Strategic Directions in Preventive Intervention Research to Advance Health Equity.

As commissioned by the Society for Prevention Research, this paper describes and illustrates strategic approaches for reducing health inequities and advancing health equity when adopting an equity-focused approach for applying prevention science evidence-based theory, methodologies, and practices. We introduce an ecosystemic framework as a guide for analyzing, designing, and planning innovative equity-focused evidence-based preventive interventions designed to attain intended health equity outcomes. To advance this process, we introduce a health equity statement for conducting integrative analyses of ecosystemic framework pathways, by describing the role of social determinants, mechanisms, and interventions as factors directly linked to specific health equity outcomes. As background, we present health equity constructs, theories, and research evidence which can inform the design and development of equity-focused intervention approaches. We also describe multi-level interventions that when coordinated can produce synergistic intervention effects across macro, meso, and micro ecological levels. Under this approach, we encourage prevention and implementation scientists to apply and extend these strategic directions in future research to increase our evidence-based knowledge and theory building. A general goal is to apply prevention science knowledge to design, widely disseminate, and implement culturally grounded interventions that incrementally attain specific HE outcomes and an intended HE goal. We conclude with recommendations for conducting equity-focused prevention science research, interventions, and training.

Unintentional injury deaths among American Indian residents of the Fort Apache Indian Reservation, 2006-2012.

This study aims to describe the epidemiology of unintentional injury deaths among American Indian residents of the Fort Apache Indian Reservation between 2006 and 2012. Unintentional injury death data were obtained from the Arizona Department of Health Services and death rates were calculated per 100 000 people per year and age adjusted using data obtained from Indian Health Service and the age distribution of the 2010 US Census. Rate ratios were calculated using the comparison data obtained through CDC's Web-based Injury Statistics Query and Reporting System. The overall unintentional injury mortality rate among American Indians residing on the Fort Apache Indian Reservation between 2006 and 2012 was 107.0 per 100 000. When stratified by age, White Mountain Apache Tribe (WMAT) mortality rates for all unintentional injuries exceed the US all races rate except for ages 10-14 for which there were no deaths due to unintentional injury during this period. The leading causes of unintentional injury deaths were MVCs and poisonings. Unintentional injuries are a significant public health problem in the American Indian and Alaska Native communities. Tribal-specific analyses are critical to inform targeted prevention and priority setting.

Engaging Native American Caregivers in Youth-Focused Diabetes Prevention and Management.

Native American youth aged 10 to 19 years are disproportionately affected by type 2 diabetes. Intergenerational programs may improve health in tribal communities. We evaluated Together on Diabetes, a diabetes prevention and management program, among 257 participating Native American youths with or at risk for type 2 diabetes and their adult caregivers. Feasibility, acceptability, and demographic data were collected from 226 adult caregivers. Data on physical measurements (weight, height, waist circumference) were collected from 37 of the caregivers. Results indicated that engaging adult caregivers was feasible, acceptable, and effective. Furthermore, a subset of adult caregivers reduced their body mass index (weight in kilograms divided by height in m2) significantly from the start to the end of the program, a 12 month period (P = .02). Findings suggest the feasibility of engaging adult caregivers in youth diabetes prevention programs.

Unintentional injury prevention in American Indian and Alaska Native communities: a scoping review of the Indian Health Service Primary Care Provider newsletter.

BACKGROUND: Unintentional injuries disproportionately impact American Indian and Alaska Native (AI/AN) populations. Developing effective and culturally tailored data collection and intervention programs requires an understanding of past prevention efforts in AI/AN communities, but limited peer-reviewed literature on the topic is available. This scoping review aims to summarize efforts that have been published in the Primary Care Provider newsletter, a source of gray literature available through the Indian Health Service. METHODS: The research team obtained all injury related articles in the Provider newsletter and excluded those that did not describe an unintentional injury prevention effort. Included articles were organized chronologically and by topic, and outcomes were described in a data abstraction form. RESULTS: A total of 247 articles from the Provider newsletter were screened, and 68 were included in this review. The most number of articles were published in 2007 (n = 15). Many focused not specifically on one tribal community but on the AI/AN community as a whole (n = 27), while others reported that certain tribes were the focus of study but did not identify tribes by name (n = 24). The following is a list of 14 tribal communities explicitly mentioned: Omaha, Cherokee, Ute, Yakama, Chippewa, Apache, Ho-Chunk, The Crow Tribe, Tohono O'odham Nation, Fort Mojave Tribe, Chemehuevi Tribe, The Rosebud Tribe, Navajo, and The Pueblo of Jemez. Published unintentional injury prevention efforts have covered the following 7 topics in AI/AN communities: falls, motor vehicle crashes, poisonings, improving data, burns, children, and other. CONCLUSION: This scoping review makes available and searchable information on injury prevention work conducted in and for AI/AN communities that is not currently found in the peer-reviewed literature.

