Feasibility, acceptability, and effects of a web-delivered behavioral parent training intervention for rural parents of children with autism spectrum disorder: A protocol.

Caregivers of children with autism spectrum disorder (ASD) often report higher levels of stress and mental health issues. Support services and parent training programs may help buffer the effects of caring for a child with ASD. However, due to the national lack of trained ASD providers and disparity of ASD support resources available in rural areas, caregivers often go without support. A possible solution to reach caregivers in rural areas is web-based interventions. This paper describes an ongoing pilot study examining the feasibility, acceptability, and preliminary effects on caregiver well-being and disruptive child behaviors for a web-based parent training program (Attend Behavior) for caregivers of young children (ages 2-11 years old) with autism spectrum disorder (ASD) living in rural areas (trial registration NCT05554198). The intervention is available on the internet as well as a downloadable app for mobile phones. Participants will be invited to use the intervention program for 12-weeks. Prior to using the program, participants will be asked to take a baseline survey assessing depressive symptoms (PROMIS Depression Short Form-6a), caregiver stress (Parenting Stress Index-Short Form), child disruptive behaviors (Home Situations Questionnaire-ASD and Aberrant Behavior Checklist). After 12-weeks, participants will be asked to complete a post-intervention survey with the same measurement scales plus questions regarding intervention acceptability, appropriateness, and feasibility (Acceptability of Intervention, Intervention Appropriateness Measure, and the Feasibility of Intervention Measure). Participants are also invited to partake in a brief 1:1 interview with a study team member to give further feedback regarding the intervention. Study retention and participant app usage data will be examined. Information generated from this pilot study will be used to inform a future larger scale randomized control trial of Attend Behavior.

Using the life course health development model to address pediatric mental health disparities.

TOPIC: Early-life experiences, the transmission of health and disease within families, and the influence of cumulative risks as well as protective factors throughout life shape the trajectory of health, including mental health. Long-term health trajectories established early in life are influenced by biologic, social, and environmental factors. Negative trajectories may be more salient if exposures to adversity occur during critical developmental periods. PURPOSE: The purpose of this brief is to (a) review pediatric health disparities related to depression and the intergenerational transmission of pediatric depression using a Life Course Health Development (LCHD) model and (b) provide recommendations for pediatric mental health research. SOURCES: Peer-reviewed papers available for PubMed, CINAL, and Medline. Other sources include published books, papers, and gray materials. CONCLUSIONS: The LCHD model is a perspective to guide and foster new scientific inquiry about the development of mental health outcomes over the life course. The model enables synthesis of mental health, nursing, and public health, linking mental health prevention, risk reduction, and treatment in children.

The EMeRGE theory of emerging adult-aged women's sexual and reproductive health self-management: A grounded theory study.

AIMS: To explore how emerging adult-aged women self-manage their sexual and reproductive health and to generate a grounded theory of these self-management processes. DESIGN: Grounded theory methods using a constructivist approach. METHODS: Between September 2019 and September 2020, 18- to 25-years-old women (n = 13) were recruited from a 4-year university, a 2-year community college, and neighbourhoods surrounding the institutions of higher education. Individual interviews were transcribed verbatim and qualitatively analysed using a constant comparative method and inductive coding. RESULTS: The theory purports that core processes of sexual and reproductive health self-management used by the women in this study included both passive and (re)active processes. These processes expanded upon and/or maintained the women's accessible sexual and reproductive health knowledge, behaviour and beliefs, defined as the sexual and reproductive health repertoire. The processes appeared to be cyclical and were often initiated by a catalysing event or catalyst and resulted in conversations with confidantes, or trusted individuals. A catalyst was either resolved or normalized by expanding or maintaining the sexual and reproductive health repertoire. CONCLUSION: The resulting theory, EMeRGE Theory, offers insight into the complex and cyclical processes emerging adult-aged women use to simultaneously develop and adapt their foundational sexual and reproductive health knowledge, behaviours and beliefs. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: This explication of emerging adult-aged women's sexual and reproductive health self-management processes can be used by nurses and nurse researchers to better address this population's unique health needs. IMPACT: The EMeRGE Theory provides valuable guidance for future exploratory and intervention research aimed at improving the health and well-being of emerging adult-aged women. REPORTING METHOD: The authors adhered to the Consolidated Criteria for Reporting Qualitative studies (COREQ) in preparation of this publication. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Patterns of participation in summer programming among United States' elementary children from low-income urban households: Results from the project SWEAT study.

