Physical Aggression and Coronary Artery Calcification: A North Texas Healthy Heart Study.

BACKGROUND: The purpose of this study was to determine the association between aspects of hostility and coronary artery calcification (CAC) scores. Specifically, analyses differentiated between subtypes of hostility and their relation to CAC. METHODS: A sample of 571 patients aged 45 or older with no history of cardiovascular disease completed assessments of demographic, psychosocial, and medical history, along with a radiological CAC determination. Logistic regression was used to determine the association between hostility and CAC. Hostility was measured using the Aggression Questionnaire, which measured total aggression and how aggression is manifested on four scales: Physical, Verbal, Anger, and Hostility Aggression. RESULTS: Regression analyses indicated that only the physical aggression parameter was related to CAC: a 5% increase in odds of CAC presence was indicated for every point increase in physical aggression. The association remained significant in adjusted analyses. Other factors associated with CAC in adjusted analyses included: age, gender, race/ethnicity, BMI, and dyslipidemia. CONCLUSIONS: Psychosocial factors, such as physical aggression, are emerging factors that need to be considered in cardiovascular risk stratification.

Implementation-effectiveness trial of systematic family health history based risk assessment and impact on clinical disease prevention and surveillance activities.

BACKGROUND: Systematically assessing disease risk can improve population health by identifying those eligible for enhanced prevention/screening strategies. This study aims to determine the clinical impact of a systematic risk assessment in diverse primary care populations. METHODS: Hybrid implementation-effectiveness trial of a family health history-based health risk assessment (HRA) tied to risk-based guideline recommendations enrolling from 2014-2017 with 12 months of post-intervention survey data and 24 months of electronic medical record (EMR) data capture. SETTING: 19 primary care clinics at four geographically and culturally diverse U.S. healthcare systems. PARTICIPANTS: any English or Spanish-speaking adult with an upcoming appointment at an enrolling clinic. METHODS: A personal and family health history based HRA with integrated guideline-based clinical decision support (CDS) was completed by each participant prior to their appointment. Risk reports were provided to patients and providers to discuss at their clinical encounter. OUTCOMES: provider and patient discussion and provider uptake (i.e. ordering) and patient uptake (i.e. recommendation completion) of CDS recommendations. MEASURES: patient and provider surveys and EMR data. RESULTS: One thousand eight hundred twenty nine participants (mean age 56.2 [SD13.9], 69.6% female) completed the HRA and had EMR data available for analysis. 762 (41.6%) received a recommendation (29.7% for genetic counseling (GC); 15.2% for enhanced breast/colon cancer screening). Those with recommendations frequently discussed disease risk with their provider (8.7%-38.2% varied by recommendation, p-values ≤ 0.004). In the GC subgroup, provider discussions increased referrals to counseling (44.4% with vs. 5.9% without, P < 0.001). Recommendation uptake was highest for colon cancer screening (provider = 67.9%; patient = 86.8%) and lowest for breast cancer chemoprevention (0%). CONCLUSIONS: Systematic health risk assessment revealed that almost half the population were at increased disease risk based on guidelines. Risk identification resulted in shared discussions between participants and providers but variable clinical action uptake depending upon the recommendation. Understanding the barriers and facilitators to uptake by both patients and providers will be essential for optimizing HRA tools and achieving their promise of improving population health. TRIAL REGISTRATION: Clinicaltrials.gov number NCT01956773 , registered 10/8/2013.

The Implementation of an Interpersonal Violence Screening Program in Primary Care Settings: Lessons Learned.

BACKGROUND: Interpersonal violence (IPV) is a public health issue that disproportionately affects women. IPV screening improves likelihood of survivor disclosure and access to additional support. To enhance primary care IPV screening, Technology Enhanced Screening and Supportive Assistance (TESSA) uses integrated technological systems to deliver bidirectional, evidence-informed health navigation, health management, and safety interventions. This study evaluates TESSA implementation in primary care clinics using the Consolidated Framework for Implementation Research (CFIR). METHOD: CFIR is a metatheoretical framework used for evaluating clinical intervention implementation. Salient constructs within CFIR's five domains (intervention characteristics, outer setting, inner setting, characteristics of individuals, and process) were identified (23 constructs), and pertinent implementation details were examined. RESULTS: Key lessons learned included intervention characteristic constructs like intervention source (e.g., selecting tablets that can screen for items integral to the program's aims) and adaptability (e.g., ensuring tablets worked with electronic medical records for each clinic), process constructs like engaging champions (e.g., garnering buy-in from key clinic stakeholders and staff), outer setting constructs like patient needs and resources (e.g., addressing pertinent patient resource needs) and external policies and incentives (e.g., incentivizing clinics by addressing clinic needs), and inner setting constructs like leadership engagement (e.g., ensuring buy-in from organizational leaders as leadership changed frequently). CONCLUSIONS: CFIR identifies important implementation factors for programs like TESSA that screen for high-risk populations and implement in primary care settings. The TESSA program implementation permits increased IPV screening among primary health care populations, thus promoting access to resources for otherwise hard-to-reach populations.

