Exploring the Association Between Trauma, Instability, and Youth Cardiometabolic Health Outcomes Over Three Years.

PURPOSE: Childhood adversity plays a fundamental role in predicting youth cardiometabolic health. Our understanding of how adverse experiences in childhood should best be conceptualized remains elusive, based on one-dimensional measures of adversity. The present study fills a major gap in existing research by examining two distinct forms of threat and instability-related exposures that may impact cardiometabolic risk (CMR) in adolescence. METHODS: We explore two specific subtypes of adversity: trauma (e.g., badly hurt, victim of crime, loss of close person) and instability (e.g., moving, change of schools, change in household structure) as differential influences that can accumulate to impact early childhood onset of CMR (body mass index, high-density lipoprotein (HDL), low-density lipoprotein, diastolic and systolic blood pressure, triglycerides, C-reactive protein, insulin sensitivity). Secondary data were drawn from a randomized control behavioral trial of youth recruited during sixth grade from urban Cleveland (Ohio) schools beginning in 2012-2014 (n = 360) and followed for 3 years. Participants reported on 12 adverse experiences, six trauma- and six instability-specific. Multiple regression assessed effects of prospective and accumulative indices of trauma and instability with 3-year trajectories of eight objective CMR markers. RESULTS: Instability was associated with increased body mass index, decreased high-density lipoprotein, and increased C-reactive protein slopes. Trauma was associated with trends in triglyceride levels but not with any other CMR outcomes. DISCUSSION: Experiences with instability distinctly impacted adolescent CMR. Future research is needed to examine factors that can enhance stability for families in marginalized communities.

Study design and protocol for Nourishing Beginnings, an integrated service delivery model addressing food insecurity and social needs of low-income pregnant individuals.

BACKGROUND: Nourishing Beginnings is an integrated referral and service delivery model supporting Medicaid-eligible pregnant individuals by providing increased nutritional food access throughout pregnancy up to three months postpartum, through community health workers (CHW), who simultaneously address and provide support for social service needs of the client. METHODS: To study the impact of possible interventions on food security, the program includes two distinct interventions each paired with traditional CHW services, nutrition educational materials, and provision of basic essential cooking tools. Interventions consist of either bi-weekly home food delivery from the local food bank or bi-weekly financial assistance with healthy food access navigation. The study population consists of 160 pregnant individuals (18 or older,<22 weeks pregnant; 80 per intervention arm) who were referred to a countywide Pathways Community HUB (HUB), a community-based care coordination network that uses an evidence-based model to connect at-risk individuals to resources that address medical, social, economic, and behavioral health needs. Key data collection occurs at baseline, eight weeks after intervention begins, near delivery (36-38 weeks gestation), and three months postpartum. Intervention groups are compared to each other as well as against HUB historical controls and a concurrent matched sample from local Medicaid data. CONCLUSION: The goal of Nourishing Beginnings is to improve long-term health outcomes (i.e., maternal and infant) both directly and mediated through a set of proximal outcomes, including prenatal care, food security, diet and nutrition, reported race discrimination and psychosocial factors including depression, stress, healthy eating self-efficacy, and social support. Clinical Trials #: NCT05341960.

Child Opportunity Index and Hospital Utilization in Children With Traumatic Brain Injury Admitted to the PICU.

