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For two decades, various initiatives have encouraged Americans to consider quality when choosing clinicians, both to enhance informed choice and to reduce disparities in access to high-quality providers. The literature portrays these efforts as largely ineffective. But this depiction overlooks two factors: the dramatic expansion since 2010 in the availability of patients' narratives about care and the growth of information seeking among consumers. Using surveys fielded in 2010, 2014, and 2015, we assessed the impact of these changes on consumers' awareness of quality information and sociodemographic differences. Public exposure to any quality information doubled between 2010 and 2015, while exposure to patient narratives and experience surveys tripled. Reflecting a greater propensity to seek quality metrics, minority consumers remained better informed than whites over time, albeit with differences across subgroups in the types of information encountered. An education-related gradient in quality awareness also emerged over the past decade. Public policy should respond to emerging trends in information exposure, establish standards for rigorous elicitation of narratives, and assist consumers' learning from a combination of narratives and quantified metrics on clinician quality.

POLICY POINTS: Narratives about patients’ experiences with outpatient care are essential for quality improvement because they convey ample actionable information that both elaborates on existing domains within patient experience surveys and describes multiple additional domains that are important to patients. The content of narrative feedback from patients can potentially be translated to improved quality in multiple ways: clinicians can learn from their own patients, groups of clinicians can learn from the experience of their peers’ patients, and health system administrators can identify and respond to patterns in patients’ accounts that reflect systemic challenges to quality. Consistent investment by payers and providers is required to ensure that patient narratives are rigorously collected, analyzed fully, and effectively used for quality improvement. CONTEXT: For the past 25 years, health care providers and health system administrators have sought to improve care by surveying patients about their experiences. More recently, policymakers have acted to promote this learning by deploying financial incentives tied to survey scores. This article explores the potential of systematically elicited narratives about experiences with outpatient care to enrich quality improvement. METHODS: Narratives were collected from 348 patients recruited from a nationally representative Internet panel. Drawing from the literature on health services innovation, we developed a two‐part coding schema that categorized narrative content in terms of (a) the aspects of care being described, and (b) the actionability of this information for clinicians, quality improvement staff, and health system administrators. Narratives were coded using this schema, with high levels of reliability among the coders. FINDINGS: The scope of outpatient narratives divides evenly among aspects of care currently measured by patient experience surveys (35% of content), aspects related to measured domains but not captured by existing survey questions (31%), and aspects of care that are omitted from surveys entirely (34%). Overall, the narrative data focused heavily on relational aspects of care (43%), elaborating on this aspect of experience well beyond what is captured with communication‐related questions on existing surveys. Three‐quarters of elicited narratives had some actionable content, and almost a third contained three or more separate actionable elements. CONCLUSIONS: In a health policy environment that incentivizes attention to patient experience, rigorously elicited narratives hold substantial promise for improving quality in general and patients’ experiences with care in particular. They do so in two ways: by making concrete what went wrong or right in domains covered by existing surveys, and by expanding our view of what aspects of care matter to patients as articulated in their own words and thus how care can be made more patient‐centered. Most narratives convey experiences that are potentially actionable by those committed to improving health care quality in outpatient settings.

Objective\ud Individuals are often defensive toward health messages that suggest they are putting their health at risk because such messages threaten their self-competence and integrity. Although self-affirmation can facilitate prevention behaviors in response to health messages, effects are variable. We examined whether disease prevention focus might strengthen self-affirmation’s effects in response to disease prevention messages, given that prevention-focused individuals are likeliest to be persuaded by those messages after self-affirmation attenuates defensiveness.\ud \ud Design\ud In Study 1, participants were self-affirmed before a message about sexually transmitted infections. In Studies 2 and 3, individuals were self-affirmed prior to a message about alcohol and cancer risk.\ud \ud Main Outcome Measures\ud Studies assessed intentions to use condoms, intentions to reduce alcohol, and willingness to drink alcohol in specific scenarios.\ud \ud Results\ud In Study 1, self-affirmation facilitated condom use intentions among those higher in prevention focus. In Studies 2 and 3, self-affirmation facilitated lower willingness to consume alcohol among those high in prevention focus. A meta-analysis across the three studies indicated that self-affirmation improved intentions and willingness under high, but not low, prevention focus (d = 0.20, p = .003).\ud \ud Conclusion\ud These findings demonstrate that health prevention-focus can strengthen self-affirmation’s effects, thereby improving responsiveness to health communications about behaviors that increase disease risk.