Development and implementation of tablet-based screening for interpersonal violence in primary care settings.

Technology Enhanced Screening and Supportive Assistance (TESSA) is program that includes a patient-facing mobile web app designed to identify primary care patients with a history of interpersonal violence (IPV). The implementation study included 1495 participants screened. Approximately one in four reported experiences with intimate partner violence (29%) or sexual assault (24%). Among those offered health advocacy services based on their victimization experiences, 31% indicated they wished to accept the assistance. We conclude that a tablet-based self-screening tool in primary care clinics is a viable way to identify and offer services to people who have experienced interpersonal violence.

Association between acculturation and metabolic syndrome in Hispanic adults mediated by fruits intake.

OBJECTIVES: Hispanic adults in the USA tend to have a disproportionate prevalence of metabolic syndrome (MetS) as compared to other races. DESIGN: We examined whether the association between acculturation and MetS and its components are mediated by the intake of fruit in Hispanics. SETTING: Data from the National Health and Nutrition Examination Surveys 2009-2016 were used in this study. PARTICIPANTS: A total of 2078 Hispanics aged ≥ 20 years were included in this analysis. RESULTS: The mediating role of total fruit intake was assessed using multivariable-adjusted logistic structural equation models with the bootstrapping method by estimating indirect (IE) and direct (DE) effects from acculturation to MetS. High acculturation was associated with increased odds of MetS (adjusted OR = 1·20, 95 % CI 1·04, 1·39), central obesity (OR = 1·24, 95 % CI 1·07, 1·44) and high blood pressure (OR = 1·16, 95 % CI 1·02, 1·32) among Hispanic adults. Total fruits intake partially mediated the associations of acculturation with MetS (ORIE = 1·02, 95 % CI 1·00, 1·03) and central obesity (ORIE = 1·02, 95 % CI 1·00, 1·03), whereas fully mediated the association between acculturation and high blood pressure (ORIE = 1·03, 95 % CI 1·01, 1·06). Moreover, intake of total fruits fully mediated the acculturation-MetS association among Mexican Americans (ORIE = 1·02, 95 % CI 1·00, 1·05). CONCLUSIONS: Our findings suggested that increasing fruit consumption may reduce the impact of high acculturation on MetS development in Hispanic adults. Further studies are needed to confirm these findings.

Environment-wide association study on childhood obesity in the U.S.

BACKGROUND: Childhood obesity is a national public health issue with increasing prevalence. It has been linked to diet, lack of physical activity, and genetic susceptibility, with more recent evidence that it could also result from environmental factors. Studies linking it to environmental factors are limited, unsystematic, incomprehensive, and inconclusive. OBJECTIVE: To conduct an environment-wide association study (EWAS) to comprehensively investigate all the environmental factors available in a nationally representative sample of children to determine factors associated with childhood obesity. METHODS: We utilized the 1999-2016 National Health and Nutrition Examination Survey (NHANES) datasets and included all children/adolescents (6-17 years). Obesity was measured using body mass index and waist to height ratio. A multinomial and binary logistic regression were used adjusting for age, sex, race/ethnicity, creatinine, calorie intake, physical activity, screen time, limitation to physical activities, and socioeconomic status. We then controlled for multiple hypothesis testing and validated our findings on a different cohort of children. RESULTS: We found that metals such as beryllium (OR: 3.305 CI: 1.460-7.479) and platinum (OR: 1.346 CI: 1.107-1.636); vitamins such as gamma-tocopherol (OR: 8.297 CI: 5.683-12.114) and delta-tocopherol (OR: 1.841 CI:1.476-2.297); heterocyclic aromatic amines such as 2-Amino-9H-pyrido (2,3-b) indole (OR: 1.323 CI: 1.083-1.617) and 2-Amino-3-methyl-9H-pyriodo(2,3-b)indole (OR: 2.799 CI: 1.442-5.433); polycyclic aromatic amines such as 9- fluorene (OR: 1.509 CI: 1.230-1.851) and 4-phenanthrene (OR: 2.828 CI: 1.632-4.899); and caffeine metabolites such as 1,3,7-trimethyluric acid (OR: 1.22 CI: 1.029-1.414) and 1,3,7-trimethylxanthine (OR: 1.258 CI: 1.075-1.473) were positively and significantly associated with childhood obesity. CONCLUSION: Following the unique concept of EWAS, certain environmental factors were associated with childhood obesity. Further studies are required to confirm these associations while investigating their mechanisms of action.