Empowering Native Adolescents: Responsibility for Their Health Behaviors.

Objectives: In this study, we assess the impact of a home-based diabetes prevention program, Together on Diabetes (TOD), on adolescent responsibility-taking for tasks related to diabetes risk. Methods: Participants were Native American youth ages 10-19 with or at risk of type 2 diabetes who participated in a 12-session, 6-month diabetes prevention program with an adult caretaker. Assessments completed at baseline, 6-month, and 12-month follow-up include demographics and the Diabetes and Obesity Task Sharing (DOTS) Questionnaire. We used latent class analysis (LCA) at baseline to examine heterogeneity in DOTS responses. We identified 3 classes (adolescent, shared, caretaker). We used latent transition analysis to examine stability and change in latent status at baseline, 6- and 12-month follow-up. Results: At baseline, the mean age of participants was 13.6 years and 55.9% were boys. From baseline to 6-month follow-up, the adolescent class was most stable, whereas the shared and caretaker classes were less stable. For participants who transition from the adolescent class, most transition to shared class compared to caretaker class. Conclusions: TOD helps to empower Native American adolescents to take responsibility for their health and engage with their caregivers in these decisions.

Native Youth Participating in the Together on Diabetes 12-Month Home-Visiting Program Reported Improvements in Alternative Healthy Eating Index-2010 Diet Quality Domains Likely to Be Associated With Blood Pressure and Glycemic Control.

BACKGROUND: The Together on Diabetes (TOD) intervention was a home-visiting diabetes prevention and management program for Native youth. OBJECTIVES: (1) Examine the impact of the TOD program on diet quality using the Alternative Healthy Eating Index (AHEI-2010); (2) determine association between diet quality and cardiometabolic health. DESIGN: The TOD program was conducted from October 2012 to June 2014 and was evaluated using a pretest-posttest study design from baseline to 12 months. Dietary intake was assessed using a food frequency questionnaire. PARTICIPANTS/SETTING: There were 240 participants between 10 and 19 years of age from 4 reservation-based, rural tribal communities in the southwestern United States that had been diagnosed with T2DM or prediabetes or were identified as at risk based on body mass index and a qualifying laboratory test. INTERVENTION: Youth were taught a 12-lesson curriculum on goal setting, nutrition, and life skills education. MAIN OUTCOME MEASURES: Behavioral and physiologic outcomes related to diabetes. STATISTICAL ANALYSIS: Changes in AHEI-2010 score and associations with cardiometabolic measures were tested, over time, using adjusted longitudinal linear mixed-effects models. RESULTS: The study sample reported an average energy intake of 2016 kcal/d (±1260) and AHEI-2010 score of 47.4 (±7.4) (range: 0-110, higher = better diet quality), indicating low diet quality at baseline. At 12 months' follow-up, there was a reduction in kilocalories (mean = -346 kcal/d; P < .001), sugar-sweetened beverages (mean = -2 fluid oz/d; P = .032), red/processed meat (mean = -1.5 oz/d; P = .008), and sodium (mean = -650 mg/d; P < .001) but no change in AHEI-2010 score (P = .600). The change in systolic blood pressure from baseline to 12 months for participants within the highest AHEI-2010 quartile group was significantly larger than the change in participants within the lowest quartile group (mean = -5.90 mm Hg; P = .036). CONCLUSIONS: Despite stable AHEI-2010 scores during follow-up, there were improvements in diet quality domains likely to be associated with cardiometabolic health. Home-visiting programs like TOD are promising interventions for decreasing dietary intake of poor-quality foods.

Effect of a Home-Visiting Intervention to Reduce Early Childhood Obesity Among Native American Children: A Randomized Clinical Trial.