The need to understand how Community-based disparities impact morbidity and mortality in pediatric critical illness, such as traumatic brain injury. Test the hypothesis that ZIP code-based disparities in hospital utilization, including length of stay (LOS) and hospital costs, exist in a cohort of children with traumatic brain injury (TBI) admitted to a PICU using the Child Opportunity Index (COI). DESIGN: Multicenter retrospective cohort study. SETTING: Pediatric Health Information System (PHIS) database. PATIENTS: Children 0-18 years old admitted to a PHIS hospital with a diagnosis of TBI from January 2016 to December 2020 requiring PICU care. To identify the most severely injured children, a study-specific definition of "Complicated TBI" was created based on radiology, pharmacy, and procedure codes. INTERVENTIONS: None. Main Outcomes and Measures: Using nationally normed ZIP code-level COI data, patients were categorized into COI quintiles. A low COI ZIP code has low childhood opportunity based on weighted indicators within educational, health and environmental, and social and economic domains. Population-averaged generalized estimating equation (GEE) models, adjusted for patient and clinical characteristics examined the association between COI and study outcomes, including hospital LOS and accrued hospital costs. The median age of this cohort of 8,055 children was 58 months (interquartile range [IQR], 8-145 mo). There were differences in patient demographics and rates of Complicated TBI between COI levels. The median hospital LOS was 3.0 days (IQR, 2.0-6.0 d) and in population-averaged GEE models, children living in very low COI ZIP codes were expected to have a hospital LOS 10.2% (95% CI, 4.1-16.8%; p = 0.0142) longer than children living in very high COI ZIP codes. For the 11% of children with a Complicated TBI, the relationship between COI and LOS was lost in multivariable models. COI level was not predictive of accrued hospital costs in this study. CONCLUSIONS: Children with TBI requiring PICU care living in low-opportunity ZIP codes have higher injury severity and longer hospital LOS compared with children living in higher-opportunity ZIP codes. Additional studies are needed to understand why these differences exist.

Improving Surveillance and Epidemic Response in Ohio Childcare Settings.

At the start of the Coronavirus Disease of 2019 (COVID-19) pandemic, the risk of cases in childcare programs was unknown. Thus, a rapid-response research approach was launched in Ohio childcare settings. Passive surveillance data from a state-operated incident reporting system were evaluated to estimate the number of COVID-19 cases from 15 August 2020 to 1 January 2021. Additionally, active surveillance with self-administered reverse transcriptase-polymerase chain reaction (RT-PCR) tests were conducted among staff at 46 childcare programs. Finally, six zoom-based focus groups with program administrators were used to gain feedback. Staff and children in childcare settings contributed 0.38% and 0.15% of the COVID-19 cases in Ohio during this timeframe, respectively. RT-PCR testing identified 3 unrecognized cases (0.88% of tests), and all occurred when the statewide positivity rate was >5%. Focus groups revealed that access to affordable cleaning supplies, masks, and reliable staffing were critical. Perhaps most importantly, we conclude that expanding the incident reporting system to include a childcare census would allow for the tracking of future health problems with highly valuable incidence rate estimations.

Measuring quality and outcomes of research collaborations: An integrative review.

INTRODUCTION: Although the science of team science is no longer a new field, the measurement of team science and its standardization remain in relatively early stages of development. To describe the current state of team science assessment, we conducted an integrative review of measures of research collaboration quality and outcomes. METHODS: Collaboration measures were identified using both a literature review based on specific keywords and an environmental scan. Raters abstracted details about the measures using a standard tool. Measures related to collaborations with clinical care, education, and program delivery were excluded from this review. RESULTS: We identified 44 measures of research collaboration quality, which included 35 measures with reliability and some form of statistical validity reported. Most scales focused on group dynamics. We identified 89 measures of research collaboration outcomes; 16 had reliability and 15 had a validity statistic. Outcome measures often only included simple counts of products; publications rarely defined how counts were delimited, obtained, or assessed for reliability. Most measures were tested in only one venue. CONCLUSIONS: Although models of collaboration have been developed, in general, strong, reliable, and valid measurements of such collaborations have not been conducted or accepted into practice. This limitation makes it difficult to compare the characteristics and impacts of research teams across studies or to identify the most important areas for intervention. To advance the science of team science, we provide recommendations regarding the development and psychometric testing of measures of collaboration quality and outcomes that can be replicated and broadly applied across studies.

Two Family Interventions to Reduce BMI in Low-Income Urban Youth: A Randomized Trial.

