Physical Activity Intervention Adaptation: Recommendations from Rural American Indian Older Adults.

Preventive interventions are critical to improving health equity among American Indian (AI) populations, yet interventions that promote physical activity (PA) among AI populations are scarce. This research addresses the research-to-practice gap by informing the adaption and implementation process of evidence-based interventions (EBIs) among rural AI older adults. We used a community-based approach and an Indigenous-focused adaptation theoretical framework. Qualitative, semi-structured interviews elicited detailed information on preferences for PA intervention among rural AI older adults. We applied a collaborative directed content analysis strategy, and established trustworthiness and relevance using an inter-rater reliability process and member checking. We conducted 21 interviews, all participants identified as AI, the mean age was 66 years (SD = 7.6), and 57% were female. Themes characterized contextual and cultural intervention considerations for adapting and implementing evidence-based PA interventions in rural AI older adults. Key findings included an emphasis on social and community interaction, strategies for targeted engagement, preference for group format, pairing PA sessions with shared meals, and inclusiveness in the PA intervention across ability levels and age groups. This study identified opportunities for adaptation of PA-focused EBIs among rural AI older adults. Findings can be applied to support the adaptation and implementation of effective and relevant PA-focused preventive interventions among this population which is at high risk for chronic disease and health disparities.

Stress, Depression and Quit Attempt Outcomes among Unmotivated Smokers.

INTRODUCTION: Stress and depressive symptoms have been linked to a reduced likelihood of sustaining smoking cessation. Because stress and depressive symptoms may negatively affect motivation to quit, stress and depression may also be important for whether or not smokers make a quit attempt. OBJECTIVE: To examine the relationship between perceived stress and depressive symptoms and initiating a quit attempt in a smoking cessation induction trial. METHODS: We conducted a secondary analysis of existing data from a randomized clinical trial (N = 255) comparing motivational interviewing to health education and brief advice for smoking cessation induction in smokers with low motivation to quit. RESULTS: We observed positive associations between baseline predictors and quit attempts at week 12 (r = 0.192, p < 0.01 for depressive symptoms and r = 0.136, p < 0.05 for perceived stress). Logistic regression models revealed similar significant positive associations between baseline perceived stress and baseline depressive symptoms and making a quit attempt by week 12 (OR = 1.5, CI:1.03, 2.19 and OR = 1.03, 95% CI: 1.01, 1.06; respectively). CONCLUSION: Unexpectedly, this study found generally small but consistently positive associations between baseline depressive symptoms and baseline perceived stress and making a quit attempt by week 12. The results can be viewed as encouraging in that interventions to encourage quit attempts do not appear counter-productive for individuals higher in stress and depressive symptoms, but these patients very likely will need additional supports to sustain abstinence.

Contraceptive Counseling in the Postpartum Period: Could Pediatricians Have a Role?

INTRODUCTION: Unplanned pregnancies lead to adverse health outcomes and contribute to economic burdens. A lack of continuity and consistency in immediate postpartum care may be a contributor. The most frequent postpartum medical encounters occur with the child's pediatric health care provider, which represents an opportunity to discuss postpartum contraception. Therefore, our objective was to evaluate postpartum family planning knowledge and behavior in women, and to assess the potential acceptability of a pediatrician-delivered intervention to improve knowledge of and convenient access to contraception among postpartum women. METHODS: This was a non-interventional pilot study that employed survey and interview methodology. RESULTS: Women attending pediatric visits for their newborn or infant (N = 346) were surveyed; 35 were interviewed. On average, respondents were 27 years old (SD = 6), 6 months postpartum (SD = 5), and resumed sex 8 weeks after delivery (SD = 6). Of those who had resumed sex, 68% were not using contraception at the time. However, only 18% of survey respondents wanted to have another child. Few exhibited accurate knowledge of birth spacing or long acting reversible contraception. Most interviewees (86%) supported the idea of pediatricians providing contraceptive counseling. Concerns identified included whether it was "allowable" and pediatrician's lack of knowledge of complex maternal health histories. DISCUSSION: This study highlights a gap between contraceptive need and provision in postpartum women. However, the findings suggest women's willingness to engage in conversations with their child's pediatrician about family planning. Future research should assess the feasibility and impact of integrating postpartum counseling into pediatric visits.