At the intersection of precision medicine and population health: an implementation-effectiveness study of family health history based systematic risk assessment in primary care.

BACKGROUND: Risk assessment is a precision medicine technique that can be used to enhance population health when applied to prevention. Several barriers limit the uptake of risk assessment in health care systems; and little is known about the potential impact that adoption of systematic risk assessment for screening and prevention in the primary care population might have. Here we present results of a first of its kind multi-institutional study of a precision medicine tool for systematic risk assessment. METHODS: We undertook an implementation-effectiveness trial of systematic risk assessment of primary care patients in 19 primary care clinics at four geographically and culturally diverse healthcare systems. All adult English or Spanish speaking patients were invited to enter personal and family health history data into MeTree, a patient-facing family health history driven risk assessment program, for 27 medical conditions. Risk assessment recommendations followed evidence-based guidelines for identifying and managing those at increased disease risk. RESULTS: One thousand eight hundred eighty-nine participants completed MeTree, entering information on N = 25,967 individuals. Mean relatives entered = 13.7 (SD 7.9), range 7-74. N = 1443 (76.4%) participants received increased risk recommendations: 597 (31.6%) for monogenic hereditary conditions, 508 (26.9%) for familial-level risk, and 1056 (56.1%) for risk of a common chronic disease. There were 6617 recommendations given across the 1443 participants. In multivariate analysis, only the total number of relatives entered was significantly associated with receiving a recommendation. CONCLUSIONS: A significant percentage of the general primary care population meet criteria for more intensive risk management. In particular 46% for monogenic hereditary and familial level disease risk. Adopting strategies to facilitate systematic risk assessment in primary care could have a significant impact on populations within the U.S. and even beyond. TRIAL REGISTRATION: Clinicaltrials.gov number NCT01956773 , registered 10/8/2013.

Implementation, adoption, and utility of family health history risk assessment in diverse care settings: evaluating implementation processes and impact with an implementation framework.

PURPOSE: This paper describes the implementation outcomes associated with integrating a family health history-based risk assessment and clinical decision support platform within primary care clinics at four diverse healthcare systems. METHODS: A type III hybrid implementation-effectiveness trial. Uptake and implementation processes were evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. RESULTS: One hundred (58%) primary care providers and 2514 (7.8%) adult patients enrolled. Enrolled patients were 69% female, 22% minority, and 32% Medicare/Medicaid. Compared with their respective clinic's population, patient-participants were more likely to be female (69 vs. 59%), older (mean age 57 vs. 49), and Caucasian (88 vs. 69%) (all p values <0.001). Female (81.3% of females vs. 78.5% of males, p value = 0.018) and Caucasian (Caucasians 90.4% vs. minority 84.1%, p value = 0.02) patient-participants were more likely to complete the study once enrolled. Patient-participant survey responses indicated MeTree was easy to use (95%), and patient-participants would recommend it to family/friends (91%). Minorities and those with less education reported greatest benefit. Enrolled providers reflected demographics of underlying provider population. CONCLUSION: Family health history-based risk assessment can be effectively implemented in diverse primary care settings and can effectively engage patients and providers. Future research should focus on finding better ways to engage young adults, males, and minorities in preventive healthcare.

How often parents make decisions with their children is associated with obesity.

