Use of a Fully Automated Internet-Based Cognitive Behavior Therapy Intervention in a Community Population of Adults With Depression Symptoms: Randomized Controlled Trial.

BACKGROUND: Although internet-based cognitive behavior therapy (iCBT) interventions can reduce depression symptoms, large differences in their effectiveness exist. OBJECTIVE: The aim of this study was to evaluate the effectiveness of an iCBT intervention called Thrive, which was designed to enhance engagement when delivered as a fully automated, stand-alone intervention to a rural community population of adults with depression symptoms. METHODS: Using no diagnostic or treatment exclusions, 343 adults with depression symptoms were recruited from communities using an open-access website and randomized 1:1 to the Thrive intervention group or the control group. Using self-reports, participants were evaluated at baseline and 4 and 8 weeks for the primary outcome of depression symptom severity and secondary outcome measures of anxiety symptoms, work and social adjustment, psychological resilience, and suicidal ideation. RESULTS: Over the 8-week follow-up period, the intervention group (n=181) had significantly lower depression symptom severity than the control group (n=162; P<.001), with a moderate treatment effect size (d=0.63). Moderate to near-moderate effect sizes favoring the intervention group were observed for anxiety symptoms (P<.001; d=0.47), work/social functioning (P<.001; d=0.39), and resilience (P<.001; d=0.55). Although not significant, the intervention group was 45% less likely than the control group to experience increased suicidal ideation (odds ratio 0.55). CONCLUSIONS: These findings suggest that the Thrive intervention was effective in reducing depression and anxiety symptom severity and improving functioning and resilience among a mostly rural community population of US adults. The effect sizes associated with Thrive were generally larger than those of other iCBT interventions delivered as a fully automated, stand-alone intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT03244878; https://clinicaltrials.gov/ct2/show/NCT03244878.

Rural Native and European American Custodial Grandparents: Stressors, Resources, and Resilience.

Native American grandparents by tradition are expected to play a role in rearing grandchildren. However, in many Native grandfamilies, grandparents are rearing grandchildren not by choice or tradition, but as the result of family crises that necessitated grandparent intervention. European American grandparents have likewise been called to rear their grandchildren when their adult children are unable or unwilling to perform parental duties. Less is known about these custodial grandparents' resilience pathways, particularly among rural grandfamilies. Guided by the Resiliency Model of Family Stress, Adjustment, and Adaptation, this study examined the relationships between stressors, resources, and resilience among rural Native and European American custodial grandparents. Correlates of resilience were economic stress and stress management. Significant interactions were found between economic stress and government assistance and economic stress and stress management, indicating complex resilience pathways. Implications of study findings for research and intervention are discussed.

Use of health services for sexually transmitted and blood-borne viral infections by young Aboriginal people in New South Wales.

The objective of the present study was to describe use of health services for sexually transmitted infections (STI), blood borne viral infections (BBV) and drug and alcohol issues by young Aboriginal people in New South Wales (NSW). A cross-sectional survey was conducted at two Aboriginal sports and cultural events in NSW, in 2007 and 2008, among Aboriginal people aged 16-30 years to ascertain their knowledge of STI, BBV, associated risk behaviours and health service access in NSW. A total of 293 young Aboriginal people completed the survey; 58% were female, the mean age was 20 years, and almost 70% were single. Just over one-third (34%) of participants had been tested for an STI in the past 12 months, and over half (58%) reported that they had ever had an STI test (including HIV). Of respondents who had had an STI test in the past 12 months, 54.0% had done so at an Aboriginal Community Controlled Health Service (ACCHS) and 29% by a GP. Just over one-third (36%) of participants had ever had a test for hepatitis C, 45% of whom had received their test at an ACCHS. Participants were also asked about the types of services they had used for advice about STI and BBV. Of the 69% who had sought STI advice, ACCHS was the most common clinical location for doing so (36% for STI and 26% for hepatitis C). This study highlights the important role that ACCHS play in the provision of STI and BBV testing care and management for a cohort of young Aboriginal people in NSW.

Social and Emotional Wellbeing of Aboriginal Community Controlled Health Services Staff during the COVID-19 Pandemic.

