Health-related social control among U.S. adults ages 30-80: Associations with alcohol use over four years.

Health-related social control (HRSC) includes efforts to regulate or influence others' health behaviors and is an important way interpersonal relationships can affect individual-level health. This study used egocentric network data to describe the size and composition of HRSC networks, identify trajectories of HRSC receipt, and examine how HRSC is related to binge drinking and alcohol-related problems. Data come from a U.S. nationally representative sample of 1235 adults age 30 and older (baseline mean age = 52, 52% female, 64% White) who completed four annual surveys between 2019 and 2022. On average, 30% of adults' network members were HRSC agents who told or reminded them to do things to protect their health. At baseline, 50% of respondents identified a spouse/partner as a HRSC agent, 56% a relative, 46% a friend, and 12% someone else. Respondents' relationships with HRSC agents were generally strong, 93% of agents were described as people "whose opinion matters," and only 10% were described as hassling or making life difficult for the respondent. Growth mixture modeling identified five trajectories of HRSC receipt over the four-year period: Stable High (36% of sample), Stable Moderate (47%), Stable Low (14%), Decreasing (2%), and Increasing (2%). Binge drinking was relatively consistent for the three Stable HRSC classes (ranging from 11% to 15% of individuals), decreased steadily for the Increasing HRSC class (32%-16%), and fluctuated for the Decreasing HRSC class (decreasing from 10% to 2%, then increasing to 8%). For alcohol problems, the Increasing HRSC class showed the largest increase (2%-21%) before dropping to near-baseline levels (4%), whereas the Decreasing HRSC class fluctuated during the first three waves followed by no individuals reporting alcohol problems at the last wave. Results highlight the importance of examining heterogeneity in adults' HRSC experiences because of its implications for understanding social influences on health-related behaviors.

Health system implementation of the PROMIS Cognitive Function Screener in the Medicare Annual Wellness Visit: framing as abilities versus concerns.

BACKGROUND: Cognitive assessment is a required component of the Medicare Annual Wellness Visit (AWV). In this prospective study, we evaluated acceptability and usefulness of a patient-reported outcome measure (the PROMIS® Cognitive Function Screener, or PRO-CS) to screen for cognitive impairment during the AWV. We compared two versions of the PRO-CS: Abilities and Concerns. METHODS: We developed PRO-CS Abilities and PRO-CS Concerns using items from the PROMIS Cognitive Function item banks. We partnered with a large health system in Pennsylvania to implement an electronic health record (EHR)-integrated version of the 4-item PRO-CS into their AWV workflow. PRO-CS Abilities was implemented in June 2022 and then replaced with PRO-CS Concerns in October 2022. We used EHR data to evaluate scores on Abilities versus Concerns and their association with patient characteristics. We gathered feedback from providers on experiences with the PRO-CS and conducted cognitive interviews with patients to evaluate their preferences for Abilities versus Concerns. RESULTS: Between June 2022 and January 2023, 3,088 patients completed PRO-CS Abilities and 2,614 patients completed PRO-CS Concerns. Mean T-scores for Abilities (54.8) were slightly higher (indicating better cognition) than for Concerns (52.6). 10% of scores on Abilities and 13% of scores on Concerns indicated concern for cognitive impairment (T-score < 45). Both Abilities and Concerns were associated with clinical characteristics as hypothesized, with lower scores for patients with cognitive impairment diagnoses and those requiring assistance with instrumental activities of daily living. Abilities and Concerns had similar negative correlations with depression (r= -0.31 versus r= -0.33) and anxiety (r= -0.28 for both), while Abilities had a slightly stronger positive correlation with self-rated health (r = 0.34 versus r = 0.28). In interviews, providers commented that the PRO-CS could be useful to facilitate conversations about cognition, though several providers noted potential limitations of patient self-report. Feedback from patients indicated a preference for PRO-CS Concerns. CONCLUSIONS: Our findings suggest potential utility of the PRO-CS for cognitive screening in the Medicare AWV. PRO-CS Abilities and Concerns had similar associations with patient clinical characteristics, but the Concerns version was more acceptable to patients.

