Focus Group Study of Heart Failure Nurses' Perceptions of the Feasibility of Cognitive Behavioral Therapy for Insomnia.

BACKGROUND: People with heart failure (HF) often report insomnia with daytime consequences, including fatigue and decreased functional performance. Cognitive behavioral therapy for insomnia is an efficacious treatment, but few have access because of a shortage of trained sleep specialists. Access may be improved by offering it where people with HF receive care. OBJECTIVES: The purpose of this study was to explore the perceptions of nurses who specialize in HF regarding the value of cognitive behavioral therapy for insomnia to their patients, the feasibility of offering it in HF clinical settings, its delivery by nurses, and preferences for modes of delivery. METHODS: We used a descriptive qualitative study design. We recruited focus group participants via e-mail to American Association of Heart Failure Nurses members and through requests for nurse collaborators to distribute within their networks. We conducted focus groups via Zoom. After describing cognitive behavioral therapy for insomnia and its efficacy for people with HF, we elicited perceptions about its value if provided in the HF outpatient clinical setting, facilitators and barriers to implementation, and other ways to increase access. We audio-recorded and transcribed the discussions. Two researchers coded the data and performed thematic analysis. RESULTS: Four focus groups included 23 registered nurses and advanced practice nurses employed in outpatient HF clinics. We identified five themes: "Insomnia Overlooked," "Cognitive Behavioral Therapy for Insomnia Works," "Nurses' Role," "Barriers and Supports," and "Modes of Delivery." Nurses endorsed the importance of insomnia to people with HF and the value of providing cognitive behavioral therapy. They expressed interest in evaluating and addressing sleep, the need for increased resources to address it, and multiple modes of delivery. All nurses believed they had a role in promoting sleep health but differed in their views about providing cognitive behavioral therapy for insomnia. DISCUSSION: Nurses specializing in HF support the implementation of cognitive behavioral therapy for insomnia. Implementation studies are needed to identify effective methods to increase access to this efficacious treatment in outpatient HF clinical settings, including support and training for nurses who are interested and able to deliver it.

The CARING study: Examining biological, behavioral, and genetic mechanisms in the intergenerational transmission of toxic stress.

When children experience extreme or persistent stressors (e.g., maltreatment, housing insecurity, intimate partner violence), prolonged elevation of the stress-response system can lead to disrupted development of multiple physiological systems. This response, known as toxic stress, is associated with poor physical and mental health across the life course. Emerging evidence suggests that the effects of toxic stress may be transmitted through generations, but the biological and behavioral mechanisms that link caregivers' childhood history with the health of the children they care for remain poorly understood. The purpose of this report is to describe the research protocol for The CARING (Childhood Adversity and Resilience In the Next Generation) Study, a cross-sectional study of caregivers with children aged 3-5 years designed to (1) examine the intergenerational transmission of toxic stress and protective factors; (2) explore three hypothesized pathways of transmission: parenting, daily routines, stressors, and supports; and (3) explore the extent to which genotypic variation in candidate genes related to caregiving and stress contribute to caregivers' and children's susceptibility to the effects of early childhood experiences (i.e., gene × environment interactions). We expect that findings from this study will provide critical data needed to identify targets for precision health interventions, reduce health disparities related to toxic stress, and prevent cycles of adversity among families at risk.

Daytime symptom trajectories among adults with stable heart failure and insomnia: evidence from a randomised controlled trial of cognitive behavioural therapy for insomnia.

People with heart failure (HF) experience a high symptom burden and prevalent insomnia. However, little is known about daytime symptom trajectories after cognitive behavioural therapy for insomnia (CBT-I). In this study we describe: (1) daytime symptom trajectories among adults with insomnia and stable HF over 1 year, (2) how symptom trajectories differ between CBT-I versus HF self-management interventions, and (3) associations between demographic, clinical, and sleep characteristics, perceived stress, health-related quality of life (HRQoL), functional performance and daytime symptoms trajectories. We retrospectively analysed data from a randomised controlled trial of CBT-I versus HF self-management (NCT0266038). We measured sleep, perceived stress, HRQoL, and functional performance at baseline and symptoms at baseline, 3, 6, and 12 months. We conducted group-based trajectory modelling, analysis of variance, chi-square, and proportional odds models. Among 175 participants (mean [standard deviation] age 63.0 [12.9] years, 57.1% male, 76% White), we found four daytime symptom trajectories: (A) low improving symptoms (38.3%); (B) low psychological symptoms and high improving physical symptoms (22.8%); (C) high improving symptoms (24.0%); and (D) high not improving symptoms (14.9%). The CBT-I versus the HF self-management group had higher odds of belonging to Group A compared to other trajectories after controlling for baseline fatigue (odds ratio = 3.27, 95% confidence interval 1.39-7.68). The difference between the CBT-I and the HF self-management group was not statistically significant after controlling for baseline characteristics. Group D had the highest body mass index, perceived stress, and insomnia severity and the lowest cognitive ability, HRQoL, and functional performance. Research is needed to further evaluate factors contributing to symptom trajectories.

