Underuse of SARS-CoV-2-Neutralizing Monoclonal Antibodies in Skilled Nursing Facilities.

OBJECTIVE: Little is known about deployment of SARS-CoV-2-neutralizing monoclonal antibodies (mab) in skilled nursing facilities (SNFs), a high-risk population for COVID-19-related complications. We assessed the utilization of mabs in SNFs and identified facility characteristics associated with effective use. DESIGN: Retrospective cohort study assessing the correlation of SNF characteristics with increasing mab use. SETTING AND PARTICIPANTS: United States SNFs participating in Project ECHO (Extensions for Community Health Outcomes). METHODS: The primary outcome was percentage of total mabs per COVID-19 cases in SNFs. Facilities were divided into 3 groups based on the percentage of the administration of mabs per number of cases: 0%, >0% to 20%, >20%. Ordinal logistic regression was applied to assess whether facility characteristics-study group, state, location, type, size, rating at baseline, weekly average of residents vaccinated, weekly average of staff vaccinated, and total weeks short staffed-correlated with the primary outcome. A multivariable model was used to evaluate the independent effect of predictors. RESULTS: A total of 130 facilities were included. Between the weeks ending on May 30, 2021, and on May 29, 2022, mean mab use when accounting for the number of COVID-19 cases was 12.96% (±26.71%) and >50% of facilities administered 0 doses of mabs. Facility location was associated with mab use (P value .030), with micropolitan facilities having the highest percentage of facilities administering mabs (30.4% in >0% to 20%, and 39.1% in >20%, respectively). There was a nonsignificant trend toward increased mab use in facilities reporting fewer staffing shortages. When the multivariable ordinal logistic regression model was applied, location in a micropolitan vs metropolitan area was associated with higher odds [3.29 (1.30, 8.32), P value .012] of increasing percentage total mabs per cases. CONCLUSIONS AND IMPLICATIONS: COVID-19 mabs were underutilized in a high-risk population for COVID-19 hospitalization and death. Understanding the barriers to effective distribution is critical in shaping pandemic preparedness efforts for the future.

Increasing the adoption of evidence-based communication practices for HPV vaccination in primary care clinics: The HPV ECHO study protocol for a cluster randomized controlled trial.

BACKGROUND: The safe, highly-effective human papillomavirus (HPV) vaccine remains underused in the US. The Announcement Approach Training (AAT) has been shown to effectively increase HPV vaccine uptake by training providers to make strong vaccine recommendations and answer parents' common questions. Systems communications, like recall notices, can further improve HPV vaccination by reducing missed clinical opportunities for vaccination. Never tested in supporting HPV vaccination, the ECHO (Extension for Community Healthcare Outcomes) model is a proven implementation strategy to increase best practices among healthcare providers. This trial uses a hybrid effectiveness-implementation design (type II) to evaluate two ECHO-delivered interventions intended to increase HPV vaccination rates. METHODS: This 3-arm cluster randomized controlled trial will be conducted in 36 primary care clinics in Pennsylvania. Aim 1 evaluates the impact of HPV ECHO (AAT to providers) and HPV ECHO+ (AAT to providers plus recall notices to vaccine-declining parents) versus control on HPV vaccination (≥1 dose) among adolescents, ages 11-14, between baseline and 12-month follow-up (primary outcome). Using a convergent mixed-methods approach, Aim 2 evaluates the implementation of the HPV ECHO and HPV ECHO+ interventions. Aim 3 explores exposure to and impact of vaccine information from providers and other sources (e.g., social media) on secondary acceptance among 200 HPV vaccine-declining parents within 12 months. DISCUSSION: We expect to demonstrate the effectiveness and evaluate the implementation of two highly scalable interventions to increase HPV vaccination in primary care clinics. Our study seeks to address the communication needs of both providers and parents, increase HPV vaccination, and, eventually, prevent HPV-related cancers. TRIAL REGISTRATION: ClinicalTrials.govNCT04587167. Registered on October 14, 2020.