Social Networks, Cultural Pride, and Historical Loss Among Non-Reservation American Indian / Alaska Native Emerging Adults.

Health disparities among American Indian/Alaska Native (AI/AN) populations in the United States are the result of historical traumas, such as colonization, forced relocation, and federal policies focused on cultural assimilation. Culturally-tailored health interventions aim to address intergenerational trauma by emphasizing cultural strengths and building positive social connections. In this article, we explore the social network characteristics of participants of the first culturally-tailored health intervention for AI/AN emerging adults (18-25) living outside of tribal lands. Participants (N = 150; 86% female) were recruited across the United States via social media and completed online egocentric network interviews prior to the start of intervention workshops. Participants' networks were diverse in composition and structure. They were primarily composed of family and friends, were people they had regular contact with, were similar age, and provided participants with support. We tested for significant associations between network characteristics, individual characteristics (age, gender, travel to reservations, speaking tribal languages, etc.) and two dependent measures: 1) cultural pride and belongingness and 2) thoughts of historical loss. Multiple regression results show that higher proportions of network members who discussed AI/AN identity with participants and having more network members who engage in traditional practices was associated with stronger cultural pride and belongingness. Higher proportions of network members having discussion of AI/AN identity with participants was also associated with more frequent thoughts of historical loss. Controlling for network factors, no individual characteristics were associated with either dependent variable. We discuss implications for the development of culturally-tailored health interventions.

Unpacking disparities in substance-related outcomes among racial, ethnic, sexual, and gender minoritized groups during adolescence and emerging adulthood.

OBJECTIVE: Alcohol and other drug (AOD) use increases substantially from adolescence to emerging adulthood, and recent longitudinal studies show disparities in AOD-related outcomes by racial and ethnic, as well as sexual and gender minority (SGM), identities. Greater insight is needed into how individual, social, and environmental contexts interact and affect such disparities, as well as why disparate outcomes are found across different domains (e.g., social, educational, economic), even after accounting for intensity of use. This commentary addresses these important and timely issues. METHOD: We provide a brief overview of the literature, including our own team's work over the last 14 years, to identify and understand disparities in AOD-related outcomes during adolescence and emerging adulthood across individuals with different racial and ethnic, and sexual and gender, identities. We then discuss paths forward to advance research and build a stronger evidence base, leading to the development and identification of effective interventions that can help mitigate disparities among historically marginalized adolescents and emerging adults. RESULTS: Existing research highlights the need for further longitudinal work in several areas, including addressing contextual factors at various levels (e.g., individual, social, environmental) that may contribute to outcomes for different groups of individuals, developing and testing culturally appropriate AOD-related services, giving greater consideration to intersectionality of multiple minority identities, and using novel statistical approaches to help improve the estimation of differences across smaller subgroups of individuals in existing cohorts. CONCLUSIONS: To inform prevention programming and policy for improving health and well-being of historically marginalized populations, it is important to continue our efforts to understand disparities in AOD-related outcomes using multidisciplinary, equity, and intersectionality lenses. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Disparities in functioning from alcohol and cannabis use among a racially/ethnically diverse sample of emerging adults.