Food insecurity increases among marginalized children during the summer when school is out of session. Summer programming that offers access to healthy meals and snacks may reduce the risk. There is a national call in the US for more research to assure equitable access to summer programming. The objective of this prospective observational study was to characterize patterns of participation in summer programming among elementary children from low-income urban neighborhoods of metropolitan[Blinded]. Summer programming was broadly defined (e.g., church, school, recreation center, community center). Caregivers(n = 100) received weekly text messages via TextIt during the summer (Jun-Aug 2017). They were asked: "How many days this week did [ChildName] attend a summer program? Please respond with a number from 0 to 5, where 0 - no days, 2 - 2 days, etc." Weekly counts were summed. Stepwise logistic and linear regression models were conducted to examine differences in patterns of attendance according to key sociodemographic characteristics. Mean age was 7.03 ± 0.23. 52 % identified as female, 70 % were low-income, and 80.0 % identified as Black. 51 % attended summer programming at least once; 49 % never attended. Those who attended at least once vs. not at all were more likely to be male(p < 0.01); 62.75 % males vs. 37.25 % females attended summer programming at least once, whereas 67.35 % females compared to 32.65 % males never attended. Overall mean attendance was 10.40 ± 1.43 days(out of 50). Mean + SE attendance was lower for females (7.52 + 1.76) vs. males (13.52 + 2.21)(p < 0.05), and non-Black (4.30 + 1.97) vs. Black (11.93 + 1.67)(p = 0.01) children. Future research is needed to understand barriers to participation in summer programming.

'Taking Care': A qualitative study of emerging adult-aged women's sexual and reproductive health definitions.

OBJECTIVE: Emerging adult-aged (EA;18-25 years) women have disproportionately high rates of unintended pregnancy and sexually transmitted infections compared to other women of reproductive age. Little is known about how EA women define and prioritize various aspects of sexual and reproductive health. The purpose of this study was to identify EA women determined definitions of sexual and reproductive health. METHODS: Between September 2019 and September 2020, 13 women were interviewed about their sexual and reproductive health. Interview transcripts were used to conduct qualitative content analysis. RESULTS: Definitions provided by participants were grouped according to three distinct thematic categories, Being Safe, Healthcare as a Tool, and Mind-Body Connection. Being Safe included using condoms and taking steps to prevent sexually transmitted infections. Healthcare as a Tool referred to utilization of healthcare services (e.g., an annual exam) to manage sexual and reproductive health. Mind-Body Connection included acknowledgement of both the physical and mental aspects of sexual and reproductive health, as well as awareness of physical and emotional discomfort related to it. These categories highlight EA women's holistic definitions of sexual and reproductive health. CONCLUSIONS: Healthcare providers and researchers can use the holistic sexual and reproductive health definitions endorsed by EA women in this study as a starting point for creating and delivering sexual and reproductive healthcare and counseling that is developmentally appropriate and sensitive to population-specific needs.

Mobile Health Application and Hypertension Management in Rural, Middle-Aged Adults: A Quality Improvement Project.

Over 29% of the adult population in the United States are diagnosed with hypertension, and rates are significantly higher in those adults who live in rural areas. Hypertension is recognized as the most prevalent comorbidity and modifiable risk factor leading to premature death. The purpose of this quality improvement project was to determine if using a mobile phone-based health application called Medisafe could enhance medication adherence and improve blood pressure control in rural-dwelling adults. A small group (N = 14) of middle-aged (45-64 years old) patients with hypertension were recruited to download the free Medisafe phone-based health application. Patients utilized the Medisafe application between their initial visit and a 4- to 6-week follow-up. At the follow-up visit, 64% (n = 9) of participants improved their level of hypertension control by blood pressure classification and improved their scores on the medication adherence questionnaire. The findings from this quality improvement project suggest the Medisafe application is useful to enhance medication adherence and blood pressure control. Future research and quality improvement initiatives are necessary to determine the broader efficacy of phone-based health applications in the rural adult population.