Introduction Many service members experiencing symptoms of mental health conditions do not receive mental health care for these symptoms. The stigma associated with having a mental health condition or seeking treatment is often cited as a specific barrier to mental health care. However, study results bearing on the question of whether and how stigma may reduce treatment-seeking have been inconsistent. Methods We searched 10 databases for sources published between 2004 and 2014 that prospectively linked stigma to treatment-related outcomes (such as treatment seeking, retention, and reports of symptoms) using longitudinal data and predictive models. The searches yielded 2,409 sources. After reviewing titles and abstracts for relevance, we retained 15 sources to undergo full-text review. Results Overall, this review illustrates that evidence exploring the direct effect of stigma on treatment-related outcomes is still scant. We identified two studies whose outcomes conflict when it comes to stigma and treatment-initiation and utilization, and three studies found no relationship between stigma and treatment-initiation and utilization. One study suggested that the relationship between stigma and experience of symptoms is nuanced and may depend on the type of stigma and types of symptoms considered. Meager evidence was available to inform the relationship between stigma and treatment duration, attrition, and quality of life/functioning. The evidence was not sufficient to draw conclusions about the state of these relationships. No conclusions could be made about the direct impact of stigma on treatment-related outcomes among military service members given that only two studies explored this relationship among military service members. Conclusion Current research does not provide a true understanding of the degree to which mental illness stigma affects treatment-related outcomes for service members experiencing mental health challenges. This understanding could only be developed through a longitudinal study assessing prospectively whether stigma affects treatment-utilization in the military. Should such a study show that stigma reduces treatment-utilization, the military would need to consider whether changes to their current approaches to stigma reduction are warranted.

Rationale Regulatory focus (i.e., focus on motivation to achieve gains or avoid losses and non-gains) is used to tailor health behavior change interventions, improving efficacy, but is currently assessed by scales that are not health-specific and may capture a version of the construct that is not ideally matched to the rationale for tailoring. Objective We developed and validated a Health Regulatory Focus Scale (HRFS), which assesses tendencies to avoid negative health consequences (prevention focus) or achieve positive health outcomes (promotion focus). Methods Across four studies (and a scale development study in supplementary online materials), we established convergent, discriminant, and predictive validity for the HRFS. In studies examining predictive validity, main outcome measures were health behavior intentions, including intentions to reduce alcohol use, quit smoking, eat a healthy diet, exercise, be screened for cancer, and engage in general cancer preventive behaviors. Results The promotion and prevention sub-scales performed well in confirmatory factor analyses. Single-factor models had significantly poorer fit than models delineating promotion and prevention. The sub-scales were differentially (and only modestly) correlated with related constructs (anxiety, optimism, information avoidance, ambiguity/fatalism). Higher HRFS-Promotion focus generally corresponded with greater health behavior intentions. Conversely, higher HRFS-Prevention focus corresponded with lower health behavior intentions. Associations were largely maintained even when controlling for established regulatory focus measures, supporting the assertion that the HRFS would predict unique variance in health behavior intentions. Conclusion The HRFS has the potential to improve the precision with which framed health messages change behavior, as it may assess a version of regulatory focus that is more ideally matched to rationale for tailoring interventions.

This brief is one in a series examining mental health public awareness campaigns' messages, consistency of messaging in their materials, and tools used to deliver content to audiences. This brief discusses materials from Recovery Month.

This brief is one in a series examining mental health public awareness campaigns' messages, consistency of messaging in their materials, and tools used to deliver content to audiences. This brief discusses materials from the Veterans Crisis Line.

Tools for Life® (TFL) is a program designed to improve school climate and safety through the proactive development of elementary and middle school students' social and emotional skills. The authors of this report describe the implementation of TFL in the Jackson (Mississippi) Public School District, calculate its costs, and evaluate the program's effectiveness.