BACKGROUND: Trajectory studies have consistently shown that alcohol and cannabis (AC) use during emerging adulthood (EA) affect functioning; however, few studies examine whether racial/ethnic disparities may occur at similar levels of use. METHODS: We conducted web-based surveys across five waves from mean age 18.3 through 22.6. The sample (N = 2945) is 55% female, 46% Hispanic, 23% Asian, 23% White, 6% multi-racial (MR)/other, and 2% Black. MEASUREMENTS: Past month substance use was defined as number of days used. Outcomes at age 22.6 included negative consequences, delinquency, physical ailments and health, depression and anxiety, peer relationship functioning, life satisfaction, employment, and education. RESULTS: Compared to White EAs, Hispanic, Asian, and MR/other EAs reported less initial alcohol use; Hispanic and Asian EAs reported less initial cannabis use, whereas Black EAs reported more cannabis use. Greater initial frequency and increased frequency of AC use were associated with poorer outcomes (e.g., worse mental health). In terms of disparities, compared to White EAs, Hispanic EAs reported poorer physical health at the same levels of AC use; Hispanic, Asian, and MR/other EAs reported greater alcohol consequences and delinquency; Black, Hispanic, Asian and MR/other EAs reported lower life satisfaction; and Hispanic and MR/other EAs were less likely to pursue education beyond high school (although Asian EAs were more likely). CONCLUSIONS: Findings emphasize that trajectories of AC use during EA are associated with a range of functional outcomes. Disparities in functioning at similar levels of AC use highlight the importance of reaching racially/ethnically diverse EAs with prevention and intervention programming.

Standardized assessment of medication reconciliation in post-acute care.

BACKGROUND: Medication reconciliation (MR) facilitates safety during transitions of care, which occur frequently across post-acute care (PAC) settings. Under the intent of the IMPACT Act of 2014, the Centers for Medicare & Medicaid Services contracted with the RAND Corporation to develop and test standardized assessment data elements (SADEs) that assess the MR process. METHODS: We employed an iterative process that incorporated stakeholder input and three rounds of testing to identify, refine, and evaluate MR SADEs. Testing took place in 186 PAC sites (57 home health agencies, 28 inpatient rehabilitation facilities, 28 long-term care hospitals, and 73 skilled nursing facilities). There were 2951 patients in the final test. Novel MR SADEs, based on the Joint Commission's framework, were refined. The final SADEs assessed whether: patient was taking high-risk medications; an indication was noted for each medication class; discrepancies were identified; patient or family/caregiver was involved in addressing discrepancies; discrepancies were communicated to physician (or designee) within 24 h; recommended physician actions regarding discrepancies were implemented within 24 h after physician response; and the reconciled list was communicated to patient, prescriber, and/or pharmacy. Two assessors per facility collected data for each patient. Analyses described completion time, data missingness, and interrater reliability, as well as feedback on assessor burden. RESULTS: Time to complete the MR SADEs was 3.2 min. Missing data were <5%. Interrater reliability was moderate to high (κ: 0.42 [whether a reconciled list was communicated to prescribers] to 0.89 [identifying patients taking hypoglycemics]). For identifying high-risk medication classes, interrater reliability was high (κ: 0.72-0.89). There were minimal differences by setting. CONCLUSIONS: This is the first set of MR SADEs that have been assessed across the PAC settings. Results demonstrate feasibility, based on missing data and completion time, and moderate to strong reliability, based on interrater comparisons, of assessing MR.

Who receives post-acute care? Characteristics of national population and field test sample.

BACKGROUND: Each year millions of Medicare beneficiaries in the United States receive post-acute care (PAC) in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), and home health agencies (HHA). We describe, overall and by PAC setting, the national population of facilities and patients, evaluate the representativeness of a national field test sample, and describe patient characteristics in the national field test sample. METHODS: We analyzed the 2016 Provider of Service file, 2016 patient assessment data reported by PAC providers to Centers for Medicare & Medicaid, and data collected from PAC providers participating in a national field test. National data included 27,234 PAC settings and 5,033,820 beneficiaries receiving PAC. The national field test sample consisted of 143 facilities across 14 markets with 25-30 patients sampled from each facility (n = 3669). We describe PAC facility and patient characteristics for both the national and field test sample. RESULTS: Nationally, PAC facilities were more likely for-profit versus not for-profit, have an average nurse-to-bed ratio between 1:10 to 1:1 (lowest in SNFs) and be in metropolitan versus other areas. PAC patients were more likely to be white, female, and 75-89 years of age; heart failure as a primary medical condition tended to be more common than stroke or sepsis. There was limited variability across setting types. In the national field test, patients in LTCHs demonstrated a greater likelihood of cognitive impairment, positive depression screening, bowel and bladder appliance use, higher rates of medication drug classes taken, and use of therapeutic diets and IV medications. CONCLUSION: The national field test facility and patient samples were fairly representative of the national population overall and across settings with a few exceptions. Moreover, differences according to PAC setting on patient characteristics in the national field test aligned with general differences in patient populations.

