Perspective: Nutrition Health Disparities Framework: A Model to Advance Health Equity.

Disparities in nutrition, such as poor diet quality and inadequate nutrient intake, arise from multiple factors and are related to adverse health outcomes such as obesity, diabetes, cardiovascular disease, and some cancers. The aim of the current perspective is to present a nutrition-centric socioecological framework that delineates determinants and factors that contribute to diet and nutrition-related disparities among disadvantaged populations. The Nutrition Health Disparities Framework (NHDF) describes the domains (biological, behavioral, physical/built environment, sociocultural environment, and healthcare system) that influence nutrition-related health disparities through the lens of each level of influence (that is, individual, interpersonal, community, and societal). On the basis of the scientific literature, the authors engaged in consensus decision making in selecting nutrition-related determinants of health within each domain and socioecological level when creating the NHDF. The framework identifies how neighborhood food availability and access (individual/built environment) intersect with cultural norms and practices (interpersonal/sociocultural environment) to influence dietary behaviors, exposures, and risk of diet-related diseases. In addition, the NHDF shows how factors such as genetic predisposition (individual/biology), family dietary practices (interpersonal/behavioral), and food marketing policies (societal) may impact the consumption of unhealthy foods and beverages and increase chronic disease risk. Family and peer norms (interpersonal/behavior) related to breastfeeding and early childhood nutrition interact with resource-poor environments such as lack of access to preventive healthcare settings (societal/healthcare system) and low usage of federal nutrition programs (societal/behavioral), which may increase risk of poor nutrition during childhood and food insecurity. The NHDF describes the synergistic interrelationships among factors at different levels of the socioecological model that influence nutrition-related outcomes and exacerbate health disparities. The framework is a useful resource for nutrition researchers, practitioners, food industry leaders, and policymakers interested in improving diet-related health outcomes and promoting health equity in diverse populations.

A Decade of Dietary Assessment Methodology Research at the National Institutes of Health, 2012-2021.

BACKGROUND: Assessment of individual and population-level dietary intake is critical for public health surveillance, epidemiology, and dietary intervention research. In recognition of that need, the National Insitutes of Health (NIH) has a history of funding research projects designed to support the development, implementation, and refinement of tools to assess dietary intake in humans. OBJECTIVES: This report provides data and information on NIH-funded dietary intake assessment methodological research over the period of 2012-2021. METHODS: Data were extracted from an internal NIH data system using the Research, Condition, and Disease Categorization (RCDC) spending category for Nutrition. Data were then examined to identify research focused on dietary assessment tools or methods to capture or analyze dietary intake. RESULTS: Over the decade of 2012-2021, NIH supported 46 grants and 2 large contracts specific to dietary assessment methods development. The top 6 Institutes and Offices funding dietary assessment methods research were identified. Most projects were limited to adults. Projects ranged from novel methods to capture dietary intake, and refinement of analytical methods, to biomarkers of dietary intake. One key contract supported the automated self-administered 24-h dietary assessment tool (ASA24), a widely used, free tool available to the research community for assessing dietary intake. CONCLUSIONS: NIH's support for dietary assessment methods development over this 10-y period was small but grew over time with an expanding number and variety of methods, data sources, and technological advancements in the assessment of dietary intake. NIH remains committed to supporting research seeking to advance the field of dietary assessment methods research.

Within-Trial Cost-Effectiveness of a Structured Lifestyle Intervention in Adults With Overweight/Obesity and Type 2 Diabetes: Results From the Action for Health in Diabetes (Look AHEAD) Study.

OBJECTIVE: To assess the cost-effectiveness (CE) of an intensive lifestyle intervention (ILI) compared with standard diabetes support and education (DSE) in adults with overweight/obesity and type 2 diabetes, as implemented in the Action for Health in Diabetes study. RESEARCH DESIGN AND METHODS: Data were from 4,827 participants during their first 9 years of study participation from 2001 to 2012. Information on Health Utilities Index Mark 2 (HUI-2) and HUI-3, Short-Form 6D (SF-6D), and Feeling Thermometer (FT), cost of delivering the interventions, and health expenditures was collected during the study. CE was measured by incremental CE ratios (ICERs) in costs per quality-adjusted life year (QALY). Future costs and QALYs were discounted at 3% annually. Costs were in 2012 U.S. dollars. RESULTS: Over the 9 years studied, the mean cumulative intervention costs and mean cumulative health care expenditures were $11,275 and $64,453 per person for ILI and $887 and $68,174 for DSE. Thus, ILI cost $6,666 more per person than DSE. Additional QALYs gained by ILI were not statistically significant measured by the HUIs and were 0.07 and 0.15, respectively, measured by SF-6D and FT. The ICERs ranged from no health benefit with a higher cost based on HUIs to $96,458/QALY and $43,169/QALY, respectively, based on SF-6D and FT. CONCLUSIONS: Whether ILI was cost-effective over the 9-year period is unclear because different health utility measures led to different conclusions.