This brief describes the results of an interim evaluation that examined the scope, content, and dissemination of mental health public awareness campaigns. RAND researchers conducted a comprehensive evaluation of four such efforts.

This brief describes the implementation of Tools for Life®, a social and emotional learning program, in elementary and middle schools in Jackson, Mississippi, and evaluates the program's effects on school climate and safety.

This brief is one in a series examining mental health public awareness campaigns' messages, consistency of messaging in their materials, and tools used to deliver content to audiences. This brief discusses materials from the Make the Connection.

This brief is one in a series examining mental health public awareness campaigns' messages, consistency of messaging in their materials, and tools used to deliver content to audiences. This brief discusses materials from the Real Warrior Campaign.

Patient narratives have emerged as promising vehicles for making health care more responsive by helping clinicians to better understand their patients’ expectations, perceptions, or concerns and encouraging consumers to engage with information about quality. A growing number of websites incorporate patients’ comments. But existing comments have fragmentary content, fail to represent less vocal patients, and can be manipulated to “manage” providers’ reputations. In this article, we offer the first empirical test of the proposition that patient narratives can be elicited rigorously and reliably using a five-question protocol that can be incorporated into large-scale patient experience surveys. We tested whether elicited narratives about outpatient care are complete (report all facets of patient experience), balanced (convey an accurate mix of positive and negative events), meaningful (have a coherent storyline), and representative (draw fulsome narratives from all relevant subsets of patients). The tested protocol is strong on balance and representativeness, more mixed on completeness and meaningfulness.

The aim of this study was to examine two under-studied factors integral to the theoretical underpinnings of contact-based mental illness stigma reduction programs: the quality of the contact and prior personal experience with persons with mental health problems. This study utilized pre- and post-survey data collected from 4122 individuals participating in a diverse set of contact-based educational programs implemented as part of California's statewide initiative to reduce mental illness stigma. Multi-level mixed regression models were used to determine whether pre-post changes in a variety of stigma-related measures varied depending on perceived quality of contact and prior personal experience with mental illness. Significant pre-post reductions in stigma were observed, but individual perceptions of contact quality strongly moderated program effects. Mean contact quality across all attendees at a presentation was rarely a moderator. Though effective for all participants, on average, contact-based educational programs were more effective for those without prior personal or family experience of mental illness. Program organizers may wish to target recruitment efforts to reach more individuals without such experience, given the greater effectiveness of contact among these individuals. More research should explore the factors underlying individual variation in perceived quality of contact-based stigma reduction programs.

Mental illness stigma disproportionately affects help seeking among youth, men, and ethnic minorities. As part of a comprehensive statewide initiative to reduce mental illness stigma and discrimination in California, a broad set of contact-based educational programs were widely disseminated. This study examined whether the effects of contact-based educational programs varied depending on the age, gender, and race-ethnicity of participants. Participants (N = 4122) attended a contact-based educational program that was delivered as part of the statewide initiative to reduce mental illness stigma and discrimination. Self-administered surveys assessing beliefs, attitudes, and intentions toward mental illnesses and treatment were conducted immediately before and after participation in contact-based educational programs. Participant age, gender, and race-ethnicity significantly moderated pre–post changes in mental illness stigma. Although all groups exhibited significant pre–post changes across most of the stigma domains assessed, young adults, females, and Asian and Latino American participants reported larger improvements compared to older adults, males, and Whites, respectively. Findings suggest that contact-based educational programs can achieve immediate reductions in mental illness stigma across a variety of sociodemographic groups and may particularly benefit young adults and racial–ethnic minorities. Further research is needed to assess whether contact-based educational programs can sustain longer-term changes and aid in the reduction of disparities in mental illness stigma and treatment.

