Identifying Priorities and Strategies for Improving Colorectal Cancer Screening in Tribal Clinics.

BACKGROUND: Colorectal cancer (CRC) is the 3rd most frequently diagnosed cancer and the 2nd leading cause of cancer death in the United States (US), and incidence and mortality rates in Oklahoma are higher for many American Indian (AI) populations than other populations. The AI CRC Screening Consortium addresses major regional CRC screening disparities among AIs with shared objectives to increase CRC screening delivery and uptake in AIs aged 50 to 75 years at average risk for CRC and to assess the effectiveness of implementations of the interventions. This manuscript reports environmental scan findings related to current practices and multi-stakeholder experiences with CRC screening in two Oklahoma Indian health care systems. METHOD: We conducted a mixed methods environmental scan across five clinical sites and with multiple stakeholders to determine the scope and scale of colorectal cancer screening in two separate AI health care delivery systems in Oklahoma. Data collection consisted of a mixture of individual interviews and group discussions at an urban site, and four clinical care sites within a tribal health system. RESULTS: Sixty-two individuals completed interviews. Data from these interviews will inform the development of evidence-based intervention strategies to increase provider delivery, community access to, and community priority for CRC screening in diverse AI health care delivery systems. Conversations with patients, providers, and clinical leadership point to individual and system-level opportunities for improvement at each site, shaped in part by differences in the delivery of services, structure of the health care system, and capacity to implement new intervention strategies. The thematic areas most central to the process of evidenced-based intervention development included: current practices, needs and recommendations, and CRC site priorities. CONCLUSION: Environmental scan data indicated clear opportunities for individual and system-level interventions to enhance CRC screening and was critical for understanding readiness for EBI implementation at each site.

Partnering With Faith-Based Organizations to Offer Flu Vaccination and Other Preventive Services.

In 2019, just one-half of Americans received their influenza vaccine, despite it being safe, effective, and important in preventing serious infection, hospitalization, and death. Black children receive fewer influenza vaccines than their White counterparts. Vaccine hesitancy can hinder influenza vaccine uptake and is partially fueled by ongoing systemic racism and historical abuse leading to medical mistrust in communities of color. Building trust may enhance the transfer of reliable vaccine information and may move people along the spectrum of vaccine intention. We sought to partner with faith-based organizations through a community influenza vaccination event to increase vaccination rates. By leveraging the reach and expertise of trusted voices, such as church "first ladies" and local community leaders, we were able to administer 600 pediatric influenza vaccines between 2016 and 2019. In addition, this event served as a platform to assess whether youth attendees had a place for regular medical care ("medical home") (>80% did in each year assessed) and to conduct preventive screenings. Most children, as reported by their caregivers, had recent medical check-ups (85% in 2016, 84% in 2017, and 82% in 2018). Of the children screened, more than one-third had an abnormal body mass index and one-half had abnormal dentition. By partnering with organizations that are well-embedded in the local community, such as faith-based organizations, health care groups may be able to maximize the impact of their health promotion campaigns.

Vaping patterns, nicotine dependence and reasons for vaping among American Indian dual users of cigarettes and electronic cigarettes.

BACKGROUND: The American Cancer Society discourages the dual use of electronic cigarettes (ECs) and cigarettes because such use has not resulted in reduced exposures to the harmful effects of smoking. American Indian (AI) people have the highest prevalence of smoking and of EC use in the United States, but very little is known about dual EC and cigarette use in AI communities. METHODS: In 2016, 375 adult AI in Oklahoma who smoked cigarettes completed a survey about EC use (vaping). We describe vaping patterns, nicotine dependence, and reasons for EC use among the subset of 44 (12%) current dual EC users. To differentiate habitual EC users from occasional or merely curious users, we defined dual use as using ECs on some days or every day in the past 30 days. RESULTS: About one-third of dual users vaped ten or more times daily. About two-thirds used a tank product. Eleven percent used ECs without nicotine and another 9% were unsure of the nicotine content. A minority (40%) enjoyed vaping more than smoking, and most (76%) would smoke first on days they did both. Thirty-one percent vaped within 5 min of waking and another 24% within 30 min. Although the two-item heaviness of use index did not differ significantly between smoking and vaping, the ten-item Penn State Dependence Index (PSDI) suggested greater dependence on smoking than vaping (11.02 vs. 6.42, respectively; p < .0001). The most common reasons for vaping were to reduce smoking (79%), enjoyment of flavors (78%), and ability to vape where smoking is not allowed (73%). Perceptions of less harm to others (69%) or to self were the next most common (65%). Fewer than half used ECs to reduce stress, for affordability, or because others used them. CONCLUSIONS: Nearly 20% of dual users used ECs either without nicotine or without knowing if the product contained nicotine. The PSDI indicated greater dependence on smoking than vaping. Reasons for vaping were nearly equal between smoking reduction and enjoying flavors. Understanding patterns of dual use will inform future efforts to address nicotine dependence for AI communities with high prevalence of smoking.