Intensive behavioral Therapy for weight loss in patients with, or At-Risk of, type 2 Diabetes: Results from the PaTH to health diabetes study.

Intensive behavioral therapy (IBT) is an important component of obesity treatment and can reduce the risk of type 2 diabetes (T2DM). Objective was to compare the effectiveness of IBT to usual care in achieving weight loss in two study cohorts within PaTH Network: T2DM and At-Risk of T2DM. The TD2M cohort was defined as age 18 years and older with an indication of T2DM in the EHR based on a validated algorithm and at least 2 outpatient primary care visits. The At-Risk of T2DM cohort was defined by a BMI ≥ 25 kg/m2. The primary outcome was weight change within 1-year of index date. Mixed-effects models assessed the effectiveness of IBT by comparing the changes between study groups. Between 2009 and 2020, a total of 567,908 patients were identified in the T2DM cohort and2,054,256 patients in the At-Risk of T2DM cohort. Both IBT patients and matched non-IBT patients in the T2DM cohort had decreased mean weight (primary outcome) (-1.56 lbs, 95 %CI: -1.88, -1.24 vs -1.70 lbs, 95 %CI: -1.95, -1.44) in 1-year after index date. In the At-Risk of T2DM cohort, both IBT and non-IBT patients experienced weight gain and resultant increased BMI. Patients with more than one IBT visit gained less weight than those with only one visit (1.22 lbs, 95 %CI: 0.82, 1.62 vs 6.72 lbs, 95 %CI: 6.48, 6.97; p < 0.001). IBT was unlikely to result in clinically significant weight loss. Barriers to utilizing IBT require further research to ensure broader adoption of obesity management in primary care.

Hospitalization and mortality in patients with COVID-19 with or at risk of type 2 diabetes: data from five health systems in Pennsylvania and Maryland.

OBJECTIVE: To identify the demographic and clinical characteristics associated with adverse COVID-19 outcomes across a 12-month period in 2020 and 2021. RESEARCH DESIGN AND METHODS: We conducted a retrospective cohort study using electronic health records from five academic health systems in Pennsylvania and Maryland, including patients with COVID-19 with type 2 diabetes or at risk of type 2 diabetes. Patients were classified based on 30-day outcomes: (1) no hospitalization; (2) hospitalization only; or (3) a composite measure including admission to the intensive care unit (ICU), intubation, or death. Analyses were conducted in patients with type 2 diabetes and patients at risk of type 2 diabetes separately. RESULTS: We included 15 725 patients with COVID-19 diagnoses between March 2020 and February 2021. Older age and higher Charlson Comorbidity Index scores were associated with higher odds of adverse outcomes, while COVID-19 diagnoses later in the study period were associated with lower odds of severe outcomes. In patients with type 2 diabetes, individuals on insulin treatment had higher odds for ICU/intubation/death (OR=1.59, 95% CI 1.27 to 1.99), whereas those on metformin had lower odds (OR=0.56, 95% CI 0.45 to 0.71). Compared with non-Hispanic White patients, Hispanic patients had higher odds of hospitalization in patients with type 2 diabetes (OR=1.73, 95% CI 1.36 to 2.19) or at risk of type 2 diabetes (OR=1.77, 95% CI 1.43 to 2.18.) CONCLUSIONS: Adults who were older, in racial minority groups, had multiple chronic conditions or were on insulin treatment had higher risks for severe COVID-19 outcomes. This study reinforced the urgency of preventing COVID-19 and its complications in vulnerable populations. TRIAL REGISTRATION NUMBER: NCT02788903.

Implementing Infection Control and Quality of Life Best Practices in Nursing Homes With Project ECHO: Protocol for a Patient-Centered Randomized Controlled Trial.