COVID-19 Among American Indian and Alaska Native Persons - 23 States, January 31-July 3, 2020.

Although non-Hispanic American Indian and Alaska Native (AI/AN) persons account for 0.7% of the U.S. population,* a recent analysis reported that 1.3% of coronavirus disease 2019 (COVID-19) cases reported to CDC with known race and ethnicity were among AI/AN persons (1). To assess the impact of COVID-19 among the AI/AN population, reports of laboratory-confirmed COVID-19 cases during January 22†-July 3, 2020 were analyzed. The analysis was limited to 23 states§ with >70% complete race/ethnicity information and five or more laboratory-confirmed COVID-19 cases among both AI/AN persons (alone or in combination with other races and ethnicities) and non-Hispanic white (white) persons. Among 424,899 COVID-19 cases reported by these states, 340,059 (80%) had complete race/ethnicity information; among these 340,059 cases, 9,072 (2.7%) occurred among AI/AN persons, and 138,960 (40.9%) among white persons. Among 340,059 cases with complete patient race/ethnicity data, the cumulative incidence among AI/AN persons in these 23 states was 594 per 100,000 AI/AN population (95% confidence interval [CI] = 203-1,740), compared with 169 per 100,000 white population (95% CI = 137-209) (rate ratio [RR] = 3.5; 95% CI = 1.2-10.1). AI/AN persons with COVID-19 were younger (median age = 40 years; interquartile range [IQR] = 26-56 years) than were white persons (median age = 51 years; IQR = 32-67 years). More complete case report data and timely, culturally responsive, and evidence-based public health efforts that leverage the strengths of AI/AN communities are needed to decrease COVID-19 transmission and improve patient outcomes.

Learning from a failure in threat assessment: 11 questions and not enough answers.

Threat assessment theory and practice have evolved significantly since Columbine. The US Secret Service's guidelines for threat assessment include 11 questions that school officials should ask to identify, investigate, and manage students of concern. Yet, no research examines how school officials implement these questions. This qualitative case study examines the way that school officials used the 11 questions with a student of concern, who underwent a threat assessment and 3 months later shot and killed a classmate and himself on school grounds. The data include deposition testimony from 12 school and district officials and more than 8,000 pages of records in the case. For each of the 11 questions, the findings reveal what the threat assessment team knew and might have learned; the findings also demonstrate the importance of multiple sources of information, a multidisciplinary team, and an investigative mindset. The questions may prove difficult to answer in "loosely coupled" systems, like schools, where information is unintentionally lost due to the organization's structural hierarchy, specialization of tasks, and heavy workloads. The findings provide critical lessons learned for threat assessment, information gathering, and violence prevention in schools.

New frontiers in building mental, emotional and behavioral health in children and youth: Introduction to the special section.

The passage of the Patient Protection and Affordable Care Act (ACA; 2010) has had tremendous influence on behavioral health in the United States (Alker & Chester, 2015). Shortly after its passage, the editors of this special section became interested in examining the provisions of the ACA related to care for mental, emotional, and behavioral disorders in children and youth and synthesizing their implications in the context of other contemporary trends in children's behavioral health promotion. We first developed a white paper with the goal of increasing our own understanding of these issues and their possible influence on the status quo of designing, implementing, financing, and evaluating behavioral health services for children and their families. From our discussions came the idea of developing a special section in the American Journal of Orthopsychiatry featuring input from researchers who have been exploring these issues and who have tangible and relevant examples of "new frontiers" in building mental, emotional, and behavioral health for children and youth. The result is the current special section, the purpose of which is to highlight the importance of prevention in behavioral health and to explore examples of efforts that have used a broad public health approach to prevention and early intervention in mental, emotional, and substance use disorders in children and youth. Before introducing the seven articles in this special section, we describe in detail our foundational thinking about building mental, emotional, and behavioral health for children and youth, as expressed in our initial white paper on this topic. (PsycINFO Database Record

The Role of Conflict Identification and Management in Sustaining Community Collaboration: Report on a Four-Year Exploratory Study.

Community collaboration has become increasingly common in behavioral health services. Conflict is likely to occur in any community coalition bringing together organizations with differing mandates, missions, and histories. However, research on how coalitions identify and handle conflict, and on the impact of conflict on sustainability is scarce. An exploratory study examined conflict in two federally funded children's "systems of care" using site visits and concept mapping to describe differences in how sites conceptualize and respond to conflict. Results suggest that unacknowledged and unaddressed conflict can negatively affect the development and sustainability of sites, and that focusing on cooperation may, paradoxically, make it more difficult to acknowledge conflict and to implement conflict transformation processes. Implications for behavioral health administrators are discussed, including potential interventions that could address these issues.

