraid it could trigger symptoms including shortness of breath, wheezing or a full-blown asthma attack, said review author Kristin V. Carson.

These fears might be encouraged from misreading their symptoms, their family’s beliefs about exercise and asthma, or even from their physicians.

Over time, Carson explains, patients can become out of shape, losing muscle mass and cardiovascular fitness. That makes any future attempts at physical activity significantly harder, increasing the chances that patients will become fatigued and breathless and further discouraging physical activity.

“This results in a spiraling cycle,” she says, in which patients are even more likely to avoid exercise.

To determine whether exercise was a danger to asthmatics, Carson and her colleagues reviewed previous studies that looked at the effects of physical training on people with asthma , comparing patients who received no or minimal physical activity to those who exercised for at least 20 minutes, twice a week, over the course of four weeks.

The researchers found that the patients who had exercised—using physical training as varied as running outdoors or on a treadmill, cycling, swimming or circuit training—were no more likely to have a serious asthma-related problem than those who weren’t exercising or who did light exercising such as yoga.

Additionally, Carson said, their findings showed that patients in exercise programs improved their cardiovascular fitness, which in turn could reduce asthma symptoms over time.

Some limited evidence from the included studies also suggested that exercise improved patients’ quality of life, she added, which could contribute to other health benefits and improved psychological well-being.

“We found no reason for people with stable asthma to refrain from regular exercise,” Carson said. “Physicians should encourage their patents with stable asthma to engage in physical training programs.”

Len Horowitz, M.D., a pulmonary specialist at Lenox Hill Hospital in New York City who wasn’t involved in this review, agrees that asthma patients shouldn’t shy away from exercise.

However, even though research suggests that exercise is safe for asthmatics, he says that many people will still use their asthma as a reason to avoid physical activity.

“Not everyone wants to exercise,” he said. “When patients think exercise makes them symptomatic or makes them risk an attack, it’s a good excuse not to do it.”

Horowitz notes that may professional athletes have asthma, which hasn’t negatively affected their careers.

However, he explains, some patients do have exercise-induced asthma, in which vigorous or prolonged exercise can trigger symptoms.

He advises patients in his practice to take precautions if they’re susceptible, including pre-treating themselves with an albuterol inhaler, avoiding exercise that exposes their lungs to cold, dry air (such as running outside in the winter) and building their activity levels gradually.

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

Seesaw With Kids_thumb

Park improvements lead to more vigorous exercise, not just more use


By Christen Brownlee, Contributing Writer
Health Behavior News Service

A new study suggests that refurbishing neighborhood parks may lead to improvements in community health. Increased visitors and higher rates of exercise were observed for more than one year when one community park provided new and varied amenities.


Study leader Jenny Veitch, Ph.D., of Deakin University in Burwood, Victoria, Australia, notes that it’s no secret that parks can be important places to spend leisure time and for physical activity.

However, she says, drawing more people to parks and having them get more exercise there is still largely an unmet public health goal.

It’s particularly important to encourage people in disadvantaged neighborhoods to exercise, she adds, where residents are at an increased risk of inactivity, which can lead to poor health.

For their study, Veitch and her colleagues took advantage of changes already scheduled to take place in a local disadvantaged neighborhood.

That neighborhood, containing two community parks, had one park scheduled for a significant refurbishment.

Before refurbishment, both parks were primarily open spaces, with few amenities. Afterward, the refurbished park would include a dog run, a playground, a 365-meter walking track, a barbeque area, new landscaping, and fencing to prevent motor vehicle access.

Veitch and her colleagues observed visitors at both parks three months before the changes took place, three months afterwards, and then a year later.

The researchers, reporting in the American Journal of Preventive Medicine, found that the number of visitors to the updated park more than quadrupled between the first observation and the last.

Moreover, the numbers of people walking or vigorously exercising in the refurbished park similarly grew.

While visitorship declined slightly in the other park, it wasn’t nearly enough to account for the number of newcomers to the refurbished park.

Investing in attractive and functional park features could pay off significantly in terms of increasing exercise, leading to positive health consequences for low-income communities, explains Veitch.

“Our previous research has shown parks in low socio-economic areas are of poorer quality compared with parks in higher socio-economic areas,” Veitch adds. “Modifying the built environment by improving park facilities and features is potentially a long term and sustainable way to increase population level physical activity.”

That exercise can improve health is an established fact that doesn’t need any additional research, adds John Librett, Ph.D., a former advisor on the effect of recreational activities on health for the Centers for Disease Control. However, he says, it’s still unclear whether park visitors continue to return after their initial visits and keep up their workout routines, a necessary step for maintaining health over the long haul.

“This study shows increased park usage, but what we don’t know is whether different people were visiting the park and not returning, or whether the same people were continually using the park every couple of days,” he says. “You have to keep exercising to maintain benefits.”

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Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.


Peer passengers bad news for teen drivers


By Valerie DeBenedette, Contributing Writer
Health Behavior News Service 

Research shows that teens who drive with peers as passengers have increased risks of crashing. Many states have responded by creating graduated driver licensing laws which include limits on the number of passengers teen drivers can have.

Two new studies in the latest Journal of Adolescent Health reviewed key factors shown to influence teen driving behaviors: perception of driving risks, parental monitoring and the presence of peer passengers.

Both studies have results that support the role of teen driver licensing restrictions and parental oversight as effective methods to prevent teen driver accidents.

Teen drivers with a stronger awareness of risks and with parents who monitor their whereabouts and set rules engage in less risky driving behavior, according to the first study.

A second study showed that teen passengers distract both male and female teen drivers, and are linked to aggressive or illegal driving by male teen drivers. Researchers at the Center for Injury Research and Prevention at the Children’s Hospital of Philadelphia led both studies.

The first study researched how sensation seeking or risk taking, risk perception and parental monitoring and rule setting affected a teen’s likelihood of risky driving and driving with multiple peer passengers.The researchers surveyed 198 teens aged 15 to 17 in two states with graduated driver license laws.

They found that higher sensation seeking, lower risk perception and less parental monitoring predicted teens’ risky driving, and having multiple peer passengers increased that risk.

“The good news is that most of the teens in the study reported being aware of the risks of driving dangerously,” said lead author Jessica Mirman, Ph.D.

Boys with multiple passengers were more likely to drive aggressively or perform illegal maneuvers.

The second study analyzed a nationally representative sample of 677 drivers aged 16 to 18 who were involved in serious crashes.

Findings from on-scene crash investigations revealed that both male and female teen drivers were more susceptible to distractions with passengers in the car.

In addition, boys with multiple passengers were more likely to drive aggressively or perform illegal maneuvers in the moments before a crash when they had passengers than they were when driving alone.

