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OBJECTIVE: Social media content featuring alcoholic beverages is posted and viewed by college students. Limited longitudinal research suggests that increased alcohol-related content (ARC) posting and exposure is associated with increased alcohol consumption among college students over time. Emerging evidence suggests this association may be bidirectional, with drinking predicting later ARC posting. The current study examined longitudinal bidirectional associations between alcohol consumption and: posting ARC (aim 1) and friend ARC exposure (aim 2). METHOD: College students engaging in heavy or problematic drinking (N = 384; Mage = 20.04; 74.2% female; 79.6% White) completed four surveys (baseline, 1-month, 3-month, 6-month). Each survey assessed social media use (including ARC posting) and alcohol use, along with ARC posting behaviors of their social network (i.e., important friends). RESULTS: Random-intercept cross-lagged panel models revealed significant large associations only at the within-subjects level for posting ARC, but significant medium-large between- and within-subjects associations for ARC exposure. Within-subjects, greater alcohol consumption predicted posting 1 month later, and posting at the 3-month follow-up predicted increased drinking at 6-months (aim 1). Between-subjects, individuals who reported greater social network ARC exposure were more likely to report greater alcohol consumption. Within-subjects, greater-than-average ARC exposure at 1-month predicted decreased alcohol consumption at 3-months (aim 2). CONCLUSIONS: Results suggest the relationship between alcohol consumption and alcohol posting (self and ARC exposure) is complex and not necessarily bidirectional, with associations between posting and drinking fluctuating within subjects, while between- and within-subjects associations were observed for exposure and drinking. Associations between posting and drinking vary within individuals over time, while associations between exposure and drinking exist for groups, indicating the more people are exposed, the more alcohol they consume.
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In a medical specialty clinic located in a rural community, a nursing team identified an opportunity to decrease the time nursing staff spent preparing charts for patients' upcoming clinical appointments. In collaboration with an informaticist, the nursing project team implemented a quality improvement project with a target goal of decreasing the average time spent preparing charts per patient by 20%, without increasing the number of discrepancies in the chart preparation process. The team used the define, measure, analyze, improve, and control framework to identify two interventions that could decrease time for chart preparation. A standardized chart preparation process was developed, and a condensed nursing view was created within the electronic health record. After the quality improvement project, the average time nurses spent on chart preparation per patient decreased by 18% after the standardized process and 16% after the condensed view was implemented.
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Historically, forensic evaluators have relied heavily upon various editions of the Diagnostic and Statistical Manual of Mental Disorders when rendering psycholegal opinions. The field of mental health is increasing moving toward dimensional models of personality and psychopathology in lieu of traditional DSM categorical models, though the domains of forensic psychology and psychiatry have been slow to make this transition. The current study therefore sought to examine forensic evaluators' familiarity with dimensional approaches to personality and psychopathology, namely the Alternative DSM-5 Model for Personality Disorders (AMPD) and the Hierarchical Taxonomy of Psychopathology (HiTOP). Forensic psychologists and psychiatrists (N = 54) completed an online survey designed to assess their familiarity with these models, as well as to determine if forensics practitioners are using these models in clinical practice. Participants endorsed greater familiarity with the AMPD, with a large majority of participants indicating they were unfamiliar with the HiTOP model. Few participants endorsed using these models in their clinical forensic practice. Implications for making the transition to dimensional models within forensic evaluation are discussed, as are paths forward for future research.
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OBJECTIVE: Empirical research and theory support the interaction of executive functions (e.g., inhibitory control, working memory) and emotion regulation in guiding goal-oriented behavior; however, applications to eating pathology (e.g., binge eating) are limited. Such research is scant with adults with overweight/obesity (AwO/O), a population reporting high levels of binge eating, emotion regulation difficulties, and deficits in inhibitory control and working memory. We tested interactions between emotion regulation and executive functioning in relation to eating pathology in AwO/O while considering stimuli-specific deficits (e.g., food-specific deficits) in behavioral task performance. METHOD: AwO/O (N = 204; MBMI = 32.11; Mage = 38.30 [SD = 12.16]) completed a preregistered, online study assessing demographics and emotion regulation difficulties (Difficulties in Emotional Regulation Scale), inhibitory control (go/no-go task, food and general stimuli), working memory (N-Back Task, food and general stimuli), binge eating (Binge Eating Scale), and disordered eating (Eating Disorder Examination-Questionnaire). RESULTS: There was limited evidence of moderation in models examining food-specific and general inhibitory control and working memory, emotion regulation difficulties, and binge eating. Preliminary support was found for emotion regulation difficulties to be more strongly associated with more disordered eating in AwO/O reporting more food-specific and general working memory deficits. Consistent, positive associations between emotion regulation difficulties and eating pathology were observed. CONCLUSIONS: Among adults with AwO/O, emotion regulation difficulties are closely related to eating pathology, regardless of performance on working memory and inhibitory control tasks. Clinicians and researchers working with AwO/O may consider how emotion regulation difficulties and working memory deficits work together to influence disordered eating.