Perceptions of Smoking and Vaping on Weight Control Among Adult American Indians Who Smoke.

Interest in electronic cigarette (EC) use, or vaping, to help control weight is increasing. Many American Indian (AI) populations have a high prevalence of smoking, obesity, and EC use, but their perceptions of EC use for weight control are unknown. In Oklahoma in 2016, 375 AI adults who smoke completed a survey including perceptions about smoking and EC effects on weight control. Only 24% believed that smoking helps control weight, and 8% believed that vaping helps control weight. Perceptions differed by EC use, with ever users more often than never users perceiving that smoking (30% vs 12%, respectively; p < .01) and vaping (10% vs 5%; p = .04) help to control weight. Sex, age group (18-44 years vs 45 + years), education (high school graduate/equivalent vs less than high school), smoking cessation attempt in past year, and likelihood to quit in 6 months were not associated with weight control perceptions for either smoking or vaping. Uncertainty regarding EC effects on weight control was less common among EC ever users compared to never users (41% vs 53%, respectively; p = .04). Most people who did not believe or were uncertain that smoking controls weight also did not believe or were uncertain that vaping controls weight. However, only a minority (29%) of people who believed smoking controls weight also believed that vaping controls weight. Among adult AI who smoke, both smoking and vaping were infrequently perceived as helping to control weight, but such perceptions were reported more frequently among those who ever used ECs.

Children's and adults' understanding of death: Cognitive, parental, and experiential influences.

This study explored the development of understanding of death in a sample of 4- to 11-year-old British children and adults (N=136). It also investigated four sets of possible influences on this development: parents' religion and spiritual beliefs, cognitive ability, socioeconomic status, and experience of illness and death. Participants were interviewed using the "death concept" interview that explores understanding of the subcomponents of inevitability, universality, irreversibility, cessation, and causality of death. Children understood key aspects of death from as early as 4 or 5years, and with age their explanations of inevitability, universality, and causality became increasingly biological. Understanding of irreversibility and the cessation of mental and physical processes also emerged during early childhood, but by 10years many children's explanations reflected not an improved biological understanding but rather the coexistence of apparently contradictory biological and supernatural ideas-religious, spiritual, or metaphysical. Evidence for these coexistent beliefs was more prevalent in older children than in younger children and was associated with their parents' religious and spiritual beliefs. Socioeconomic status was partly related to children's biological ideas, whereas cognitive ability and experience of illness and death played less important roles. There was no evidence for coexistent thinking among adults, only a clear distinction between biological explanations about death and supernatural explanations about the afterlife.

All Nations Breath of Life: A Randomized Trial of Smoking Cessation for American Indians.