“Distraction from peer passengers appears to play a prominent role for both male and female drivers,” said Allison E. Curry, Ph.D., MPH, director of the Epidemiology and Biostatistics Core at the Center and lead author on this study. “One in five females and one in four males who were driving with friends were distracted by something inside the vehicle just before they crashed.”

Passengers affected boys and girls in different ways. Boys were more prone to crash due to speeding or reckless driving while girls were more apt to crash because of distractions such as looking at their friends, eating, texting or using their cell phones, said Jeffrey Weiss, M.D., pediatric hospitalist at Phoenix Children’s Hospital, and a spokesman for the American Academy of Pediatrics on teen driving issues.

“The $64,000 question about graduated driver’s licensing rules is, ‘Why do they work?’” 

Graduated driver licensing laws vary by state, Weiss said. Forty-eight states and the District of Columbia restrict young drivers from driving at night, according to the Governors Highway Safety Association. Forty-five states and D.C. restrict the number of their passengers. These laws have reduced the incidence of crashes among teen drivers, said Weiss.

“The $64,000 question about graduated driver’s licensing rules is, ‘Why do they work?’” Weiss noted. “We’ve shown that they work, but is it because of the passenger restriction or the night restriction or a combination of both? Is it because of parental education?”

Some of the beneficial effect might be because some teens wait to drive until they can get a full license without restrictions, he added.

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

Stairs thumb

Signs can get us to use stairs instead of the elevator


By Sharyn Alden, Contributing WriterPoster: Burn Calories, Not Electricity
Health Behavior News Service 

Signs that read, “Burn Calories, Not Electricity” posted in lobbies of New York City buildings, motivated more people to take the stairs and continue to use them even months later.

A new study, which appears online in the February issue of the American Journal of Preventive Medicine, observed and analyzed people making 18,462 trips up and down stairs at three sites. The signs immediately increased stair use between 9.2 and 34.7 percent at all locations.

“The gains in physical activity continued to be observed nine months after the signs were first placed,” noted Karen K Lee, M.D., author of the study at New York City Department of Health and Mental Hygiene. “We found that placing stair prompts at the point of decision is effective.”

The study is among the first to assess the effects of stair prompts on stair climbing as well as descent in different types of buildings over many months. Prompts were posted in a three-story health clinic, a 10-story affordable housing building, and an 8-story academic site and studied over several months.

“Human-made environments in everyday life offer numerous opportunities for maintaining health, controlling weight and preventing disease,” Lee said. “One of those health opportunities is stair climbing, a vigorous activity which can burn more calories than jogging.”

“For almost no investment we can improve health.”

Patrick Remington, M.D., associate dean for public health in the University of Wisconsin School of Medicine & Public Health said, “For decades, we’ve known this type of intervention works, but few, if any, places actually have these signs.”

Instead of removing the signage after the study was completed, the prompts were purposely left in place. New York City continues to promote the health benefits of stair climbing by distributing free stair signs to owners and managers of public and private buildings who request them.

“So far, we’ve distributed over 26,000 signs to owners and managers of about 1,000 buildings including residential, worksites, hospitals and academic centers,” said Lee.

Remington sees opportunities for widespread use of prompts. “For example, a zoning law could be enacted that requires buildings to have stair prompts …like they require signs for exits.”

Remington added, “Overall, this is a great study, showing how for almost no investment we can improve health.”

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.


Small steps to big health change


By Randy Dotinga & Kelly Malcom

Health Behavior News Service 

We often give a chilly reception to the idea of going “cold turkey” when it comes to anything that has to do with changing behaviors and habits, even those that may be important for our health.

And no wonder: habits become habits because they give us something we think we need. Maybe they make us feel better (hello, chocolate!) or they bring comfort, familiarity or convenience to our lives.

Once we get used to doing things a certain way, the idea of changing a routine behavior can seem overwhelming. And we worry (with good reason) that we won’t be successful if we try to change our habits all at once.

Joan Christensen, a 57-year-old dance teacher from North Branford, Conn., understands. The recession and personal challenges sent her into a depression. She coped by eating more, ballooning her 5-foot-4 frame up to 204 pounds. “I was feeling sorry for myself and food became my solace,” she says. Yet, she wasn’t motivated to turn her life around.

Then a medical crisis hit. Suddenly, Christensen was ready to make changes, but didn’t know where to start. With the help of her physician, she began to take small but meaningful steps to reduce her weight. It worked.

“I’m a new woman,” Christensen says. Through a series of small steps over a period of six months, she lost 44 pounds.

What can I do to ensure my success in changing my behavior?

  • Get help from your primary care doctor (or another professional, like a nutritionist)—they may have access to resources you don’t know about.
  • Make changes you’re about 70 to 80 percent sure you can accomplish.
  • Set up your environment to trigger the behavior you want to engage in (i.e. if you want to floss your teeth more frequently, put the dental floss next to your toothbrush).
  • Focus on the positive impact of what you are doing, rather than how far you have to go.
  • Think about finding or creating a support group.

It’s not just common sense that backs up her go-slow approach. Research supports it too, suggesting we’re more likely to improve our health if we don’t pressure ourselves into developing new routines overnight but instead take time to learn new habits.

“We talk as if willpower were the whole show,” says Christensen’s physician, David Katz, M.D., director of Yale University’s Prevention Research Center. “But that’s like thinking you can climb Mount Everest if you just want to badly enough. Nonsense. You need mountaineering skills.”

Tipping Points

“Rationally, you’d think motivation would be strong enough to get you to adopt a health behavior, but it’s not,” says BJ Fogg, Ph.D., director of the Persuasive Technology Lab at Stanford University.

“Motivation and habits actually live in different worlds.”

Fogg works on creating systems to change human behavior and adapting those systems for use with mobile devices. “Motivation and habits actually live in different worlds,” Fogg says.

Motivation, he explains, is important for developing the initial surge in energy to make a change, what he calls a motivational wave.

For Christensen, her motivational wave wasn’t voluntary. She became ill one particularly busy day after eating an unhealthy breakfast and skipping lunch.

Nausea, stomach pains and shortness of breath hit her all at once. “I sat down and cried,” she recalls. “I was spiraling out of control and had hit bottom. I then knew that it was now or never.”

It’s quite common for a medical crisis to serve as a tipping point, Katz notes.

“Unfortunately, tipping points do tend to come in the aftermath of calamity, such as after a heart attack or stroke. Sometimes they occur when a medical crisis strikes a family member or friend,” he says. “Sometimes they are due to other kinds of events that change our perspective-such as pregnancy. What is most powerful varies with the individual.”

If you can’t quite bring yourself to begin changing your health for the better, there are things you can do to help move in that direction. Talk to your doctor, Katz suggests, and ask about the perils of the status quo and the possible benefits of changing your habits.