Correlates of cognition among people with chronic heart failure and insomnia.

PURPOSE: This study aimed to describe cognitive characteristics and their associations with demographic and clinical factors among adults with chronic heart failure (HF) and insomnia. METHODS: We performed a cross-sectional analysis of baseline data from the HeartSleep Study (NCT#02,660,385), a randomized controlled trial designed to evaluate the effects of cognitive-behavioral therapy for insomnia. Demographic characteristics and health history were obtained. We measured sleep characteristics with the Insomnia Severity Index, the PROMIS Sleep Disturbance Questionnaire, and wrist actigraphy. Sleepiness, stress, and quality of life were measured with validated questionnaires. Measures of cognition included frequency of lapses on the psychomotor vigilance test and the PROMIS cognitive abilities scale where ≥ 3 lapses and a score of ≤ 50, respectively, suggested impairment. These variables were combined into a composite score for multivariable analyses. RESULTS: Of a sample that included 187 participants (58% male; mean age 63.1 [SD = 12.7]), 77% had New York Heart Association class I or II HF and 66% had HF with preserved ejection fraction. Common comorbidities were diabetes (35%), hypertension (64%), and sleep apnea (54%). Impaired vigilant attention was associated with non-White race, higher body mass index, less education, and more medical comorbidities. Self-reported cognitive impairment was associated with younger age, higher body mass index, and pulmonary disease. On adjusted analysis, significant risk factors for cognitive impairment included hypertension (OR 1.94), daytime sleepiness (OR 1.09), stress (OR 1.08), and quality of life (OR 0.12). CONCLUSIONS: Impaired cognition is common among people with chronic HF and insomnia and associated with hypertension, daytime sleepiness, stress, and poor quality of life. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: Insomnia Self-management in Heart Failure; NCT#02,660,385.

Symptom Cluster Profiles Among Adults with Insomnia and Heart Failure.

OBJECTIVE/BACKGROUND: Both heart failure (HF) and insomnia are associated with high symptom burden that may be manifested in clustered symptoms. To date, studies of insomnia have focused only on its association with single symptoms. The purposes of this study were to: (1) describe daytime symptom cluster profiles in adults with insomnia and chronic HF; and (2) determine the associations between demographic and clinical characteristics, insomnia and sleep characteristics and membership in symptom cluster profiles. PARTICIPANTS: One hundred and ninety-five participants [M age 63.0 (SD12.8); 84 (43.1%) male; 148 (75.9%) New York Heart Association Class I/II] from the HeartSleep study (NCT0266038), a randomized controlled trial of the sustained effects of cognitive behavioral therapy for insomnia (CBT-I). METHODS: We analyzed baseline data, including daytime symptoms (fatigue, pain, anxiety, depression, dyspnea, sleepiness) and insomnia (Insomnia Severity Index), and sleep characteristics (Pittsburgh Sleep Quality Index, wrist actigraphy). We conducted latent class analysis to identify symptom cluster profiles, bivariate associations, and multinomial regression. RESULTS: We identified three daytime symptom cluster profiles, physical (N = 73 participants; 37.4%), emotional (N = 12; 5.6%), and all-high symptoms (N = 111; 56.4%). Body mass index, beta blockers, and insomnia severity were independently associated with membership in the all-high symptom profile, compared with the other symptom profile groups. CONCLUSIONS: Higher symptom burden is associated with more severe insomnia in people with stable HF. There is a need to understand whether treatment of insomnia improves symptom burden as reflected in transition from symptom cluster profiles reflecting higher to lower symptom burden.

Costs and Resource Utilization of People with Stable Heart Failure and Insomnia: Evidence from a Randomized Trial of Cognitive Behavioral Therapy for Insomnia.