Evolution of Amplitude-Integrated Electroencephalogram as a Predictor of Outcome in Term Encephalopathic Neonates Receiving Therapeutic Hypothermia.

OBJECTIVES: This study aims to evaluate the ability of (1) a novel amplitude-integrated electroencephalogram (aEEG) background evolution classification system; and (2) specific hour of life (HOL) cut points when observation of aEEG normalization and development of cycling can predict adverse neurological outcomes in infants with hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN: Continuous aEEG data of term neonates with HIE were reviewed for background pattern and aEEG cycling from start of monitoring through rewarming. Infants were classified by overall background evolution pattern. Adverse outcomes were defined as death or severe magnetic resonance imaging injury, as well as developmental outcomes in a subset of patients. aEEG characteristics were compared between outcome groups by multivariate regression models, likelihood ratios (LR), and receiver operating characteristic (ROC) curve analyses. RESULTS: Overall, 80 infants receiving therapeutic hypothermia met the inclusion criteria. Background evolution pattern seemed to distinguish outcome groups more reliably than background pattern at discrete intervals in time (LR: 43.9, p value < 0.001). Infants who did not reach discontinuous background by 15.5 HOL, cycling by 45.5 HOL, and normalization by 78 HOL were most likely to have adverse outcomes. CONCLUSION: Evolution of aEEG in term neonates with HIE may be more useful for predicting outcome than evaluating aEEG at discrete intervals in time.

Implicit Attitudes and Smoking Behavior in a Smoking Cessation Induction Trial.

INTRODUCTION: Although studies have suggested that implicit attitudes may predict smoking-related decisions, evidence that changes in implicit attitudes toward smoking are related to changes in smoking behavior is lacking. Using data from a trial comparing interventions to induce quit attempts among unmotivated smokers, this study examined whether changes in implicit attitudes were associated with quit attempts and cessation after controlling for explicit motivation. METHODS: Daily smokers recruited from the community completed measures of implicit attitudes (Implicit Association Test) and explicit measure of motivation to smoke at baseline, mid-intervention (week 12 [W12]) and follow-up (week 26 [W26]). Quit attempts and cessation were assessed at follow-up, and cessation was biochemically verified. RESULTS: As hypothesized, Implicit Association Test scores became more negative from baseline to W12, a change that was sustained at follow-up. Logistic regression analyses in which implicit attitudes were used to predict smoking outcomes revealed that negative changes in implicit attitudes from baseline to W12 and from baseline to W26 were significantly related to quit attempts (OR = 0.71, 95% CI [0.52, 0.97], p < .05 for both) independent of explicit motivation. Negative changes in implicit attitudes from baseline to W26 were significantly related to cessation (OR = 0.50, 95% CI [0.25, 1.00], p < .05). CONCLUSIONS: Negative changes in implicit attitudes were associated with positive changes in smoking behavior independent of explicit motivation. This result indicates that smoking cessation interventions may be enhanced by incorporating strategies to change implicit attitudes, and that changes in implicit attitudes are also potentially important intervention outcomes. IMPLICATIONS: Smoking cessation interventions may be improved by going beyond the current focus on explicit psychological constructs and targeting automatic cognitive processes such as implicit attitudes. The results are encouragement to examine how best to manipulate smokers' implicit attitudes as well as to determine the effect on their smoking behavior.

Association of brain injury and neonatal cytokine response during therapeutic hypothermia in newborns with hypoxic-ischemic encephalopathy.