BACKGROUND: Our primary aim was to evaluate the effects of 2 family-based obesity management interventions compared with a control group on BMI in low-income adolescents with overweight or obesity. METHODS: In this randomized clinical trial, 360 urban-residing youth and a parent were randomly assigned to 1 of 2 behaviorally distinct family interventions or an education-only control group. Eligible children were entering the sixth grade with a BMI ≥85th percentile. Interventions were 3 years in length; data were collected annually for 3 years. Effects of the interventions on BMI slope (primary outcome) over 3 years and a set of secondary outcomes were assessed. RESULTS: Participants were primarily African American (77%), had a family income of <25 000 per year, and obese at enrollment (68%). BMI increased over time in all study groups, with group increases ranging from 0.95 to 1.08. In an intent-to-treat analysis, no significant differences were found in adjusted BMI slopes between either of the family-based interventions and the control group (P = .35). No differences were found between the experimental and control groups on secondary outcomes of diet, physical activity, sleep, perceived stress, or cardiometabolic factors. No evidence of effect modification of the study arms by sex, race and/or ethnicity, household income, baseline levels of child and parent obesity, or exposure to a school fitness program were found. CONCLUSIONS: In this low-income, adolescent population, neither of the family-based interventions improved BMI or health-related secondary outcomes. Future interventions should more fully address poverty and other social issues contributing to childhood obesity.

Socioecological Path Analytic Model of Diet Quality among Residents in Two Urban Food Deserts.

BACKGROUND: Diet is critical to chronic disease prevention, yet there are persistent disparities in diet quality among Americans. The socioecological model suggests multiple factors, operating at multiple levels, influence diet quality. OBJECTIVE: The goal was to model direct and indirect relationships among healthy eating identity, perceived control of healthy eating, social support for healthy eating, food retail choice block scores, perceptions of healthy food availability, and food shopping behaviors and diet quality measured using Healthy Eating Index-2010 scores (HEI-2010) for residents living in two urban communities defined as food deserts. DESIGN: A cross-sectional design was used including data collected via self-reported surveys, 24-dietary recalls, and through objective observations of food retail environments. PARTICIPANTS/SETTING: Data collection occurred in 2015-2016 in two low-income communities in Cleveland (n=243) and Columbus (n=244), OH. MAIN OUTCOME MEASURE: HEI-2010 scores were calculated based on the average of three 24-hour dietary recalls using the Nutrition Data System for Research. ANALYSIS: Separate path models, controlled for income, were run for each community. Analysis was guided by a conceptual model with 15 hypothesized direct and indirect effects on HEI-2010 scores. Associations were considered statistically significant at P<0.05 and P<0.10 because of modest sample sizes in each community. RESULTS: Across both models, significant direct effects on HEI-2010 scores included healthy eating identity (ß=.295, Cleveland; ß=.297, Columbus, P<0.05) and distance traveled to primary food store (ß=.111, Cleveland, P<0.10; ß=.175, Columbus, P<0.05). Perceptions of healthy food availability had a significant, inverse effect in the Columbus model (ß=-.125, P<0.05). The models explained greater variance in HEI-2010 scores for the Columbus community compared with Cleveland (R2=.282 and R2=.152, respectively). CONCLUSIONS: Findings highlight the need for tailored dietary intervention approaches even within demographically comparable communities. Interventions aimed at improving diet quality among residents living in food deserts may need to focus on enhancing healthy eating identity using culturally relevant approaches while at the same time addressing the need for transportation supports to access healthy food retailers located farther away.

People and places shaping food procurement among recipients of Supplemental Nutrition Assistance Program (SNAP).

A key gap in existing food environment research is a more complex understanding of the interplay between physical and social contexts, including the influence of social networks on food habits. This mixed methods research examined the nature of social connections at food procurement places among a sample of 30 people receiving Supplemental Nutrition Assistance Program (SNAP) benefits in an urban setting. Results highlight the significance of social connections as motivators to use food places, the value of access to information and other resources at food places, and the role of weak ties with actors within food places to facilitate utilization and interaction. Social connections at the varied places individuals procure food may be leveraged to disseminate information and resources to further healthy food access.

