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Egbert AH, Irizarry B, Lualdi E, Tortolani CC, Donaldson DL, Goldschmidt AB. A qualitative assessment of provider-perceived barriers to implementing family-based treatment for anorexia nervosa in low-income community settings. J Eat Disord 2024; 12:51. [PMID: 38664842 PMCID: PMC11045456 DOI: 10.1186/s40337-024-01008-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Family-based treatment (FBT) is a front-line empirically supported intervention for adolescent anorexia nervosa, but it is often inaccessible to families from lower income backgrounds, as it is most typically available in specialty research and private practice settings. In preparation for a pilot trial of FBT delivered in the home setting, this study qualitatively examined provider perceptions of implementing FBT in lower-income communities. METHODS Eating disorder clinicians working in community clinics (therapists, medical doctors, dietitians, and social workers; n = 9) were interviewed about their experiences using FBT. Interview transcripts were analyzed both deductively, using an approach consistent with applied thematic analysis, and inductively, using the Replicating Effective Programs implementation framework, to examine barriers to FBT implementation. RESULTS Prevailing themes included concern about the time and resources required of caregivers to participate in FBT, which may not be feasible for those who work full time, have other caregiving demands, and/or lack family support. Psychosocial problems outside of the eating disorder, such as food insecurity, other untreated mental health concerns (in themselves or other family members), or externalizing behaviors on the part of the adolescent, were also discussed as barriers, and participants noted that the lack of cohesive treatment teams in the community make it difficult to ensure continuity of care. CONCLUSION Findings from this qualitative study indicate the need to address systemic socioeconomic barriers to improve the efficacy of implementation of FBT in the community and to understand how provider perceptions of these barriers influence their uptake of FBT.
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Affiliation(s)
- Amy H Egbert
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA.
- Department of Psychological Sciences, The University of Connecticut, Storrs, CT, USA.
| | - Bailey Irizarry
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Christina C Tortolani
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Counseling, Educational Leadership, and School Psychology, Rhode Island College, Providence, RI, USA
| | - Deidre L Donaldson
- Department of Family Medicine, Warren Alpert Medical School of Brown University/Gateway Healthcare, Providence, RI, USA
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Dimitropoulos G, Singh M, Sauerwein J, Pedram P, Kimber M, Pradel M, Eckhardt S, Forsberg S, Keery H, Allan E, Bruett L, Le Grange D. Examining clinicians' perceptions and experiences working with diverse families in family-based treatment: Common adaptations and considerations for treatment engagement. Int J Eat Disord 2024; 57:635-647. [PMID: 38268225 DOI: 10.1002/eat.24144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 01/26/2024]
Abstract
OBJECTIVE Family-Based Treatment (FBT) is the leading manualized treatment for adolescent eating disorders; however, there is limited research on the adaptation of FBT for diverse families (i.e., families belonging to identity groups subject to systemic barriers and prejudices). The purpose of this qualitative study was to address: (1) adaptations made to the FBT model (if any) by clinicians working with diverse youth and families; (2) the barriers/facilitators of maintaining adherence (fidelity) to the model for these families; and, (3) the barriers/facilitators to access and engagement in FBT for diverse families. METHOD Forty-one FBT clinicians were recruited globally using purposive and snowball sampling, and listservs from eating disorder networks. Clinicians participated in individual interviews or focus groups, discussing their experiences delivering and adapting FBT for diverse families. Qualitative data was transcribed verbatim and analyzed using directed content analysis. RESULTS Some participants reported making adaptations to every phase of the FBT model, while others did not, when working with diverse families. In Phase 1, participants cited adapting the family meal, length/number of sessions provided, and addressed systemic barriers. In Phase 2, participants adapted the length of the phase and rate/level of independence given back to the adolescent. In Phase 3, participants increased or decreased the number of sessions, or eliminated this phase to address barriers to engagement in FBT. DISCUSSION This is the first study to qualitatively examine clinicians' experiences of implementing FBT with diverse families. Results may inform future FBT planning, clinician training, clinical decision-making tools, and opportunities for modifications to the foundational model. PUBLIC SIGNIFICANCE This qualitative study examined clinicians' perceptions and experiences implementing FBT with diverse families, specifically what adaptations (if any) were made to the foundational model, and the barriers and facilitators to adhering to and engaging in the model. Results show that some participants reported making adaptations to every phase of FBT, while others did not, with diverse families. Findings may inform future treatment planning, clinician training, clinical decision-making tools, and potential modifications to FBT.