BACKGROUND: Nursing homes in the United States were devastated by COVID-19, with 710,000 cases and 138,000 deaths nationally through October 2021. Although facilities are required to have infection control staff, only 3% of designated infection preventionists have taken a basic infection control course prior to the COVID-19 pandemic. Most research has focused on infection control in the acute care setting. However, little is known about the implementation of infection control practices and effective interventions in nursing homes. This study utilizes Project ECHO (Extension for Community Health Outcomes), an evidence-based telementoring model, to connect Penn State University subject matter experts with nursing home staff and administrators to proactively support evidence-based infection control guideline implementation. OBJECTIVE: Our study seeks to answer the research question of how evidence-based infection control guidelines can be implemented effectively in nursing homes, including comparing the effectiveness of two ECHO-delivered training interventions on key patient-centered outcomes such as reducing the number of residents with a COVID-19 diagnosis. METHODS: A stratified cluster randomized design was utilized. Using a 1:1 ratio, we randomly assigned 136 nursing homes to ECHO or ECHO Plus arms. Randomization was stratified by geographic location, baseline COVID-19 infection rate, and facility capacity. The study had two phases. In phase one, completed in July 2021, nursing homes in both study arms received a 16-week infectious disease and quality improvement training intervention via real-time, interactive videoconferencing and the ECHO learning model. Phase one sessions were up to 90 minutes in duration. In phase two, completed in November 2021, the ECHO group was offered optional 60-minute office hours for 9 weeks and the ECHO Plus group received 9 weeks of 60-minute sessions on emerging topics and an additional 8-session refresher series on infection control. RESULTS: A total of 290 nursing home facilities were assessed for eligibility, with 136 nursing homes recruited and randomly assigned to ECHO or ECHO Plus. Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we will simultaneously evaluate the study's effectiveness and implementation outcomes at baseline (intervention start date), and at 4, 6, 12, and 18 months. The primary outcome is the COVID-19 infection rate in nursing homes. Secondary outcomes include COVID-19 hospitalizations and deaths, flu-like illness, and quality of life. Surveys and interviews with participants will also provide data as to the adoption, implementation, and maintenance of best practices taught throughout ECHO sessions. CONCLUSIONS: A multipronged approach to improving infection control and emergency preparedness in nursing homes is important, given the toll that the COVID-19 pandemic has taken on residents and staff. The ECHO model has significant strengths when compared to traditional training, as it allows for remote learning delivered by a multidisciplinary team of experts, and utilizes case discussions that match the context and capacity of nursing homes. TRIAL REGISTRATION: ClinicalTrials.gov NCT04499391; https://clinicaltrials.gov/ct2/show/NCT04499391.

Hospital utilization for hypoglycemia among patients with type 2 diabetes using pooled data from six health systems.

INTRODUCTION: Hypoglycemia is the most common serious adverse effect of diabetes treatment and a major cause of medication-related hospitalization. This study aimed to identify trends and predictors of hospital utilization for hypoglycemia among patients with type 2 diabetes using electronic health record data pooled from six academic health systems. RESEARCH DESIGN AND METHODS: This retrospective open cohort study included 549 041 adults with type 2 diabetes receiving regular care from the included health systems between 2009 and 2019. The primary outcome was the yearly event rate for hypoglycemia hospital utilization: emergency department visits, observation visits, or inpatient admissions for hypoglycemia identified using a validated International Classification of Diseases Ninth Revision (ICD-9) algorithm from 2009 to 2014. After the transition to ICD-10 in 2015, we used two ICD-10 code sets (limited and expanded) for hypoglycemia hospital utilization from prior studies. We identified independent predictors of hypoglycemia hospital utilization using multivariable logistic regression analysis with data from 2014. RESULTS: Yearly rates of hypoglycemia hospital utilization decreased from 2.7 to 1.6 events per 1000 patients from 2009 to 2014 (p-trend=0.023). From 2016 to 2019, yearly event rates were stable ranging from 5.6 to 6.6, or 6.3 to 7.3, using the limited and expanded ICD-10 code sets, respectively. In 2014, the strongest independent risk factors for hypoglycemia hospital utilization were chronic kidney disease (OR 2.86, 95% CI 2.33 to 3.57), ages 18-39 years (OR 2.43 vs age 40-64 years, 95% CI 1.78 to 3.31), and insulin use (OR 2.13 vs no diabetes medications, 95% CI 1.67 to 2.73). CONCLUSIONS: Rates of hypoglycemia hospital utilization decreased from 2009 to 2014 and varied considerably by clinical risk factors such that younger adults, insulin users, and those with chronic kidney disease were at especially high risk. There is a need to validate hypoglycemia ascertainment using ICD-10 codes, which detect a substantially higher number of events compared with ICD-9.