OBJECTIVES: Nearly half of patients with chronic heart failure (HF) report insomnia symptoms. The purpose of this study was to examine the impact of CBT-I versus HF self-management on healthcare costs and resource utilization among patients with stable chronic HF who participated in a clinical trial of the effects of CBT-I compared to HF self-management education (attention control) over 1 year. METHODS: We measured resource utilization as self-reported (medical record review) physician office visits, emergency department visits, and inpatient admissions at 3-month intervals for 1 year after enrollment. Costs were estimated by applying price weights to visits and adding self-reported out-of-pocket and indirect costs. Univariate comparisons were made of resource utilization and costs between CBT-I and the HF self-management group. A generalized linear model (GLM) was used to model costs, controlling for covariates. RESULTS: The sample included 150 patients [79 CBT-I; 71 self-management (M age = 62 + 13 years)]. The CBT-I group had 4.2 inpatient hospitalizations vs 4.6 for the self-management group (p = .40). There were 13.1 outpatient visits, in the CBT-I compared with 15.4 outpatient visits (p-value range 0.39-0.81) for the self-management group. Total costs were not significantly different in univariate or ($7,813 CBT-I vs. $7,538 self-management), p = .96) or multivariable analyses. CONCLUSIONS: Among patients with both HF and insomnia, CBT-I and HF self-management were associated with similar resource utilization and total costs. Additional research is needed to estimate the value of CBT-I relative to usual care and other treatments for insomnia in patients with HF.

Sleep, Stress, and Symptoms Among People With Heart Failure During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic raised concerns about the effects of stress on sleep and mental health, particularly among people with chronic conditions, including people with heart failure (HF). OBJECTIVE: The aim of this study was to examine changes in sleep, sleep-related cognitions, stress, anxiety, and depression among people with HF who participated in a randomized controlled trial of cognitive behavioral therapy for insomnia before the COVID-19 pandemic. METHODS: Participants self-reported sleep characteristics, symptoms, mood, and stress at baseline, 6 months after cognitive behavioral therapy for insomnia or HF self-management education (attention control), and during the pandemic. RESULTS: The sample included 112 participants (mean age, 63 ± 12.9 years; 47% women; 13% Black; 68% New York Heart Association class II or III). Statistically significant improvements in sleep, stress, mood, and symptoms that occurred 6 months post treatment were sustained during the pandemic. CONCLUSIONS: Improving sleep and symptoms among people with HF may improve coping during stressful events, and cognitive behavioral therapy for insomnia may be protective.

Something Has to Give: An Urban Community-Engaged Focus Group Study of Teen Sleep.

Sleep is critical to teen physical and mental health, daily function, and school performance. Yet, sleep deficiency is prevalent among ethnoracially diverse teens. The purpose of this community-engaged focus group study was to explore multilevel influences on teen sleep from teen and community stakeholder perspectives and to use this information to develop a tailored sleep health intervention. We conducted seven focus groups (N = 46) and analyzed data via content analysis. Five themes, each with subthemes, described sleep knowledge/attitudes, sleep habits, the multilevel causes and consequences of decreased nighttime sleep and suggestions for improving teen sleep. Teen health, mood, and school engagement were all impacted by inadequate nighttime sleep. Exhaustion emerged as an overarching theme and coincided with the transition to high school. The data from this study provide insight into important areas of focus for a sleep intervention tailored to the needs of ethnoracially diverse teens living in an urban community.

Treatment Fidelity in a Randomized Controlled Trial of Cognitive Behavioral Therapy for Insomnia in Heart Failure.