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Affiliation(s)
| | - Manya Singh
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Jessica Sauerwein
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Pardis Pedram
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Melissa Kimber
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Offord Centre for Child Studies, McMaster University, Hamilton, Ontario, Canada
| | - Martin Pradel
- Department of Pediatrics, The Royal Children's Hospital, Melbourne, Australia
| | - Sarah Eckhardt
- Center for the Treatment of Eating Disorders, Children's Minnesota, Minneapolis, Minnesota, USA
| | - Sarah Forsberg
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Helene Keery
- Center for the Treatment of Eating Disorders, Children's Minnesota, Minneapolis, Minnesota, USA
| | - Erica Allan
- Department of Adolescent Medicine, The Royal Children's Hospital, Melbourne, Australia
| | - Lindsey Bruett
- Department of Psychiatry and Behavioral Sciences, UCSF Weill Institute for Neurosciences, University of California, San Francisco, California, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Neuroscience (Emeritus), The University of Chicago, Chicago, Illinois, USA
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Friedlich CE, Park H, Duval CJ, Keshishian T, Murray SB. The prevalence of disordered eating in outpatient general psychiatry settings in publicly insured populations: a case series. Eat Disord 2024; 32:169-177. [PMID: 37933621 DOI: 10.1080/10640266.2023.2277055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
There is a dearth of research assessing the prevalence of eating disorders in publicly insured populations. While evidence shows that eating disorders affect people of all racial, ethnic, and socioeconomic backgrounds, research has neglected to focus on the rate at which they occur among those who have public health insurance. The present study indexes the prevalence of clinically significant disordered eating in a case series of 165 adults in a publicly insured sample at an outpatient general psychiatry clinic in Los Angeles, California. Results illustrate that 46 (27.8%) participants screened positive for clinically significant disordered eating with no significant differences relating to age or gender in those who screened positive versus those who did not (p > .05). This markedly elevated frequency of disordered eating presentations underscores the need for improved clinician training and education around disordered eating and eating disorder assessment as a whole. In addition, there is a critical need to study publicly insured populations so as to mitigate stereotypes about who has eating disorders and improve the likelihood of diagnosis and care.
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Affiliation(s)
- Cassandra E Friedlich
- Department of Psychiatry and the Behavioral Sciences, University of Southern California, Los Angeles, California, USA
| | - Hyoungjin Park
- Department of Psychiatry and the Behavioral Sciences, University of Southern California, Los Angeles, California, USA
| | - Christina J Duval
- Department of Psychiatry and the Behavioral Sciences, University of Southern California, Los Angeles, California, USA
| | - Talene Keshishian
- Department of Psychiatry and the Behavioral Sciences, University of Southern California, Los Angeles, California, USA
| | - Stuart B Murray
- Department of Psychiatry and the Behavioral Sciences, University of Southern California, Los Angeles, California, USA
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Vendlinski SS, Laboe AA, Crest P, McGinnis CG, Fennig M, Wilfley DE, Taylor CB, Fitzsimmons-Craft EE, Accurso EC. Adaptations of an Online Cognitive-Behavioral Therapy Intervention for Binge-Purge Type Eating Disorders in Publicly-Insured and Uninsured Adults: A Pilot Study. RESEARCH SQUARE 2024:rs.3.rs-3879484. [PMID: 38352466 PMCID: PMC10862964 DOI: 10.21203/rs.3.rs-3879484/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