Utilization of intensive behavioural treatment for obesity in patients with diabetes.

Obesity is a leading public health concern. The Centers for Medicare and Medicaid Services implemented a healthcare procedure code for intensive behavioural therapy (IBT) in 2012 to facilitate payment for addressing obesity in primary care settings, followed by universal coverage by insurers for all adults. Our objective was to understand utilization of IBT from 2009 to 2017 in patients with a diabetes diagnosis. Leveraging electronic health record data from the PaTH Clinical Data Research Network (CDRN), a partnership of six health systems, utilization of IBT was summarized at a yearly basis. The trend of IBT prevalence was examined for patients with diabetes by gender, race, age (>=65 vs <65) and rurality. A total of 205, 913 patients were included. While utilization of IBT is low (0.24% in 2017), use of IBT increased among patients with commercial insurance and Medicaid (codes S9449 and S9470) in 2011, and among patients with Medicare (code G0447) in 2012. IBT users tended to be less than 65 years of age, female, non-White (Black or Hispanic), and reside in urban areas. Overall, use of IBT in patients with diabetes remains low. Future work is necessary to understand the impact of IBT and, if effective, how to increase use within primary care.

Reducing Alcohol and Opioid Use Among Youth in Rural Counties: An Innovative Training Protocol for Primary Health Care Providers and School Personnel.

BACKGROUND: Given that youth alcohol use is more common in rural communities, such communities can play a key role in preventing alcohol use among adolescents. Guidelines recommend primary care providers incorporate screening, brief intervention, and referral to treatment (SBIRT) into routine care. OBJECTIVE: The aim is to train primary care providers and school nurses within a rural 10-county catchment area in Pennsylvania to use SBIRT and facilitate collaboration with community organizations to better coordinate substance use prevention efforts. METHODS: To build capacity to address underage drinking and opioid use among youth aged 9-20 years, this project uses telehealth, specifically Project ECHO (Extension for Community Healthcare Outcomes), to train primary care providers and school nurses to address substance use with SBIRT. Our project will provide 120 primary care providers and allied health professionals as well as 20 school nurses with SBIRT training. Community-based providers will participate in weekly virtual ECHO sessions with a multidisciplinary team from Penn State College of Medicine that will provide SBIRT training and facilitate case discussions among participants. RESULTS: To date, we have launched one SBIRT ECHO project with school personnel, enrolling 34 participants. ECHO participants are from both rural (n=17) and urban (n=17) counties and include school nurses (n=15), school counselors (n=8), teachers (n=5), administrators (n=3), and social workers (n=3). Before the study began, only 2/13 (15.5%) of schools were screening for alcohol use. CONCLUSIONS: This project teaches primary care clinics and schools to use SBIRT to prevent the onset and reduce the progression of substance use disorders, reduce problems associated with substance use disorders, and strengthen communities' prevention capacity. Ours is an innovative model to improve rural adolescent health by reducing alcohol and opioid use. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/21015.

Reaching the Hispanic Community About COVID-19 Through Existing Chronic Disease Prevention Programs.

