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Women who are deaf experience higher rates of reproductive healthcare barriers and adverse birth outcomes compared with their peers who can hear. This study explores the pregnancy experiences of women who are deaf to better understand their barriers to and facilitators of optimal pregnancy-related health care.Qualitative study using thematic analysis.Semi-structured, individual, remote or in-person interviews conducted in the USA.Forty-five women who are deaf and communicate using American Sign Language (ASL) and gave birth in the USA within the past 5 years participated in the interviews.Semi-structured interviews explored how mothers who are deaf experienced pregnancy and birth, including access to perinatal information and resources, relationships with healthcare providers, communication access and their involvement with the healthcare system throughout pregnancy. A thematic analysis was conducted.Barriers and facilitators related to a positive experience of perinatal care access among women who are deaf.Three major themes emerged: (1) communication accessibility; (2) communication satisfaction; and (3) healthcare provider and team support. Common barriers included choosing healthcare providers, inconsistent communication access and difficulty accessing health information. However, when women who are deaf were able to use ASL interpreters, they had more positive pregnancy and birth experiences. Self-advocacy served as a common facilitator for more positive pregnancy and healthcare experiences.Healthcare providers need to be more aware of the communication and support needs of their patients who are deaf, especially how to communicate effectively. Increased cultural awareness and consistent provision of on-site interpreters can improve pregnancy and birth experiences for women who are deaf.

As recent as the mid-twentieth century, eugenics practices on women with intellectual and developmental disabilities were commonplace. Deinstitutionalization has led to an increasing proportion of women with intellectual and developmental disabilities living in the community and becoming pregnant. Previous research has reported barriers to maternal health care (i.e., perceived provider stigma, inadequate communication, stress surrounding child protective services involvement, and financial strain). Research shows that this population is at increased risk of adverse outcomes including preterm delivery, low birth weight babies, and maternal mortality.This study aimed to explore recommendations from mothers with intellectual and developmental disabilities for other women to potentially improve pregnancy experiences for this population.We conducted semi-structured individual interviews among 16 women with intellectual and developmental disabilities. Data were coded using a content analysis process and iteratively analyzed using inductive and deductive techniques to determine emergent themes.Participants offered recommendations for navigating pregnancy to their peers who are pregnant, or thinking about becoming pregnant. Themes included: (1) planning for birth; (2) advocating at the point-of-care; (3) seeking supports and services; (4) interacting with child protective services; (5) communicating with providers; and (6) exhibiting resilience.Our study highlights recommendations for improving pregnancy experiences of women with intellectual and developmental disabilities. Informed by the lived pregnancy experiences of our participants, these recommendations can inform clinician training, new guidelines, and services to support and improve pregnancy experiences for women with intellectual and developmental disabilities.

BACKGROUND: Women with intellectual and developmental disabilities (IDD) experience disparities in obstetric care access and quality, in addition to communication gaps with healthcare providers. Many obstetric providers are untrained and uneducated about critical aspects of providing care to persons with IDD. OBJECTIVE: The study was conducted to describe obstetric clinicians’ training experiences related to providing obstetric care to women with IDD, to assess the perceived need for formalized training, and to identify recommendations for training content. METHODS: This study involved qualitative individual interviews (n=9) and one focus group (n=8) with obstetric clinicians who self-reported experience caring for women with IDD during pregnancy. Descriptive coding and content analysis techniques were used to develop an iterative codebook related to education and training; codes were applied to the data. Coded data were analyzed for larger themes and relationships. RESULTS: Analysis revealed three main themes: 1. Need for obstetric training and education: No participant reported receiving any training in caring for pregnant women with IDD. Participants expressed a need for formal education. 2. Recommendations for formal training: Participants noted the need for training during residency and beyond, and all healthcare staff should be included in training. 3. Training outcomes should increase knowledge, enhance attitudes, and develop practical skills related to care for pregnant women with IDD. CONCLUSION: Results indicate a need for systematic training efforts regarding obstetric care for women with IDD. Improved training and education may decrease health inequities and improve the quality of care, and thus pregnancy outcomes, for women with IDD. LEVEL OF EVIDENCE: VI