This study explores the impact of the COVID-19 pandemic on the work and social and emotional well-being (SEWB) of staff at Aboriginal Community Controlled Health Services (ACCHS) in Australia. Between September and November 2021, staff from three ACCHSs in New South Wales completed an online survey to report changes to their roles, concerns about becoming infected with the COVID-19 virus, and job satisfaction in the last month. The survey measured emotional exhaustion and psychological distress by using the Maslach Burnout Inventory-Human Services Survey and Kessler-5 scale, respectively. The survey determined staff's access to SEWB support. Descriptive statistics were calculated for each variable. Among 92 staff from three ACCHSs, 36% reported a COVID-19-related change in their role and 64% were concerned about becoming infected. In spite of the pandemic, most staff (69%) were satisfied with their job. While most staff were not burnt out or psychologically distressed, 25% had high emotional exhaustion and 30% had high to very high psychological distress. Relatedly, 37% had accessed SEWB support at least once in their lifetime and 24% had accessed support in the last month. As the pandemic continues, it is important to identify factors influencing burnout or psychological distress among ACCHS staff and implement evidence-based solutions.

Childhood obesity prevention in rural settings: background, rationale, and study design of '4-Health,' a parent-only intervention.

BACKGROUND: Childhood obesity in rural communities is a serious but understudied problem. The current experiment aims to assess a wide range of obesity risk factors among rural youth and to offer an 8-month intervention program for parents to reduce obesity risk in their preteen child. METHODS/DESIGN: A two-group, repeated measures design is used to assess the effectiveness of the 4-Health intervention program. Assessments include anthropometric measures, child self-evaluations, parent self-evaluations, and parent evaluations of child. County Extension agents from 21 rural Montana counties recruit approximately 150 parent-child dyads and counties are semi-randomly assigned to the active intervention group (4-Health Educational Program) or a "best-practices" (Healthy Living Information) control group. DISCUSSION: This study will shed light on the effectiveness of this parent-only intervention strategy in reducing obesity risk factors among rural preteens. The 4-Health program is designed to provide information and skills development for busy rural parents that will increase healthy lifestyles of their preteen children and improve the parents' ability to intervene effectively in the lives of their families during this critical developmental period. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT01510587.

Establishing an enduring co-production platform in Aboriginal health.

Co­production in Aboriginal health research builds on participatory, strength-based approaches where Aboriginal knowledge, expertise and priorities are valued and used to generate evidence to drive improvements in Aboriginal health and healthcare. The Coalition for Research to Improve Aboriginal Health (CRIAH), led by a partnership between the Aboriginal Health & Medical Research Council (AH&MRC), Sax Institute and six Aboriginal Community Controlled Health Services (ACCHSs) in NSW, has a long history of successfully co-producing evidence to guide policy and program planning. Data collected through CRIAH's first project, the Study of Environment on Aboriginal Resilience and Child Health (SEARCH), a cohort of urban Aboriginal children, has been effectively used to improve child health outcomes. An evaluation of CRIAH's co-production model highlighted trusting relationships, sharing of power, valuing Aboriginal knowledge and expertise, respectful communication, strong Aboriginal leadership, and ongoing investment and collaboration as instrumental to the success and longevity of this multidisciplinary partnership. In recent years, CRIAH's co-production platform has responded to emerging areas of need identified by participating ACCHSs. This paper highlights three initiatives driven through the co-production platform: 1) examining how local mental health service systems are working for Aboriginal children and young people and how they can be improved; 2) understanding how the cancer care system is working for older Aboriginal people to develop scalable and sustainable approaches to improving cancer care; and 3) finding effective ways to measure the impact of innovative, Aboriginal-led primary health care programs. These initiatives represent co-produced, fit-for-purpose research aimed at driving tangible improvements in Aboriginal health..

Partnering to Increase Colorectal Cancer Screening: Perspectives of Community Advisory Board Members.

The Patient-Centered Outcomes Research Institute (PCORI) defines engagement in research as the meaningful involvement of patients, caregivers, clinicians, insurers, and others throughout the entire research process-from planning to conducting the study to disseminating study results. The purposes of this paper are to (a) describe methods used to engage community members across the various phases of a PCORI-funded comparative effectiveness trial to increase colorectal cancer screening; and (b) report results of qualitative and quantitative evaluations of community advisory board members' experiences on this project. Decisions to join and stay engaged with the study included feeling valued and appreciated, being compensated, the opportunity to contribute to research based on their skills and expertise, and being committed to colon cancer prevention efforts. Challenges identified by advisory board members included the significant time commitment, transportation, and meeting location. Lessons learned and guidance for researchers committed to patient and community engagement are described.