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PURPOSE: To determine whether patients presenting with Patient-Reported Outcome Measurement Information System (PROMIS) anxiety scores at >95th percentile of the US population undergo elective hand surgery at rates different from patients with less anxiety. Secondarily, we aimed to assess surgeon notation of these patients' emotional states and incidences of postoperative complications. METHODS: This single-center retrospective cohort study analyzed data from new adult patients presenting for hand care between January 2019 and December 2020. Patients with initial PROMIS anxiety scores ≥70 were identified as the high anxiety burden (HAB) group. For each patient with HAB presenting with carpal tunnel syndrome, trigger finger, and distal radius fractures (n = 45), three controls were matched (n = 135). After matching, bivariate statistical analysis compared outcome variables of interest between patient groups. Sentiment analysis was used to explore if patient anxiety was realized and considered in surgical decision making. RESULTS: After matching, patients with HAB averaged baseline PROMIS scores in every assessed domain that were ≥1 SD worse than unaffected patients. Patients with HAB and control patients were offered surgery at a comparable rate (58% vs 47%). Among those offered surgery, patients with HAB were less likely to undergo surgery (73% vs 92%). Postoperative complications occurred more frequently in the patients with HAB (32% vs 8%). Sentiment analysis of office notes revealed that the patients with HAB had their emotional state explicitly noted more often (40% vs 24%), but the majority of patients with HAB did not have this addressed in records. CONCLUSIONS: Patients with HAB both underwent surgery offered less frequently and when undergoing surgery, experienced more complications. Surgeons are likely to miss opportunities to positively influence extreme patient anxiety as most patients with HAB were treated without mention of their emotional state. Future investigations should explore whether preoperative anxiety alleviation could diminish these disparities. TYPE OF STUDY/LEVEL OF EVIDENCE: Symptom prevalence III.
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Rural communities in the US have increasing HIV burden tied to injection drug use, yet engagement in pre-exposure prophylaxis (PrEP) care has been low among people who inject drugs (PWID). Syringe service programs (SSPs) are widely implemented in Kentucky's Appalachian region, presenting an important opportunity to scale PrEP services. This paper examines PrEP awareness, interest and preferences among PWID attending community-based SSPs in Appalachia. Eighty participants were enrolled from two SSP locations. Eligibility included: ≥ 18 years old, current injection drug use and SSP use, and an indication for PrEP as defined by CDC guidelines. Participants completed a structured baseline interview. Predictors of PrEP awareness, interest and formulation preferences were examined. 38.8% reported baseline awareness of PrEP, 50% expressed high interest in PrEP, and 48.1%reported a preference for injectable PrEP. Significant bivariate predictors of PrEP interest included: current worry about health, higher perceived HIV risk, higher community HIV stigma, and higher enacted substance use stigma in the past year; in the adjusted model, enacted substance use stigma remained significant. Findings demonstrate substantial interest in PrEP among rural PWID. Intrapersonal and social determinant factors were associated with PrEP interest, which suggests the importance of multi-level intervention targets to increase PrEP uptake.