The behavior at bifurcation from global synchronization to partial synchronization in finite networks of coupled oscillators is a complex phenomenon, involving the intricate dynamics of one or more oscillators with the remaining synchronized oscillators. This is not captured well by standard macroscopic model reduction techniques which capture only the collective behavior of synchronized oscillators in the thermodynamic limit. We introduce two mesoscopic model reductions for finite sparse networks of coupled oscillators to quantitatively capture the dynamics close to bifurcation from global to partial synchronization. Our model reduction builds upon the method of collective coordinates. We first show that standard collective coordinate reduction has difficulties capturing this bifurcation. We identify a particular topological structure at bifurcation consisting of a main synchronized cluster, the oscillator that desynchronizes at bifurcation, and an intermediary node connecting them. Utilizing this structure and ensemble averages we derive an analytic expression for the mismatch between the true bifurcation from global to partial synchronization and its estimate calculated via the collective coordinate approach. This allows to calibrate the standard collective coordinate approach without prior knowledge of which node will desynchronize. We introduce a second mesoscopic reduction, utilizing the same particular topological structure, which allows for a quantitative dynamical description of the phases near bifurcation. The mesoscopic reductions significantly reduce the computational complexity of the collective coordinate approach, reducing from $\mathcal{O}(N^2)$ to $\mathcal{O}(1)$. We perform numerical simulations for Erd\H{o}s-R\'enyi networks and for modified Barab\'asi-Albert networks demonstrating excellent quantitative agreement at and close to bifurcation.

Background: The benefits of breastfeeding are well established, and breastfeeding is now widely practiced in the United States. Although increasing numbers of women with physical disabilities are having children, little information is available about breastfeeding practices among these women. Nonetheless, the children of women with physical disabilities should benefit from breastfeeding just as children of nondisabled mothers do. Research aim: This study aimed to explore the facilitators and barriers to breastfeeding among women with physical disabilities. Methods: This study involved semistructured telephone interviews with a convenience sample of women ( N = 25) with diverse physical disabilities from across the United States. All participants had given birth within the past 10 years. Interviews were audio-recorded, professionally transcribed, and analyzed using content analysis. Results: Analyses found four broad themes indicating facilitators to breastfeeding: (a) adaptations and equipment, (b) use of breast pump, (c) physical assistance from others, and (d) peer support. We also found five broad themes suggesting barriers to breastfeeding: (a) lack of supports, (b) disability-related health considerations, (c) limited information, (d) difficulties with milk production, and (e) difficulties latching. Conclusion: The need for greater supports for women with physical disabilities who desire to breastfeed as well as information for women and their clinicians about facilitating breastfeeding.

Women with physical disabilities increasingly aspire to become pregnant and bear children. Limited information about the potential interaction of their disabling conditions with pregnancy and childbirth exists to guide these women and their clinicians.The interview guide was created with questions on topics such as pregnancy complications and secondary conditions, the impact of prior surgeries, experiences with pain relief during labor, and the impact on women's independence and participation in life activities. Interviews were conducted by telephone with 25 women with physical disabilities. They were subsequently transcribed verbatim and analyzed by using Atlas TI.Women generally reported a relatively modest impact of disabling conditions on their pregnancies. Most women were satisfied with the mode of delivery, but they experienced challenges during the labor and delivery process. The women found that careful advanced planning was helpful in managing the impact of their disabling conditions. The involvement of clinicians with disability-related expertise was, in some cases, another factor that contributed to a positive outcome.The importance of advanced planning and the utility of involving clinicians with disability-related expertise suggest that the use of integrated, interdisciplinary team approaches could promote quality care by facilitating improved planning and management. Additional clinical research is needed to provide women and their clinicians with more information on potential complications and options for labor and delivery.

Background Childbirth is widely acknowledged as one of the most painful experiences most women will undergo in their lifetimes. Alleviating labor and delivery pain for women with physical disabilities can involve an additional level of complexity beyond that experienced by most women, but little research has explored their experiences. Objective The purpose of this study was to explore the experiences of women with physical disabilities with respect to pain relief during labor and delivery with the goal of informing their care. Methods Data were collected using semi-structured interviews with twenty-five women with physical disabilities from across the United States. Results Women expressed specific preferences for the method of pain relief. Some confronted systemic barriers in exploring their options for pain relief, while others were given a choice. At times, anesthesiologists lacked knowledge and experience in caring for women with disabilities. Conversely, some women described how the administration of anesthesia was meticulously planned and attributed their positive labor and delivery experiences to this careful planning. Conclusions Advanced, individualized planning and evaluation of their options for pain relief was most satisfying to women and enabled them to make an informed choice. This approach is consistent with the recommendations of clinicians who have successfully provided pain relief during labor to women with complex physical disabilities. Clinicians who have successfully delivered babies of women with these and similar disabilities emphasize the importance of a team approach where the anesthesiologist and other specialists are involved early on in a woman's care.