BACKGROUND: Cytokines have been proposed as mediators of neonatal brain injury via neuroinflammatory pathways triggered by hypoxia-ischemia. Limited data are available on cytokine profiles in larger cohorts of newborns with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH). METHODS: Serum cytokines interleukin (IL)-1ß, IL-2, IL-4, IL-6, IL-8, IL-10, IL-13, tumor necrosis factor-α, and interferon-γ were measured in newborns with HIE at 24 and 72 h of TH. Differences between infants with favorable (survivors with mild/no magnetic resonance imaging (MRI) injury) vs. adverse outcome (death or moderate/severe MRI injury) were compared using mixed models to adjust for covariates. RESULTS: Data from 36 term newborns with HIE (favorable outcome: n = 20, adverse outcome: n = 16) were evaluated. Cytokines IL-1ß, IL-2, IL-6, IL-8, IL-10, and IL-13 were elevated in the adverse relative to favorable outcome group at 24 h. IL-6 remained significantly elevated in the adverse outcome group at 72 h. IL-6 and IL-10 remained significantly associated with outcome group after controlling for covariates. CONCLUSION: Inflammatory cytokines are elevated in HIE newborns with brain injury by MRI. In particular, IL-6 and IL-10 were associated with adverse outcomes after controlling for baseline characteristics and severity of presentation. These data suggest that cytokine response may identify infants in need of additional neuroprotective interventions.

Recruiting unmotivated smokers into a smoking induction trial.

Little is known about effective methods to recruit unmotivated smokers into cessation induction trials, the reasons unmotivated smokers agree to participate, and the impact of those reasons on study outcomes. A mixed-method approach was used to examine recruitment data from a randomized controlled cessation induction trial that enrolled 255 adult smokers with low motivation to quit. Over 15 months, 33% of smokers who inquired about the study were enrolled. Common recruitment methods included word-of-mouth, print advertisements and clinic referrals. Frequently mentioned reasons for participating included to: gain financial incentives (44.7%), learn about research or help others quit (43%), learn about smoking and risks (40%) and help with future quits (i.e. Quit Assistance, 23.9%). Separate regression models predicting study outcomes at 26 weeks indicated that smokers who said they participated for Quit Assistance reported higher motivation to quit (B 1.26) and were more likely to have made a quit attempt (OR 2.03) compared to those not mentioning this reason, when baseline characteristics were controlled. Understanding reasons for unmotivated smokers' interest in treatment can help practitioners and researchers design effective strategies to engage this population.

Relationship of Autonomy Social Support to Quitting Motivation in Diverse Smokers.

BACKGROUND: Research examining relationships between social support and smoking cessation has paid little attention to non-treatment seeking smokers and not considered the role of autonomy support for fostering quitting motivation. This study examined if autonomy support received from family and friends was associated with quitting motivation and making a quit attempt among diverse smokers with varying levels of quitting motivation. Demographic characteristics associated with autonomy support were explored. METHODS: Participants (N=312) responded to advertisements seeking smokers "not quite ready to quit," and were primarily Black, low-income, and unemployed. Most (255) enrolled in a clinical trial of smoking cessation induction strategies (treatment sample). An additional 57 not meeting the trial eligibility criteria of low quitting motivation enrolled for baseline assessments only. Participants completed baseline measures of autonomy support received from friends and autonomous quitting motivation. In the treatment sample, quit attempts were assessed at 6-months follow-up. RESULTS: Females reported higher levels than males of autonomy support from friends (p=0.003). Participants with a high school diploma/GED reported higher levels of support from family (p<0.001) and friends (p=0.014) than those with less education or a college/graduate degree. Both family (p=0.007) and friend (p=0.004) autonomy support scores were significantly, albeit weakly, associated with autonomous quitting motivation. Autonomy support was not associated with making a quit attempt. CONCLUSIONS: Support from family and friends may promote autonomous reasons to quit among diverse smokers. Research is needed to assess the role of social support in the pre-quitting phases among racial and socio-economically diverse populations.

Impaired cerebral autoregulation and brain injury in newborns with hypoxic-ischemic encephalopathy treated with hypothermia.

Impaired cerebral autoregulation may contribute to secondary injury in newborns with hypoxic-ischemic encephalopathy (HIE). Continuous, noninvasive assessment of cerebral pressure autoregulation can be achieved with bedside near-infrared spectroscopy (NIRS) and systemic mean arterial blood pressure (MAP) monitoring. This study aimed to evaluate whether impaired cerebral autoregulation measured by NIRS-MAP monitoring during therapeutic hypothermia and rewarming relates to outcome in 36 newborns with HIE. Spectral coherence analysis between NIRS and MAP was used to quantify changes in the duration [pressure passivity index (PPI)] and magnitude (gain) of cerebral autoregulatory impairment. Higher PPI in both cerebral hemispheres and gain in the right hemisphere were associated with neonatal adverse outcomes [death or detectable brain injury by magnetic resonance imaging (MRI), P < 0.001]. NIRS-MAP monitoring of cerebral autoregulation can provide an ongoing physiological biomarker that may help direct care in perinatal brain injury.