BACKGROUND: Cognitive behavioral therapy for insomnia (CBT-I) is an efficacious treatment for people with chronic insomnia, including those with heart failure (HF). Treatment fidelity evaluation is needed to ensure study validity and reliability. OBJECTIVE: The aim of this study was to apply the National Institutes of Health Behavioral Change Consortium framework to ensure adequate treatment fidelity in a randomized controlled trial of CBT-I for people with stable HF. METHODS: We describe strategies to ensure treatment fidelity in study design, provider training, and treatment delivery. We measured treatment receipt (observation and self-report) and enactment of CBT-I strategies (self-report and actigraphy). We used the Dysfunctional Beliefs and Attitudes About Sleep Scale and the Sleep Disturbance Questionnaire to indicate sleep-related beliefs and cognitions. We computed descriptive statistics for demographic characteristics, treatment receipt, and enactment variables. We compared baseline and post-intervention dichotomous sleep behaviors using the two-sided Wilcoxon rank-sum test. We calculated the root mean square of successive difference in time of sleep onset and midpoint (actigraphy) to indicate day-by-day variability in bed and wake times. RESULTS: Most participants completed the CBT-I intervention and follow-up assessments and attended each group or make-up session. Most correctly computed their sleep efficiency and completed their homework. Most participants used the sleep tracker and reported using strategies to improve their sleep schedules. There was a significant decrease in actigraph-measured light intensity during the 30 minutes and 1 hour before bedtime between baseline and post-intervention and no statistically significant changes in light intensity after waking or in nap frequency. Most of those who woke during the night got out of bed, consistent with recommendations. There were significant improvements on all of the Dysfunctional Beliefs and Attitudes About Sleep items and total score and all but one item on the Sleep Disturbance Questionnaire. DISCUSSION: Preserved treatment fidelity may explain the large and sustained effects in people with HF found in our trial. Further research is needed to evaluate CBT-I's effectiveness and implementation strategies among people with HF in real-world clinical settings.

Sleep Characteristics, Mood, Somatic Symptoms, and Self-Care Among People With Heart Failure and Insomnia.

BACKGROUND: Almost 50% of people with heart failure (HF) experience chronic insomnia and must perform self-care to manage their day-to-day healthcare needs. Understanding multifactorial influences on self-care, including demographic, clinical, and sleep characteristics, and mood and somatic symptoms will help identify people at highest risk for poor self-care. However, past research focused only on the associations of single symptoms and self-care. Multivariate approaches are needed to account for the synergistic associations of self-care with sleep, mood, and somatic symptoms among people with HF. OBJECTIVES: The aims of the study were to (a) evaluate the levels of self-care maintenance and self-care confidence among people with stable HF and chronic insomnia; (b) identify the clinical and demographic correlates of self-care maintenance and confidence among people with stable HF and chronic insomnia; and (c) identify the associations between sleep characteristics, mood and somatic symptoms, and self-care maintenance and confidence among people with stable HF and chronic insomnia. METHODS: We utilized a cross-sectional design with 195 adult participants who had chronic HF and insomnia. We assessed for symptoms of anxiety; depression; dyspnea; fatigue; stress; insomnia severity; and sleep disturbance, impairment, and quality. Self-care was measured using the Self-Care for Heart Failure Index v6.2. We used generalized linear models to test the associations between the demographic and clinical factors and self-care maintenance and confidence; exploratory and confirmatory factor analysis to identify the factor structure underlying the symptoms; and structural equation modeling to test the combined associations of the demographic and clinical factors and latent factors with self-care maintenance and confidence. RESULTS: Self-care maintenance, confidence, and management were inadequate in most participants. We identified three latent factors among the nine symptoms: "sleep characteristics," "mood," and "somatic symptoms." In the structural equation model, "sleep characteristics," White race, and having a left ventricular ejection fraction of <45 were associated with self-care maintenance. Age was negatively associated with self-care confidence. DISCUSSION: Poor sleep characteristics negatively influence the ability of people with HF and insomnia to perform self-care behaviors. Knowledge of the associations among age, left ventricular ejection fraction, and race with self-care will help clinicians and future researchers identify those at risk for poor self-care.

Formin Cdc12's specific actin assembly properties are tailored for cytokinesis in fission yeast.

Formins generate unbranched actin filaments by a conserved, processive actin assembly mechanism. Most organisms express multiple formin isoforms that mediate distinct cellular processes and facilitate actin filament polymerization by significantly different rates, but how these actin assembly differences correlate to cellular activity is unclear. We used a computational model of fission yeast cytokinetic ring assembly to test the hypothesis that particular actin assembly properties help tailor formins for specific cellular roles. Simulations run in different actin filament nucleation and elongation conditions revealed that variations in formin's nucleation efficiency critically impact both the probability and timing of contractile ring formation. To probe the physiological importance of nucleation efficiency, we engineered fission yeast formin chimera strains in which the FH1-FH2 actin assembly domains of full-length cytokinesis formin Cdc12 were replaced with the FH1-FH2 domains from functionally and evolutionarily diverse formins with significantly different actin assembly properties. Although Cdc12 chimeras generally support life in fission yeast, quantitative live-cell imaging revealed a range of cytokinesis defects from mild to severe. In agreement with the computational model, chimeras whose nucleation efficiencies are least similar to Cdc12 exhibit more severe cytokinesis defects, specifically in the rate of contractile ring assembly. Together, our computational and experimental results suggest that fission yeast cytokinesis is ideally mediated by a formin with properly tailored actin assembly parameters.