Background Publicly-insured and uninsured individuals-many of whom are marginalized because of race/ethnicity, disability and/or sexual preferences-experience barriers to accessing evidence-based interventions for eating disorders (EDs). Additionally, EBIs have not been developed with or for diverse populations, exacerbating poor treatment uptake. Mobile technology is perfectly positioned to bridge this gap and increase access to low-cost, culturally-sensitive EBIs. Methods This study leverages a user-centered design approach to adapt an existing coached cognitive-behavioral therapy-based digital program and evaluate its usability in a sample of 11 participants with (sub)clinical binge-purge type EDs who are publicly-insured ( n = 10) or uninsured ( n = 1). Participants were primarily Non-Hispanic White ( n = 8) women ( n = 8). Two semi-structured interviews occurred with participants: one to assess treatment needs and the other to obtain app-specific feedback. Interviews were coded using inductive thematic analysis. Results Interview 1 feedback converged on three themes: Recovery Journey, Treatment Experiences, and Engagement with and Expectations for Online Programs. Participants endorsed facing barriers to healthcare, such as poor insurance coverage and a lack of trained providers, and interest in a coach to increase treatment accountability. Interview 2 feedback converged on three themes: Content Development, Participant Experiences with Mental Health, and Real-World Use. Participants liked the content but emphasized the need to improve diverse representation (e.g., gender, body size). Conclusions Overall, user feedback is critical to informing adaptations to the original EBI so that the intervention can be appropriately tailored to the needs of this underserved population, which ultimately has high potential to address critical barriers to ED treatment. Trial Registration This study was reviewed and approved by the Institutional Review Board (IRB) at the University California, San Francisco (IRB #22-35936) and the IRB at Washington University in St. Louis (IRB ID 202304167).
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Lau JS, Kline-Simon AH, Schmittdiel JA, Sterling SA. Adolescent utilization of eating disorder higher level of care: roles of family-based treatment adherence and demographic factors. J Eat Disord 2024; 12:22. [PMID: 38308378 PMCID: PMC10835916 DOI: 10.1186/s40337-024-00976-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/20/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Outpatient family-based treatment (FBT) is effective in treating restrictive eating disorders among adolescents. However, little is known about whether FBT reduces higher level of care (HLOC) utilization or if utilization of HLOC is associated with patient characteristics. This study examined associations between utilization of eating disorder related care (HLOC and outpatient treatment) and reported adherence to FBT and patient characteristics in a large integrated health system. METHODS This retrospective cohort study examined 4101 adolescents who received care for restrictive eating disorders at Kaiser Permanente Northern California. A survey was sent to each medical center to identify treatment teams as high FBT adherence (hFBT) and low FBT adherence (lFBT). Outpatient medical and psychiatry encounters and HLOC, including medical hospitalizations and higher-level psychiatric care as well as patient characteristics were extracted from the EHR and examined over 12 months post-index. RESULTS 2111 and 1990 adolescents were treated in the hFBT and lFBT, respectively. After adjusting for age, sex, race/ethnicity, initial percent median BMI, and comorbid mental health diagnoses, there were no differences in HLOC or outpatient utilization between hFBT and lFBT. Females had higher odds of any utilization compared with males. Compared to White adolescents, Latinos/Hispanics had lower odds of HLOC utilization. Asian, Black, and Latino/Hispanic adolescents had lower odds of psychiatric outpatient care than Whites. CONCLUSIONS Reported FBT adherence was not associated with HLOC utilization in this sample. However, significant disparities across patient characteristics were found in the utilization of psychiatric care for eating disorders. More efforts are needed to understand treatment pathways that are accessible and effective for all populations with eating disorders.
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Affiliation(s)
- Josephine S Lau
- Department of Adolescent Medicine, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, USA.