Publicly available data on racial and ethnic disparities related to coronavirus disease 2019 (COVID-19) are now surfacing, and these data suggest that the novel virus has disproportionately sickened Hispanic communities in the United States. We discuss why Hispanic communities are highly vulnerable to COVID-19 and how adaptations were made to existing infrastructure for Penn State Project ECHO (Extension for Community Healthcare Outcomes) and Better Together REACH (a community-academic coalition using grant funds from Racial and Ethnic Approaches to Community Health) to address these needs. We also describe programming to support COVID-19 efforts for Hispanic communities by using chronic disease prevention programs and opportunities for replication across the country.

Correction: A Patient-Centered PaTH to Address Diabetes: Protocol for a Study on the Impact of Obesity Counseling.

[This corrects the article DOI: 10.2196/12054.].

PaTH to partnership in stakeholder-engaged research: A framework for stakeholder engagement in the PaTH to Health Diabetes study.

Engaging a diverse stakeholder group, including patients, clinicians, policy makers, and leadership from national professional organizations as partners in research supports the pursuit of patient-centered outcomes. Utilizing the Patient-Centered Outcomes Research (PCOR) Engagement Principles and applying adult learning theories to training opportunities can enhance stakeholder-investigator collaborations. Regularly scheduled study meetings with stakeholders can help streamline communication, offer a platform for stakeholder voices to be shared, and increase study productivity. Ongoing engagement evaluations provide an important opportunity to assess engagement activities and improve processes moving forward. Benefits of a robust patient partner and stakeholder body extend beyond the study's objectives and translate into the creation of larger networks where resources are shared and patient-centeredness is enhanced.

Reproductive Life Planning and Contraceptive Action Planning for Privately Insured Women: The MyNewOptions Study.

CONTEXT: Although reproductive life planning (RLP) is recommended in federal and clinical guidelines and may help insured women make personalized contraceptive choices, it has not been systematically evaluated for effectiveness. METHODS: In 2014, some 984 privately insured women aged 18-40 who were not intending to become pregnant in the next year were randomly assigned to receive RLP, RLP with contraceptive action planning (RLP+) or information only (the control group). Women's contraceptive use, prescription contraceptive use, method adherence, switching to a more effective method, method satisfaction and contraceptive self-efficacy were assessed at six-month intervals during the two-year follow-up period. Differences between groups were identified using binomial logistic regression, linear regression and generalized estimating equation models. RESULTS: During the follow-up period, the proportion of women using any contraceptive method increased from 89% to 96%, and the proportion using a long-acting reversible contraceptive or sterilization increased from 8% to 19%. Contraceptive adherence was high (72-76%) in all three groups. In regression models, the sole significant finding was that women in the RLP+ group were more likely than those in the RLP group to use a prescription method (odds ratio, 1.3). No differences were evident between the intervention groups and the control group in overall contraceptive use, contraceptive adherence, switching to a more effective method, method satisfaction or contraceptive self-efficacy. CONCLUSIONS: The study does not provide evidence that web-based RLP influences contraceptive behaviors in insured women outside of the clinical setting. Further research is needed to identify strategies to help women of reproductive age identify contraceptive methods that meet their needs and preferences.

Multi-model implementation of evidence-based care in the treatment of opioid use disorder in Pennsylvania.

Pennsylvania has the third highest rate of death due to drug overdose (44.3 per 100,000) in the country, which is significantly higher than the national rate. This continues to have drastic societal impact. Medication assisted treatment (MAT), which includes opioid agonist medications, is the gold standard in treatment for OUD; however, a significant gap remains between the number of individuals in need of treatment and the number of MAT providers. Penn State Health established a system to address the opioid epidemic through the Pennsylvania Coordinated Medication Assisted Treatment program utilizing lessons learned from existing validated models. Connecting primary care sites and hospital systems through a combination of Hub and Spoke, bridge clinic services provided at the Hub, peer recovery services, Project Extension for Community Health Outcomes (ECHO), and layered emergency department (ED) initiation of buprenorphine, this model is an innovative approach that addresses many known barriers to MAT treatment initiation. Early results within the first six months indicate significantly shortened wait time for patients seeking treatment, provision of waiver training to 70 local physicians to prescribe buprenorphine, and improved knowledge and ability to provide patient care for providers participating in our first Project ECHO cohort.