Perceived Stress, Subjective, and Objective Symptoms of Disturbed Sleep in Men and Women with Stable Heart Failure.

Objective/Background: Sleep disturbance is prevalent among patients with heart failure (HF) and is associated with increased morbidity and mortality. Stress also affects health and quality of life among patients with cardiovascular disease and likely plays a prominent role in HF. However, little is known about the associations between stress and sleep among HF patients.Participants: One hundred fifty-three stable New York Heart Association (NYHA) Classification I-IV HF patients with at least low symptoms of insomnia (Mage:63.0 ± 12.8, 42% Women).Methods: We examined baseline stress, sleep disturbance, and sleep-related characteristics from a randomized controlled trial of cognitive behavioral therapy for insomnia, including the Perceived Stress Scale, Insomnia Severity Index, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Sleep Disturbance Questionnaire, Dysfunctional Beliefs about Sleep Scale, PROMIS Cognitive Ability, SF-36 Mental Health, and wrist actigraphy. We used Pearson correlations and general linear models to assess stress-sleep associations, including the potential moderating effects of sex and symptom severity (NYHA).Results: There were moderate-to-large correlations between stress and self-reported sleep disturbance, dysfunctional beliefs about sleep, cognitive ability, and mental health (p's < 0.01). High stress was associated with more objectively-measured (i.e., actigraph-assessed) awakenings and sleep fragmentation among women than men (ß = - 0.04, p < 0.01; ß = - 0.71, p = 0.04). Relationships between stress and objectively-measured sleep did not vary by symptom severity.Conclusions: Perceived stress is related to sleep disturbance among HF patients, and effects may be sex-dependent. Subsequent research should determine the temporal links between sleep and stress, and optimal opportunities for intervention among HF patients.

Day-to-day Relationships between Physical Activity and Sleep Characteristics among People with Heart Failure and Insomnia.

OBJECTIVE: Examine the bidirectional relationships between within-person day-to-day fluctuations in physical activity (PA) and sleep characteristics among people with heart failure (HF) and insomnia. PARTICIPANTS: Ninety-seven community-dwelling adults [median age 61.9 (interquartile range 55.3,70.9) years, female 41%] with stable HF and insomnia (insomnia severity index >7). METHODS: This sub-study longitudinally analyzed 15 consecutive days and nights of wrist actigraphy recordings, that were collected for baseline data prior to participation in a randomized controlled trial of cognitive behavioral therapy for insomnia. We used two-level mixed models of within- (daily) and between-participants variation to predict daytime PA counts/minutes from sleep variables (total sleep time, sleep efficiency) and predict sleep variables from PA. RESULTS: PA counts/minutes were low compared to prior cohorts that did not have HF (209 (166,259)) and negatively associated with NYHA class (standardized coefficient ßs = -0.14, p < .01), age (ßs = -0.13, p = .01), comorbidities (ßs = -0.19, p < .01), and body mass index (ßs = -0.12, p = .04). After adjustment for all significant covariates, the within-participant association of total sleep time with next-day PA was estimated to be positive among participants with NYHA class II-IV HF (ßs = 0.09, p = .01), while the within-participant association of PA with same-night total sleep time was estimated to be positive among participants aged ≥60 years (ßs = 0.10, p = .03). CONCLUSIONS: Depending upon age and HF class, daytime PA was associated with longer same-night sleep and/or longer sleep was associated with greater next-day PA. Among those with more advanced HF, realistic sleep improvements were associated with clinically meaningful PA gains the next day.

Sleep health in young children living with socioeconomic adversity.