Improving understanding of the quitting process: psychological predictors of quit attempts versus smoking cessation maintenance among college students.

This study examined motivation, positive and negative outcome expectations of quitting, and self-efficacy as predictors of quit attempts and cessation maintenance in a smoking cessation intervention for college students (N = 303). Psychological measures assessed at baseline were used to predict smoking behavior outcomes. Analysis of variance (ANOVA) and logistic regression analysis revealed that motivation and self-efficacy were strong, differential predictors of quit attempts and cessation maintenance, respectively. This study extends the previous findings regarding psychological predictors of quitting processes to college students, and suggests the need for interventions tailored according to phases of quitting processes.

Depression Screening Scores and Allergy and Gastrointestinal Medication Use in Adolescents.

INTRODUCTION: Between 2005 and 2014, the 12-month prevalence of major depressive episodes among adolescents aged 12 to 17 years increased from 8.5% to 11.3%. Adolescent-onset depression is related to increased risk for depression and suicidal attempts in adulthood. It is known that depression is an adverse effect among adults taking OAM; however, the effect of OAM on adolescents is unknown. AIM: The aim of this study was to describe the relationship between Patient Health Questionnaire 9- Modified (PHQ9-M) scores and OAM use among adolescents. METHODS: This study included data abstracted from charts of adolescents aged 12 to 21 years who completed a Kansas Be Healthy wellness appointment at the KUSM-W Peds Clinic in 2017. Odds ratios were used to calculate the relationship between oral allergy medication and gastrointestinal medication use among adolescents and PHQ9-M scores. RESULTS: Of the 425 adolescent charts analyzed, 22% (n=96) had positive PHQ9-M screens (a score of 10 or greater), and 13% (n=56) reported current use of allergy medication and/or GI medications. Adolescents taking oral allergy medication were 1.77 times more likely to have a positive PHQ9-M screen than those not taking oral allergy medication. Among adolescents on allergy medication, there was no difference in PHQ9- M scores based on the drug class (1^st or 2nd generation antihistamine or Montelukast). CONCLUSION: Healthcare providers must diligently explore OAM/GI use with adolescents during clinical encounters and discuss possible adverse effects of OAM on mood.

Understanding Pediatric Mental Health in Primary Care: Needs in a Rural State.

The need for mental health care for pediatric patients outstrips the supply, especially in states, like Kansas, that experience shortages of mental health professionals. Pediatric mental health care access programs, like KSKidsMAP (Kansas Kids Mental health Access Program), increase access to care by building competence and confidence in primary care physicians and clinicians (PCPs) through a statewide integrated system that includes a consultation line. This study is a secondary analysis of KSKidsMAP consultation Line inquiries regarding patients aged 0 to 21 years with mental and behavioral health concerns. The study employs a mixed-method approach with descriptive statistics and thematic analysis of inquiries. Five themes were identified: (1) pharmacotherapy, (2) diagnostic evaluation, (3) community resources, (4) psychotherapy, and (5) other. This study sheds light on PCPs needs and illustrates the importance of Pediatric Mental Health Care Access programs offering interprofessional expertise to consulting PCPs, allowing for expansion of pediatric mental illness care into the primary care setting.

Expert Team in Your Back Pocket: Recommendations From a Pediatric Mental Health Access Program.