BACKGROUND: Evidence supports that better parental involvement and communication are related to reduced obesity in children. Parent-child collaborative decision-making is associated with lower BMI among children; while child-unilateral and parent-unilateral decision-making are associated with overweight children. However, little is known about associations between joint decision-making and obesity among Hispanic youth. The purpose of this analysis was to determine the relationship between parent-child decision making and obesity in a sample of predominantly Hispanic adolescents. METHODS: Data from two studies focused on risk for type II diabetes were analyzed. A total of 298 adolescents 10-14 years of age and their parent/legal guardian were included. Parents completed questionnaires related to psychosocial, family functioning, and environmental factors. Multiple logistic regression was used to determine the association between obesity (≥ 95th percentile for age and gender), the dependent variable, and how often the parent felt they made decisions together with their child (rarely/never, sometimes, usually, always), the primary independent variable. Covariates included gender, age, ethnicity, total family income, and days participated in a physical activity for at least 20 min. ORs and 95% CIs were calculated. RESULTS: Adolescent participants were predominantly Hispanic n = 233 (78.2%), and approximately half n = 150 (50.3%) were female. In multivariate analyses, adolescents who rarely/never made decisions together with their family had significantly higher odds (OR = 3.50; 95% CI [1.25-9.83]) of being obese than those who always did. No association was observed between either those who sometimes make decisions together or those who usually did and those that always did. CONCLUSIONS: Parents and children not making decisions together, an essential aspect of parent-child communication, is associated with increased childhood obesity. The results of our study contribute to evidence of parental involvement in decision-making as an important determinant of adolescent health. Further studies should explore temporal relationships between parenting or communication style and obesity.

Correlation of Lipid Profile and Risk of Developing Type 2 Diabetes Mellitus in 10-14 Year Old Children.

BACKGROUND/AIMS: The role of lipid profile in predicting the risk of Type 2 diabetes mellitus (T2DM) in children is not clearly established. Our aim is to screen non-diabetic children aged 10-14 years for risk of developing T2DM and evaluate the association of abnormal lipids and socioeconomic status (SES). METHODS: Data on race/ethnicity, family history, body mass index percentile, blood pressure and presence of neck pigmentation (acanthosis nigricans) were collected from 149 non-diabetic children. Using these factors, children were classified into low risk (<3 risk factors) and high risk (>3 risk factors) groups. Logistic regression model and chi-square tests were used to evaluate the association of blood lipid profile and demographic variables. Independent t-test was used to compare the ratio of Total Cholesterol (TC) and High Density Lipids (HDL) with T2DM risk. RESULTS: 60% of children were at high risk for developing T2DM. HDL (p<0.001), triglycerides (p=0.02) and TC/HDL ratio (p<.001) were significantly abnormal in high risk group. Low SES showed a marginal association with high risk group. There were no gender or age differences between high and low risk groups. CONCLUSIONS: The significant determinants associated with high risk group were modifiable factors providing an opportunity for early intervention and prevention.

Association Between Healthcare Provider Type and Intent to Breastfeed Among Expectant Mothers.

BACKGROUND: The primary purpose of this study was to determine the association between type of healthcare provider delivering prenatal care and intent to exclusively breastfeed. METHODS: A self-report survey was administered to 455 expectant mothers. Logistic regression was performed to determine the association between prenatal care provider type [obstetrician; other primary care physician (family doctor/general practitioner/internist/or other physician); midwife/nurse midwife; more than one provider; and other] with intent to breastfeed (exclusive/non-exclusive). RESULTS: Having a midwife/nurse midwife as a prenatal care provider was associated with intent to breastfeed compared to having an obstetrician (OR 2.544, 95 % CI 1.385-4.675). There was no difference in intent between women with another primary care physician and an obstetrician. Women with another type of health care provider, no prenatal care from a health professional, or no knowledge of who is providing prenatal care were less likely to intend to breastfeed (OR 0.228, CI 0.068-0.766) as compared to those with an obstetrician. DISCUSSION/CONCLUSIONS: Provider type is associated with intent to breastfeed among pregnant women. Women's intent to breastfeed is an important predictor of breastfeeding initiation, continuation, and duration that may be assessed by healthcare providers during the prenatal period. A consideration of what features of provider care are associated with improved breastfeeding outcomes and characteristics of women seeking prenatal care with midwives may serve to formulate future prenatal care policies and education during prenatal care visits.

Suicide risk and mental health co-morbidities in a probationer population.