Racially and ethnically diverse young children who live with socioeconomic adversity are at high risk for sleep deficiency, but few behavioral sleep interventions (BSIs) are tailored to their needs. To support the future development of a feasible, acceptable, and culturally relevant sleep intervention, we conducted a community-engaged, mixed-methods study with 40 low-income, racially, and ethnically diverse parents to describe sleep characteristics, sleep habits, and parental sleep knowledge of their 6-36-month-old children and to examine the associations between children's sleep characteristics and sleep habits. This report presents quantitative data from this mixed-methods study. We measured objective (actigraphy) and parent-reported sleep (Brief Infant Sleep Questionnaire) characteristics, sleep habits at bedtime, sleep onset, and during night awakenings, parental sleep knowledge, psychological function (Brief Symptom Inventory), and parenting stress (Parenting Stress Index). Children had low sleep duration (537.2 ± 54.7 nighttime and 111.2 ± 29.8 nap minutes), late bedtimes (22:36 ± 1.5 hr), and high bedtime variability (mean squared successive difference = 3.68 ± 4.31 hr) based on actigraphy. Parental knowledge about sleep recommendations was limited. Sleep habits before bedtime, at sleep onset, and during night awakenings were varied. Sixty-five percent of parents reported co-sleeping. Feeding near bedtime or during the night was associated with later bedtimes, more fragmented sleep, and increased bedtime variability. These findings suggest the need for BSIs to support earlier bedtimes and improve sleep duration and continuity by addressing modifiable behaviors. Tailored BSIs that consider socioecological influences on the development of sleep habits are needed.

Knowledge, Attitudes, and Needs: Assessing the COVID-19 Impact in Rural America.

OBJECTIVE: There is a lack of information concerning the impact of COVID-19 on rural populations. This report shares key results from a cross-sectional survey of South Dakota residents' perceptions on the impact and knowledge of COVID-19 during the early phases of the pandemic. METHODS: From March 24 to April 14, 2020, South Dakota residents (n = 4,761) reported on their psychological symptoms, pandemic-related stressful experiences, top concerns regarding the pandemic, attitudes towards COVID-19, and social distancing behaviors, and where residents were getting COVID information and who they trust to provide accurate information. RESULTS: Most participants were engaging in at least some social distancing and indicated at least moderate concern about COVID-19. Across age groups, getting sick from the coronavirus was the most frequently endorsed concern. Younger adults endorsed concerns about not being able to work, whereas older adults endorsed concerns about accessing medical care. The majority of the sample reported anxiety, worry, and sleep problems; about half the sample reported depressed mood, anhedonia, and appetite problems. Results highlight the importance of engaging public health experts and physicians in COVID-19 health messaging campaigns. CONCLUSIONS: These data provide insight into the specific challenges experienced by adults and youth in a rural state during the early phase of the pandemic. Public Health professionals and medical doctors are in a unique position to guide targeted interventions and health messaging.

Community partnership for healthy sleep: Research protocol.

Beginning early in life, sleep health, including adequate quality, quantity, and consistent sleep routines, is critical to growth and development, behavior, and mental and physical health. Children who live in economically stressed urban environments are at particular risk for sleep deficiency and its negative consequences. Although efficacious sleep health interventions are available, few address the context of economically stressed urban environments. The purpose of this paper is to describe a two-phase protocol for an ongoing NIH/NINR-funded community-engaged study designed to understand the perspectives of parents, community child care and pediatric health care providers about sleep habits, factors that contribute to sleep and sleep habits, sleep difficulty, and potentially useful sleep promotion strategies among children living in economically stressed urban environments. The social-ecological model guides this study. Phase I employs a convergent mixed-methods design, in which we are conducting semi-structured interviews with parents, childcare providers, and primary health care providers. We are collecting 9 days of objective sleep data (wrist actigraphy) from children who are 6-18 months (n = 15) and 19-36 months of age (n = 15) and parent reports of sleep and sleep-related factors using standard questionnaires. In Phase I, we will use a qualitative descriptive approach to analyze the interview data, and descriptive statistics to analyze the survey and actigraph data. In Phase II, we will use the information to develop a contextually relevant program to promote sleep health. Our long-term goal is to improve sleep health and sleep-related outcomes in these children.

Environmental factors associated with physical activity in childcare centers.

BACKGROUND: Child care centers influence physical activity levels among children, yet little is known about the specific aspects of the environment that support generous amounts of activity. The purpose of this study was to examine the practices, and environmental aspects of the child care center that are associated with children's moderate and vigorous physical activity. METHODS: Thirty-five child care centers serving 389 3 to 5 year old children were assessed for: 1) environmental characteristics of the center; and 2) staff practices related to child physical activity. Children's physical activity was measured using accelerometers over a single day in child care. RESULTS: Fourteen percent (an average of 9 minutes per waking hour) were spent in moderate to vigorous physical activity (MVPA). The strongest environmental predictors of MVPA were: time spent in outdoor play, suitability of indoor play space, and teacher encouragement of (but not participation in) indoor play. CONCLUSIONS: In order to reach the U.S. recommended 120 minutes of physical activity per day, significant changes will need to occur in the child care setting, including increased time outdoors and more opportunities for indoor physical activity.