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Fecal Microbiota Transplant (FMT) has shown some success in treating inflammatory bowel diseases (IBD). There is emerging evidence that host engraftment of donor taxa is a tenet of successful FMT. We undertook a double-blind, randomized, placebo-controlled pilot study to characterize the response to FMT in children and young adults with mild to moderate active Crohn's disease (CD) and ulcerative colitis (UC). Subjects with CD or UC were randomized to receive antibiotics and weekly FMT or placebo in addition to baseline medications. We enrolled 15 subjects aged 14-29 years. Four subjects had CD, and 11 had UC. Subjects exhibited a wide range of microbial diversity and donor engraftment. Specifically, engraftment ranged from 26 to 90% at week 2 and 3-92% at 2 months. Consistent with the current literature, increases over time of both alpha diversity (p < 0.05) and donor engraftment (p < 0.05) correlated with improved clinical response. We discovered that the post-antibiotic but pre-FMT time point was rich in microbial correlates of eventual engraftment. Greater residual alpha diversity after antibiotic treatment was positively correlated with engraftment and subsequent clinical response. Interestingly, a transient rise in the relative abundance of Lactobacillus was also positively correlated with engraftment, a finding that we recapitulated with our analysis of another FMT trial.
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Transplante de Microbiota Fecal , Lactobacillus , Humanos , Transplante de Microbiota Fecal/métodos , Adulto , Adolescente , Feminino , Masculino , Adulto Jovem , Método Duplo-Cego , Doenças Inflamatórias Intestinais/terapia , Doenças Inflamatórias Intestinais/microbiologia , Microbioma Gastrointestinal , Projetos Piloto , Fezes/microbiologia , Resultado do Tratamento , Doença de Crohn/terapia , Doença de Crohn/microbiologia , Antibacterianos/uso terapêutico , Antibacterianos/farmacologia , Colite Ulcerativa/terapia , Colite Ulcerativa/microbiologiaRESUMO
Interprofessional care improves outcomes for medically complex patients and may be a valuable addition to standard lifestyle medicine practice, but implementation barriers exist. The purpose of this study was to explore the key features, perceived impact, and implementation considerations related to holding interprofessional team meetings as part of an intensive lifestyle medicine program. In this mixed-methods study, focus groups were conducted with 15 lifestyle medicine clinicians from various healthcare disciplines who had participated in interprofessional team meetings. Quantitative descriptive statistics of the meeting minutes were also calculated. Clinician-perceived benefits from participating in interprofessional team meetings included increased acquisition of knowledge, access to other clinicians, collaborative decision-making, patient satisfaction, and achievement of patient-centered goals. Participants described the importance of preparing an agenda for the interprofessional team meetings in advance, but a major implementation challenge was the time required to prepare for and conduct the meetings. Commitment and financial support by organization and program leadership were reported as key facilitators to implementing the meetings. Clinicians perceive significant value from incorporation of interprofessional team meetings into an intensive lifestyle medicine program, but successful implementation of meetings requires investment from all levels within a healthcare system.
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OBJECTIVE: This work examined the relationship of the constructs measured by the trust scales developed by Chancey et al. (2017) and Jian et al. (2000) using a multilevel confirmatory factor analysis (CFA). BACKGROUND: Modern theories of automation trust have been proposed based on data collected using trust scales. Chancey et al. (2017) adapted Madsen and Gregor's (2000) trust scale to align with Lee and See's (2004) human-automation trust framework. In contrast, Jian et al. (2000) developed a scale empirically with trust and distrust as factors. However, it remains unclear whether these two scales measure the same construct. METHOD: We analyzed data collected from previous experiments to investigate the relationship between the two trust scales using a multilevel CFA. RESULTS: Data provided evidence that Jian et al. (2000) and Chancey et al. (2017) automation trust scales are only weakly related. Trust and distrust are found to be distinct factors in Jian et al.'s (2000) scale, whereas performance, process, and purpose are distinct factors in Chancey et al.'s (2017) trust scale. CONCLUSION: The analysis suggested that the two scales purporting to measure human-automation trust are only weakly related. APPLICATION: Trust researchers and automation designers may consider using Chancey et al. (2017) and Jian et al. (2000) scales to capture different characteristics of human-automation trust.
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G protein-coupled receptor (GPCR) transmembrane protein family members play essential roles in physiology. Numerous pharmaceuticals target GPCRs, and many drug discovery programs utilize virtual screening (VS) against GPCR targets. Improvements in the accuracy of predicting new molecules that bind to and either activate or inhibit GPCR function would accelerate such drug discovery programs. This work addresses two significant research questions. First, do ligand interaction fingerprints provide a substantial advantage over automated methods of binding site selection for classical docking? Second, can the functional status of prospective screening candidates be predicted from ligand interaction fingerprints using a random forest classifier? Ligand interaction fingerprints were found to offer modest advantages in sampling accurate poses, but no substantial advantage in the final set of top-ranked poses after scoring, and, thus, were not used in the generation of the ligand-receptor complexes used to train and test the random forest classifier. A binary classifier which treated agonists, antagonists, and inverse agonists as active and all other ligands as inactive proved highly effective in ligand function prediction in an external test set of GPR31 and TAAR2 candidate ligands with a hit rate of 82.6% actual actives within the set of predicted actives.