Importance: Early childhood obesity disproportionately affects Native American communities. Home visiting is a promising strategy for promoting optimal infant growth in this population. Objective: To assess the impact of a brief home-visiting approach, Family Spirit Nurture (FSN), on sugar-sweetened beverage (SSB) consumption, responsive parenting and infant feeding practices, and optimal growth through 12 months post partum. Design, Setting, and Participants: This study was a 1:1 randomized clinical trial comparing FSN with an injury prevention education control condition in a reservation-based community. Participants were Navajo mothers 13 years or older with infants younger than 14 weeks recruited between March 22, 2017, and May 18, 2018, and followed up through 12 months post partum. Intent-to-treat analyses were conducted. Interventions: The 6-lesson FSN curriculum, delivered 3 to 6 months post partum by Navajo paraprofessionals, targeted optimal responsive and complementary feeding practices and avoidance of SSBs. The control group received 3 injury prevention lessons. Main Outcomes and Measures: Primary outcomes established a priori were infant SSB consumption and responsive parenting and complementary feeding practices (responsive feeding scale, age at complementary food introduction, and percentage of mothers who introduced complementary food to infants at 6 months of age or older). The secondary outcome was the effect of the intervention on infant body mass index z scores (zBMIs). Results: A total of 134 Navajo mothers of infants younger than 14 weeks were enrolled in the randomized clinical trial, including 68 (mean [SD] maternal age at enrollment, 27.4 [6.4] years) in the intervention group and 66 (mean [SD] maternal age at enrollment, 27.5 [6.1] years) in the control group. Intervention participants reported statistically significantly lower infant SSB consumption through 12 months post partum (mean [SE], 0.56 [0.12] cups per week in the intervention group and 1.78 [0.18] cups per week in the control group; incidence rate ratio, 0.31; 95% CI, 0.19-0.50). Improvements in responsive feeding practices were observed through 9 months post partum (mean [SE], 3.48 [0.07] in the intervention group and 3.22 [0.08] in the control group) (difference, 0.26; 95% CI, 0.06-0.47); statistical significance was lost at 12 months post partum. Age at which the infant was given first food was younger in the intervention group (mean [SE] age, 4.61 [0.21] months in the intervention group and 5.28 [0.23] months in the control group) (difference, -0.67; 95% CI, -0.04 to -1.29). Infants in the intervention group had lower zBMI at 6 and 9 months compared with those in the control group (mean [SE] at 9 months, 0.27 [0.14] in the intervention group and 0.81 [0.14] in the control group; difference, -0.54; 95% CI, -0.94 to -0.14). The 12-month between-group difference was meaningful but not statistically significant (mean [SE], 0.61 [0.16] in the intervention group and 1.07 [0.20] in the control group; difference, -0.46; 95% CI, -0.92 to 0.01). Conclusions and Relevance: Infants of Native American mothers who participated in a home-visiting intervention had substantially lower SSB consumption and improvements in responsive feeding practices and infant zBMI scores, suggesting the intervention is effective for promoting healthy infant feeding and growth. Trial Registration: ClinicalTrials.gov Identifier: NCT03101943.

Continuous Regional Anesthesia and Inpatient Rehabilitation for Pediatric Complex Regional Pain Syndrome.

BACKGROUND: Evidence supports treatment of pediatric complex regional pain syndromes (CRPS) with physical and occupational therapy and cognitive-behavioral therapy. Some patients have persistent pain and/or limb dysfunction despite these treatments. We performed a retrospective study of pediatric patients with CRPS treated by continuous epidural or peripheral perineural local anesthetic infusions along with inpatient rehabilitation at Boston Children's Hospital. METHODS: After approval from the institutional review board, electronic medical records were reviewed for patients treated between September 2003 and September 2014. Primary outcomes were pain and functional scores. Data were collected at the first encounter, at follow-up visits between 4 months before and after admission, and daily while inpatient. Changes over time were assessed using Wilcoxon tests with Dunn corrections. Clinical significance of benefit or harm was assessed by the method of Jacobson and Truax. Response predictors were analyzed using linear mixed models and exploratory logarithmic regression analyses. RESULTS: Pain, function, and disability scores improved during hospitalization and in follow-up over a 4-month period. Seventy percent of patients achieved clinically significant benefit (56% for pain reduction and 40% increased functionality, respectively). Univariate and adjusted predictors of favorable outcome included preadmission resting Numeric Pain Rating Scale score of less than 6 (odds ratio, 5.0; P = 0.0164 and subsequent attendance at the Pediatric Pain Rehabilitation Center at Boston Children's Hospital (odds ratio, 5.0; P = 0.0206). Mean pain scores greater than 3 during the regional anesthesia infusion predicted less favorable outcome. CONCLUSIONS: Continuous regional anesthesia may be an option to facilitate intensive rehabilitation for selected pediatric patients with CRPS. Further research should help clarify the role of regional anesthesia in a comprehensive management program.