Development and testing of a standardized pain interview assessment for use in post-acute care.

OBJECTIVES: Pain is highly prevalent among patients in post-acute care (PAC) settings and can affect quality of life, treatment outcomes, and transitions in care. Routine, accurate assessment of pain across settings is important for pain management and care planning; however, existing PAC assessment instruments do not assess patient pain in a standardized manner. METHODS: We developed and tested a set of pain interview data elements for use across PAC settings (skilled nursing facilities, inpatient rehabilitation facilities, long term care hospitals, home health agencies) as part of a larger effort undertaken by the Centers for Medicare & Medicaid Services to develop standardized assessment data elements to meet the requirements of the IMPACT Act of 2014. The interview assessed six pain constructs: presence; frequency; interference with sleep; interference with rehabilitation therapies [if applicable]; interference with daily activities; worst pain; and pain relief from treatments/medications). A total of 3031 PAC patients at 143 PAC settings (across 14 U.S. geographic/metropolitan areas in 10 states) participated in a national field test of standardized data elements from November 2017 to August 2018. We assessed item response distributions, time to complete interviews, inter-assessor agreement, and, for a subset of patients, change in responses between admission and discharge assessments. We also conducted focus groups with nurse assessors about their experiences administering the items. RESULTS: For patients reporting any pain, average time to complete the pain interview was 3.1 min (SD = 1.3), and interrater reliability was excellent for all data elements (kappa range: 0.95-0.99). Findings were similar across types of PAC settings. Qualitative data from nurses emphasized ease of administration and high perceived clinical utility. CONCLUSION: Findings provide support for feasibility of implementing a standardized pain interview assessment in PAC settings. This tool can support tracking of patient needs across settings and interoperability of data in electronic medical records.

Standardized assessment of cognitive function of post-acute care patients.

BACKGROUND: The assessment of cognitive function in post-acute care (PAC) settings is important for understanding an individual's condition and care needs, developing better person-directed care plans, predicting resource needs and understanding case mix. Therefore, we tested the feasibility and reliability of cognitive function assessments, including the Brief Interview for Mental Status (BIMS), Confusion Assessment Method (CAM©), Expression and Understanding, and Behavioral Signs and Symptoms for patients in PAC under the intent of the IMPACT Act of 2014. METHODS: We conducted a national test of assessments of four standardized cognitive function data elements among patients in PAC. One hundred and forty-three PAC settings (57 home health agencies, 28 inpatient rehabilitation facilities, 28 long-term care hospitals, and 73 Skilled Nursing Facilities) across 14 U.S. markets from November 2017 to August 2018. At least one of four cognitive function data elements were assessed in 3026 patients. We assessed descriptive statistics, percent of missing data, time to complete, and interrater reliability between paired research nurse and facility staff assessors, and assessor feedback. RESULTS: The BIMS, CAM©, Expression and Understanding, and Behavioral Signs and Symptoms demonstrated low rates of missing data (less than 2%), high percent agreement, and substantial support from assessors. The prevalence of Behavioral Signs and Symptoms was low in our sample of PAC settings. CONCLUSION: Findings provide support for feasibility of implementing standardized assessment of all our cognitive function data elements for patients in PAC settings. The BIMS and CAM© were adopted into federal Quality Reporting Programs in the fiscal year/calendar year 2020 final rules. Future work could consider implementing additional cognitive items that assess areas not covered by the BIMS and CAM©.