Exploring Perceptions of a Computerized Cognitive Behavior Therapy Program in a U.S. Rural Western State.

Computerized mental health interventions have the potential to address existing mental health care disparities in rural communities. The aim of this study was to conduct an exploratory examination on the acceptability of an interactive computerized cognitive behavior therapy program to reduce depressive symptoms for adults in a rural Western state. Partnering with the land-grant university Extension system and a state non-profit organization, we identified and interviewed 18 key informants and conducted 19 focus groups in 15 rural communities to ascertain attitudes and perspectives about the program. Key informants were provided access to the Thrive program prior to the interviews. Focus group participants were provided a brief demonstration of the program and asked to provide feedback. Content analyses of interview and focus group transcripts yielded four general themes of program acceptability: privacy, accessibility, user-friendliness, and cultural inappropriateness. Overall, participants indicated that the Thrive program would be useful for many in their communities. They also reported that the program could be improved by making videos that better represent rural community members' lifestyles and experiences. The study team members acted on these findings to improve the Thrive program for rural Western populations.

Catheter lock heparin concentration: effects on tissue plasminogen activator use in tunneled cuffed catheters.

The optimal cost-effective heparin concentration for locking tunneled cuffed hemodialysis catheters (TCC) is unclear. We performed a retrospective review of tissue plasminogen activator (tpa) use in TCC in 2 hemodialysis units that used different heparin concentrations for TCC lock to evaluate the effectiveness of lower dose heparin as a lock for TCC. Catheter blood flow rate per treatment, units of heparin given during treatments, patient hemoglobin values and use of warfarin, and tpa use were compared for all patients using TCC for at least 3 months in 2 in-center hemodialysis units between 11/04 and 5/05. Both units used the same type of catheters and biocompatible, non-re-use dialyzers. Unit A used heparin 1000 U/mL for catheter locks, and Unit B used heparin 10,000 U/mL for catheter locks. Twelve of 19 Unit A patients, tpa and 14 of 45 Unit B patients received intracatheter during the study period (p=0.0009). There were no differences in the number of patients on warfarin, treatment blood flow rate, or mean hemoglobin levels between the 2 groups. The mean heparin units given during hemodialysis treatments was higher in Unit A patients (3.92+/-2.2 vs. 3.83+/-2.5 1000 U, p=0.05). Assuming a 4.1 mL total catheter lumen volume, the cost of heparin 1000 U/mL lock was 0.20 dollars per treatment and heparin 10,000 U/mL cost 2.67 dollars/treatment; tpa cost 89.02 dollars/use. Using the 10,000 U/mL heparin as a catheter lock was associated with less frequent use of tpa. However, the significantly lower cost of the 1000 U/mL heparin could result in significant savings despite higher tpa use. This retrospective, uncontrolled study of a small number of patients suggests that comparing low and high heparin concentrations as a TCC lock would be worthwhile. Prospective studies would be helpful to define the most appropriate and cost-effective lock for TCC.

Using SNOMED CT as a reference terminology to cross map two highly pre-coordinated classification systems.

We hypothesized that SNOMED CT, a granular formal reference terminology, could be used to assist in the creation of a valid crosswalk between two administrative classifications: the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and the U.S. Veterans Benefits Administration (VBA) disability code set. To establish a baseline, we created an ICD-9-CM terminology server and directly mapped textual descriptions of the VBA disability codes to ICD-9-CM. We next mapped ICD-9-CM and the VBA Disability codes to SNOMED CT. The SNOMED CT mappings were matched across classification systems and terms from related concepts were displayed for an expert coder's review. We report the rate of direct ICD-9-CM to VBA Disability Code mapping (26%), the eventual success of the SNOMED CT based crosswalk (95%) and the rate at which the reviewer had to add codes to complete the mapping (99%). The method using the SNOMED CT crosswalk provided significantly better coverage than the ICD-9-CM direct mapping alone (Pearson Chi Square test; p<0.001). We conclude that SNOMED CT can be a useful adjunct to direct mapping between administrative classifications.

Effects of parent-only childhood obesity prevention programs on BMIz and body image in rural preteens.