Simply having motivation, wherever it originates, is not enough to develop new habits. “One of the problems is when people fail at changing their behavior they blame themselves and their lack of motivation. They are blaming the wrong thing,” says Fogg.

Online Support for Health Change

You might start out with an online health assessment like this tool from Dartmouth:

Looking for ideas about small steps that could make a big difference to your health? Check these online resources:

  • General health information and guidance about healthy living is available from the U.S Department of Health and Human Services at
  • The U.S. Department of Health & Human Services offers 119 ideas about small steps you can take to improve your diet and get more exercise. Examples: Grill, steam or bake instead of frying. Choose a checkout line without a candy display. Walk to a co-worker’s desk instead of emailing or calling.
  • The American Dietetic Association offers a variety of small ways to shave calories off your daily diet. Examples: Don’t eat out of a box or bag because you’ll feel like you need to finish everything. Satisfy your ice cream urge by buying brands that are slow-churned and have reduced calories.


  • is available from the Tobacco Control Research Branch of the National Cancer Institute to offer help with quitting smoking.

Mental health and substance abuse:

  • This resource guide from a California non-profit lead by Robert and Jeanne Segal with support from Rotary International could be helpful for a wide range of health concerns including mental health and substance use information:

Skill-Building over Time

Katz says some people actually prefer to make a big change in one fell swoop. They might suddenly quit smoking or start following their insulin injection routine to the letter. “It’s constitutionally who they are,” he says.

But researchers have found that most people do better with a slower, step-by-step approach, Katz says. To use this approach effectively, however, you may need an education in exactly what your options can be.

People often fail at making important changes because they lack information, adds Judith H. Hibbard, Ph.D., a professor of health policy at the University of Oregon who studies the choices people make about their health. “They don’t know what their role is in the care process, and they’re overwhelmed with the task of managing their health. It’s more like being defeated and discouraged rather than being lazy.”

With her doctor’s help, Christensen learned new weight-loss techniques. She started keeping a food diary, for instance, to give her insight into her daily diet. “You don’t realize what you are putting in [your body] until you see it on paper,” she says.

She began eating six times a day instead of going from breakfast to dinner without food. She cut down on sugar by changing brands, learned to savor her food instead of wolfing it down and tried new recipes.

“It isn’t easy…in the beginning it was very hard to give up sugar,” she says. “But you soon learn that it’s not a necessity. I can now go out and watch people have dessert around me, and it doesn’t faze me. It is empowering to know that you are in control. And I have found that gaining control over my weight and eating habits has taught me to take control in the areas of my life that were causing the overeating.”

If you’re overweight, you may think Christensen’s success is unrealistic. But a landmark 2002 study published in the New England Journal of Medicine finds that a moderate amount of weight loss, the kind you can achieve through fairly minor changes in exercise and eating habits, had a bigger positive effect on overweight people at risk for diabetes than preventive medication had.

Those who exercised a half-hour a day and lost just 5 to 10 percent of their weight-10 to 20 pounds for a 200-pound person-were almost 60 percent less likely to develop diabetes.

If 30 minutes seems like too much, Fogg suggests starting shorter. “Tiny habits grow into full behaviors over time. If you get in the tiny habit of exercising for three minutes and that becomes a true habit, you will eventually just naturally end up doing 30 minutes,” he says. “Over time, you develop the physical capabilities and arrange the world around you to make it easier.”

Building Confidence

Needles don’t bother Joan Reder, a medical transcriptionist with the Scripps Health System in San Diego. That’s a good thing: She has had type 1 diabetes for 35 years and daily insulin injections have long been part of her daily routine.

But something does make the 59-year-old Reder nervous: technology.

Recently, she was intrigued by the idea of converting to using an insulin pump that would allow greater control of her insulin levels. But it worried her, too.

For one thing, the idea of using new technology didn’t thrill her. “I’m not a techie person. I know what I need to know to use my computer, and the rest…well, I don’t want to know,” she says.

She had also heard a secondhand horror story about the pump and didn’t want to shell out money for a pump that she might not want to keep using. “So having a pump was really scary to me,” she recalls.

Then she discovered that she could enroll in a study that allowed her to get extra support from medical staff and try the pump without making a major financial commitment. It also helped that she was able to turn to other diabetics in a support group and learn tips about how to use the pump.

“They know things that your doctor can’t tell you unless your doctor has diabetes, like how to eat pizza or M&Ms with the pump,” she says.

Christensen tried the pump and loved it. Instead of giving herself insulin injections throughout the day, she programs the pump’s computer to deliver the amount she needs based on what she eats.

That’s much easier than going through the multiple injections that she used to endure to be able to safely eat certain foods.

She now regularly wears the pump, which weighs about half a pound and delivers the insulin through a tube that goes under the skin in her stomach. “There’s a lab test that I take every time before I see my endocrinologist. The ideal measurement is 7 or below. The day I started on the pump, it was 8.4. Three months later, it was a 6.7.”

That improvement wouldn’t have happened without the support that helped her gain the confidence to take the small step of simply trying the pump, she says.

Taking It Home

Confidence, it turns out, is crucial to improving health through small steps. To take advantage of the powers of confidence, it’s a good idea to make changes that you’re about 70 to 80 percent sure you can accomplish, says David Sobel, M.D., medical director of patient education and health promotion for Kaiser Permanente’s Northern California system.

Judith Hibbard said she’s heard of dieters whose first step was to eat nine donuts a day instead of 12.

Katz and Hibbard say there are many other small steps you can take if your goal is to lose weight. Don’t shop while you’re hungry, for instance, and prepare a shopping list to guide healthier choices. At work, take the stairs a few days a week instead of the elevator.

You further your chance at success if you set up your environment to help trigger the behavior you want, according to Fogg. “If you want to floss more, put the floss next to your toothbrush.

When developing habits, you should try to make something you already do become the trigger for the next thing.”

Success, if you reach it, will build your sense of confidence, but don’t stop early in the process. “The thing about small steps is that you need to keep moving forward and take the next step after that,” Hibbard says.

Luckily, Fogg points out, “In general, the more you do a behavior, the easier it is to do.”

As you move forward, remember the lessons of Christensen and Reder: it’s easier to change your life when supportive people are behind you. Friends and family can make a big difference, as can the staff at your medical office. Some people also seek out support groups.

“Social support can be helpful if the people around you already have the habit you want,” says Fogg.

If you can’t find the help you need, consider creating support systems yourself, as Reder did. She co-founded a group at Scripps Health’s Behavioral Diabetes Institute that matches diabetic patients with other similar patients who serve as mentors. The program is called Diabetes TLC, with the initials standing for “talk, listen, connect.

The idea is to give the kind of insight and support that doctors can’t provide because they don’t suffer from the condition themselves, Reder says.