We Run This City: Impact of a Community-School Fitness Program on Obesity, Health, and Fitness.

INTRODUCTION: The We Run This City (WRTC) Youth Marathon Program is a community-supported, school-based fitness program designed to increase physical activity in a large, urban school district by engaging middle school youth to train 12 to 14 weeks to run or walk 1.2 miles, 6.2 miles, or 13.1 miles of the Rite Aid Cleveland Marathon. The objective of our study was to evaluate the effect of the intervention on adolescent health. METHODS: We assessed changes in obesity, health, and fitness, measured before training and postintervention, among 1,419 sixth- to eighth-grade students participating in WRTC for the first time, with particular interest in the program's effect on overweight (85th-94th body mass index percentile) or obese (≥95th percentile) students. We collected data from 2009 through 2012, and analyzed it in 2016 and 2017. Outcomes of interest were body mass index (BMI), waist-to-hip ratio (WHR), elevated blood pressure, and fitness levels evaluated by using the Progressive Aerobic Cardiovascular Endurance Run (PACER) test and the sit-to-stand test. RESULTS: We saw significant improvements overall in fitness and blood pressure. Controlling for demographics, program event, and training dosage, BMI percentile increased among normal weight participants and decreased among overweight and obese participants (P < .001). WHR increased among obese participants, whereas reductions in blood pressure among those with elevated blood pressure were associated with higher amounts of training and lower baseline BMI. CONCLUSION: Even small amounts of regular physical activity can affect the health and fitness of urban youths. School-community partnerships offer a promising approach to increasing physical activity by supporting schools and making a school-based activity inclusive, fun, and connected to the broader fitness community.

Development of the Systems Thinking Scale for Adolescent Behavior Change.

This report describes the development and psychometric testing of the Systems Thinking Scale for Adolescent Behavior Change (STS-AB). Following item development, initial assessments of understandability and stability of the STS-AB were conducted in a sample of nine adolescents enrolled in a weight management program. Exploratory factor analysis of the 16-item STS-AB and internal consistency assessments were then done with 359 adolescents enrolled in a weight management program. Test-retest reliability of the STS-AB was .71, p = .03; internal consistency reliability was .87. Factor analysis of the 16-item STS-AB indicated a one-factor solution with good factor loadings, ranging from .40 to .67. Evidence of construct validity was supported by significant correlations with established measures of variables associated with health behavior change. We provide beginning evidence of the reliability and validity of the STS-AB to measure systems thinking for health behavior change in young adolescents.

The Hawthorne effect in direct observation research with physicians and patients.

RATIONALE, AIMS, AND OBJECTIVES: This study examines the degree to which a "Hawthorne effect" alters outpatient-visit content. METHODS: Trained research nurses directly observed 4454 visits to 138 family physicians. Multiple data sources were used to examine the Hawthorne effect including differences in medical record documentation for observed visits and the prior visit by the same patient, time use during visits on the first versus the second observation day of each physician, and report by the patient, physician, and observer of the effect of observation. RESULTS: Visits on the first versus the second observation day were longer by an average of 1 minute (P < .001); there were time-use differences for 4 of 20 behaviour categories evaluated. No effect of the observer on the interaction was reported by 74% of patients and 55% of physicians. Most of those that reported an affect indicated it was slight. Patients with non-White race, lower-educational level, and poorer health were more likely to report being affected by the observer. CONCLUSIONS: In a study that was designed to minimize the Hawthorne effect, the presence of an observer had little effect on most patient-physician visits but appeared to at least slightly effect a subgroup of vulnerable patients.

Use of Appreciative Inquiry To Engage Parents as Codesigners of a Weight Management Intervention for Adolescents.