This experiment compared body image (BI) and BMI changes resulting from two parent-only obesity prevention interventions aimed at 8-12 year olds. Parents in the experimental intervention attended ten face-to-face educational sessions, while parents in the minimal (control) intervention received similar mailed information. Parent-child dyads (N=150) were semi-randomly assigned to intervention groups. Children were assessed before, after, and 6 months following the interventions; children did not attend experimental intervention sessions. Child BI assessments included weight and size perception, weight management goals, body esteem, and appearance attitudes. Significant effects included small decreases in BMIz scores and overweight dissatisfaction, as well as improvements in aspects of body esteem and appearance attitudes. Some BI effects were gender-specific. Decreases in overweight dissatisfaction were greater following the experimental treatment. Neither treatment reduced body size misperception. Thus, parent-only obesity prevention interventions can reduce body weight and body image concerns among rural preteens.

A case study of enhanced clinical care enabled by Aboriginal health research: the Hearing, EAr health and Language Services (HEALS) project.

OBJECTIVE: To describe and evaluate Hearing EAr health and Language Services (HEALS), a New South Wales (NSW) health initiative implemented in 2013 and 2014 as a model for enhanced clinical services arising from Aboriginal health research. METHODS: A case-study involving a mixed-methods evaluation of the origins and outcomes of HEALS, a collaboration among five NSW Aboriginal Community Controlled Health Services (ACCHS), the Sydney Children's Hospitals Network, NSW Health, the Aboriginal Health and Medical Research Council, and local service providers. Service delivery data was collected fortnightly; semi-structured interviews were conducted with healthcare providers and caregivers of children who participated in HEALS. RESULTS: To circumvent health service barriers, HEALS used relationships established through the Study of Environment on Aboriginal Resilience and Child Health (SEARCH) to form a specialist healthcare network. HEALS employed dedicated staff and provided a Memorandum of Understanding (detailing mutual goals and responsibilities) for each ACCHS. Despite very tight timeframes, HEALS provided services for 653 Aboriginal children, including 5,822 speech-language pathology sessions and 219 Ear, Nose and Throat procedures. Four themes reflecting the perceived impact of HEALS were identified: valued clinical outcomes, raising community awareness, developing relationships/networks and augmented service delivery. CONCLUSIONS: HEALS delivered rapid and effective specialist healthcare services through an existing research collaboration with five ACCHS, cooperation from local health service providers, and effective community engagement. Implications for Public Health: HEALS serves as a framework for targeted, enhanced healthcare that benefits Aboriginal communities by encapsulating the 'no research without service' philosophy.

Public health decisions: the laboratory's role in the Lorain County, Ohio, investigation.

In 1994 officials from the Ohio Department of Health reported that some residents of Lorain County, Ohio, possibly had been exposed to methyl parathion (MP), a highly toxic restricted-use pesticide. The U.S. Centers for Disease Control and Prevention (CDC) assisted in the investigation by providing epidemiologic and laboratory support to the state and local health departments. Although the initial investigation found MP inside the homes, it was unclear if the residents were exposed. CDC used a new biological monitoring method to measure urinary p-nitrophenol (PNP), the metabolite of MP. This biological monitoring measures the internal dose from exposure to toxic chemicals from all routes. Laboratory analyses demonstrated that the urine of residents contained moderate to high levels of PNP, with median, mean, and highest reported concentrations of 28, 240, and 4,800 g/L, respectively, thus confirming exposure of the residents. Almost 80% of the residents had urinary PNP concentrations above the 95th percentile of the reference range concentrations. This information, combined with other analytical results of air and wipe tests, guided public health officials' decisions about the potential risk in each household. In this article we illustrate the laboratory's role in providing information to assist in making these public health decisions. Furthermore, it illustrates how a multidisciplinary team from various governmental agencies worked together to protect the public's health.

Evaluating from the outside: conducting cross-cultural evaluation research on an American Indian reservation.

There is limited guidance for conducting competent and responsive cross-cultural evaluation research with American Indian communities. The authors draw on Fisher and Ball's Tribal Participatory Research Model to highlight ways in which this project is attempting to be culturally appropriate and sensitive as they partner with an American Indian community to implement and evaluate a youth-based initiative. Challenges encountered during the evaluation are shared, as well as the authors' collective responses to such challenges. Implications for future cross-cultural evaluation researchers are also discussed in light of these experiences.