A Patient-Centered PaTH to Address Diabetes: Protocol for a Study on the Impact of Obesity Counseling.

BACKGROUND: Overweight and obesity are America's number one health concern. The prevalence of obesity in the United States is greater than 36%, a rate that has doubled since 1970. As the second most preventable cause of death, obesity is a risk factor for diabetes, cardiovascular disease, stroke, and cancer, all major causes of death. Primary care clinics may be an ideal setting for weight control interventions to help manage and prevent diabetes. For this reason, the Centers for Medicare and Medicaid Services (CMS) implemented a health care procedure coding system code for intensive behavioral therapy (IBT) for obesity within primary care in 2012 to facilitate payment for addressing obesity, which was followed by broader coverage by most insurers for IBT for adults in 2013. However, the impact of this coverage on patient-centered outcomes is largely unknown. OBJECTIVE: The overarching goal of this study is to understand the comparative effectiveness of obesity counseling as covered by CMS and other insurers in improving weight loss for adults either with or at increased risk for type 2 diabetes. METHODS: This study leverages the novel infrastructure of the Patient-Centered Outcomes Research Institute-funded PaTH Clinical Data Research Network. The PaTH network is comprised of Geisinger Health System, Johns Hopkins University, Johns Hopkins Health System, Lewis Katz School of Medicine at Temple University, Temple Health System, Penn State College of Medicine, Penn State Milton S Hershey Medical Center, University of Pittsburgh, UPMC and UPMC Health Plan, and the University of Utah. Electronic health record (EHR) data will originate from the 6 PaTH health systems. Specifically, we will (1) evaluate the impact of broader preventive service coverage for obesity screening and counseling on weight loss, diabetes incidence, and diabetes outcomes in patients with diabetes or at increased risk for diabetes (defined by body mass index [BMI] ≥25). We will determine how the annual probability of receiving obesity and/or nutritional counseling changed pre- and postpolicy across all insurers in a cohort of patients with diabetes and at high risk for diabetes. We will (2) compare patient weight loss and diabetes-related outcomes among those who receive obesity screening and counseling with those who do not, following implementation of preventive service coverage. We will examine postpolicy impact of obesity screening and counseling in a cohort of patients with diabetes and at increased risk for diabetes. Specific outcomes to be examined include weight loss, diabetes incidence, and diabetes outcomes. Exploratory outcomes will include patient-reported outcomes. Furthermore, we will determine patient characteristics, including demographics, and practice characteristics, including provider type. RESULTS: Our PCORI-funded study is underway. To date, we have obtained our second data extraction from the PaTH CDRN and are performing data editing and cleaning. Next steps include analysis of early policy change. CONCLUSIONS: Given patients who are overweight are at highest risk for diabetes, improved weight management services could prevent diabetes and its negative health outcomes. Comparing weight and diabetes outcomes in 3 states using EHRs and claims data before and after this policy was implemented using the PaTH Network will allow important insight into policy effectiveness. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12054.

Body Mass Index Screening and Follow-Up: A Cross-Sectional Questionnaire Study of Pennsylvania School Nurses.