“The small steps our clients have taken with support from one of our teammates have assisted many of them in making huge changes, including better lab results, weight loss, testing their glucose more often and more balanced lives,” she says. “If you give people a list of 22 things they have to do, they’ll say forget it. If you do things one or two steps at a time, you’ll experience success and get ready to do more.”

It’s a small steps-big change success story. And there’s not a cold turkey in sight.

Randy Dotinga is a Contributing Writer, and Kelly Malcom is an Editor for Health Behavior News Service.

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

surgeons performing surgery in operating room

Reducing your risk of being injured by a medical error


By Kelly Malcom, Editor & Becky Ham, Science Writer
Health Behavior News Service 

A 1999 report from the Institute of Medicine (IOM) revealed just how pervasive and harmful medical errors are in American health care, killing an estimated 98,000 patients each year.

Although the IOM report drew significant attention to medical errors, studies suggest that errors remain common more than a decade later.

A 2010 study, conducted by the U.S. Department of Health and Human Services’ Office of the Inspector General, found that an estimated 13.5 percent—about 1 in 7—of hospitalized Medicare patients experienced adverse events during their hospital stays, and an August 2011 study in the journal Health Affairs suggested that as many as one in three hospitalized patients could be harmed or killed by medical error.

“Medicine in some ways is a victim of its own success,” says Peter Pronovost, M.D., professor in the departments of anesthesiology and critical care medicine and surgery and director of the Armstrong Institute for Patient Safety at Johns Hopkins Medical School.

“Many years ago, the only therapies we had were what the doctor held in his black bag. Now we have amazingly complex treatments; we can put a new hip in you or operate on your heart. But all of that complexity also added risk,” he said.

Tracking and reducing medical errors are part of widespread efforts to improve patient safety. “Many of the negative patient safety events are related to systems and how people operate within them,” says Jeff Brady, M.D., of the U.S. Health and Human Services’ Agency for Research and Quality (AHRQ). He refers to slices of Swiss cheese to describe how errors might happen.

“There are flaws within health care systems like the holes in Swiss cheese. Normally, when there’s a hole, there’s a check in another part of the system that will prevent something from happening. A patient safety event often occurs when the normal system of checks and balances fails in an unfortunately coordinated way.”

Errors are often the result of poor coordination within the health care system and poor communication on the part of physicians, nurses and patients.

When Care Goes Wrong

MRI of the knee

Virginia resident Herminia Briones struggled for a year after her knee replacement surgery, battling scar adhesions, a blood clot and a severe infection that eventually led to the removal of her knee implant. But for months before that, her symptoms were brushed off by multiple physicians as “routine” and “part of the healing process.”

“Even if the doctor tells you there is nothing wrong, ask him or her to conduct tests,” Briones suggests. “Ask questions. Seek second opinions.”

“We have to educate our clinicians to be welcoming to being questioned. Too often, clinicians give the message that ‘I don’t want to be questioned, I have the answers’,” commented Pronovost.

Lori Ames, a mother from Babylon, N.Y., wrote a letter to her son’s doctors after he was eventually diagnosed with a brain tumor following many missed diagnoses by pediatricians and other specialists.

When an Error Occurs

Despite efforts to change the culture of the healthcare system, errors do unfortunately occur. If a patient feels that an error has just been committed, or is ongoing, they should speak first with the health care workers who were “on the scene” of an error, to ensure that proper care and follow-up begins immediately, said Carol Cronin, MSW, the executive director of the Informed Patient Institute.

If a suspected problem isn’t resolved through discussions with the care team, Cronin said, patients should seek out a patient ombudsman or patient advocate who could be employed by either a hospital, the practice group to which a doctor may belong or the patient’s insurance company.

These “patient relations” specialists usually have a procedure that they will follow to report and resolve a potential medical error. If this process doesn’t resolve the issue, Cronin advises patients to “escalate your concern” by talking with the head of a hospital, the state department of health or the national Joint Commission.

Patients who are considering legal action in response to an error should preserve a record of all conversations, said Salvatore Zambri, a Washington, D.C. attorney and expert on medical negligence law at the firm Regan, Zambri & Long PLLC. “You should also preserve any evidence that might be relevant to a potential claim, and collect all medical records from the doctor or facility where you think the potential malpractice took place.”

Patients should always speak up about errors, Zambri says, because their concerns can lead to better health for themselves and others treated by the same doctors and facilities.

“There are a lot of wonderful physicians practicing medicine, but every now and then you have errors that are made, even by good physicians,” he says. “You need to advocate for yourself to get the treatment you need to maximize your health.”

“I wrote a letter to all of his previous doctors, as well as the head of the first E.R.,” Ames said, “explaining that I wanted them all to use this as a learning experience that they should always look a little further, and never blow off a mother’s concern.”

AHRQ has launched a national ad campaign, “Questions Are the Answer”, designed to encourage patients to speak up on their own behalf before, during and after receiving health care.

Susan Sheridan, co-founder of the patient advocacy group Consumers Advancing Patient Safety, echoes the importance of asking questions. In 2002, her husband Pat died after a diagnosis of spinal cancer failed to be communicated. “I wish I would have known to request a copy of a final pathology. Retrospectively, I wonder what if I had been in the loop?”

Gathering documents, ensuring that a hospital has best practices in place and asking questions are critical steps patients should take to ensure they receive the best care, she says. “I think being a passive patient is one of the worst things we can be…it’s dangerous.”

Pronovost adds, “The challenge is getting both parties to recognize that if you bring both sources of wisdom together, medical training and the patient’s personal experience, we’re going to give much better care.”

Preventing Medical Errors

One of the best ways to prevent medical error is to be well-informed about what to expect during your treatment before it starts. You (or a friend or family member, if you’re unable to take charge of your care) can ask about the procedures you’ll be undergoing, the medicines you need to take, the expected side effects and the timing of each part of your care.

Here are other trusted resources you may find helpful:

Patient Safety Risks

Treatment risks are different for hospital patients and outpatients. For outpatients, errors often occur due to a lack of information. A patient forgets to list a medication they are taking or a doctor fails to sufficiently explain a new medication or to follow-up with the results of a test that was ordered.

“Patients have to get away from assuming no news is good news,” says Brady. “It’s important for them to confirm the results of every test, including those that are negative.”

Patients in the hospital face another set of risks, ones they can defend against by asking questions. Infections, blood clots and poor coordination between a team of doctors and nurses are the most common causes of harm in hospitalized patients. Indeed, Briones experienced all three of these following her knee surgery.

Pronovost suggests that patients ask about the rates of infection at their chosen hospital and that they make sure anyone who enters their hospital room or delivers treatment washes their hands first. If a patient has any tubes into their body, be it a urinary catheter or breathing tube, they should ask whether they are medically necessary and when they can be removed.