Practical strategies for qualitative inquiry in a virtual world.

AIM: The aim of this article is to provide practical strategies for maintaining methodological rigour in executing a virtual qualitative study. Strategies are based on evidence from existing research about virtual qualitative methods and on the strategies used by the authors to convert a planned in-person qualitative, grounded theory study to an entirely virtual grounded theory study during the COVID-19 pandemic. The study began in-person in September 2019 and was converted to virtual in March 2020. Virtual data collection was completed in September 2020. DESIGN: This article provides a case exemplar of virtual adaptations made to a study underway when the pandemic rendered all in-person research impractical and potentially dangerous. DATA SOURCES: The strategies discussed are based on our own experiences and the supporting theoretical assumptions of qualitative research, specifically grounded theory methods. IMPLICATIONS FOR NURSING: Nursing scholars conducting qualitative inquiry may find these strategies helpful in continuing research activities during periods of limited access to the phenomena or persons of interest. Furthermore, these strategies allow nursing scholars to conduct rigorous, in-depth research without geographical limitations, providing greater possibilities for international collaborations and cross-institution research. CONCLUSION: Despite novel challenges, methodological adaptations that are carefully planned and purposeful allow qualitative and non-qualitative scholars to continue research activities in a fully virtual manner. IMPACT: This case exemplar and discussion provide practical strategies for qualitative scholars to consider while planning new studies or converting an in-person study to a virtual one. Despite the in-person nature of in-depth qualitative inquiry, a historic pandemic and a changing research environment require qualitative researchers to adapt to virtual methods while still conducting high quality, methodologically rigorous research. Qualitative scholars can use the strategies presented here to continue rigorous qualitative inquiry despite limited access to phenomena or persons.

Improving Research, Policy, and Practice to Address Women's Sexual and Reproductive Health Care Needs During Emerging Adulthood.

Women in the period of emerging adulthood (18-25 years of age) have the greatest rates of unintended pregnancy and sexually transmitted infections. Despite this disproportionate risk, women's sexual and reproductive health needs during emerging adulthood are poorly understood. As a result, few age-specific policies or person-centered practice guidelines are available to reduce sexual risk. In this commentary we explore the unique characteristics of emerging adulthood that contribute to greater sexual and reproductive health risks for women. Current evidence on sexual and reproductive health outcomes of women during emerging adulthood and limited practice guidelines are discussed. Recommendations for health care providers, especially nurses, for guiding personalized care for women in emerging adulthood are discussed.

"Bringing Tap Back": Expanding the "Sodabriety" Teen Advisory Council Approach in Tennessee High Schools.

Sugar-sweetened beverages (SSBs) are a large source of added sugar in teenagers' diets, comprising 20-25% of daily calories. Despite efforts, teens in rural and southern states continue to have the high SSB consumption rates. Using Teen Advisory Councils (TAC), students designed and delivered school-specific interventions at five Tennessee schools. Using repeated measures models with Bonferroni correction, data were collected on SSBs and water consumption at baseline and 30 days postintervention. The 573 participants ranged from 13 to 19 years; mean age 15.97 years (SD = 1.4). Daily SSB servings decreased from a mean of 2.37 (SD = 2.06) to 1.87 (SD = 1.89; p = .024). Weekly SSB behaviors decreased 10%. Daily water consumption increased 19.5% to 4.46 (SD = 2.97) servings (p = .03). Student-led efforts supported behavioral changes. TACs were effective at changing lifestyle behaviors. Community-driven solutions may result in manageable changes to sustain behaviors.

The future of pediatric nursing science.