Standardized assessment of cognitive function, mood, and pain among patients who are unable to communicate.

BACKGROUND: Assessments of patients have sought to increase the patient voice through direct patient interviews and performance-based testing. However, some patients in post-acute care (PAC) are unable to communicate and cannot participate in interviews or structured cognitive tests. Therefore, we tested the feasibility and reliability of observational assessments of cognitive function, mood, and pain for patients who are unable to communicate in PAC settings. METHODS: We conducted a national test of observational assessments of cognitive function, mood, and pain in 143 PAC facilities (57 home health agencies, 28 Inpatient Rehabilitation Facilities, 28 Long-Term Care Hospitals, and 73 Skilled Nursing Facilities) across 14 U.S. markets from November 2017 to August 2018. For the 548 patients identified as unable to make themselves understood, we assessed descriptive statistics, percent of missing data, time to complete, and inter-rater reliability (IRR) between paired research nurse and facility staff assessors. RESULTS: Most sampled non-communicative patients were administered all three observational assessments. Among assessed patients, overall missing data was high for some items within the Staff Assessment for Mental Status (2.9% to 33.5%) and Staff Assessment of Patient Mood (12.4% to 44.3%), but not the Observational Assessment of Pain or Distress (0.0% to 4.4%). Average time to complete the data elements ranged from 2.4 to 3.5 min and IRR was good to excellent for all items (kappa range: 0.74-0.98). CONCLUSION: The three observational data elements had acceptable reliability. Although results revealed varying feasibility, there was support for feasibility overall in terms of implementing a standardized observational assessment of pain for patients in PAC settings. Additional work is needed for the Staff Assessment for Mental Status and the Staff Assessment of Patient Mood to improve the observable nature of these data elements and enhance instructions and training for standardizing the assessments.

Developing standardized patient assessment data elements for Medicare post-acute care assessments.

BACKGROUND: To support interoperability and care planning across provider types, the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires the submission of standardized patient assessment data using the assessment instruments provided by the Centers for Medicare & Medicaid Services (CMS). CMS was tasked with developing standardized assessment data elements (SADEs) within clinical categories named in the IMPACT Act. METHOD: We used environmental scans, subject matter expert, and stakeholder input to identify candidate SADEs; tested candidate data elements in alpha testing; revised SADEs and training protocols based on alpha analyses and stakeholder feedback; tested SADEs across post-acute care (PAC) settings in a national field test that included 3121 patients across 143 home health agencies, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities in 14 markets across the United States; and analyzed data and stakeholder input from national testing. Field testing measured the time required for assessment, percent completion, and inter-rater reliability. We analyzed qualitative feedback from stakeholder focus groups and technical expert panels. We also obtained survey and focus group feedback from data collectors. RESULTS: We developed a mixed-method, multi-stakeholder procedure to identify and gather input on SADE for cross-setting use. This process yielded feasible and reliable SADEs for PAC settings that assess pain, cognitive status, mood, and medication reconciliation. The success of this work depended on working iteratively with diverse stakeholders and providing qualitative as well as quantitative evidence. CONCLUSIONS: The procedures applied in this project for developing and adopting SADEs for PAC, as well as the challenges and strategies to overcome challenges, should be considered in future item and quality measure development.

Standardized assessment of depression symptoms in post-acute care: A screening threshold approach.