An Exploratory Study of Conflict and Its Management in Systems of Care for Children with Mental, Emotional, or Behavioral Problems and Their Families.

Since 1993, the Substance Abuse and Mental Health Services Administration has invested more than $1 billion establishing systems of care (SOC) in over 173 local communities to provide services to children with mental, emotional, and behavioral problems and their families. The SOC model requires that effective partnerships be developed between parents and professionals and also among different service sectors and agencies. To date, there has been no systematic examination of these interagency partnerships associated with the presence of conflict and its management. This paper reports the findings from a survey of the members of the governing boards of currently funded and graduated SOC sites related to interorganizational conflict. The results indicated that conflict was common in SOC regardless of the stage of the system's development. The most common types of conflict included incompatible goals, interpersonal relationships, and overlapping authority. When conflict occurred, a number of management efforts were used including analyzing the conflict and developing a strategy to deal with it and dealing with the conflict behind the scenes. Suggestions are provided for identifying and managing conflict.

Impact of an intensive lifestyle intervention on use and cost of medical services among overweight and obese adults with type 2 diabetes: the action for health in diabetes.

OBJECTIVE: To assess the relative impact of an intensive lifestyle intervention (ILI) on use and costs of health care within the Look AHEAD trial. RESEARCH DESIGN AND METHODS: A total of 5,121 overweight or obese adults with type 2 diabetes were randomly assigned to an ILI that promoted weight loss or to a comparison condition of diabetes support and education (DSE). Use and costs of health-care services were recorded across an average of 10 years. RESULTS: ILI led to reductions in annual hospitalizations (11%, P = 0.004), hospital days (15%, P = 0.01), and number of medications (6%, P < 0.001), resulting in cost savings for hospitalization (10%, P = 0.04) and medication (7%, P < 0.001). ILI produced a mean relative per-person 10-year cost savings of $5,280 (95% CI 3,385-7,175); however, these were not evident among individuals with a history of cardiovascular disease. CONCLUSIONS: Compared with DSE over 10 years, ILI participants had fewer hospitalizations, fewer medications, and lower health-care costs.

A scenario and forecast model for Gulf of Mexico hypoxic area and volume.

For almost three decades, the relative size of the hypoxic region on the Louisiana-Texas continental shelf has drawn scientific and policy attention. During that time, both simple and complex models have been used to explore hypoxia dynamics and to provide management guidance relating the size of the hypoxic zone to key drivers. Throughout much of that development, analyses had to accommodate an apparent change in hypoxic sensitivity to loads and often cull observations due to anomalous meteorological conditions. Here, we describe an adaptation of our earlier, simple biophysical model, calibrated to revised hypoxic area estimates and new hypoxic volume estimates through Bayesian estimation. This application eliminates the need to cull observations and provides revised hypoxic extent estimates with uncertainties corresponding to different nutrient loading reduction scenarios. We compare guidance from this model application, suggesting an approximately 62% nutrient loading reduction is required to reduce Gulf hypoxia to the Action Plan goal of 5000 km(2), to that of previous applications. In addition, we describe for the first time, the corresponding response of hypoxic volume. We also analyze model results to test for increasing system sensitivity to hypoxia formation, but find no strong evidence of such change.

Barriers and facilitators to implementation of the institute of medicine recommendations on preventing mental, emotional, and behavioral disorders among young people.

PROBLEM: The purpose of this study was to gain an understanding of the barriers and facilitators to implementation of the five overarching recommendations of the Institute of Medicine report and to consider the implications for nursing. METHODS: Data were collected through use of a semi-structured interview of purposive sample of 22 key informants regarding the barriers and facilitators to implementation of the report's five major recommendations. FINDINGS: The major barriers were competing priorities, lack of infrastructure for implementation, lack of public education regarding mental health and the effectiveness of prevention, stigma, and a paucity of facilitating factors. The facilitators were leadership, flexible resources, linkage to healthcare reform or other legislation, coordination across agencies and governmental levels, and additional research. CONCLUSIONS: The discussion focuses on ways of promoting facilitating factors and consideration of nursing's potential contributions in the areas of education, practice, and research.

Functional difficulties and health conditions among children with special health needs.