Nationwide challenges with the lack of access to mental health care for youth have prompted efforts to integrate mental health into pediatric primary care. Kansas Kids Mental Health Access Program (KSKidsMAP) was developed to promote mental health workforce development through primary-care practitioners (PCPs) by offering free access to consultations, training, and care coordination. Kansas Kids Mental Health Access Program, a federally funded pediatric mental health care access program (PMHCA), is highly interprofessional in nature, and recommendations reflect the team composition and collaboration efforts. Therefore, a mixed-methods study was conducted to assess the type of recommendations provided to PCPs who requested case consultation services. Seven themes were identified: (1) psychotherapy; (2) diagnostic evaluation; (3) community resources; (4) pharmacotherapy; (5) patient resources and toolkits; (6) education; and (7) other health recommendations. This study highlights the multifaceted approach of KSKidsMAP in addressing PCPs' pediatric mental health concerns.

Motivational Interviewing for encouraging quit attempts among unmotivated smokers: study protocol of a randomized, controlled, efficacy trial.

BACKGROUND: Although the current Clinical Practice Guideline recommend Motivational Interviewing for use with smokers not ready to quit, the strength of evidence for its use is rated as not optimal. The purpose of the present study is to address key methodological limitations of previous studies by ensuring fidelity in the delivery of the Motivational Interviewing intervention, using an attention-matched control condition, and focusing on unmotivated smokers whom meta-analyses have indicated may benefit most from Motivational Interviewing. It is hypothesized that MI will be more effective at inducing quit attempts and smoking cessation at 6-month follow-up than brief advice to quit and an intensity-matched health education condition. METHODS/DESIGN: A sample of adult community resident smokers (N = 255) who report low motivation and readiness to quit are being randomized using a 2:2:1 treatment allocation to Motivational Interviewing, Health Education, or Brief Advice. Over 6 months, participants in Motivational Interviewing and Health Education receive 4 individual counseling sessions and participants in Brief Advice receive one brief in-person individual session at baseline. Rigorous monitoring and independent verification of fidelity will assure the counseling approaches are distinct and delivered as planned. Participants complete surveys at baseline, week 12 and 6-month follow-up to assess demographics, smoking characteristics, and smoking outcomes. Participants who decide to quit are provided with a self-help guide to quitting, help with a quit plan, and free pharmacotherapy. The primary outcome is self-report of one or more quit attempts lasting at least 24 hours between randomization and 6-month follow-up. The secondary outcome is biochemically confirmed 7-day point prevalence cessation at 6-month follow-up. Hypothesized mediators of the presumed treatment effect on quit attempts are greater perceived autonomy support and autonomous motivation. Use of pharmacotherapy is a hypothesized mediator of Motivational Interviewing's effect on cessation. DISCUSSION: This trial will provide the most rigorous evaluation to date of Motivational Interviewing's efficacy for encouraging unmotivated smokers to make a quit attempt. It will also provide effect-size estimates of MI's impact on smoking cessation to inform future clinical trials and inform the Clinical Practice Guideline. TRIAL REGISTRATION: ClinicalTrials.gov NCT01188018.

Parental influence on obesity in Northern Plains American Indian youth.

Little is known regarding American Indian (AI) parental influence on children's diet and physical activity (PA), or if this influence is associated with childhood weight. We compared AI parents' diet, PA, and support for these behaviors with the child's body mass index. Scores for parental support of positive PA and diet were higher among parents of overweight/obese children. Parent PA and nutrition behaviors were in a similar, but not significant, direction with respect to child body mass index. Findings suggest that future research is needed to determine what parental, societal, or community variables influence AI children to engage in healthy eating and PA, especially if they are overweight or obese, and the age at which these variables would have the most impact on these behaviors.

A Systematic Review of Interventions to Increase Physical Activity Among American Indian and Alaska Native Older Adults.