BACKGROUND: Depression symptoms have impacts on quality of life, rehabilitation and treatment adherence, and resource utilization among patients in post-acute care (PAC) settings. The PHQ-2 and PHQ-9 are instruments for the assessment of depression, previously used in PAC settings, that have tradeoffs in terms of measurement depth versus respondent/assessor burden. Therefore, the present study tested a gateway version of the protocol (PHQ-2 to 9). METHODS: In 143 PAC settings in 14 U.S. markets across 10 states from November 2017 to August 2018, facility and research nurses administered the PHQ-2 to communicative patients (n = 3010). Nurses administered the full PHQ-9 if the patient screened positive for either of the two cardinal symptoms assessed by the PHQ-2 (depressed mood and anhedonia). We assessed the prevalence and frequency of depression symptoms using the PHQ-2 to 9, associations between depression screening results and patient characteristics and clinical conditions, and feasibility indicators. RESULTS: More than 1 in 4 patients (28%) screened positive on the PHQ-2. Only 6% of those completing the full PHQ-9 had a score indicating "minimal" severity. The average score (M = 11.9) met the threshold for moderate depression. Positive PHQ-2 screening was associated with age, female gender, disposition at discharge, septicemia/severe sepsis, and dependence for ADLs of toileting and lying to sitting mobility. Age was also associated with full PHQ-9 scores; patients ages 45-64 had the highest mean score. Length of stay was not associated with PHQ-2 screening results or full PHQ-2 to 9 scores. Missing data were minimal (<2.4%). The average time to complete was 2.3 min. Interrater reliability and percent agreement were excellent. CONCLUSIONS: These findings suggest the feasibility of a gateway scoring approach to standardized assessment of depression symptoms among PAC patients, and that depression symptoms are relatively common among this inpatient population.

Loneliness and multiple health domains: associations among emerging adults.

Emerging adults (18-25 years), particularly racially/ethnically diverse and sexual and gender minority populations, may experience loneliness following major life transitions. How loneliness relates to health and health disparities during this developmental period is not well understood. We examine associations of loneliness with physical (self-rated health), behavioral (alcohol/marijuana consequences; nicotine dependence), and health behavior outcomes (weekday and weekend sleep; trouble sleeping), and investigate moderating effects by sex, race/ethnicity, and sexual/gender minority (SGM) status. Adjusted models using cross-sectional data from 2,534 emerging adults, predominantly in California, examined associations between loneliness and each outcome and tested interactions of loneliness with sex, race/ethnicity, and SGM status. Higher loneliness was significantly associated with worse self-rated health, higher marijuana consequences, less weekday sleep, and greater odds of feeling bothered by trouble sleeping. None of the interactions were significant. Findings suggest that interventions to reduce loneliness may help promote healthy development among emerging adults across subgroups.

Alcohol use and cannabis use trajectories and sexual/gender minority disparities in young adulthood.

OBJECTIVE: Sexual and gender minority (SGM) young people may use alcohol or cannabis (A/C) at higher rates that non-SGM peers, but little is known about whether SGM young adults experience poorer health, psychosocial, and other outcomes at similar levels of A/C use. METHOD: We used longitudinal survey data from a community cohort recruited from California middle schools in 2008 (average age 11.5) and followed across 12 waves through 2020. Participants reported on past-month A/C use at each wave. Individuals also reported SGM status as well as outcomes in multiple domains in Wave 12. Sequelae of change models tested differences in intercept and slope for A/C use trajectories from Waves 1-12 across SGM groups, and simultaneously examined differences in outcomes by SGM status adjusting separately for A/C trajectories. RESULTS: SGM (n = 445) and non-SGM (n = 2,089) groups did not differ on baseline probability of A/C use. SGM individuals showed steeper increases in probability of cannabis but not alcohol use over time. Adjusting for trajectories of A/C use, SGM individuals had significant disparities relative to non-SGM peers with respect to: Employment and economic stability, criminal justice involvement, social functioning, subjective physical health, behavioral health, and perceived unmet mental health treatment need. CONCLUSIONS: At the same levels of A/C use from middle school through young adulthood, SGM individuals show disparities in multiple domains compared to non-SGM peers. Targeted efforts to reduce substance use in conjunction with other structural disadvantages experienced by SGM youths are needed to address the emergence of disparities in young adulthood. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Behavioral Health and Service Usage During the COVID-19 Pandemic Among Emerging Adults Currently or Recently Experiencing Homelessness.