OBJECTIVES: To describe the functional difficulties of children with special health needs and to demonstrate the shared and unique contributions in predicting health outcomes and informing therapeutic interventions, policies, and research by using data from the 2005-2006 National Survey of Children With Special Health Care Needs. RESULTS: Children with special health care needs experience an array of health conditions and functional difficulties that are interrelated. Although health conditions tend not to change, the characteristics of functional difficulties are subject to changes over time with age or as a result of interventions. Descriptive data highlight common functional difficulties across health conditions. Multiple regression analyses support both health conditions and functional difficulties predicting (1) health services, such as emergency department visits, (2) personal limitations such as impairment of daily activities and school absences, and (3) family impact, stopping or reducing work. Functional difficulties were, however, the stronger predictor for all outcomes except school absences. CONCLUSIONS: The results support the utility of expanding measures of children with special health care needs to include functional difficulties in survey research, as well as clinical and public health practice. Systematic inclusion of functional difficulties will inform policy development, program planning, outcome assessment, and resource allocation for this vulnerable population. A focus on functional difficulties facilitates stronger coordination of services across sectors including physical health, mental health, education, and other social services to improve the health and well-being for these children and youth.

Workforce development and the organization of work: the science we need.

The industrialization of health care, underway for several decades, offers instructive guidance and models for speeding access of children and families to clinically and cost effective preventive, treatment, and palliative interventions. This industrialization--i.e., the systematized production of goods or services in large-scale enterprises--has the potential to increase the value and effects of care for consumers, providers, and payers (Hayes and Gregg in Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice. Academic Press, San Diego, 2001), and to generate efficiencies in care delivery, in part because workforce responsibilities become more functional and differentiated such that individuals with diverse educational and professional backgrounds can effectively execute substantive clinical roles (Rees in Clin Exp Dermatol, 33, 39-393, 2008). To date, however, the models suggested by this industrialization have not been applied to children's mental health services. A combination of policy, regulatory, fiscal, systemic, and organizational changes will be needed to fully penetrate the mental health and substance abuse service sectors. In addition, problems with the availability, preparation, functioning, and status of the mental health workforce decried for over a decade will need to be addressed if consumers and payers are to gain access to effective interventions irrespective of geographic location, ethnic background, or financial status. This paper suggests that critical knowledge gaps exist regarding (a) the knowledge, skills, and competencies of a workforce prepared to deliver effective interventions; (b) the efficient and effective organization of work; and (c) the development and replication of effective workforce training and support strategies to sustain effective services. Three sets of questions are identified for which evidence-based answers are needed. Suggestions are provided to inform the development of a scientific agenda to answer these questions.

Prevention of mental, emotional, and behavioral disorders in youth: the Institute of Medicine report and implications for nursing.

TOPIC: Preventing Mental, Emotional, and Behavioral Disorders among Young People: The Institute of Medicine (IOM) Report and Implications for Nursing. PURPOSE: The purpose of this manuscript is to review the recently released IOM report on preventing mental, emotional, and behavioral disorders among young people and to identify some implications of this report for nursing. SOURCES: The primary source of this information is the recently released IOM report. CONCLUSIONS: Mental, emotional, and behavioral disorders are common among young people, and a growing research base supports preventive interventions. Nurses can play an important role in supporting the implementation and evaluation of these interventions in a variety of practice and community settings.

Language skills in shy and non-shy preschoolers and the effects of assessment context.

Nineteen shy, twenty-three middle and twenty-five non-shy junior kindergarten children were assessed at school by an unfamiliar examiner, and at home where their parents administered a parallel form of the expressive and receptive vocabulary tests given at school. A speech sample between the child and parent was also collected at home. Shy children spoke less than non-shy and middle children at home. Additionally, the parents of shy children spoke less than parents of non-shy children. Although there were no language differences between the groups, results showed a context effect for expressive vocabulary, in that all groups of children scored higher at school. The pattern of results suggests that previously observed language differences found between shy and non-shy children are not robust, and that testing children at school does not negatively impact their performance.

Integrating nursing care into systems of care for children with emotional and behavioral disorders.

PROBLEM: Recent developments in providing care to children with emotional and behavioral disorders, especially those with serious emotional disturbance, have included the establishment of systems of care. Guided by a set of principles and values, these systems of care have organized and delivered services to children and families with complex needs. To date, nurses have not had a salient role in systems of care. RESULTS: It is estimated that 20% of American children and adolescents have an emotional or mental disorder. As many as two thirds of these children are not receiving services. Systems of care have been funded to provide services for these children, particularly for the most severely affected. To date, nursing has not had a prominent role in these systems of care. CONCLUSIONS: Based on their knowledge, skills, and holistic approach to care, nurses could better integrate nursing care into systems of care. Possible roles as case managers, primary therapists, in-home interventionists, and in educational programs are suggested.