What may be the most difficult task is also the most important. Pronovost says, “Ask to be included in rounds every day. Nurses and doctors will often stand outside a patient’s door and talk about them and never talk to them. Demand that you or your loved one be included in the discussion.”

Leaving the hospital is a particularly vulnerable time. One in five Medicare patients is readmitted to the hospital within a month. “When you leave, you want to make sure that you or your loved one is capable of caring for your disease yourself.

One of the best strategies that patients can request is called a teach-back.” During a teach-back, a patient will say back, in their own words, the instructions given to them by their physician or nurse, including details about follow-up.

“I think we as patients have never really been invited by the healthcare system and by our providers to really participate in our care. If physicians, nurses, and administrators invited us, encouraged us, gave us permission to ask our questions, I think we’d have a much more engaged patient population,” said Sheridan.

Despite the best efforts of patients, their advocates and their caregivers, errors can and do still occur. What happens next can often depend on the response of the hospital and clinicians involved (see sidebar #1).

Barbara Kaberna’s mother went into the hospital with a suspected case of the flu. The 70-year old woman seemed to recover quickly with antibiotics,” Kaberna, a Sarasota, Fla., designer, recalled, “but her liver enzymes weren’t right so they kept her and started running tests to determine the cause.”

The last test was a liver biopsy, after which Kaberna’s mother was scheduled to leave the hospital the next day. But as her husband prepared to pick her up in the morning, the hospital called him to say that something had gone wrong with the biopsy.

“She was in a coma and that her blood pressure was something like 50 over 10. She had bled out,” Kaberna said. Her mother died shortly after the whole family gathered at the hospital.

Kaberna was pleased and comforted by the doctor’s open apology in the hospital waiting room. “He didn’t blame anyone, he didn’t make any excuses. He was genuinely shaken. He prayed with us. It made a difference in how we saw his actions,” she remembers. “If he’d been arrogant and pointed fingers elsewhere, I think we’d have taken a different course.”

Kaberna, Ames and Briones all said that they hoped their discussions with doctors and hospitals could help prevent similar errors from happening to more patients. After speaking at length with their mother’s doctor, Kaberna says, he agreed to change his biopsy procedure.

To learn more read the Institute of Medicine report “To err is human”.


Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

Group thumb

Group programs effective in preventing childhood depression


Photo: Sigurd Decroos

By Milly Dawson
Health Behavior News Contributing Writer 

Psychological interventions to prevent depression in children and adolescents can be useful, with protective effects that last for up to a year, finds a new systematic review..
“Our results were encouraging because depression is so common. It’s one of the costliest disorders internationally,” said lead author Sally Merry, M.D., a pediatric psychiatrist with the department of psychological medicine at the University of Auckland in New Zealand.

Depression ranked second greatest cause of disability in developed countries and first in many developing ones. 

According to research cited in the new review, in 2002, depression ranked second greatest cause of disability in developed countries and first in many developing ones.

The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research.

Key Points:

  • Psychological interventions for preventing depression in children and adolescents are generally effective for up to a year, according to a new systematic review.
  • Depression prevention courses can often be given in groups, making them resource-efficient.
  • Because having an episode of depression increases the risk of subsequent illness, preventing depression in children and adolescents is critical, according to experts.

Depression can erode young people’s enjoyment of daily life, undercut their social relationships and school performance, and increase their risk of substance use, according to Tamar Mendelson, PhD., an assistant professor at the Johns Hopkins Bloomberg School of Public Health who focuses on strategies to prevent mental illnesses.

She notes that a first episode of depression dramatically increases the risk of subsequent episodes, initiating what is often a recurring course of illness.

Preventing depression and other mental illnesses is critical for many reasons, said Mendelson. “For one, there are far too few clinicians to treat all the people suffering from depression and other mental illnesses.”

She also points out that even effective, evidence-based treatments for depression do not work for all individuals. Even when care is available, many people with depression or other mental illnesses avoid seeking help because of stigma.

“By intervening before the start of a disorder, prevention strategies have the potential to avert a chronic, episodic course of mental illness. Thus, prevention efforts with children and adolescents are particularly critical,” Mendelson said.

The research team analyzed 53 studies, completed in various countries. The studies included a total of 14,406 participants between the ages of 5 and 19. The youngsters involved were free of depressive disorder at the time they began to participate in the prevention programs.

Young people who participated in prevention programs were significantly less likely to have a depressive disorder in the year following the program than youth who did not participate.

The effect was the same whether the interventions were targeted toward a specific subset of children, such as just boys, or universal. The prevention programs were diverse and generally involved groups.

“Group-based prevention strategies may offer a means of reaching more individuals than most treatment approaches,” said Mendelson. She added that prevention strategies are often less stigmatizing and therefore more acceptable to people than mental health treatments.

Most of the psychological interventions included some components of cognitive behavioral therapy. Other psychological programs emphasized self-efficacy, stress reduction techniques and methods for handling trauma and maintaining optimism.

Both Merry and Mendelson noted that with widespread depression among young people, these findings have importance for many audiences including young people and their parents, school personnel and healthcare professionals who serve children and families.

Policy makers concerned with improving public health and controlling the massive costs associated with depression are also likely to be interested. In many countries, note the authors, “governments are keen to take action” to limit the massive human and financial costs associated with depression.

PHOTO by Sigurd Decroos 

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.


Using Physician Rating Websites


By Becky Ham and Kelly Malcom
Health Behavior News Service

Angie’s List can help you locate a reputable handyman. Yelp can push you in the direction of the perfect restaurant for your anniversary dinner. Amazon’s consumer reviews can even help you choose the TV that will fit in the corner of your den. So why wouldn’t you turn to the Internet to find your next doctor?

39- year-old Jennifer Stevens did just that when she needed an obstetrician for her first child.

Not wanting to reveal her pregnancy too soon by asking friends for suggestions for a good OB, she turned to the Web for more information on potential physicians. She soon found that a lot of the information she needed to make this important decision was missing.

“A lot of sites gave stars, but I didn’t really know what those stars meant. I just wasn’t comfortable picking an OB based on that kind of vague information,” she said.

Lindsay Luthe, a 30-year old Washington, D.C. resident, consulted the popular ratings website Yelp after asking her friends to recommend a physician.

“I perused the reviews for this particular doctor and saw how positive they were. Those reviews, combined with my friend’s personal recommendation, led me to make an appointment with the doctor. I think I even used the contact info on the Yelp page to call the office,” she said.

“We’re Listed With the Plumbers Now”

The success of physician ratings websites—such as HealthGrades, or RateMyMD, among many others—has been mixed. It’s easier than ever to find at least a little more information about your next partner in health. But patients are still frustrated with the dearth of details online, and remain confused about how to evaluate the facts they find there. Some experts have suggested that these sites are still not as useful as they could be—in some cases, misleading potential patients with incorrect or out-of-date information.