PURPOSE: This study provides information on how the coronavirus disease 2019 (COVID-19) outbreak is affecting emerging adults currently or recently homeless in terms of engagement in protective behaviors, mental health, substance use, and access to services. METHODS: Ninety participants in an ongoing clinical trial of a risk reduction program for homeless, aged 18-25 years, were administered items about COVID-19 between April 10 and July 9, 2020. RESULTS: Most participants reported engaging in COVID-19 protective behaviors. Past week mental health symptoms were reported by 38%-48% of participants, depending on symptoms. Among those who used substances before the outbreak, 16%-28% reported increased use of alcohol, tobacco, and marijuana. More than half of the participants reported increased difficulty meeting basic needs (e.g., food), and approximately 32%-44% reported more difficulty getting behavioral health services since the outbreak. CONCLUSIONS: Innovative strategies are needed to address the increased behavioral health needs of young people experiencing homelessness during events such as the COVID-19 outbreak.

The SMART Moms Program: A Randomized Trial of the Impact of Stress Management on Perceived Stress and Cortisol in Low-Income Pregnant Women.

BACKGROUND: Dysregulations in maternal hypothalamus-pituitary-adrenal function and the end product, cortisol, have been associated with a heightened risk for stress-related health complications during pregnancy and post partum. Given the adverse health impact that maternal cortisol may have on expectant mothers and their infants, empirically-based prenatal interventions are needed to target optimal management of stress and its biological effects in at-risk pregnant women, a primary example of which is cognitive behavioral stress management (CBSM). This randomized-controlled trial examined the effects of a prenatal CBSM intervention on reduction in perceived stress and regulation of salivary cortisol patterns [i.e., overall cortisol output (area under the curve), cortisol awakening response (CAR), diurnal slope] during pregnancy and the early postpartum period, as compared to a control group. METHODS: One hundred low-income pregnant women (71% Latina; 76% annual income < $20 K) with low or high anxiety during pregnancy were randomized (stratified by anxiety) to either an eight-week CBSM group intervention (n = 55) or a control group (n = 45). They provided seven salivary cortisol samples (four am samples, 12 pm, 4 pm, and 8 pm samples on one collection day) at baseline (1st trimester; < 17 weeks of gestation), after their prenatal program (2nd trimester), and also in the third trimester and at three months post partum. RESULTS: Women receiving CBSM had lower perceived stress levels throughout pregnancy and early post partum compared to women in the control group (p = .020). Among women with high prenatal anxiety, those in CBSM showed a steeper decline in their diurnal cortisol at three months post partum compared to those in the control group (p = .015). Further, non-Latina women in CBSM had a lower CAR at three months post partum compared to non-Latina women in the control group (p = .025); these randomization group differences on the CAR were not observed among Latina women. CONCLUSIONS: These findings provide preliminary support for the efficacy of prenatal CBSM interventions in improving stress outcomes among low-income pregnant women and suggest the need to test the effects of these interventions on a larger scale for improving maternal and infant health outcomes long-term.

The buddy system: A randomized controlled experiment of the benefits and costs of dieting in pairs.

A total of 67 pairs of female roommates were randomized into a diet condition: (1) both ate normally; (2) one dieted, the other ate normally; and (3) both dieted. Adherence, weight loss, anxiety, depression, disordered eating symptoms, and stress were measured. Dieters lost more weight than non-dieters, but average loss was <1 pound. Pairs where both dieted reported higher anxiety, depression, and disordered eating than one-dieter pairs. Structural equation models revealed an interrelated network of stress, anxiety, depression, and disordered eating. This was weakest when one roommate dieted. The "buddy system" may not promote weight loss, but living with a non-dieting partner may buffer consequences.

Design and participant characteristics of a primary care adaptation of the Look AHEAD Lifestyle Intervention for weight loss in type 2 diabetes: The REAL HEALTH-diabetes study.