Introduction Negative psychosocial expectancies of smoking include aspects of social disapproval and disappointment in oneself. This paper describes analyses conducted to develop and evaluate item banks for assessing psychosocial expectancies among daily and nondaily smokers. Methods Using data from a sample of daily (N = 4,201) and nondaily (N =1,183) smokers, we conducted a series of item factor analyses, item response theory analyses, and differential item functioning analyses (according to gender, age, and race/ethnicity) to arrive at a unidimensional set of psychosocial expectancies items for daily and nondaily smokers. We also evaluated performance of short forms (SFs) and computer adaptive tests (CATs) to efficiently assess psychosocial expectancies. Results A total of 21 items were included in the Psychosocial Expectancies item banks: 14 items are common across daily and nondaily smokers, 6 are unique to daily, and 1 is unique to nondaily. For both daily and nondaily smokers, the Psychosocial Expectancies item banks are strongly unidimensional, highly reliable (reliability = 0.95 and 0.93, respectively), and perform similarly across gender, age, and race/ethnicity groups. A SF common to daily and nondaily smokers consists of 6 items (reliability = 0.85). Results from simulated CATs showed that, on average, fewer than 8 items are needed to assess psychosocial expectancies with adequate precision when using the item banks. Conclusions Psychosocial expectancies of smoking can be assessed on the basis of these item banks via the SF, by using CAT, or through a tailored set of items selected for a specific research purpose.

Introduction Smokers' health-related outcome expectancies are associated with a number of important constructs in smoking research, yet there are no measures currently available that focus exclusively on this domain. This paper describes the development and evaluation of item banks for assessing the health expectancies of smoking. Methods Using data from a sample of daily (N = 4,201) and nondaily (N = 1,183) smokers, we conducted a series of item factor analyses, item response theory analyses, and differential item functioning analyses (according to gender, age, and race/ethnicity) to arrive at a unidimensional set of health expectancies items for daily and nondaily smokers. We also evaluated the performance of short forms (SFs) and computer adaptive tests (CATs) to efficiently assess health expectancies. Results A total of 24 items were included in the Health Expectancies item banks; 13 items are common across daily and nondaily smokers, 6 are unique to daily, and 5 are unique to nondaily. For both daily and nondaily smokers, the Health Expectancies item banks are unidimensional, reliable (reliability = 0.95 and 0.96, respectively), and perform similarly across gender, age, and race/ethnicity groups. A SF common to daily and nondaily smokers consists of 6 items (reliability = 0.87). Results from simulated CATs showed that health expectancies can be assessed with good precision with an average of 5-6 items adaptively selected from the item banks. Conclusions Health expectancies of smoking can be assessed on the basis of these item banks via SFs, CATs, or through a tailored set of items selected for a specific research purpose.

Purpose – Interest in using mindfulness as a clinical intervention technique has increased, with evidence suggesting that it can be successfully integrated both into treatment for adolescents and for people with substance use disorders. The purpose of this paper is to explore the degree to which mindfulness training can be implemented among adolescents undergoing residential substance abuse treatment. Design/methodology/approach – Nine adolescent males in a residential therapeutic community (TC) substance use treatment center enrolled in a voluntary mindfulness training program consisting of eight 90 minute sessions, each led by a clinical psychologist trained in mindfulness-based stress reduction. After the training program concluded, a brief participant survey and participant and staff focus groups were conducted. Findings – Both survey and focus group discussions indicate that the mindfulness training program was perceived as helpful, acceptable, and feasible. Suggestions for integrating mindfulness training into residential treatment facilities for adolescents are discussed. Originality/value – This study highlights the potential of mindfulness training to augment traditional TC treatment for adolescents, and provides enough information for practitioners to implement mindfulness training in their treatment settings.

Provides a detailed methodological overview of the SelectMD 2.0 provider choice experiment.

We examined whether self-affirmation would facilitate intentions to engage in colorectal cancer (CRC) screening among individuals who were off-schedule for CRC screening and who were categorized as unrealistically optimistic, realistic, or unrealistically pessimistic about their CRC risk. All participants received tailored risk feedback; in addition, one group received threatening social comparison information regarding their risk factors, a second received this information after a self-affirmation exercise, and a third was a no-treatment control. When participants were unrealistically optimistic about their CRC risk (determined by comparing their perceived comparative risk to calculations from a risk algorithm), they expressed greater interest in screening if they were self-affirmed (relative to controls). Non-affirmed unrealistic optimists expressed lower interest relative to controls, suggesting that they were responding defensively. Realistic participants and unrealistically pessimistic participants who were self-affirmed expressed relatively less interest in CRC screening, suggesting that self-affirmation can be helpful or hurtful depending on the accuracy of one’s risk perceptions.