BACKGROUND: Focus groups are often used to involve families as codesigners of weight management interventions. Focus groups, however, are seldom designed to elicit families' strengths and positive experiences. The purpose of this study was to describe the use of the Appreciative Inquiry process in the conduct of focus groups to engage families in the design of a weight management intervention for adolescents. METHODS: A convenience sample of 44 parents (84% female; 82% minority) of adolescent children with a BMI ≥ 85th percentile, who were in the 6th-8th grade in a large urban school, participated in focus groups designed to elicit family-positive experiences and strengths regarding healthy living. A structured set of questions based on the Appreciative Inquiry process was used in the focus groups. Analyses consisted of the constant comparative method to generate themes. RESULTS: Parent-positive perceptions regarding their family's healthy living habits were reflected in five themes: (1) Having healthy children is a joy; (2) Becoming healthy is a process; (3) Engaging in healthy habits is a family affair; (4) Good health habits can be achieved despite obstacles; and (5) School, community, and social factors contribute to their family's health habits. Parents generated ideas to improve their families' health. CONCLUSIONS: Focus groups based on the Appreciative Inquiry process were found to be a useful approach to discover features that are important to low-income, urban-living parents to include in an adolescent weight management program. Recommendations for designing and conducting focus groups based on the Appreciative Inquiry process are provided.

Individual, Parental, and Environmental Correlates of Cigar, Cigarillo, and Little Cigar Use Among Middle School Adolescents.

INTRODUCTION: Youth use of cigars, cigarillos, and little cigars (CCLC) is increasing. While correlates of cigarette smoking have been well documented, use of CCLC is not as well understood among young adolescents. This study assessed whether smoking beliefs, parenting practices, and environmental exposures were associated with CCLC use among 7th to 8th grade youth in an urban, mid-Western city. METHODS: The Cleveland Youth Risk Behavior Survey was conducted with 7th to 8th grade students in spring 2012. CCLC use was assessed by asking if students had smoked CCLC in the past 30 days. Covariates include self-reported gender, race, grade, acceptability of smoking, parental monitoring, hours of self-care, visits to corner stores, and current cigarette smoking. Bivariate and multivariate analyses were conducted to determine associations with current CCLC use. RESULTS: Overall, 14.3% of youth reported current CCLC use. Students reporting higher acceptability of smoking, lower parental monitoring, longer periods of self-care, more visits to corner stores and current cigarette smoking were more likely to report current CCLC use in both bivariate and multivariable logistic regression models. CONCLUSIONS: CCLC use is associated with multiple levels of influence, indicating that prevention of youth CCLC use must utilize a multilevel approach. Increased utilization of corner stores was associated with higher odds of CCLC use, and could indicate that youth stopping at corner stores may be exposed to increased tobacco retail advertising and tobacco products. The findings of this study have implications for FDA regulation to prevent CCLC initiation among youth. IMPLICATIONS: While correlates of cigarette smoking have been well documented, use of CCLC is not as well understood among young adolescents. This is the first study that has examined the association between individual, family, and environmental characteristics and CCLC use. The results of this study illustrate that youth attitudes, perceived parenting practices, and environmental exposure are associated with adolescent CCLC use. This is important as the tobacco control community begins to identify strategies to prevent and reduce CCLC use. The findings of this study have clear implications for FDA regulation to prevent CCLC initiation among youth.

Partnership Among Peers: Lessons Learned From the Development of a Community Organization-Academic Research Training Program.