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Simulação de Acoplamento Molecular , Receptores Acoplados a Proteínas G , Receptores Acoplados a Proteínas G/metabolismo , Receptores Acoplados a Proteínas G/química , Ligantes , Sítios de Ligação , Descoberta de Drogas/métodos , Humanos , Ligação ProteicaRESUMO
Background: The association between chronic oral diseases and other major systemic health conditions, commonly referred to as the oral-systemic health connection, has been previously studied with several underlying common risk factors and pathways linking both groups of diseases. Psychosocial factors contribute to an increased susceptibility to chronic oral and non-oral diseases. The aim of this review is to summarize the current state of knowledge on the role of psychosocial stress in chronic oral and systemic diseases. Methods: A search strategy was built and a literature search was conducted using four databases (CINAHL, Embase, Medline, PsycINFO). A combination of search terms related to psychosocial stress, systemic disease, and oral conditions were used. Studies were eligible for inclusion if they included human adults (aged 18 years and older), included psychosocial factors as an exposure measure, and outcome measures of both an oral and systemic condition. Only English-language articles were considered. Pilot testing of the data extraction form and calibration were conducted and data were extracted independently by one researcher. Results: A total of fifteen articles out of eighty full-text articles screened were determined to be eligible for inclusion in this review. Periodontal disease was the most commonly studied oral disease, measured in 53% of included articles, with the most commonly studied systemic diseases being of mental health conditions (40%) and diabetes (47%). Psychosocial stress was measured using a range of psychometric indicators and/or biomarkers, including perceived stress, individual behaviours, childhood adversity, and cortisol. In total, fourteen studies found a positive association between measures of psychosocial stress and oral-systemic health. Conclusion: Psychosocial stress may be a common contributor to both chronic oral and non-oral diseases.
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Direct relationships between perceived discrimination and eating pathology in ethnic minorities are well-documented. However, theoretical work examining unique risk and resilience factors that strengthen or weaken the relation between these constructs in ethnic minorities is lacking. The current study aims to address this gap by incorporating stress-process and tripartite frameworks to examine social and personal resources as they relate to perceived discrimination and eating pathology. In a sample of Black, Asian, and Latine women (N = 296, M age = 30.82), social support did not mediate the relationship between perceived discrimination and eating pathology. A significant interaction effect was observed for thin-ideal internalization strengthening the relation between perceived discrimination and negative emotional eating. Thin-ideal internalization moderated the relation between perceived discrimination and negative emotional eating in Latine Women, and disordered eating in Black Women. Overall, findings suggest ethnic minority Women have both personal and social resources that may influence the strength of effect on the relation between perceived discrimination on eating pathology.
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Parkinson's disease (PD) is the second most common neurodegenerative disorder and lacks disease-modifying therapies. We developed a Drosophila model for identifying novel glial-based therapeutic targets for PD. Human alpha-synuclein is expressed in neurons and individual genes are independently knocked down in glia. We performed a forward genetic screen, knocking down the entire Drosophila kinome in glia in alpha-synuclein expressing flies. Among the top hits were five genes (Ak1, Ak6, Adk1, Adk2, and awd) involved in adenosine metabolism. Knockdown of each gene improved locomotor dysfunction, rescued neurodegeneration, and increased brain adenosine levels. We determined that the mechanism of neuroprotection involves adenosine itself, as opposed to a downstream metabolite. We dove deeper into the mechanism for one gene, Ak1, finding rescue of dopaminergic neuron loss, alpha-synuclein aggregation, and bioenergetic dysfunction after glial Ak1 knockdown. We performed metabolomics in Drosophila and in human PD patients, allowing us to comprehensively characterize changes in purine metabolism and identify potential biomarkers of dysfunctional adenosine metabolism in people. These experiments support glial adenosine as a novel therapeutic target in PD.