The influence of incidental emotion on responsiveness to risk feedback was investigated. One hundred and eighty‐seven male and female undergraduate students experienced a film emotion induction procedure to elicit happiness, sadness, or neutral affect. They then received false feedback indicating that their risk of getting a fictional type of influenza was high or low, and were given the chance to obtain more information about this type of flu and how to prevent it. Among low‐risk participants, experiencing any emotion (happy or sad) resulted in obtaining more information than those in the neutral condition. Conversely, high‐risk participants who experienced any emotion took less information than those in the neutral group. High‐risk feedback produced less positive affect, more negative affect and worry, and higher risk perceptions than low‐risk feedback. The findings have implications for how threatening risk feedback will affect information seeking behavior in the context of an emotional state.

Much research in the decision sciences has shown that risk perception and decision-making are influenced not only by cognitive processes – such as the use of statistical ‘rules of thumb’– but also by motives such as loss aversion, ambiguity aversion, and regret aversion. The field of social psychology has long been interested in a variety of motives that influence self-judgment, social perception, and interpersonal relations. These include, among others, self-enhancement, social comparison, predictability/control, favorable self-presentation, effective resource management, preparedness for bad news, goal attainment, and existential meaning. We suggest that more attention to these motives would greatly strengthen our understanding of how people think about risk and how they make decisions. In this article, we consider the influence of motives on risk perception and decision-making in the context of health outcomes. We argue that theories relating to these various motives (e.g., social comparison theory) can be greatly enhanced by testing them in the context of health-related risk perception and decision-making.

This article describes the results of RAND's evaluation of the San Francisco-based Center for Dignity, Recovery, and Empowerment's technical assistance program for stigma-reduction programs through interviews with community-partner participants.

Reports on an evaluation of online resources developed by the California Mental Health Services Authority's stigma and discrimination reduction initiative program partners and provides an overview of these resources and the use of partner websites.

Describes the methods and results of a RAND evaluation of stigma and discrimination reduction trainings delivered by two program partners, Disability Rights California and Mental Health America of California.

Describes the methods and results of a RAND evaluation of stigma and discrimination reduction efforts by Runyon Saltzman Einhorn, Inc., involving screenings of a documentary film called "A New State of Mind: Ending the Stigma of Mental Illness."

This fact sheet summarizes the first-year evaluation of California's Stigma and Discrimination Reduction Initiative.

This fact sheet assesses the progress that partners in California's Prevention and Early Intervention (PEI) Program have made so far in developing capacities and reaching Californians in accordance with the statewide strategic PEI plan.

California's Mental Health Services Act of 2004 mandates the state and counties to develop mental health prevention and early intervention services and education. This document summarizes first-year findings from an ongoing evaluation of one element of that program, an initiative to reduce stigma and discrimination toward those with mental illness.

The authors review data on the prevalence of youth mental health disorders and schools' use of student mental health (SMH) programs. They also describe the role of schools in addressing SMH concerns and outline a conceptual model for guiding evaluation of SMH programs. Finally, they touch on issues related to evaluation of cross-system collaborations that can influence students' access to resources and services and then review some of the challenges associated with evaluating SMH programs. They determine that SMH programs can be effective and can improve staff, faculty, and student knowledge of mental health problems; provide skills for identifying and referring students with mental health and social and emotional difficulties; and change attitudes toward mental health problems.

A number of programs aim to reduce the stigma and discrimination associated with mental illness, and they can include a variety of components such as training, education, media campaigns, and contact with people with mental illness. Stigma and discrimination reduction activities are evaluated in this article, using evidence from an extensive literature review. Specific areas reviewed include relevant theories of stigma and prejudice reduction, what is and is not known about the effectiveness of various approaches to reducing the stigma of mental illness, the kinds of methodologies previously used in evaluating these approaches, and the methodologies that should be employed in the future. The authors also introduce a conceptual model of mental health stigma reduction based on a variety of existing theories and evidence.