“We’re listed with the plumbers now,” joked Zucel Solc, M.D. The Pinellas County, Fla., radiation oncologist, like many doctors and patients, has reservations about online rating sites. But the sites won’t be disappearing any time soon, and patients may have a chance to contribute the next generation of ratings.

What You’ll Find Online

2008 Wall Street poll found that 91 percent of those surveyed would refer to online information about doctors provided by their health plan(s) and 87 percent expressed interest in providing feedback to health plan sites for physician rating.

And there are plenty of reasons to want to know more about a doctor before you choose one. Doctors aren’t equal in many respects. Studies show that the care you receive can vary depending on their experience their familiarity with the latest medical advances or whether they use electronic medical records.

Evaluating Doctor Ratings Sites

They may not have all the information you’re looking for, but online doctor rating sites can aid your search for a new doctor if you click carefully. Here are a few questions to ask and answer when evaluating a ratings site. This information isn’t always clearly listed on a website, so you may need to dig deep.

  • Who owns the site? Is it a nonprofit or for-profit site?
  • Do doctors pay for their own reviews?
  • Are reviews or ratings anonymous? Is there any way to tell if a reviewer is a patient?
  • Is the information complete? Do you notice any missing doctors in your area?
  • Does the website have an indication of how often information is updated? If a physician’s data is out of date, you may miss important updates to their certification or disciplinary actions.
  • How many ratings does a doctor have? If a doctor has one positive and one negative rating, how much do you really know about his or her performance?

Unfortunately, most physician rating sites include little information on these topics. Most sites allow you to search by a doctor’s name or by a geographical area. Click on an individual doctor, and you’ll usually find out more about where she practices, where she went to school, whether she’s been certified to practice a certain specialty within medicine and perhaps whether there are any disciplinary actions taken against her by a state licensing board. Visitors to the sites can usually rate the doctor’s skills in a short survey and sometimes leave specific comments.

The sites vary considerably in how much information they provide, whether that information is up-to-date, and how easy they are to navigate. PhysicianCompare, a U.S. government directory of health care providers who accept Medicare beneficiaries, was widely criticized on these points. After it was launched in December 2010, health care consultant Michael Millenson, president of Health Quality Advisors LLC, called the site “confusing and unfriendly to consumers, painfully slow and, worst of all, factually unreliable.”

Tara Lagu, M.D., an assistant professor at Tufts University School of Medicine who has studied several ratings sites, agrees that many lack essential details. “Things that we think a patient might really like to look for,” such as a doctor’s gender or the language he or she speaks,” she says.

Lagu and others also say these sites offer little information on a physician’s area of focus, other than specialty certification. “When a doctor specializes in different aspects of care, maybe that he sees mostly older patients or young women, he has no way of telling potential patients coming to these sites that this is what he really works on.”

Without knowing more about a provider’s specialty, says patient advocate Trisha Torrey, “it’s not fair to lump all doctors into one site and rate them with the same rating system. It’s like comparing a taxi cab to a jet.”

Many rating sites are silent on another point: Which doctors offer quality care? At PhysicianCompare, among other sites, said Maribeth Shannon, director of the market and policy monitor program at the California Healthcare Foundation, “there isn’t really any clinical quality information available—how good are they at actually treating the condition you have?”

Shannon said these clinical performance measures are “particularly important for conditions where there are alternative treatments and there is ‘time to shop,’” such as in the case of an elective knee surgery. “Before I decide where to have this done, I’d like to know what the long-term outcomes have been,” she said. “Do similar patients report a quick recovery? How often was follow-up care needed? What has been the surgical infection rate for the doctor and hospital?”

Both Lagu and Shannon noted that patients want different information from physician rating sites depending on whether they’re looking for a doctor to treat a serious condition or for routine office visits.

For more routine care, patients seek out—but often don’t find—information on “the patient-doctor relationship, on parking and wait times and politeness of the reception staff,” Lagu says. “And we just didn’t find that these sites were all that patient-centered. Patients say one of their number-one concerns is to find a doctor who practices shared decision making—but only one of the sites we reviewed asked about that.”

Shared decision-making was one of the most important qualities for Stevens in her potential obstetrician. “I wanted to find a doctor who would let me control the flow of labor. The ratings sites didn’t tell me that,” she said.

Perhaps most importantly, most doctor rating sites lack enough ratings- whether on a lot of doctors or a lot of ratings for any one doctor. Unlike the extensive reviews on other consumer websites, most physicians have very few ratings to help patients in their evaluations. “There just isn’t any momentum on these sites yet,” said Torrey. “We need ten more years, and thousands of ratings.”

Are Online Ratings Trustworthy?

Despite its considerable shortcomings, PhysicianCompare hopes to someday provide a non-profit alternative to physician rating sites that charge for their information.

For-profit ratings sites may purchase their information from a large database, and in some cases will charge the doctors themselves to include their information.

Some sites even offer “enhanced profiles” to doctors—listing their best reviews first, or putting them first in a search—for a fee, Lagu said, “focusing more on their profit motive than providing real information to patients.”

“A couple years ago, there was one website that was rating doctors and going to doctors who had a handful of negative reviews and offering to pull down those reviews for a certain amount of money,” Torrey said. There are also cases, she said, where physicians will give their current patients a discount off their next services if the patient posts a favorable review of the doctor online.

While patients may worry that doctors are paying for better ratings, doctors are worried that a handful of bad reviews may ruin their professional reputation. Most ratings sites allow people to leave reviews anonymously, without any way to confirm that a reviewer was treated by the doctor in question. Medical privacy laws prevent doctors from responding to poor reviews, since the response might reveal details about a patient’s care.

Some doctors ask their new patients to sign a “mutual privacy agreement” that prohibits them from posting comments or reviews to ratings sites, usually in exchange for privacy considerations such as not selling the patient’s anonymous information to a third party, who may then market it as part of a larger database.

Lagu’s studies suggest that the majority of reviews on the sites are positive.

But with so few ratings available online for each doctor, one bad review can stand out, Solc says. He compared the effect to a drawing of a tiny black dot on a white piece of paper. “We always look at the dot in the sea of white.”

The Best Ratings? Face to Face

The proliferation of social media such as Facebook and Twitter has made it easier to people share information about doctors without using a dedicated ratings site. Physicians’ personal sites may show off their personalities in a way that can help patients decide if they would be comfortable and compatible with their care, Torrey said. “You could follow a doctor on Twitter, read their blog posts, or look at their videos.

“I think we will see an increase in health care as a topic for discussion on social media sites,” Shannon said. “People have always asked their friends and neighbors for advice on hospitals and doctors, this is just a high-tech alternative to a conversation on the phone or over the fence.”