Background Despite concerns raised in the literature on the adverse pregnancy outcomes of women with physical disabilities, there is little information about unmet needs of women with physical disabilities during pregnancy and childbirth. Objective This article provides an in-depth examination of unmet health care needs during and around the time of pregnancy among a sample of women with physical disabilities. It also offers recommendations to other women with physical disabilities who are considering pregnancy. Methods Twenty-five phone interviews were conducted with women with physical disabilities from across the United States who had a baby in the past ten years. Individual semi-structured qualitative interviews lasting about 2 h were conducted. Interviews were audio-recorded, transcribed, and analyzed using an iterative, interpretive process. Results Women reported a wide range of disabling conditions. Analysis revealed three broad themes related to unmet needs during pregnancy among women with physical disabilities. They included (1) clinician knowledge and attitudes, (2) physical accessibility of health care facilities and equipment, (3) need for information related to pregnancy and postpartum supports. The women also provided recommendations to other women with disabilities who are currently pregnant or thinking of becoming pregnant. Recommendations related to finding a clinician one trusts, seeking peer support, self-advocating, and preparing oneself for the baby. Conclusions This study sheds light on the unmet needs and barriers to care of women with mobility disabilities during pregnancy and childbirth. The study findings highlight the need for policy and practice recommendations for perinatal care of women with mobility disabilities.

There is a paucity of information concerning adaptive parenting strategies utilised by mothers with physical disabilities, particularly during early motherhood. The purpose of this study is to describe the adaptive strategies used by mothers with physical disabilities during early motherhood. This qualitative study included semi-structured telephone interviews between January and March 2014 with US mothers with a range of physical disabilities who had a baby within the past 10 years (N = 25). Interviews were audio-recorded, professionally transcribed, and coded using content analysis. Analysis revealed five broad themes indicating important adaptive parenting strategies for mothers with physical disabilities caring for infants and toddlers: They are as follows: (a) acquiring or modifying baby-care equipment, (b) adapting the home environment, (c) accessing information and supports, (d) developing communication strategies to facilitate safety, and (e) receiving assistance from others. This study indicates that mothers with physical disabilities employ a variety of adaptive strategies during early motherhood. The findings from the study suggest the need for more availability of supports and equipment for mothers with physical disabilities as well as information for prospective mothers with disabilities. In addition, healthcare and social work professionals must receive training about adaptive parenting strategies.

Objective The objective of this study was to compare the prevalence of select preconception health indicators among women with and without disabilities. Methods 2010 Behavioral Risk Factor Surveillance System data were used to estimate the prevalence of health behaviors, health status indicators, and preventive health care among non-pregnant women ages 18–44 years with (N = 8370) and without (N = 48,036) disabilities. Crude percentages were compared with Chi square statistics. Multivariable logistic regressions adjusted for socio-demographic factors. Results Women with disabilities were more likely than women without disabilities to currently smoke (30.5 vs. 14.5 %, p

Background Women with physical disabilities (WPD) experience major barriers to care during pregnancy. Lack of education about disability in health professionals' education is a pervasive barrier to quality care. In an effort to explore this issue, this study examined the issue from the perspective of obstetric clinicians who provide care to WPD. Objective This qualitative descriptive study explored perspectives of obstetric clinicians who provide perinatal care for WPD to inform the educational preparation of clinicians to care for women with disabilities. Method We contacted 33 obstetric clinicians who care for pregnant WPD. Thirteen obstetricians and one nurse midwife participated in semi-structured telephone interviews. Interview transcriptions were content analyzed to identify initial themes. Investigators discussed and revised the themes as additional transcripts were reviewed and new themes were identified. Results Themes identified from transcript analyses included: lack of education at any level including during postgraduate residency and fellowship on care of pregnant WPD, unplanned career pathway, educating other clinicians, and positive and negative experiences providing obstetrical care to women with physical disability. Several clinicians provided this care because of requests from other clinicians and did not begin their careers with the goal of providing obstetric care to women with physical disabilities. None had received formal education or training including during their residencies or fellowships. The clinicians described very rewarding experiences caring for WPD. Conclusions The experiences reported by this study's participants suggest the need to include disability in undergraduate and postgraduate education and training to improve obstetric care to WPD.