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Coreia , Humanos , Feminino , Coreia/etiologia , Coreia/diagnóstico , Idoso de 80 Anos ou maisRESUMO
OBJECTIVES: The risk for mpox virus (MPXV) transmission in most workplaces has not been thoroughly assessed in the context of the 2022 global mpox outbreak. Our objectives were to describe mpox case patients who worked while infectious and the subsequent workplace contact tracing efforts, risk assessments, and outcomes. METHODS: The Centers for Disease Control and Prevention requested information from health departments in the United States in September 2022 to identify people with confirmed or probable mpox who worked outside the home while infectious, either before or after diagnosis, from June 1 through August 31, 2022. We collected and summarized data on demographic, clinical, and workplace characteristics of case patients and workplace contact investigations. We stratified data by industry and occupation categories. RESULTS: In total, 102 case patients were reported by 6 jurisdictions. The most common industries were accommodation and food services (19.8%) and professional business, management, and technical services (17.0%). Contact investigations identified 178 total contacts; 54 cases (52.9%) had no contacts identified. Of 178 contacts, 54 (30.3%) were recommended to receive postexposure prophylaxis (PEP) and 18 (10.1%) received PEP. None of the contacts developed a rash or were tested for orthopox or mpox, and none were reported to have confirmed or probable mpox. CONCLUSION: Data from 6 jurisdictions suggest that the risk of MPXV transmission from workers to others in workplace settings in many industries is low. These findings might support future updates to exposure risk classifications and work activity recommendations for patients. These findings also demonstrate the importance of collecting and analyzing occupation and industry data in case reports to better understand risks in workplaces.
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Busca de Comunicante , Local de Trabalho , Humanos , Masculino , Estados Unidos/epidemiologia , Adulto , Feminino , Pessoa de Meia-Idade , Exposição Ocupacional/prevenção & controle , Exposição Ocupacional/efeitos adversos , Surtos de Doenças/prevenção & controle , Medição de Risco , Adulto Jovem , Adolescente , Centers for Disease Control and Prevention, U.S. , IdosoRESUMO
Phage Damascus was isolated from soil in northwestern Wisconsin using Microbacterium paraoxydans as the host. The Damascus genome is 56,477 bp with 3' single-stranded overhangs and 56.5% G+C content. Damascus was assigned to cluster EL and shares 42.6%-91.7% gene content with the three other phages in this cluster.
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Extensive research exists on the association between self-reported emotional eating (EE) and disordered eating (DE) behaviors. Heterogeneity exists by type (e.g., unidimensional vs. multidimensional) and valence (e.g., negative vs. positive) of self-reported EE, and no previous meta-analyses have examined the association between self-reported EE and DE behaviors. A total of 67 studies (N = 26,289; 43 reporting relations in one model, and 24 reporting relations in more than one model) met inclusion criteria; ranges for age and publication date were 18.0-61.8 years old and 1995 to 2022. Five models quantified relations between DE behaviors and 1) broad negative EE, 2) EE in response to depression, 3) EE in response to anger and anxiety, 4) EE in response to boredom, and 5) EE in response to positive emotions. Using random-effects models, pooled Cohen's d effect sizes suggested small, positive relations between DE behaviors and self-reported broad negative EE (d = 0.40, p < 0.001), EE-depression (d = 0.41, p < 0.001), EE-anger/anxiety (d = 0.35, p < 0.001), and EE-boredom (d = 0.38, p < 0.001). A significant, but very small, positive relation was observed between DE behaviors and self-reported EE-positive (d = 0.08, p = 0.01). Subgroup analyses suggested a medium, positive relation between self-reported broad negative EE and binge eating (d = 0.53, p < 0.001) and a small, positive relation between self-reported broad negative EE and dietary restraint (d = 0.20, p < 0.001). Significant heterogeneity was identified across all models except for the EE-boredom and DE behaviors model. Higher BMI, but not age, clinical status, or type of DE behavior strengthened the positive relation between self-reported broad negative EE and DE behaviors. Findings support previous research suggesting that negative and positive EE are distinct constructs, with negatively valenced EE being more closely associated with DE behaviors, especially binge eating.