Impact of a discharge medication therapy management program in an extended care hospital.

OBJECTIVES: To study the feasibility and effectiveness of a discharge medication therapy management program. DESIGN: Quasi-experimental pre-post study design. SETTING: Thirty-six-bed hospital within an extended care hospital. PARTICIPANTS: All patients admitted to facility from January 2009 to December 2009 (control) and February 2010 to January 2011 (program). INTERVENTION: Pharmacist review of anticipated discharge following 18-20 days of stay, with suggested medication changes communicated to physicians via patient chart. Agreed changes were implemented on the next day. MEASUREMENTS: Patient readmissions within 30, 60, and 90 days into the hospital system. Medication interventions were quantified as to type. RESULTS: During the control period, 432 patients were followed, and during the intervention period, 369 patients were followed, with similar lengths of stay. In the intervention period, 565 medication interventions were attempted on 216 patients, with an 85.3% acceptance rate. The major intervention was discontinuation of medications. Mean maintenance medications per patient decreased from 10.57 to 9.46 in the intervention group, and daily medication doses per patient decreased from 17.95 to 15.73 (P < 0.001). Readmission rates were lower at 30 and 60 days in the intervention group, with a 90-day overall decrease in system readmission rate from 51% to 39% (P < 0.001). CONCLUSION: The discharge medication management program was successful in decreasing both number and type of discharge medications via pharmacist intervention. Overall, patient system readmission rates were also significantly decreased in the intervention period.

Successful partnerships are the key to improving Aboriginal health.

Partnership is a process that must be recognised as a fundamental part of any strategy for improving health outcomes for Aboriginal people. Addressing the inequities in health outcomes between Aboriginal people and other Australians will require a sustained, coordinated and well-informed approach that works to a set of goals and targets developed with input from the Aboriginal community. Partnerships provide the most effective mechanism for obtaining this essential input from Aboriginal communities and their representative organisations, enabling Aboriginal people to have an influence at all stages of the health-care process. Within the health sector, effective partnerships harness the efforts of governments and the expertise of Aboriginal Community Controlled Health Services, which offer the most effective means of delivering comprehensive primary health care to Aboriginal people.

Safer sex and condom use: a convenience sample of Aboriginal young people in New South Wales.

BACKGROUND: This paper examines condom use in a sample of Aboriginal young people in New South Wales (NSW) aged 16-30 years. METHODS: Cross-sectional data were collected using hand-held computer devices from 293 Aboriginal people attending two Aboriginal events in NSW. RESULTS: Almost two-thirds of respondents reported having had a casual sex partner in the previous 6 months. Of these, 39.2% reported always using a condom with casual partners. Having always used a condom with casual partners varied among respondents, and was more likely among younger respondents (adjusted odds ratio (AOR): 2.7, 95% confidence interval (CI): 1.2-6.1) and less likely among those who used illicit drugs (AOR: 0.2, 95% CI: 0.1-0.7). CONCLUSIONS: In comparison to published studies of other Australians, casual sex appears to be more common among this sample of Aboriginal young people; however, the proportion who report having always used condoms with casual partners is very similar. This suggests that although casual sex is more common, Aboriginal young people do not engage in risky behaviour any more often than other young Australians. Further work should be conducted with those who do not always use condoms, such as those who are older and who use illicit drugs, particularly with regards to how abstinence from drug use supports protective behaviours such as condom use among this population of Aboriginal young people.

The health of urban Aboriginal people: insufficient data to close the gap.

The Australian Government has committed to reducing Indigenous disadvantage, including closing the life-expectancy gap within a generation, and to halving the gap in mortality rates for children under 5 years of age within a decade. Sixty per cent of the health gap between Indigenous and non-Indigenous Australians is attributable to the health of Indigenous people living in non-remote areas of Australia. We conducted a brief review of recent Australian original research publications on the health of the 53% of Indigenous people who live in urban areas, and found that data are sparse; there were only 63 studies in the past 5 years (11% of all articles about Indigenous health during this period). Although Indigenous Australians living in remote areas experience greater health disparity, the government will not achieve its aims without paying due attention to the non-remote-living population. More research is required, and particularly research that actually tests the impact of policies and programs.