BACKGROUND: Childhood overweight and obesity health concerns can affect a student's academic performance, so it is important to identify resources for school nurses that would help to improve self-efficacy, knowledge, and confidence when approaching parents with sensitive weight-related information and influence overall obesity prevention efforts in the school setting. OBJECTIVE: The purpose of this study was to conduct a Pennsylvania (PA) state-wide 29-item survey addressing school nursing barriers and practices, supplementing information already known in this area. Although the survey covered a range of topics, the focus was body mass index (BMI) screening and its related practice within the schools. METHODS: We conducted a state-wide Web-based survey of school nurses in PA to understand current areas of care, find ways to address child health through school BMI screenings and follow up, and identify current educational gaps to assist school nurses with providing whole child care within the realm of weight management. Chi-square test of independence was conducted to determine the relationship between BMI screening follow up and interest in a BMI toolkit. RESULTS: Nurse participants (N=210), with a 42% (210/500) response rate, represented 208 school districts across PA. Participants were asked about their current process for notifying parents of BMI screening results. The majority (116/210, 55.2%) send a letter home in the mail, while others (62/210, 29.5%) send a letter home with students. A small number (8/210, 3.8%) said they did not notify parents altogether, and some (39/210, 18.6%) notify parents electronically. More than one-third (75/210, 35.7%) of nurses reported receiving BMI screening inquiries from parents; however, under half (35/75, 46.7%) of those respondents indicated they follow up with parents whose child screens overweight or obese. Overall, the vast majority (182/210, 86.7%) do not follow up with parents whose child screens overweight or obese. The majority (150/210, 71.4%) of the nurses responded they would benefit from a toolkit with resources to assist with communication with parents and children about BMI screenings. A significant association between respondent follow up and interest in a BMI toolkit was observed (P=.01). CONCLUSIONS: Schools must start recognizing the role school nurses play to monitor and promote children's health. This goal might include involving them in school-based preventive programs, empowering them to lead initiatives that support whole child health and ensuring opportunities for professional development of interest to them. Nonetheless, the first step in facilitating obesity prevention methods within schools is to provide school nurses with meaningful tools that help facilitate conversations with parents, guardians, and caregivers regarding their child's weight status and health through a BMI screening toolkit.

The dual burden of malnutrition in the United States and the role of non-profit organizations.

The dual burden of malnutrition (obesity or a non-communicable disease coupled with malnutrition) is prevalent in more than half of all malnourished households that reside in the US. Non-profit organizations should make a conscientious effort to not serve products high in sugar and saturated fat, and low in fiber. Instead, they should diligently serve nutrient-dense foods rich in produce, whole grains and omega 3 fatty acids to minimize health disparities prevalent in LSES households. Nonprofit organizations have the potential to decrease health disparities nationally by feeding health sustaining products such as whole grains, fresh produce and lean proteins. This commentary lists feasible options for organizations to serve healthier options and reduce health disparities such as implementing nutrition policies, capitalizing on donations and securing partnerships.

Investigating the effectiveness of webinars in the adoption of proven school wellness strategies.

OBJECTIVE: Recent federal legislation in the USA highlights the role schools play in student health by requiring the utilisation of wellness councils for policy development and oversight. One barrier to developing good-quality wellness policies and wellness culture is limited knowledge of resources among school professionals. This article describes an approach to webinar delivery to improve school wellness efforts. DESIGN: Eight webinars, 30-60 minutes in length, were delivered on topics designed to enhance school wellness environments. SETTING: Webinars were delivered using an online meeting software platform to school professionals, who participated from their respective school buildings remotely. METHOD: Webinars featured content experts for the selected topics and were promoted to school professionals and wellness organisations. Attendees were invited to participate in a post-webinar questionnaire regarding satisfaction with the session and intent to act on knowledge gained from participation. RESULTS: Webinars reached 280 school and wellness professionals (teachers, administrators, nurses, etc.). Participants who completed post-webinar surveys (n = 78) rated the webinar's ability to enhance their knowledge in the respective topic area with an average score of 4.3 out of 5.0 (1 = poor, 5 = excellent). Most respondents (n = 69) intended to share the information gained with a colleague. CONCLUSION: Webinars provide a viable method of instruction and education for school personnel interested in strategies for improving a school's wellness environment. Further investigation is necessary to determine the best strategies for promoting webinar engagement. Future research should also explore the link between webinar participation and positive changes in school wellness environments.

Opportunities and challenges in screening for childhood sexual abuse.