The provision of safe and effective nursing care to children is dependent upon pediatric nurse scientists creating knowledge that guides and directs day-to-day nursing practice. Current trends demonstrating steady decreases of pediatric nurses and inadequate numbers of PhD-prepared pediatric nurse scientists put the health of our children at risk. The purposes of this paper are to (1) summarize current health care demands in pediatrics, (2) present our concern that the number of pediatric nurse scientists is inadequate to generate foundational knowledge to guide pediatric nursing practice, (3) present our perspectives on factors influencing the number of pediatric nurse scientists, and (4) recommend specific actions for nursing leaders, nursing faculty, and professional nursing organizations to increase the depth and breadth of pediatric nursing science to meet current and future pediatric care needs.

Efficacy of "Mentoring to Be Active" on Weight Loss, Body Mass Index, and Body Fat among Obese and Extremely Obese Youth in Rural Appalachia.

PURPOSE: This study compares the efficacy of a behavioral skills mentoring program (Mentored Planning to Be Active [MBA]) to a teacher-led program (Planning to Be Active [PBA]) for increasing physical activity in Appalachian teens on health outcomes (weight loss, body mass index (BMI), and body fat). METHODS: Secondary analysis of a larger group-randomized controlled trial was conducted in 20 rural Appalachian schools. Descriptive Pearson correlations and multivariate analyses with between-subject effects were conducted. Effect sizes (ES) using Cohen's d and odds ratios (OR) with 95% confidence intervals were calculated. FINDINGS: The obese MBA group lost 77.5% more weight by T3 compared to the PBA group; T2 was (F = 8.51, P = .000) and T3 was (F = 7.62, P = .000). ES was 0.34. OR = 1.45 (95% CI: 0.558-3.792) at T2 and OR = 3.32 (95% CI: 1.103-9.978) at T3. Extremely obese in the MBA group lost 80.0% more weight compared to the PBA group; T2 was (F = 5.23, P = .025) and at T3 (F = 6.33, P = .015) ES was 0.58. OR = 4.36 (95% CI: 0.981-19.34). Extremely obese females lost more weight compared to males (F = 4.75, P = .034). BMI and body fat had similar results; youth in the MBA group had the most improvement. CONCLUSIONS: Rural Appalachian youth are disproportionately extremely obese. BMI does not capture adiposity or cardiovascular risk. BMI, BMI percentile, raw weight, fat mass, and percent body fat are more complete analyses of adiposity and cardiovascular risk.

Overcoming Challenges in Multisite Trials.

BACKGROUND: Conducting multisite studies has many challenges, including determining the geographic distance between sites, ensuring effective communication, monitoring intervention and data integrity, handling institutional policy variations, seeking institutional review board approval with unique site needs or complex subcontracts, and planning for additional costs. OBJECTIVES: This article discusses common challenges in conducting multisite studies and identifies strategies to overcome these challenges using real-world examples from the literature, the authors' research studies, and their personal experiences. METHODS: A summary of articles on multisite trials conducted within the past 10 years was explored to uncover common challenges in conducting multisite trials. To enrich the context, exemplars from authors' works are included. Based on literature and experience, strategies to combat challenges are summarized. RESULTS: Unique issues related to multisite studies include site selection, use of epicenters/coordinating centers, hiring/managing staff, fidelity monitoring, institutional review board approval, statistical considerations, and approaches to authorship. CONCLUSION: Addressing challenges a priori can improve scientific rigor, reproducibility, and evidence from multisite studies. Given the benefits to scientific rigor, reproducibility, and design, findings from multisite studies are more likely to provide evidence to transform clinical practice and influence policy.

Implementing Evidence-Based Care for Women Who Have Experienced Human Trafficking.

Human trafficking is a significant women's health issue in the United States. Clinicians who provide care to women are often unaware of the signs and symptoms of human trafficking and are unprepared to provide appropriate care. Nurses represent one of the few agents of change who women may encounter while they are in captivity; this places nurses at the forefront of their care. To provide safe and effective care, nurses can use the ABCD treatment model, which stands for assessment, buy-in, case management, and diversion programming. Any gaps between recognition of women's health care needs and the provision of appropriate care must be closed. Integrating evidence-based human trafficking education and skill building into nursing curricula, standard nursing orientation, and continuing education is an essential step to help nurses transform care and advocate on behalf of those who have been trafficked.