INTRODUCTION: American Indians have the highest cigarette smoking prevalence of any racial/ethnic group in the U.S. There is currently no effective empirically based smoking-cessation program for American Indians. The purpose of this study was to determine if a culturally tailored smoking-cessation program, All Nations Breath of Life (ANBL), is more effective than a non-tailored cessation program among American Indian smokers. DESIGN: A multisite RCT was conducted from September 2009 to July 2014; analysis was conducted in 2015. SETTING/PARTICIPANTS: Participants were rural or reservation-based American Indian smokers aged ≥18 years. INTERVENTION: Smokers were group randomized to either the culturally tailored ANBL or non-tailored current best practices (CBP) for a total enrolled sample size of 463 (ANBL, n=243; CBP, n=220). MAIN OUTCOME MEASURES: The primary outcome of interest was salivary cotinine-verified 7-day point prevalence smoking abstinence at 6 months. Results for both responder-only and intent-to-treat analyses for self-reported and cotinine-verified abstinence are presented. RESULTS: Intention-to-treat, imputing all non-responses as smokers, the self-reported point prevalence abstinence rates at 12 weeks were 27.9% in the ANBL arm and 17.4% in the CBP arm (p=0.028). There was a statistically significant difference in self-reported 6-month intent-to-treat point prevalence abstinence rates between ANBL (20.1%) and CBP (12.0%) arms (p=0.029). None of the cotinine-verified results were statistically significant. CONCLUSIONS: The culturally tailored smoking-cessation program ANBL may or may not be an effective program in promoting cessation at 12 weeks and 6 months. Participants in the culturally tailored ANBL program were approximately twice as likely to quit smoking at 6 months compared with the CBP program, using self-reported abstinence.

Starting out - Death of young patient hit us all hard during an emotional shift.

It was my second shift on an acute under-12s' children's ward. Handover began and I could tell by the look on the night shift nurse's face that it had been difficult.

Minnesota Rural Palliative Care Initiative: building palliative care capacity in rural Minnesota.

BACKGROUND: Significant gaps exist in the availability of palliative care in rural hospitals and communities, even though rural populations are often disproportionately elderly and chronically ill. Few studies have examined what models of palliative care would be sustainable in a rural community. METHODS: We studied the effects of a novel approach to palliative care program development with 10 rural Minnesota community teams over 18 months. The Minnesota Rural Palliative Care Initiative (MRPCI) included a three-prong framework consisting of community capacity theory, a learning collaborative model, and the National Quality Forum (NQF) Preferred Practices for Palliative and Hospice Care Quality. RESULTS: MRPCI confirmed the feasibility of building palliative care capacity in rural communities using this framework. By the end of the 18 months, all 10 teams had identified a target population, developed and refined an action plan, and included at least two strategies to address community needs or gaps related to NQF preferred practices. Only one community had an existing palliative care program at the start of the MRPCI. During the course of the collaborative, five additional communities built a core team to implement a palliative care program. CONCLUSIONS: Palliative care development is necessary in rural communities, and envisioning a program that combines structure, accountability, customized guidance, tools, and networking across settings is essential for success.

Reducing stimulus overselectivity through an increased observing-response requirement.

An adult with autism and a mild intellectual disability participated in a 0-s delayed matching-to-sample task. In each trial, two sample stimuli were presented together until the participant completed an observing-response requirement consisting of 1 or 10 mouse clicks in the baseline and experimental phases, respectively. One of the two sample stimuli then appeared randomly as a comparison stimulus (S+), along with two other comparison stimuli (S-). Higher levels of correct responding occurred under the larger observing-response requirement, and the proportion of errors related to one of the two sample stimuli decreased. Thus, stimulus overselectivity was reduced without requiring differential observing responses.

Low heat flow inferred from >4 Gyr zircons suggests Hadean plate boundary interactions.

The first approximately 600 million years of Earth history (the 'Hadean' eon) remain poorly understood, largely because there is no rock record dating from that era. Detrital Hadean igneous zircons from the Jack Hills, Western Australia, however, can potentially provide insights into the conditions extant on our planet at that time. Results of geochemical investigations using these ancient grains have been interpreted to suggest the presence of a hydrosphere and continental crust before 4 Gyr. An underexploited characteristic of the >4 Gyr zircons is their diverse assemblage of mineral inclusions. Here we present an examination of over 400 Hadean zircons from Jack Hills, which shows that some inclusion assemblages are conducive to thermobarometry. Our thermobarometric analyses of 4.02-4.19-Gyr-old inclusion-bearing zircons constrain their magmatic formation conditions to about 700 degrees C and 7 kbar. This result implies a near-surface heat flow of approximately 75 mW m(-2), about three to five times lower than estimates of Hadean global heat flow. As the only site of magmatism on modern Earth that is characterized by heat flow of about one-quarter of the global average is above subduction zones, we suggest that the magmas from which the Jack Hills Hadean zircons crystallized were formed largely in an underthrust environment, perhaps similar to modern convergent margins.