This paper explores how stakeholder expectations are managed through the social entrepreneurship process of opportunity construction, evaluation and pursuit. Building on an in-depth case study, a model of stakeholder engagement through identity, governance and legitimacy is presented. Stakeholders are managed by an identity constructed through an integration of the organization's multiple identities to form a meta-identity. Governance is important in the management of stakeholders in order to be entrepreneurial while being accountable. Stakeholders support the organization based on legitimacy that is gained through creating stakeholder value and by conforming to existing social structures as well as creating new operating models, practices and ideas.

Despite potential advantages in scalability and efficiency of web-based training for trauma providers, few controlled trials of feasibility and effectiveness of web-based mental health training have been performed. Our study compared web-based training in 3 intervention skills (motivation enhancement [ME], goal setting [GS], behavioral task assignment [BTA]) with web-based training plus telephone consultation, and a no-training control. The primary outcome measures included objective measures of skills acquisition (standardized patient assessments). Results showed significant differences among the training conditions. The overall tests of differences among the groups were statistically significant for ME and BTA skills (p < .001 and p = .005, respectively), but not for GS (p = .245). The web training plus consultation group improved in ME skills by 0.35 units compared to 0.12 units in the web only group (p < .001) and no change in the control group (p = .001). For BTA skills, the web training plus consultation improved by 0.27 units compared to 0.17 units in the web only group (p = .175) and no change in the control group (p = .004). Overall, these findings support the use of web-based dissemination for large-scale training programs for trauma providers in health care delivery systems. Further studies are needed to clarify the specific role of consultation as an adjunct to web-based training. Resumen A pesar de las ventajas potenciales en escalabilidad y eficiencia de los entrenamientos basados en la web para proveedores de trauma, pocas investigaciones controladas de la factibilidad y efectividad de entrenamiento basado en la web en salud mental han sido realizadas. Nuestro estudio compara el entrenamiento basado en la web en 3 habilidades de intervencion (aumento de la motivacion (AM), establecimiento de objetivos (EO), asignacion de tareas conductuales (ATC) con entrenamiento basado en la web mas consulta telefonica y un control sin entrenamiento. Las principales medidas resultantes incluyeron mediciones objetivas de la adquisicion de habilidades (evaluaciones estandarizadas de los pacientes). Los resultados muestran diferencias significativas entre las condiciones de entrenamiento. Las pruebas generales de diferencias entre grupos fueron estadisticamente significativas para habilidades AM y ATC (p

Background and Methods: The authors designed and delivered an innovative Web course on cognitive behavioral therapy (CBT), a specific empirically based treatment, to a diverse group of addiction counselors and supervisors in 54 addiction units across the country, and conducted a randomized controlled trial of its effectiveness with 127 counselors. The primary focus of the trial was to assess “adequate adherence to CBT practice” after training as judged by raters blinded to training condition who listened to audiotapes of actual client sessions. Counselors who passed were judged to satisfy 2 criteria: (a) low pass or greater on at least 1 of 3 “CBT-generic skills” assessing session structure; and (b) low pass or greater on at least 1 of 3 “CBT-specific skills” related to use of functional analysis, cognitive skills practice, or behavioral skills practice. Results: Although the counselors’ use of CBT skills in sessions increased after Web course training, it was not statistically significant and not larger than the gain of control-group counselors trained with a written CBT manual.

Background Women with physical disabilities are known to experience disparities in maternity care access and quality, and communication gaps with maternity care providers, however there is little research exploring the maternity care experiences of women with physical disabilities from the perspective of their health care practitioners. Objective This study explored health care practitioners' experiences and needs around providing perinatal care to women with physical disabilities in order to identify potential drivers of these disparities. Methods We conducted semi-structured telephone interviews with 14 health care practitioners in the United States who provide maternity care to women with physical disabilities, as identified by affiliation with disability-related organizations, publications and snowball sampling. Descriptive coding and content analysis techniques were used to develop an iterative code book related to barriers to caring for this population. Public health theory regarding levels of barriers was applied to generate broad barrier categories, which were then analyzed using content analysis. Results Participant-reported barriers to providing optimal maternity care to women with physical disabilities were grouped into four levels: practitioner level (e.g., unwillingness to provide care), clinical practice level (e.g., accessible office equipment like adjustable exam tables), system level (e.g., time limits, reimbursement policies), and barriers relating to lack of scientific evidence (e.g., lack of disability-specific clinical data). Conclusion Participants endorsed barriers to providing optimal maternity care to women with physical disabilities. Our findings highlight the needs for maternity care practice guidelines for women with physical disabilities, and for training and education regarding the maternity care needs of this population.