| | | | - Julie A Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, USA
- Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Stacy A Sterling
- Division of Research, Kaiser Permanente Northern California, Oakland, USA
- Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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Coury J, Coronado G, Currier JJ, Kenzie ES, Petrik AF, Badicke B, Myers E, Davis MM. Methods for scaling up an outreach intervention to increase colorectal cancer screening rates in rural areas. Implement Sci Commun 2024; 5:6. [PMID: 38191536 PMCID: PMC10775579 DOI: 10.1186/s43058-023-00540-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 12/14/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Mailed fecal immunochemical test (FIT) outreach and patient navigation are evidence-based practices shown to improve rates of colorectal cancer (CRC) and follow-up in various settings, yet these programs have not been broadly adopted by health systems and organizations that serve diverse populations. Reasons for low adoption rates are multifactorial, and little research explores approaches for scaling up a complex, multi-level CRC screening outreach intervention to advance equity in rural settings. METHODS SMARTER CRC, a National Cancer Institute Cancer Moonshot project, is a cluster-randomized controlled trial of a mailed FIT and patient navigation program involving 3 Medicaid health plans and 28 rural primary care practices in Oregon and Idaho followed by a national scale-up trial. The SMARTER CRC intervention combines mailed FIT outreach supported by clinics, health plans, and vendors and patient navigation for colonoscopy following an abnormal FIT result. We applied the framework from Perez and colleagues to identify the intervention's components (including functions and forms) and scale-up dissemination strategies and worked with a national advisory board to support scale-up to additional organizations. The team is recruiting health plans, primary care clinics, and regional and national organizations in the USA that serve a rural population. To teach organizations about the intervention, activities include Extension for Community Healthcare Outcomes (ECHO) tele-mentoring learning collaboratives, a facilitation guide and other materials, a patient navigation workshop, webinars, and individualized technical assistance. Our primary outcome is program adoption (by component), measured 6 months after participation in an ECHO learning collaborative. We also assess engagement and adaptations (implemented and desired) to learn how the multicomponent intervention might be modified to best support broad scale-up. DISCUSSION Findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings. TRIAL REGISTRATION Registered at ClinicalTrials.gov (NCT04890054) and at the NCI's Clinical Trials Reporting Program (CTRP no.: NCI-2021-01032) on May 11, 2021.
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Affiliation(s)
- Jennifer Coury
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA.
| | | | - Jessica J Currier
- Division of Oncological Sciences, Knight Cancer Institute, OHSU, Portland, USA
| | - Erin S Kenzie
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
- Department of Family Medicine, OHSU, Portland, USA
| | | | - Brittany Badicke
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Emily Myers
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Melinda M Davis
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
- OHSU-PSU School of Public Health, OHSU, Portland, USA
- Department of Family Medicine, OHSU, Portland, USA
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Halbeisen G, Brandt G, Paslakis G. A Plea for Diversity in Eating Disorders Research. Front Psychiatry 2022; 13:820043. [PMID: 35250670 PMCID: PMC8894317 DOI: 10.3389/fpsyt.2022.820043] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/21/2022] [Indexed: 12/22/2022] Open
Abstract
Eating disorders (EDs) are often stereotyped as affecting the SWAG, that is, as affecting mostly skinny, White, affluent girls. Over the last decade, however, significant progress has been made toward increasing diversity in ED research. There is consensus that EDs affect individuals of all genders, ages, sexual orientations, ethnic, and socio-economic backgrounds, with recent studies exploring social determinants of ED etiology, ED presentation, and developing diversity-affirming ED assessments. This article provides a brief summary of current developments related to diversity as a research theme, and proposes different perspectives toward further improving diversity in ED research. Specifically, we argue for exploring the role of diversity in ED treatment settings and outcomes, for pursuing diversity-oriented research pro-actively rather than as a reaction to issues of under-representation, and for integrating diversity across different areas of medical education and trainings in psychotherapy. Limitations with respect to the paucity of research, and the link between diversity as a research theme and ED-related workforce diversity are discussed.
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Affiliation(s)
- Georg Halbeisen
- University Clinic for Psychosomatic Medicine and Psychotherapy, Medical Faculty, Campus East-Westphalia, Ruhr-University Bochum, Luebbecke, Germany
| | - Gerrit Brandt
- University Clinic for Psychosomatic Medicine and Psychotherapy, Medical Faculty, Campus East-Westphalia, Ruhr-University Bochum, Luebbecke, Germany
| | - Georgios Paslakis
- University Clinic for Psychosomatic Medicine and Psychotherapy, Medical Faculty, Campus East-Westphalia, Ruhr-University Bochum, Luebbecke, Germany
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