Retrospective studies suggest 1 in 4 girls and 1 in 6 boys will experience sexual abuse before 18 years of age, resulting in future morbidity. Successful interventions exist, however, victims are reluctant to disclose. Screening for childhood sexual abuse (CSA) may provide an opportunity to overcome this barrier, yet no current model for universal CSA screening exists. We sought to understand the perspective of key stakeholders on CSA screening through qualitative research. Eight focus groups of 7-10 participants each (n=62) were conducted from April-September 2016. Stakeholders included school nurses, school teachers, counselors and administrators, pediatric providers, and parents. The interview guide focused on reporting suspected CSA and impressions of a CSA screening tool. Sessions were audiotaped and transcribed. Researchers used qualitative content analysis to develop conceptual categories that related to CSA screening and reporting. Two research team members independently open-coded 20% of the data for interrater reliability (kappa=0.98) prior to completing the coding process. Three major categories emerged to inform CSA screening. First, early screening (e.g. kindergarten) was preferred. Confidentiality was a concern, specifically privacy in the school-setting. As CSA perpetrators are often known to the child, parental presence in the medical office was also a concern. Finally, refinement of the screening process was discussed starting with routine education on safe touch and defining "normal." Rather than direct questioning, consistent and repeated offering of opportunities to disclose CSA and identification of a trusted adult were suggested. Next steps should involve partnering with evidence-based CSA prevention programs to incorporate and evaluate the aforementioned elements.

Reducing Unintended Pregnancies Through Web-Based Reproductive Life Planning and Contraceptive Action Planning among Privately Insured Women: Study Protocol for the MyNewOptions Randomized, Controlled Trial.

BACKGROUND: The Affordable Care Act mandates that most women of reproductive age with private health insurance have full contraceptive coverage with no out-of-pocket costs, creating an actionable time for women to evaluate their contraceptive choices without cost considerations. The MyNewOptions study is a three-arm, randomized, controlled trial testing web-based interventions aimed at assisting privately insured women with making contraceptive choices that are consistent with their reproductive goals. METHODS: Privately insured women between the ages of 18 and 40 not intending pregnancy were randomly assigned to one of three groups: 1) a reproductive life planning (RLP) intervention, 2) a reproductive life planning enriched with contraceptive action planning (RLP+) intervention, or 3) an information only control group. Both the RLP and RLP+ guide women to identify their individualized reproductive goals and contraceptive method requirements. The RLP+ additionally includes a contraceptive action planning component, which uses if-then scenarios that allow the user to problem solve situations that make it difficult to be adherent to their contraceptive method. All three groups have access to a reproductive options library containing information about their contraceptive coverage and the attributes of alternative contraceptive methods. Women completed a baseline survey with follow-up surveys every 6 months for 2 years concurrent with intervention boosters. Study outcomes include contraceptive use and adherence. ClinicalTrials.gov identifier: NCT02100124. DISCUSSION: Results from the MyNewOptions study will demonstrate whether web-based reproductive life planning, with or without contraceptive action planning, helps insured women make patient-centered contraceptive choices compared with an information-only control condition.

How far can one walk wearing a self-contained self rescuer?

Self-contained self rescuers (SCSRs) are used for emergency escapes in oxygen-deficit atmospheres. Certified by NIOSH to last 1 hour, SCSRs generate oxygen by chemical reaction and must meet a minimum oxygen generation time of 60 min when used according to instructions. Wearers must walk or crawl at a controlled rate to conform to the limits of the devices. The aim of the is study was intended to determine the distance that can be walked when using SCSRs as intended. Fourteen volunteer subjects walked on a treadmill at moderate rates that they controlled. They were instructed to walk as far as possible without using oxygen at a rate higher than the SCSR could produce. Distances walked ranged from 2.1 km to 9.2 km with an average distance of 6.0 km. SCSR operating times ranged from 30 min to 94 min. If the required walking distance is farther than this, multiple units will have to be available to allow safe escape.