The effectiveness of melatonin for promoting healthy sleep: a rapid evidence assessment of the literature.

A systematic review was conducted using Samueli Institute's Rapid Evidence Assessment of the Literature (REAL) process to determine the evidence base for melatonin as an agent to optimize sleep or improve sleep quality, and generalize the results to a military, civilian, or other healthy, active, adult population. Multiple databases were searched yielding 35 randomized controlled trials (RCTs) meeting the review's inclusion criteria, which were assessed for methodological quality as well as for melatonin effectiveness. The majority of included studies were high quality (83.0%). Overall, according to Grading Recommendations, Assessment Development and Evaluation (GRADE) methodology, weak recommendations were made for preventing phase shifts from jet lag, for improving insomnia in both healthy volunteers and individuals with a history of insomnia, and for initiating sleep and/or improving sleep efficacy. Based on the literature to date, no recommendations for use in shift workers or to improve hormonal phase shift changes in healthy people can be made at this time. Larger and longer-duration RCTs utilizing well characterized products are needed to warrant melatonin recommendations in young, healthy adults.

"It's all connected:" A mixed methods study of insomnia, stigma, and discrimination among individuals on medication for opioid use disorder.

OBJECTIVES: Insomnia is one of the most common sleep disorders among those with opioid use disorder (OUD), including those on medication for OUD. There is a dearth of literature exploring the role of social stressors on sleep outcomes among this group. The purpose of this study was to explore the association between OUD-related stigma and intersectional discrimination with insomnia among individuals on medication for OUD. METHODS: Participants were recruited from treatment clinics in the Northeast United States. Using a convergent mixed-methods research design, we explored associations with stigma (The Brief Opioid Stigma Scale), intersectional discrimination (Intersectional Discrimination Index), and insomnia (Insomnia Severity Index) through quantitative survey data and qualitative data from interviews for participant experiences. Data from the quantitative (n = 120) and qualitative (n = 25) components of the study were integrated for interpretation. RESULTS: Quantitative analysis indicated weak to moderate positive correlations between intersectional discrimination, and exploratory variables including pain, perceived stress, and psychological distress with insomnia severity. The qualitative analysis generated 4 main themes, which highlighted negative emotions and ruminations as factors that participants connected experiences with stigma and discrimination to poor sleep outcomes. Integration of data identified concordant and discordant findings. CONCLUSIONS: Stigma, discrimination, physical symptoms, and psychological distress appear to contribute to poor sleep outcomes among those with OUD. Future research should target maladaptive outcomes of rumination and negative emotions to improve sleep outcomes among those with OUD.

Estimating the budget impact of a Tuberculosis strategic purchasing pilot study in Medan, Indonesia (2018-2019).

BACKGROUND: Indonesia has the world's second-highest tuberculosis (TB) burden, with 969,000 annual TB infections. In 2017, Indonesia faced significant challenges in TB care, with 18% of cases missed, 29% of diagnosed cases unreported, and 55.4% of positive results not notified. The government is exploring a new approach called "strategic purchasing" to improve TB detection and treatment rates and offer cost-effective service delivery. OBJECTIVES: We aimed to analyze the financial impact of implementing a TB purchasing pilot in the city of Medan and assess the project's affordability and value for money. METHODS: We developed a budget impact model to estimate the cost-effectiveness of using strategic purchasing to improve TB reporting and treatment success rates. We used using data from Medan's budget impact model and the Ministry of Health's guidelines to predict the total cost and the cost per patient. RESULTS: The model showed that strategic purchasing would improve TB reporting by 63% and successful treatments by 64%. While this would lead to a rise in total spending on TB care by 60%, the cost per patient would decrease by 3%. This is because more care would be provided in primary healthcare settings, which are more cost-effective than hospitals. CONCLUSIONS: While strategic purchasing may increase overall spending, it could improve TB care in Indonesia by identifying more cases, treating them more effectively, and reducing the cost per patient. This could potentially lead to long-term cost savings and improved health outcomes.