BACKGROUND/AIMS: The REAL HEALTH -Diabetes Study is a practice-based clinical trial that adapted the Look AHEAD lifestyle intervention for implementation in primary care settings. The trial will compare the effectiveness and cost-effectiveness of in-person group lifestyle intervention, telephone group lifestyle intervention, and individual medical nutrition therapy (MNT), the current recommended standard of care in type 2 diabetes. The primary outcome is percent weight loss at 6 months with outcomes also measured at 12, 18, 24 (intervention completion), and 36 months. Here, we describe the adaptation, trial design, implementation strategies, and baseline characteristics of enrolled participants. METHODS: The study is a three-arm, patient-level, randomized trial conducted in three community health centers (CHCs) and one diabetes practice affiliated with one academic medical center. RESULTS: The study used existing clinical infrastructure to recruit participants from study sites. Strategies for successful conduct of the trial included partnering with health-center based co-investigator clinicians, engaging primary care providers, and accommodating clinical workflows. Of 248 eligible patients who attended a screening visit, 211 enrolled, with 70 randomly assigned to in-person group lifestyle intervention, 72 to telephone group lifestyle intervention, and 69 to MNT. The cohort was 55% female, 29% non-white, with mean age 62 years and mean BMI 35 kg/m2. Enrollment rates were higher at CHC sites. CONCLUSIONS: A practice-based randomized trial of a complex behavioral lifestyle intervention for type 2 diabetes can be implemented in community health and usual clinical settings. Participant and provider engagement was higher at local CHC sites reflecting the study implementation focus. CLINICAL TRIAL REGISTRATION: NCT02320253.

Ethnic Differences in Cigarette Use Trajectories and Health, Psychosocial, and Academic Outcomes.

PURPOSE: Cigarette smoking among youth is associated with poorer health and psychosocial outcomes. However, few studies address how smoking may differentially relate to the emergence of disparities in functioning across races/ethnicities over adolescence. METHODS: Youth (n = 2,509) were surveyed eight times from ages 11 to 18. We measured cigarette use, academic and social functioning, mental and physical health, and delinquency. Sequelae of change models controlled for sociodemographic factors, and tested whether intercept and slope for smoking trajectories were associated with outcomes at the end of high school, and examined racial/ethnic differences in outcomes assuming similar smoking trajectories across groups. RESULTS: Youth were 45% Hispanic, 20% Asian, 20% white, 10% multiethnic, 2% black, and 1% other ethnicities. Higher average probability of smoking and steeper slopes of smoking trajectories were associated with poorer outcomes in multiple domains. Controlling for smoking trajectories, we observed the following disparities (vs. white youth; all p's < .05): black, Hispanic, and multiethnic youth reported lower academic performance; Asian, black, and multiethnic youth reported higher academic unpreparedness; Asian and multiethnic youth reported poorer mental health; Asian, Hispanic, and multiethnic youth reported poorer physical health; and Asian youth reported higher delinquency and poorer social functioning. CONCLUSIONS: Statistically adjusting for similar smoking trajectories, racial/ethnic minority youth demonstrated poorer outcomes in multiple domains compared with white peers. Smoking may be a particularly robust marker for risk of negative outcomes in racial/ethnic minority youth. Screening for cigarette use and intervening on smoking and associated risk behaviors among minority youth may help reduce disparities in functioning.

Learning to Apply Algebra in the Community for Adults With Intellectual Developmental Disabilities.

Students with intellectual and developmental disabilities (IDD) are routinely excluded from algebra and other high-level mathematics courses. High school students with IDD take courses in arithmetic and life skills rather than having an opportunity to learn algebra. Yet algebra skills can support the learning of money and budgeting skills. This study explores the feasibility of algebra instruction for adults with IDD through an experimental curriculum. Ten individuals with IDD participated in a 6-week course framing mathematics concepts within the context of everyday challenges in handling money. The article explores classroom techniques, discusses student strategies, and proposes possible avenues for future research analyzing mathematics instructional design strategies for individuals with IDD.