Background Historically, people with disabilities who become parents have confronted discriminatory societal attitudes and public policies. Today, although more women with disabilities are bearing children, little is known about the perceptions of their pregnancies, even among their family members. In addition, little is understood about how family members’ attitudes and reactions affect women with physical disabilities around the time of pregnancy. Method This qualitative study involved interviews with 25 women with physical disabilities from across the United States who had a baby within the past 10 years. Semistructured telephone interviews were conducted. Interviews were audio-recorded, professionally transcribed, and analyzed using an iterative, interpretive process. Findings Women reported a wide range of physical disabilities. Before, during, and after pregnancy, participants reported experiencing wide-ranging attitudes and reactions from family members concerning their pregnancies. These responses fell into six categories: 1) initial negative reactions, 2) concern about mother's well-being, 3) questioning of parenting capability, 4) negative perceptions of disability, 5) genetic concerns, and 6) excited and supportive. Conclusions This study sheds light on the attitudes and reactions toward pregnancy that women with physical disabilities experience from family members. Our findings suggest the need for increased social support and family education. Greater availability of peer supports as well as information for women with disabilities considering pregnancy is also needed.

Objective To explore the perinatal experiences of women with physical disabilities (WWPD) and their associated recommendations for maternity care clinicians to improve care. Design A mixed-methods study was conducted with a semistructured interview guide to identify the experiences of WWPD. This qualitative descriptive study was part of a larger study of the unmet needs and barriers to perinatal care experienced by WWPD Setting Telephone interview. Participants Twenty-five women with physical disabilities who gave birth within the last 10 years and were 21 to 55 years of age were recruited and agreed to participate in the study. Methods Participants were asked about their interactions with clinicians during pregnancy and their recommendations for clinicians to improve perinatal care for women with physical disabilities. Content analysis was used to analyze transcribed interviews. Themes that emerged from analysis of the interviews were identified and coded. Kurasaski's coding was used to establish the reliability of the coding. Results Three themes emerged from analysis of the interview data: Clinicians' lack of knowledge about pregnancy-related needs of WWPD; Clinicians' failure to consider women's knowledge, experience, and expertise about their own disabilities; and Clinicians' lack of awareness of the reproductive concerns of WWPD. Women provided recommendations that warrant attention from clinicians who provide perinatal care for women who live with physical disabilities. Conclusion Participants experienced problematic interactions with clinicians related to pregnancy and identified recommendations for maternity care clinicians to address those problems with the goal of improving perinatal health care for WWPD.

Objectives The aim of this study was to examine barriers to the use of electronic diaries within the clinic setting and determine outcome differences between patients who used electronic diaries to monitor their progress with summary data feedback and patients who monitored their progress with paper diaries without summary data feedback. Methods One hundred thirty-four (n=134) chronic pain patients were asked to monitor their pain, mood, activity interference, medication use, and pain location on either a paper or electronic diary immediately before each monthly clinic visit for 10 months. Patients and their treating physicians in the electronic diary group (n=67) were able to observe changes in their ratings whereas patients using the paper diaries (n=67) had no feedback about their data entry. Results Most participants believed that completing pain diaries was beneficial; yet, only 23% of patients in the experimental condition felt that the data from the electronic diaries improved their care and less than 15% believed that their doctor made a change in their treatment based on the summary diary information. Conclusion In general, treating physicians were positive about the use of electronic diaries, although they admitted that they did not regularly incorporate the summary data in their treatment decision making because either they forgot or they were too busy. Future studies in understanding barriers to physicians' and patients' use of diary data to impact treatment outcome are needed to improve care for persons with chronic pain.

This study demonstrates that reliable sex differences in nociceptive and antinociceptive mechanisms are present in even very young subjects. Sex differences were observed in mice tested either on the day of birth or 1 week later on basal tail-flick latency and morphine analgesic magnitude. Female mice had longer tail-withdrawal latencies; male mice demonstrated stronger analgesic responses to morphine. In addition, basal pain behavior and analgesic responsiveness differed between day-old and week-old animals on the hot plate, with day-old mice showing enhanced pain behavior and reduced morphine antinociception compared to week-old subjects. These findings further support the competence of pain processing circuitry in even very young subjects and highlight the early development of nociceptive and antinociceptive mechanisms. Perspective This study highlights the competence of nociceptive circuitry and the analgesic efficacy of morphine as early as the day of birth in mice, reinforcing the importance of evaluating and treating pain in even the youngest subjects. Sex differences were present, suggesting infant sex as one of several potential factors that predict the experience of procedural or pathological pain and analgesic requirement.