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Depressão , Emoções , Comportamento Alimentar , Transtornos da Alimentação e da Ingestão de Alimentos , Autorrelato , Humanos , Transtornos da Alimentação e da Ingestão de Alimentos/psicologia , Comportamento Alimentar/psicologia , Adulto , Depressão/psicologia , Feminino , Pessoa de Meia-Idade , Adulto Jovem , Masculino , Adolescente , Ansiedade/psicologia , Inquéritos e Questionários , IraAssuntos
Antibacterianos , Doenças do Gato , Infecções por Escherichia coli , Pielonefrite , Animais , Gatos , Doenças do Gato/tratamento farmacológico , Doenças do Gato/microbiologia , Infecções por Escherichia coli/veterinária , Infecções por Escherichia coli/tratamento farmacológico , Pielonefrite/veterinária , Pielonefrite/tratamento farmacológico , Antibacterianos/uso terapêutico , Escherichia coli/efeitos dos fármacos , Injúria Renal Aguda/veterinária , Penicilinas/uso terapêutico , Farmacorresistência Bacteriana , PrognósticoRESUMO
Arab, Middle Eastern, and North African (A-MENA) American women are often subject to intersectional discrimination, and they have also not been traditionally recognized as a distinct racial group in disordered eating literature. No study to date has provided descriptive information on disordered and emotional eating A-MENA American women, nor has examined perceptions of widely used measurements of eating pathology in this population. The current study generated descriptive information among A-MENA women on two widely used measures of eating pathology, the Eating Disorder Examination Questionnaire (EDE-Q) and the Emotional Eating Scale (EES). Participants (N = 244) were A-MENA adult women were recruited via social media and snowball sampling. Qualitative findings provide potential sociocultural predictors of disordered eating that should be further explored, such as bicultural identity and family pressures/comments toward appearance. Secondly, themes from the EES-R indicate adding emotion of shame and considering identity-related stress. The current study provides prevalence data and future directions of research on widely used eating pathology and appearance attitude measurements for A-MENA American women.
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Árabes , Transtornos da Alimentação e da Ingestão de Alimentos , População do Oriente Médio , População do Norte da África , Adolescente , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Adulto Jovem , África do Norte/etnologia , Árabes/psicologia , Árabes/estatística & dados numéricos , Emoções , Transtornos da Alimentação e da Ingestão de Alimentos/epidemiologia , Transtornos da Alimentação e da Ingestão de Alimentos/etnologia , Transtornos da Alimentação e da Ingestão de Alimentos/psicologia , Comportamento Alimentar/psicologia , Comportamento Alimentar/etnologia , Oriente Médio/etnologia , Inquéritos e Questionários , Estados Unidos/epidemiologia , População do Oriente Médio/psicologia , População do Oriente Médio/estatística & dados numéricos , População do Norte da África/psicologia , População do Norte da África/estatística & dados numéricos , Mídias Sociais , Identificação Social , Cultura , Estresse Psicológico , Imagem Corporal/psicologia , Relações Familiares/etnologia , Relações Familiares/psicologiaRESUMO
Youth with mental health disorders (MHD), particularly those who take psychotropic medications, are at increased risk of being overweight or obese (OW/OB) when compared to typical youth. Parents are important resources for interventions addressing OW/OB. However, parents of youth with MHD may face challenges that require interventions designed to address their needs. Prior to investing research funding in the development of interventions for this group, research is needed to understand factors associated with parents' decisions to enroll in these programs. The theory of planned behavior (TPB) provided a framework for examining parents' salient beliefs, direct attitudes, and intention to enroll in a hypothetical online healthy lifestyle intervention for their youth (ages 11-17) with OW/OB and treated with psychotropic medication. Parents who were enrolled in the study (n = 84) completed demographic questionnaires and a TPB questionnaire which was constructed for this study. A confirmatory factor analysis (CFA) of the direct attitude (i.e., attitude toward the behavior, subjective norm, perceived behavioral control) questions generally supported the three-factor model (i.e., RMSEA = .07, 90% CI .03-.11, p = .18; CFI = .96, SRMR = .06). Results from a multiple regression analysis demonstrated that direct attitudes predicted parent intention to participate in an online healthy lifestyle intervention for this sample of youth accounting for 84% of variance. In this preliminary study, the TPB appears to be a promising framework for understanding direct attitudes associated with parent intentions toward intervention participation in this population of youth. Interventions for parents of youth with OW/OB who are prescribed psychotropic medication should consider addressing these direct attitudes to improve intention.