Sugar-sweetened beverage behaviors of Tennessee school children: How do parent- and child-report compare on school days and nonschool days?

INTRODUCTION: This study describes sugar-sweetened beverage (SSB) behaviors of children and compares child-reported SSB behaviors to parent-reported SSB behaviors during school days and nonschool days. METHOD: Six elementary schools from Tennessee participated with 444 students and 287 parents. Descriptive statistics included means, standard deviation (SD), ranges of values, and measures of central tendency. To explore the relationship between parent and child report, intraclass correlation coefficients (ICC) were analyzed. The mean ( SD) differences and limits of agreement were calculated using paired t tests with Bonferroni corrections for multiple outcomes of interest. A p < 0.05 was significant. RESULTS: Reporting differed with SSB type of school day. Children reported higher quantities of sweet tea and "coke/soda." Both agreed on SSB abstention, except for juice. ICCs ranged from 0.383 to 0.513 ( p = 0.000). The lowest and highest ICCs were for sweet tea, based on school days or nonschool days. DISCUSSION: To determine the best estimate of SSBs, information should be obtained from children and parents to improve accuracy and enhance education about health behaviors.

Rates of Obesity and Obesogenic Behaviors of Rural Appalachian Adolescents: How Do They Compare to Other Adolescents or Recommendations?

BACKGROUND: To better understand the unique challenges of Appalachians, community-based studies are needed to establish benchmark rates. This study compares obesity rates and obesogenic behaviors among Appalachian adolescents to other adolescent populations or clinical recommendations. METHODS: This study was conducted in 11 Appalachian schools. Body mass index, body mass index percentile, and body fat percentage were measured using a Tanita DC-430U analyzer. Physical activity was measured using Actigraph wGT3X-BT accelerometers. Sugar-sweetened beverage consumption was self-reported. Pearson's correlations, independent t tests, and multivariate analyses with tests of between-subject effects were conducted. RESULTS: Mean (n = 345) age was 15.23 (SD = 1.02) years. Appalachian adolescents were extremely obese (13.1%) by more than double that of national adolescent rates. Nearly 29% of males and over 55% of females were at increased cardiovascular risk. Only 15% were moderately active for at least 60 minutes a day, but only for 1 day per week. Mean afterschool sedentary time was 4.75 hours. Only 2.1% recorded vigorous activity for a minimum of 10 minutes at 1 day per week. Nearly all regularly consumed sugar-sweetened beverages. CONCLUSION: Obesogenic health disparities were evident in Appalachia. Rates of obesogenic factors among Appalachian adolescents exceed national rates. Appalachian adolescents were far less active, and extreme obesity is a major health concern.

A Review of Systematic Reviews Targeting the Prevention and Treatment of Overweight and Obesity in Adolescent Populations.

PURPOSE: Adolescent obesity is a powerful predictor of morbidity and mortality, yet amenable to modifiable behaviors. To accurately summarize the effects of behavioral interventions on changes in adolescent body mass index and/or weight status, we assessed existing systematic reviews for reporting transparency and methodological quality. METHODS: Five databases were searched through September 2017 to identify relevant systematic reviews. Reviews were evaluated for reporting transparency and methodological quality using PRISMA Reporting Checklist and Assessment of Multiple Systematic Reviews Instrument. Evidence was synthesized across high-quality reviews. RESULTS: Four of twelve systematic reviews were of high methodological quality. All four focused on the treatment of overweight/obesity in adolescent populations, representing 97 international studies. Findings indicate intervention compared with no intervention/wait list showed larger effects for improving BMI/BMI z-scores. Small improvements (averaging a 3.7-kg decrease) in weight/weight percentile were observed following a supervised exercise plus dietary and/or behavior support intervention. Health-related quality of life may improve following interventions, but overall attention to associated psychological variables (depression, self-esteem/perception) is limited. CONCLUSIONS: Adherence to objective checklists and protocols for rigorous conduct and reporting of systematic reviews is warranted. Consensus evidence is urgently needed to define and report behavior change interventions related to obesity prevention and treatment.