The Impact of a Home-Based Diabetes Prevention and Management Program on High-Risk American Indian Youth.

PURPOSE: The purpose of this study was to examine the impact of a home-based diabetes prevention and management program on high-risk American Indian youth. METHODS: Together on Diabetes (TOD) was designed via a participatory approach with 4 tribal communities in the southwestern United States. A multisite pre- and postevaluation design was used to evaluate the efficacy of the TOD intervention on improving youth's psychosocial, knowledge, behavioral, and physiological outcomes at 4 time points from baseline to 12 months postenrollment. RESULTS: A total of 256 youth and 225 support persons were enrolled in the TOD program. At 12 months postenrollment, improvements were observed in youth's quality of life (P < .001), depressive symptoms (P < .001), knowledge related to TOD content (P < .001), standardized body mass index scores (P = .004), and hypertension (P = .026). Improvements in mean A1C were observed among diabetic youth with baseline A1C >6.5% (P = .036). CONCLUSIONS: The TOD program was feasible, acceptable, and effective in lowering diabetes risk among reservation-based American Indian youth. It is the first efficacious youth-focused diabetes prevention and management program developed and implemented in partnership with tribal communities.

A Home-Visiting Diabetes Prevention and Management Program for American Indian Youth: The Together on Diabetes Trial.

PURPOSE: The purpose of this study was to test the feasibility of a family-based, home-visiting diabetes prevention/management intervention for American Indian (AI) youth with or at risk for type 2 diabetes. METHODS: The Together on Diabetes program, developed through community-based participatory research, enrolled 255 AI youth (aged 10-19 years) with or at risk for type 2 diabetes and 223 support persons. Delivered by local AI paraprofessionals in 4 rural AI communities, the program included home-based lifestyle education and psychosocial support, facilitated referrals, and community-based healthy living activities. Changes in AI youth participants' knowledge, behavior, psychosocial status, and physiological measurements were assessed over 12 months. RESULTS: Over one-half (56.1%) of youth were boys. The median age was 13.2 years. At baseline, 68.0% of youth reported no physical activity in the past 3 days; median percentages of kilocalories from fat (36.18%) and sweets (13.67%) were higher than US Department of Agriculture recommendations. Nearly 40% of participants reported food insecurity in the past month; 17.1% screened positive for depression. Support persons were predominantly family members, few reported having home Internet access (38.6%), and the majority reported being long distances (>30 minutes) from food stores. Whereas support persons were primarily responsible (≥69%) for obtaining medical care for the youth, the youth had a greater role in behavioral outcomes, indicating joint diabetes prevention/management responsibility. CONCLUSIONS: Baseline results confirmed the need for family-based youth diabetes prevention interventions in rural AI communities and indicated that enrolling at-risk youth and family members is feasible and acceptable.

Permanganate oxidation of 1,5,9-trienes: stereoselective synthesis of tetrahydrofuran-containing fragments.

Permanganate oxidation of farnesoate esters 12a-d afforded perhydro-2,2'-bifuranyl compounds 16a-d, with control of relative stereochemistry at four new stereocenters. Subsequent oxidative cleavage of 16a-d then provided tetrahydrofuran-containing fragments 17a-d, one of them 17b possessing the same relative stereochemistry present in the C13-C21 portion of the polyether antibiotic semduramycin (1). Control of the absolute stereochemistry was achieved through the use of the Oppolzer sultam chiral auxiliary. The requisite starting trienes were prepared stereoselectively in just three steps from geranyl chloride or neryl chloride, providing a short and versatile route to polyether fragments.