BACKGROUND: Community engagement and rigorous science are necessary to address health issues. Increasingly, community health organizations are asked to partner in research. To strengthen such community organization-academic partnerships, increase research capacity in community organizations, and facilitate equitable partnered research, the Partners in Education Evaluation and Research (PEER) program was developed. The program implements an 18-month structured research curriculum for one mid-level employee of a health-focused community-based organization with an organizational mentor and a Case Western Reserve University faculty member as partners. METHODS: The PEER program was developed and guided by a community-academic advisory committee and was designed to impact the research capacity of organizations through didactic modules and partnered research in the experiential phase. Active participation of community organizations and faculty during all phases of the program provided for bidirectional learning and understanding of the challenges of community-engaged health research. The pilot program evaluation used qualitative and quantitative data collection techniques, including experiences of the participants assessed through surveys, formal group and individual interviews, phone calls, and discussions. Statistical analysis of the change in fellows' pre-test and post-test survey scores were conducted using paired sample t tests. The small sample size is recognized by the authors as a limitation of the evaluation methods and would potentially be resolved by including more cohort data as the program progresses. Qualitative data were reviewed by two program staff using content and narrative analysis to identify themes, describe and assess group phenomena and determine program improvements. OBJECTIVES: The objective of PEER is to create equitable partnerships between community organizations and academic partners to further research capacity in said organizations and develop mutually beneficial research partnerships between academia and community organizations. CONCLUSION: PEER demonstrates a commitment to successfully developing sustainable research capacity growth in community organizations, and improved partnered research with academic institutions.

The Cleveland-Cuyahoga County Food Policy Coalition: "we have evolved".

Several pieces of legislation passed in Cleveland, Ohio, from 2007 to 2011, focused on improving the city's food environment through urban agriculture initiatives. We used qualitative, case study methods, including interviews with 7 key informants, to examine the policy development process and investigate the role of the Cleveland-Cuyahoga County Food Policy Coalition in developing and implementing 4 pieces of legislation. In this article, we focus on 2 pieces of legislation: zoning designation of an urban garden and allowance of small farm animals and bees on residential property. Five key themes emerged: impetus for policy came from community needs; education and raising awareness helped mitigate barriers; a cultural shift took place among policy makers; social connections and individual champions were needed; and concerns over food access and health influenced policy decisions. Legislative actions are important tools to influence the nutrition environment, as long as they are based on local needs and context.

Effectiveness of health education teachers and school nurses teaching sexually transmitted infections/human immunodeficiency virus prevention knowledge and skills in high school.

BACKGROUND: We examined the differential impact of a well-established human immunodeficiency virus (HIV)/sexually transmitted infections (STIs) curriculum, Be Proud! Be Responsible!, when taught by school nurses and health education classroom teachers within a high school curricula. METHODS: Group-randomized intervention study of 1357 ninth and tenth grade students in 10 schools. Twenty-seven facilitators (6 nurses, 21 teachers) provided programming; nurse-led classrooms were randomly assigned. RESULTS: Students taught by teachers were more likely to report their instructor to be prepared, comfortable with the material, and challenged them to think about their health than students taught by a school nurse. Both groups reported significant improvements in HIV/STI/condom knowledge immediately following the intervention, compared to controls. Yet, those taught by school nurses reported significant and sustained changes (up to 12 months after intervention) in attitudes, beliefs, and efficacy, whereas those taught by health education teachers reported far fewer changes, with sustained improvement in condom knowledge only. CONCLUSIONS: Both classroom teachers and school nurses are effective in conveying reproductive health information to high school students; however, teaching the technical (eg, condom use) and interpersonal (eg, negotiation) skills needed to reduce high-risk sexual behavior may require a unique set of skills and experiences that health education teachers may not typically have.

IMPACT: a multi-level family and school intervention targeting obesity in urban youth.