Peer mentor versus teacher delivery of a physical activity program on the effects of BMI and daily activity: protocol of a school-based group randomized controlled trial in Appalachia.

BACKGROUND: Rural Appalachian populations have poorer health and fewer positive health-related behaviors compared to other United States populations. Appalachians are the most sedentary U.S. population and teens are particularly sedentary. Obesity prevention through improving physical activity is a top priority in Rural Healthy People 2020. Obesity prevalence among Appalachian teens exceeds the national rates of 13.9% and has consistently been greater than 26%. Organized sports has not been effective at improving daily physical activity or health outcomes for Appalachian teens. The purpose of this study is to test the efficacy of a 10-week school-based intervention in promoting self-regulation of physical activity among adolescents not participating in organized sports. By using accelerometers, our study will measure both sedentary time and planned exercise during waking hours. METHODS: The design for this four-year study is a group-randomized controlled trial (G-RCT). We will recruit high schools in 3 waves, with 4 in Wave 1, 8 in Wave 2, and 8 in Wave 3, for a total of 20 schools. For each wave of schools, we will randomly assign half of the schools to each condition--intervention (peer-to-peer mentoring [MBA]) and comparison (teacher-led [PBA])--for a total of 10 schools in each of the two conditions by study's end. We will collect data at baseline (T1), 3 months post intervention (T2), and 6 months post intervention (T3). Linear Mixed Models (LMMs) and Generalized Linear Mixed Models (GLMMs) will be used to test the main hypotheses. Power for this study was based the primary analysis comparing BMI outcomes at T2 between the groups, adjusting for baseline BMI values. DISCUSSION: This study provides age-appropriate lifestyle education and skill building. Peer-to-peer mentoring by local high school students and school-based tailored support strengthens sustainable behavioral change. Focusing on unique healthy-lifestyle challenges prevalent in low-resource areas such as Appalachia such as overcoming environmental, social, and psychological barriers may improve adherence to physical activity. Serving as role models, peer mentors may improve their own lifestyle behaviors, providing a dual intervention. TRIAL REGISTRATION: NCT02329262 .

A Structured Peer-Mentoring Method for Physical Activity Behavior Change Among Adolescents.

Despite national guidelines for regular physical activity, most adolescents are not physically active. Schools serve an estimated 60 million youth and provide an educational environment to meet the current physical activity guidelines. The obesity epidemic and chronic disease comorbidities associated with physical inactivity are not likely to be reversed without a strong contribution from local schools. This article describes how a structured peer-mentoring method provides a feasible, flexible, and tailored means to meet the current guidelines for best practice in a school setting. Structured peer mentoring using trained high school mentors to support behavior change in younger peers is an innovative method to meeting the School Health Guidelines to Promote Healthy Eating and Physical Activity Through structured peer mentoring, adolescents are provided consistent social support in a caring and personalized manner. This support builds skills and competencies enhancing self-efficacy to sustain a lifetime of physical activity behavior.

General practitioners' perceptions of different practice models: a qualitative study.

Ownership of general practices is changing, but perceptions of GPs about ownership and the factors influencing their decisions about this are not well understood. The aim of this study was to explore GPs' perceptions and attitudes towards different practice models. GPs (n=138) in the Southern Adelaide-Fleurieu-Kangaroo Island Medicare Local region participated in semi-structured interviews, which were analysed thematically. Thirty-nine per cent of participants were practice owners, and 64% were working in a practice with six or more GPs. Factors driving practice ownership were flexibility, autonomy and financial reward. Factors discouraging ownership were increased responsibility, time commitment and the potential for financial burden. Some interest in future practice ownership was evident, but concerns were also raised about the knowledge and skills required. Strategies are needed both to support GPs who do wish to be practice owners and to facilitate a range of practice models to ensure continued delivery of accessible, quality primary medical care to patients.