Despite potential advantages in scalability and efficiency of web-based training for trauma providers, few controlled trials of feasibility and effectiveness of web-based mental health training have been performed. Our study compared web-based training in 3 intervention skills (motivation enhancement [ME], goal setting [GS], behavioral task assignment [BTA]) with web-based training plus telephone consultation, and a no-training control. The primary outcome measures included objective measures of skills acquisition (standardized patient assessments). Results showed significant differences among the training conditions. The overall tests of differences among the groups were statistically significant for ME and BTA skills (p.001 and p = .005, respectively), but not for GS (p = .245). The web training plus consultation group improved in ME skills by 0.35 units compared to 0.12 units in the web only group (p.001) and no change in the control group (p = .001). For BTA skills, the web training plus consultation improved by 0.27 units compared to 0.17 units in the web only group (p = .175) and no change in the control group (p = .004). Overall, these findings support the use of web-based dissemination for large-scale training programs for trauma providers in health care delivery systems. Further studies are needed to clarify the specific role of consultation as an adjunct to web-based training.

This article describes (a) a Web-based course for substance abuse counselors on cognitive behavioral therapy (CBT), and (b) the evaluation of a prototype module from the Web-based course to determine the feasibility of the e-learning program for a community-based counselor audience. The course is part of a unique study that trains counselor-supervisor teams to increase the transfer of learned skills to the agency. Following curriculum design, the authors sought counselor reactions to the prototype module on strengths/limitations of the design, functionality, and effectiveness. Results showed that counselors learned new information, found this format effective compared to other training, and wanted to complete a full CBT Web course. Counselors’ evaluation led to content and technology changes: the authors added and segmented material aimed at the advanced, more theoretically oriented counselor, and housed these topics behind an “advanced concept” graphics button; added seven screens to accommodate text broken into smaller units; and increased the difficulty of the end-of-module quiz.

The long-term consequences of neonatal noxious stimulation on adulthood pain behavior were investigated in male and female mice. On the day of birth, mouse pups were exposed to a laparotomy under cold anesthesia followed by an analgesic dose of morphine (10 mg/kg) post-operatively, or a saline control. An additional group of subjects was exposed to the non-noxious aspects of the surgical procedure (cold exposure, separation from the dam, injection) comprising a 'sham' surgery control group, whereas another group of control subjects was administered an injection of saline or morphine, but was otherwise undisturbed. Behavioral observations of the pups immediately following the procedure indicated that the laparotomy produced increased distress vocalizations in the ultrasonic range (40 kHz) compared to both groups of control subjects. During 90 min observations periods following the surgery and 1-week later, maternal care did not vary among treatment conditions. In adulthood, offspring were tested for nociceptive sensitivity on the hot-plate (HP; 53 degrees C), tail-withdrawal (TW; 50 degrees C) and acetic acid abdominal constriction test (AC). On both the TW and the AC tests, neonatal surgery decreased pain behavior relative to both groups of control subjects, an effect that was reversed by post-operative morphine treatment. On the HP test, both groups of subjects exposed to the stressful aspects of neonatal surgery (laparotomy or sham surgery) exhibited decreased pain behavior in adulthood. These findings suggest that early exposure to noxious and/or stressful stimuli may induce long-lasting changes in pain behavior, perhaps mediated by alterations in the stress-axis and antinociceptive circuitry.

This paper presents the rationale and methods for a randomized controlled evaluation of web-based training in motivational interviewing, goal setting, and behavioral task assignment. Web-based training may be a practical and cost-effective way to address the need for large-scale mental health training in evidence-based practice; however, there is a dearth of well-controlled outcome studies of these approaches. For the current trial, 168 mental health providers treating post-traumatic stress disorder (PTSD) were assigned to web-based training plus supervision, web-based training, or training-as-usual (control). A novel standardized patient (SP) assessment was developed and implemented for objective measurement of changes in clinical skills, while on-line self-report measures were used for assessing changes in knowledge, perceived self-efficacy, and practice related to cognitive behavioral therapy (CBT) techniques. Eligible participants were all actively involved in mental health treatment of veterans with PTSD. Study methodology illustrates ways of developing training content, recruiting participants, and assessing knowledge, perceived self-efficacy, and competency-based outcomes, and demonstrates the feasibility of conducting prospective studies of training efficacy or effectiveness in large healthcare systems.