Mental health problems are disproportionately represented in the community corrections system with limited information on the epidemiology of mental health and correlated factors such as suicide among probationers. This study recruited 2,077 probationers who completed screeners for mental health and substance disorders and suicide risk. Results found 13% of probationers were at high risk of suicide. Those who screened positive for a mental health condition were between 2 and 8 times more likely to screen positive for suicide risk. Allocation of additional resources to mental health in the criminal justice system and to effectively coordinate existing mental health services is needed.

Paternal race/ethnicity and very low birth weight.

BACKGROUND: The purpose was to examine the association between paternal race/ethnicity and very low birth weight stratified by maternal race/ethnicity. METHODS: Birth data for Tarrant County, Texas 2006-2010 were analyzed. Very low birth weight was dichotomized as yes (<1,500 g) and no (≥1,500 g). Paternal race/ethnicity was categorized as Caucasian, African American, Hispanic, other, and missing. Missing observations (14.7%) were included and served as a proxy for fathers absent during pregnancy. Potential confounders included maternal age, education, and marital status, plurality, previous preterm birth, sexually transmitted disease during pregnancy, smoking during pregnancy, and Kotelchuck Index of prenatal care. Logistic regressions were stratified by maternal race/ethnicity. Odds ratios and 95% confidence intervals were calculated. RESULTS: Of 145,054 births, 60,156 (41.5%) were Caucasian, 22,306 (15.4%) African American, 54,553 (37.6%) Hispanic, and 8,039 (5.5%) other mothers. There were 2,154 (1.5%) very low birth weights total, with 3.1% for African American mothers and 1.2% for all other race/ethnicities. Among Caucasian mothers, African American paternal race was associated with increased odds of very low birth weight (OR = 1.52; 95% CI:1.08-2.14). Among Hispanic mothers, African American paternal race (OR = 1.66; 95% CI:1.01-2.74) and missing paternal race/ethnicity (OR = 1.65; 95% CI:1.15-2.36) were associated with increased odds of very low birth weight. CONCLUSIONS: Paternal race/ethnicity is an important predictor of very low birth weight among Caucasian and Hispanic mothers. Future research should consider paternal race/ethnicity and further explore the association between paternal characteristics and very low birth weight.

The patient perspective on overactive bladder: a mixed-methods needs assessment.

BACKGROUND: While overactive bladder is often managed in the primary care setting, a number of barriers including embarrassment, poor communication, and low patient adherence contribute to the under-treatment of patients with burdensome urinary symptoms. In order to address these challenges, it is crucial to have a fundamental understanding of patient perspectives toward OAB and urinary symptoms. To meet this aim, researchers designed and conducted a study to identify patients' knowledge, experiences and attitudes, barriers to treatment adherence, and desires and tendencies regarding patient/clinician communications. METHODS: A mixed-methods qualitative/quantitative needs assessment of patients with overactive bladder and/or urinary symptoms. Researchers conducted in-depth qualitative interviews via telephone with 40 patients. Interview results informed the design and dissemination of a quantitative survey, which was completed by 200 self-selected respondents who had previously identified themselves as having overactive bladder or bladder problems. Statistical and qualitative analysis of results were conducted. RESULTS: Among survey respondents, an average of 3.5 years elapsed between symptom onset and seeking diagnosis by a physician. In the long term most patients do not experience improvement in symptoms. Medication non-adherence is common and is related to therapy effectiveness and adverse effects. Patients clearly indicate that communication and patient/physician relationships are important to them and they would prefer the clinician initiate the conversation on overactive bladder. Patient experiences, perspectives, and attitudes toward their bladder symptoms differ in many ways from clinicians' assumptions. CONCLUSIONS: The significant time gap between symptom onset and diagnosis indicates ongoing need for screening and diagnosis of overactive bladder. Contrary to guideline recommendations, urinalysis and physical examination are not widely used in clinical practice. Many patients experience no improvement in symptoms over time. Patients indicate that clinician/patient relationships and communication regarding their condition are important.

Risk of future offense among probationers with co-occurring substance use and mental health disorders.