Even the best ratings sites can’t compare to a face-to-face meeting when you’re looking for a new physician, experts say. “There’s only so much research you can do,” Solc says. “What’s going to make or break it is your first interview with the doctor.

“To the extent that you can, get the best information ahead of time,” Torrey agrees. “But then at your appointment, do your best to find out if you can establish an upfront, candid, and communicative relationship with the doctor.”

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

Your Medical Mind Thumb

Making up your ‘medical’ mind – Book Review


By Jesse Gruman, Ph.D.
President and founder of the Center for Advancing Health 

Can we have “evidence-based” care and “shared decision making”? Are they in concert or in competition with one another?

Drs. Pamela Hartzband and Jerome Groopman, in essays published over the past few years, have argued that an impending collision between these two perspectives stands to decimate the responsiveness of U.S. health care and undermine patient autonomy.

In their new book, Your Medical Mind: How to Decide What is Right for You, the authors focus their attention on the patient experience in making treatment decisions and in the process, present a rich collection of stories and evidence that strengthen their argument that a crash is indeed imminent.

In Your Medical Mind, Hartzband and Groopman invite us, the public, to understand their concerns by unpacking how scientific evidence – and the lack thereof – plays an often limited and sometimes quite unexpected role in treatment decisions made by doctors and patients: “The effort to reduce medical decision making to numbers is ill-conceived and reductionist, overly simplifying a complex and vexing process that is fraught with conflict and emotion.”

The thesis of the book is that medical decisions are in part driven by established facts and evidence (some spotty and ambiguous), but that personal traits, fluctuating emotions, cognitive biases, health status, personal history and emerging situations also powerfully influence the treatment choices of patients.

To their credit, the authors do not exempt clinicians from being subject to these biases and conditions, but rather describe how sometimes clinician and patient characteristics conflict in shared decision making.

The authors recount stories of people making choices about a range of medical interventions.  They pull from the literatures of health psychology, behavioral medicine, health services research, behavioral economics and decision science to show the patterns through which personal, situational and contextual factors interact over time as these people wrestle with their choices.

There’s Omar with Hepatitis B who shares carefully with his wife all the details and considerations of treatment as his health declines while waiting for a liver transplant but who delegates to his clinicians decisions about his care prior to the transplant, asking his wife to follow their lead.

There’s Lisa, who took a natural approach to treating her lupus that she later abandoned when she decided to get surgery to correct a painful bone spur and ganglion cyst – and despite her efforts to gather information and make a choice that leads to the best outcome, the surgery is unsuccessful.

And many others.

The authors are good story-tellers and they stick with their subjects over time. The portrayal of the nuances of each individual’s choices – what influences them, how their physicians’ views affect their decisions – reflect the reality of many of us who take seriously our participation in decisions about our treatment.

Doing this is hard work.  Uncertainty about what the right choice is for a given individual can be excruciating, especially when that choice is different from the one our family or physician would make. The arduousness of the process may be the reason so many of us defer to the certainty of our physician’s choice.  We’d prefer not to acquire working knowledge of the complexity or feel the chilly uncertainty that close examination of our options entails. “When a person actively chooses a treatment and the outcome is poor, he or she can feel a deeper sense of self-blame and persistent regret.”

After reading about the deep, thoughtful and sometimes existential deliberations of these individuals, it is hard to imagine that we could be denied the option of participating fully in decisions about our treatment.

The reality is, however, that many of us are denied the kind of relationship with our doctors that allow for the exploration of benefits, risks, values, and preferences described in this book.  We don’t have health insurance.  Our insurance doesn’t cover our chosen treatment.  The FDA hasn’t approved the drug we think we need.  Our clinicians aren’t willing to engage: they don’t have time; they don’t get paid to do this; this is not how they were trained.

Your Medical Mind offers an orderly, well-sourced, approachable account of the challenges we and our clinicians face when we are truly engaged in making medical decisions together.

Your Medical Mind is not a how-to manual for making “good” medical decisions, despite its title.  If you want guidance on doing that, you’ll have to go to this article where you can see the interviewer try to get the authors to extract some snappy advice from the material they have presented.

If you are looking for the political and practical implications of a growing patient population that wants to actively deliberate about their treatment, you will be disappointed.  Just how can we avoid the impending collision between the blunt instruments of enforced evidence-focused quality improvement initiatives and the expectation that patients can and will engage meaningfully in decisions about our treatments? Perhaps the answers will be found in Hartzband and Groopman’s next book or essay.

Your Medical Mind offers an orderly, well-sourced, approachable account of the challenges we and our clinicians face when we are truly engaged in making medical decisions together.

If you are a person who wants to be involved in making decisions about your care, you will see yourself reflected in these stories – you may recognize patterns and learn about some of your own quirks.  But if you are an advocate for shared decision making, an enthusiast for patient “empowerment” or a clinician working to implement patient-centered care, this book is required reading.  It shows that implementing true shared decision making is not simple, it is not cheap and you can’t just supply a decision support tool and say you’ve done the job.  You need to know just how complicated this is, because in the absence of a practice and policy agenda supplied by Drs. Hartzband and Groopman, it’s up to you to propose one that will prevent the collision.


Related Links:

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.


Getting the right help for acute pain


By Maia Szalavitz, Contributing Writer
Health Behavior News Service

Whether caused by injury, surgery or a toothache so bad it slams you awake in the middle of the night, acute pain is difficult. Receiving prompt and helpful treatment can make all the difference in the world. But lack of care or inadequate care means that the acute pain may develop into chronic agony.

Fortunately, acute pain is not always long lasting or overwhelming, such as when you have a short severe cramp or multiple bee stings that can be handled with time, over-the-counter medication and other home remedies [See Sidebar: Pain Treatment Options].

Since individuals’ tolerance for pain varies widely, the question of when pain itself requires urgent medical attention is difficult to answer.Chest pain should prompt a visit to the emergency room, of course—but other types of pain are trickier to call.

“If it hurts like hell, come to the E.R.,” says Dr. Sergey Motov, assistant program director for emergency medicine at Maimonides Medical Center in Brooklyn. “The problem is that it’s so subjective, there’s no really good objective way to tell when [help is required]. If it’s the worst pain you’ve ever experienced, [come].”

Once you seek medical attention, you should be treated promptly and with compassion. “If you don’t treat acute pain properly, it can become chronic,” Motov says. “If someone comes in with acute pain and it’s sub-optimally treated, they go home and come back in three days and it’s sub-optimally treated again and later on they’re in chronic pain, that started with us because we did not address the acute pain properly in the first place.”

So how should extreme acute pain be treated? Jan Adams, a retired general practitioner herself, describes receiving excellent care after she had back surgery following an injury. She was immediately given strong opioid medication because of the intensity of the pain.