BACKGROUND AND OBJECTIVES: Physical activity (PA) is a powerful protective factor known to reduce risk for chronic conditions across the life span. PA levels are lower among American Indians and Alaska Natives (AIANs) when compared with other racial/ethnic groups and decrease with age. This evidence justifies a synthesis of current intervention research to increase PA levels among AIANs. This systematic review examines completed interventions to increase PA among AIAN older adults and considers recommended practices for research with Indigenous communities. RESEARCH DESIGN AND METHODS: The systematic review was designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for systematic review protocols and reporting guidelines. Three electronic databases, PubMed, Web of Science, and PsycINFO, were searched for academic literature. Trials investigating interventions to increase PA among AIAN adults older than 50 years were eligible. The Quality Assessment Tool for Quantitative Studies was used to evaluate the quality of evidence. RESULTS: Three published trials were identified, including one group-level, clinic-based and two individual-level, home-based interventions. All were 6 weeks in duration, took place in urban areas, and used self-report PA measures. Findings indicated an overall increase in PA levels, improved PA-related outcomes, and improved psychosocial health among participants. None described community-engaged or culture-centered research strategies. DISCUSSION AND IMPLICATIONS: The narrow yet promising evidence represents a need for expanded research and a call to action for using culture-centered strategies. An advanced understanding of cultural and contextual aspects of PA may produce more impactful interventions, supporting health and mobility across the life span.

Applying indigenous community-based participatory research principles to partnership development in health disparities research.

This case study of community and university research partnerships utilizes previously developed principles for conducting research in the context of Native American communities to consider how partners understand and apply the principles in developing community-based participatory research partnerships to reduce health disparities. The 7 partnership projects are coordinated through a National Institutes of Health-funded center and involve a variety of tribal members, including both health care professionals and lay persons and native and nonnative university researchers. This article provides detailed examples of how these principles are applied to the projects and discusses the overarching and interrelated emergent themes of sharing power and building trust.

Analysis of smoking patterns and contexts among college student smokers.

Many who smoke in college do so infrequently and smoking conditions are not well understood. We examined smoking patterns among college fraternity and sorority members (N = 207) from a Midwestern university in three successive fall semesters in 2006-2008. Participants completed calendar-assisted retrospective assessments of 30-day smoking at up to five assessment points over 96 days. Overall smoking rates declined over the course of each semester and higher smoking on weekends was observed, with more variability among daily smokers. The most frequent categories of events to cue recall of smoking were socializing, work, and school. Findings can be used to target prevention efforts.

Lessons Learned in Conducting Community Participatory School-Based Health Research on an American Indian Reservation.

BACKGROUND: Describing lessons learned from using a community-based participatory research (CBPR) approach to conduct school-based child health research in a tribal community is an important contribution to the literature. OBJECTIVES: To identify how CBPR principles shaped the process of conducting a school-based child health intervention, and to describe lessons learned. METHODS: The study evaluates how CBPR principles guided a mixed-methods, school-based child health intervention to increase physical activity (PA). RESULTS: Nine key lessons are identified, associated with CBPR principles. CONCLUSIONS: This information can help researchers understand how to successfully navigate the challenges and opportunities of conducting CBPR-guided research in the context of a small, short-term project, including leadership turnover, multiple Institutional Review Board (IRB)s, and study design approaches amidst schools policy changes. Collectively, understanding the lessons learned through the perspective of CBPR principles may help others conduct meaningful research with schools and children in tribal communities.

Trends in Internet Safety Education by Healthcare Providers.

INTRODUCTION: The purpose of this study was to explore healthcare provider training, comfort, and provision of internet safety counseling. Prior research has demonstrated increased parental concern regarding the pervasive access to the internet by children, including the potential impacts of risky internet behavior and adverse media exposure. METHODS: A self-reported survey was provided to a convenience sample of 31 healthcare providers during a mental health training seminar. Responses were analyzed using descriptive statistics. RESULTS: Internet safety counseling, especially regarding risky online behavior, was not a focal point of provider-patient interaction in the sample population. This finding was reinforced with more than half of the respondents indicating that they infrequently or never provide internet safety counseling (n = 17, 56%). While research has placed an emphasis on the importance of discussing the risks of exposure to violence, drugs, and sexually explicit media online, this study found that the topics most often discussed were setting time limits (77%), limiting access to media devices (67%), and supervising internet use (50%). This may be due in part to the fact that most respondents (n = 17, 57%) reported never receiving training on internet safety counseling. CONCLUSIONS: Overall, significant deficits were identified in internet safety counseling training for professionals and provision of education for families. These finding were inconsistent with the American Academy of Pediatrics recommendations around media use counseling and a point of urgent concern given the increasing time spent on media devices, particularly during the COVID pandemic.