The criminal justice system is the primary service delivery system for many adults with drug and alcohol dependence, mental health, and other health service needs. The purpose of this study was to examine the relationship between risk of future offense, mental health status and co-occurring disorders in a large substance abuse diversion probationer population. A purposive sample of 2,077 probationers completed an assessment to screen for mental health disorders, substance use disorders, risk of future crime and violence, and several demographic characteristics. Probationers who screened positive for co-occurring substance use and mental health disorders were significantly more likely to be at higher risk of future crime and violence compared to probationers who screened positive for only substance use, only a mental health disorder, or no substance use or mental health disorder. Implications for substance use and mental health service delivery are discussed, and recommendations are made for further research.

Medication Management Strategies by Community-Dwelling Older Adults: A Multisite Qualitative Analysis.

OBJECTIVES: Community-dwelling older adults taking 5 or more medications are at risk for medication-related harm. Managing multiple medications is a challenging task for patients and caregivers. Community-dwelling older adults self-manage their medications with minimal healthcare professional supervision. Although organizations, such as the Food and Drug Administration, often issue guidelines to ensure medication safety, how older adults understand and mitigate the risk of harm from medication use in the home environment is poorly understood. METHODS: We conducted semistructured interviews with community-dwelling older adults 65 years and older who took 5 or more prescription medications to explore medication safety strategies they use. We also compared 2 organizations' medication safety guidelines for areas of concordance and discordance. RESULTS: A total of 28 older adults were interviewed. Four overarching themes of medication management strategies emerged: collaborating with prescribers, collaborating with pharmacists, learning about medications, and safe practices at home. Study findings revealed that older adults followed some of the published guidelines by the 2 government organizations, although there were some areas of discord. Some of the strategies used were unintentionally against the recommended guidelines. For example, older adults tried weaning themselves off their medications without notifying their providers. CONCLUSIONS: Older adults and their caregivers in our study used strategies different from those recommended by government organizations in managing medications to enhance drug safety. Patient-provider collaboration and positive patient outcomes can be improved by understanding and respecting strategies older adults use at home. Future studies must effectively incorporate older adults' perspectives when developing medication safety guidelines.

Effectiveness of provider communication training for increasing human papillomavirus vaccine initiation at a safety-net health system.

Background: Strong provider recommendation can increase uptake of human papillomavirus (HPV) vaccination. Therefore, we developed and implemented a provider education intervention on communication strategies for recommending HPV vaccination with clinic-level audit and feedback (HPV: Communicating about HPV to Adults and Teens [HPV CHAT]). We aimed to evaluate the effect of HPV CHAT on HPV vaccine uptake in seven family medicine and pediatric clinics in a large urban health system (USA). Methods: We used a quasi-experimental design, where the eligible population included people aged 9-26 years with at least one encounter in June 2020-February 2023 at one of the participating community health clinics. We used interrupted time-series analysis to assess changes in the prevalence of HPV vaccine uptake. We used segmented Poisson regression with a log link function to estimate prevalence ratios (PR) and 95% confidence limits (CL) for level (immediate) and slope (over time) changes with adjustment for seasonality using Fourier transformation. Results: Our study population comprised 60,328 observations in which the median age was 17 years (interquartile range: 13-21). A majority (58%) were female and 87% were racial/ethnic minorities. Overall, we observed no sizeable effect of the intervention on HPV vaccination uptake. Nonetheless, heterogeneity was observed by age group with modest increases in individuals aged 9-12 and 13-17 years. Conclusion: Our provider feedback intervention had minimal effect on increasing prevalence of HPV vaccination in seven family medicine and pediatric clinics. Novel strategies are needed to address provider barriers related to HPV vaccination.

Evaluation of a human papillomavirus vaccination training implementation in clinical and community settings across different clinical roles.

Improving human papillomavirus (HPV) vaccination is a national priority but uptake declined following the coronavirus pandemic. A strong predictor of HPV vaccination in the USA is a strong provider recommendation. Therefore, we developed a brief, asynchronous training on HPV vaccine recommendations in clinical and community settings as part of a multisite quality improvement initiative. This paper aims to describe the implementation and initial outcomes of the training provided. A 20-minute training on HPV vaccine bundled recommendations, motivational interviewing, and brief responses to patient concerns (Communicating about HPV vaccination to Adults and Teens; HPV CHAT) was implemented at seven safety-net clinics, two practice-based research network clinics, and nine county immunization clinics. We integrated training with clinical care teams; thus, we assessed immediate training outcomes across their different clinical roles compared to pre-training. In April-May 2022, HPV CHAT training was launched. One hundred eighty-seven people participated in the training and completed the pre-/postevaluation surveys. Knowledge about the HPV vaccine guidelines improved with notable changes in correctly reporting vaccine eligibility (P < .05). A significant change in participants' confidence when addressing safety concerns and answering questions about the HPV vaccine (clinicians, 26.8% and 17.1%; nurses, 29.0% and 23.2%, and clinical staff, 18.2% and 37.7%) was observed. At post-test, more than 85% of clinicians and nurses reported their plan to routinely recommend the HPV vaccine. This quality improvement initiative demonstrated implementation feasibility of a brief HPV vaccine training that improved provider and clinical staff knowledge, confidence, and intention to routinely recommend HPV vaccination.