“What they did right was allow me to manage how much pain medication I needed for the first few days,” she says. “I needed more at first and what they did right was to allow me to manage the pain, understanding that there’s a big difference between abuse of pain medication and acute pain use of narcotics.”

Mike Gaynes, a media consultant, received similarly caring treatment with opioids when he reached the ER suffering with kidney stones. Although he does not normally have high blood pressure, the pain had made it skyrocket.

“This was cork-popping,” he says, “They gave me I.V. morphine and it helped somewhat, then they gave me more and it helped a little more. It took the edge off but did not shut [the pain] down entirely.”

Toughing it out with severe acute pain is not recommended, because of the possibility that it could become a chronic problem. However, Dr. Kenneth Goldschneider, director of pain management at Cincinnati Children’s Hospital, says that complete elimination of pain is often an unrealistic goal because of the side effects of drugs.

Toughing it out with severe acute pain is not recommended . . . it could become a chronic problem.

 “I could give you anesthesia for a week and you would have no pain, but that would come at some cost,” he says. “You want the maximal amount of pain relief with the minimum amount of side effects like sedation.”

Adams’ bad experience of pain management came during an emergency colonoscopy, which she needed during treatment for a rare form of mouth cancer. Radiation therapy had left her weakened and malnourished, cutting off the blood supply to her colon. Because of the painful cancer treatment, she was already taking an extremely strong opioid called fentanyl and had developed a tolerance to it.

That same medication was used for anesthesia during the procedure. Because of Adams’ tolerance and the physician’s choice not to use an additional anesthetic along with it, she was left in agony. “He’s pumping air into my colon and I’m feeling like raw hamburger,” she recalls. “The entire floor heard me screaming but he wouldn’t give me anything more,” she says, explaining that she has typically been stoic when in pain

To avoid having a similar experience, Adams suggests a conversation about pain management before surgery. She says to ask explicitly, ‘What do you think is appropriate pain management?’ “One thing you want to hear is that ‘I’ll be sure that either I or the nursing staff will be trying to evaluate your pain [regularly] to make sure you’ll be as comfortable as possible,” she says.

Patients should also discuss any medications they are taking with their doctors before surgery. If someone has a tolerance to a particular medication, the anesthesiologist needs to be prepared to use higher doses or choose a different drug.

Pain Treatment Options:

Pain can be treated in a number of ways, depending upon its severity and cause. Treatment options might include one or more of the following:

  • Non-steroidal anti-inflammatory drugs (NSAIDs), a specific type of painkiller such as Motrin® or Aleve®
  • Acetaminophen (such as Tylenol®)
  • Narcotics (such as morphine or codeine)
  • Localized anesthetic (a shot of a pain killer medicine into the area of the pain)
  • Nerve blocks (the blocking of a group of nerves with local anesthetics)
  • Acupuncture
  • Electrical stimulation
  • Physical therapy
  • Surgery
  • Psychotherapy (talk therapy)
  • Relaxation techniques such as deep breathing
  • Biofeedback (treatment technique in which people are trained to improve their health by using signals from their own bodies)
  • Behavior modification

Some pain medicines are more effective in fighting pain when they are combined with other methods of treatment. Patients might need to try various methods to maintain maximum pain relief.

Adapted from The Cleveland Clinic Foundation.

“I would always encourage people to change physicians or get another opinion if something doesn’t seem right when you talk about pain,” Adams says.

A decade ago, the Joint Commission on the Accreditation of Health Care Organizations (now known as the Joint Commission), which sets standards for medical centers, labeled pain as the “fifth vital sign.” Hospitals are now required to assess pain when other vital signs are taken after surgery or more frequently with especially painful conditions.

“There’s no excuse not to treat acute pain properly.”

“There’s no excuse not to treat acute pain properly,” Motov says. If pain is not being adequately addressed, the hospital’s ombudsman or patient advocate should be contacted.

Dental pain is one of the worst forms of common, acute pain. Lys Fulda, then in her early 20s, had a toothache so severe that she went to her dentist’s office before it opened to make sure she’d be seen as quickly as possible.

The dentist injected her with Novocain, but it didn’t completely alleviate the pain as he began to drill. He tried another injection, this time directly into the tooth. “It felt like lightning went through my entire body. It created innate deep fear of dentists,” Fulda says.

While it’s not always possible to avoid such incidents because people’s nerves are sometimes anatomically unusual, experienced dentists can almost always prevent them.

“You need to take pain seriously,” says Dr. Dennis Bohlin, a Manhattan dentist and the educational coordinator for the New York State Dental Association’s committee on chemical dependency. “Part of it is reassuring [patients] that there is going to be end to it. Part of the anxiety about pain is the fear that it will last forever. It’s not going to, we can handle it. That reassurance is really important.”

Organizations That Can Help

American Pain Foundation

The American Pain Foundation web site is an online resource for people with pain, their families, friends, caregivers and the general public. This site is devoted to patient information and advocacy, and provides many links to additional resources.

Anxiety itself actually increases pain—so techniques that reduce anxiety are an important part of dealing with acute pain. With children, Bohlin says, it’s particularly important to calm the parents as well so that they don’t transfer their own anxiety to the child.

Incidents like what happened to Fulda or negative childhood experiences with dentists can create what Bohlin calls “subliminal anxiety,” which can drive avoidance of dentistry below conscious awareness.

“It’s hard enough to come as it is,” he says, adding that this type of anxiety makes dragging yourself to the chair even more difficult. Fulda found that a reassuring, sympathetic dentist was able to help her overcome her fear.

If dental pain strikes in the middle of the night or on a weekend, Bohlin suggests taking a drug like ibuprofen, naproxen or aspirin—all of which fight inflammation, which is a big part of dental pain. Don’t take antibiotics, which can make the dentist’s job harder when he or she tries to diagnose the problem.

Acute pain can be harrowing, but fortunately in most cases it can be rapidly relieved.

Treating Acute Pain at Home

Most acute pain is not serious and can be handled with home care methods. Some advice from Dr. Kenneth Goldschneider, director of pain management at Cincinnati Children’s Hospital:

For minor injuries, use a cold pack but for no longer than 20 minutes, he suggests.

For sore throats, gargle with salt water— the only advice that has changed since grandma’s time is that aspirin is no longer used for children or adolescents. Use children’s ibuprofen or acetaminophen instead, he says.

He adds that for infants under six months, sugar water has been found to have a short-term analgesic effect: In many hospitals it is now used for giving shots and placing IV’s and other procedures that produce brief, acute pain. It doesn’t work for older children or adults, however.

For toothache, Manhattan dentist Dennis Bohlin says that when you cannot immediately get to a dentist, use an NSAID drug like ibuprofen or naproxen that has anti-inflammatory properties, since inflammation is often a big part of the problem.

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.