IMPACT (Ideas Moving Parents and Adolescents to Change Together) is a 3-group randomized, multi-level trial comparing the efficacy of two distinct behavioral interventions and a control condition on body mass index (BMI) in middle school urban youth who are overweight/obese. Interventions include: (1) SystemCHANGE (SC), a promising new behavior change approach that focuses on system redesign of the family environment and daily routines; (2) HealthyCHANGE (HC), a cognitive-behavioral and Motivational Interviewing (MI)-consistent approach to behavior change that focuses on increasing intrinsic motivation, self-monitoring, goal setting, and problem solving; and (3) diet and physical education counseling (attention control). In addition, about half of the participants are enrolled in a K-8 public school that offers an innovative community-sponsored fitness program, augmented by study-supported navigators. In addition to the primary interventions effects, the study assesses the moderating effect of the school environment on BMI, blood pressure, cardiovascular risk factors, and quality of life. The sample consists of 360 children entering 6th grade from a large urban school district in the Midwest, identified through an existing BMI screening program. The intervention period is 36 months, and measures are obtained at baseline, 12, 24, and 36 months. Using intent-to-treat analyses across the 36-month intervention window, we hypothesize that both SC and HC will have a greater impact on BMI and other health outcomes compared to health education alone, and that the enriched school environment will enhance these effects. This manuscript describes IMPACT's study design and methods.

Enforcement of Ohio's Smoke Free Workplace Law through the lens of public health practice.

OBJECTIVES: Little is known about whether public health (PH) enforcement of Ohio's 2007 Smoke Free Workplace Law (SFWPL) is associated with department (agency) characteristics, practice, or state reimbursement to local PH agencies for enforcement. We used mixed methods to determine practice patterns, perceptions, and opinions among the PH workforce involved in enforcement to identify agency and workforce associations. METHODS: Focus groups and phone interviews (n=13) provided comments and identified issues in developing an online survey targeting PH workers through e-mail recruitment (433 addresses). RESULTS: A total of 171 PH workers responded to the survey. Of Ohio's 88 counties, 81 (43% rural and 57% urban) were represented. More urban than rural agencies agreed that SFWPL enforcement was worth the effort and cost (80% vs. 61%, p=0.021). The State Attorney General's collection of large outstanding fines was perceived as unreliable. An estimated 77% of agencies lose money on enforcement annually; 18% broke even, 56% attributed a financial loss to uncollected fines, and 63% occasionally or never fully recovered fines. About half of agency leaders (49%) felt that state reimbursements were inadequate to cover inspection costs. Rural agencies (59%) indicated they would be more likely than urban agencies (40%) to drop enforcement if reimbursements ended (p=0.0070). Prioritization of SFWPL vs. routine code enforcement differed between rural and urban agencies. CONCLUSIONS: These findings demonstrate the importance of increasing state health department financial support of local enforcement activities and improving collection of fines for noncompliance. Otherwise, many PH agencies, especially rural ones, will opt out, thereby increasing the state's burden to enforce SFWPL and challenging widespread public support for the law.

Value of audio-enhanced handheld computers over paper surveys with adolescents.

OBJECTIVE: To examine the impact of 3 data collection modes on the number of questions answered, data quality, and student preference. METHODS: 275 urban seventh-grade students were recruited and randomly assigned to complete a paper survey (SAQ), PDA survey (PDA), or PDA survey with audio (APDA). Students completed a paper debriefing survey. RESULTS: APDA respondents completed significantly more questions compared to SAQ and PDA. PDA and APDA had significantly less missing data than did SAQ. No differences were found for student evaluation. CONCLUSIONS: Strong benefits may be gained by the use of APDA for adolescent school-based data collection.

Boundary spanning and health: invitation to a learning community.

Boundaries, which are essential for the healthy functioning of individuals and organisations, can become problematic when they limit creative thought and action. In this article, we present a framework for promoting health across boundaries and summarise preliminary insights from experience, conversations and reflection on how the process of boundary spanning may affect health. Boundary spanning requires specific individual qualities and skills. It can be facilitated or thwarted by organisational context. Boundary spanning often involves risk, but may reap abundant rewards. Boundary spanning is necessary to optimise health and health care. Exploring the process, the landscape and resources that enable boundary spanning may yield new opportunities for advancing health. We invite boundary spanners to join in a learning community to advance understanding and health.