The human papillomavirus (HPV) vaccine is key to cancer prevention. Despite this fact, HPV vaccination is not widely accepted. Studies have shown that a strong recommendation can lead to HPV vaccination. Therefore, virtual educational training (Communicating about HPV vaccination to Adults and Teens; HPV CHAT) was developed to equip clinicians, nurses, and clinical staff with communication tools to support HPV recommendation and respond to patient concerns. HPV CHAT, a quality improvement initiative, was launched across numerous community and county clinical teams. To capture HPV CHAT training impact, pre- and post-evaluation surveys were disseminated alongside the training to capture training impact. After HPV CHAT implementation, training participants reported a positive impact on confidence and knowledge items; these findings were observed across all clinical roles in varying degrees. Overall, this quality improvement initiative successfully improved communication skill self-efficacy and knowledge across different clinical roles. This paper discusses training implementation strategies and the changes in knowledge and confidence after participating in the training.

Do unmet needs differ geographically for children with special health care needs?

The purpose of this study was to identify geographic differences in health indicators for children with special health care needs (CSHCN). It was hypothesized that geographic differences in unmet health care needs exist among CSHCN by region in the United States. Data were obtained from the National Survey of Children with Special Health Care Needs, 2005-2006. Nine variables representing unmet needs were analyzed by geographic region. The region with the highest percent of unmet needs was identified for each service. Logistic regression was utilized to determine differences by region after controlling for age, gender, ethnicity, race, federal poverty level, relationship of responder to child, insurance status, severity of condition, and size of household. A total of 40,723 CSHCN were represented. Crude analysis demonstrated that the greatest unmet need for routine preventive care, specialist care, prescription medications, physical/occupational/speech therapy, mental health care, and genetic counseling occurred in the West. The greatest unmet need for preventive dental care, respite care, and vision care occurred in the South. Significant differences between regions remained for six of the nine services after controlling for potential confounders. Geographic differences in unmet health care needs exist for CSHCN. Further delving into these differences provides valuable information for program and policy planning and development. Meeting the needs of CSHCN is important to reduce cost burden and improve quality of life for the affected child and care providers.

A Cross-Sectional Study Comparing Traumatic Alopecia Among B-Boys and B-Girls to Other Dance Styles and Its Impact on Dance Performance and Health.

INTRODUCTION: Breaking, often mislabeled as breakdancing in the media, is a dance style originating from the Bronx of New York in the early 1970s. A unique condition in this population is a form of alopecia known as "headspin hole," or "breakdancer overuse syndrome" of the scalp. This form of hair loss may show a variety of patterns based on the activities of the dancer. The purpose of this study was to investigate the relationship between alopecia and breaking, the level of concern dancers have regarding hair loss, barriers to medical treatment, and how it affects their dancing. METHODS: This was a cross-sectional study using an online survey. The survey addressed participants' demographics, hair, dancing styles, training, and health history. Questions about the effects of hair loss on the participants were also asked. RESULTS: This study found that there was a significant difference in hair loss among breakers compared to non-breakers. This was not seen after controlling for age and sex. However, the concern for hair loss was significant even after controlling for these variables. Similarly, hair loss was significantly associated with the frequency of headspins. Despite these concerns, breakers were less likely to seek medical attention. CONCLUSIONS: This study showed that there are significant disparities in hair loss between breaking and other dance styles. Hair loss due to breaking has been shown to have significant effects on an individual's concerns, which may be compounded by the fact that this population is less likely to seek out medical care and have significantly greater substance use compared to the other dancers surveyed. Further research is necessary to investigate interventions to prevent and treat hair loss in this population and the means to decrease the gap in health care in the dance population.