Pairing Project ECHO and patient navigation as an innovative approach to improving the health and wellness of cancer survivors in rural settings.

PURPOSE: We conducted a 12-month pilot study of 2 complementary strategies for improving rural cancer survivorship outcomes: (1) Project ECHO, a telementoring model to increase knowledge and skills about cancer survivorship among multidisciplinary health care provider teams in rural areas and (2) patient navigation (PN) services to connect rural cancer survivors with resources for enhancing health and wellness. METHODS: We recruited 4 CDC-funded National Comprehensive Cancer Control Program sites to implement Project ECHO and PN interventions for a defined rural population in each of their jurisdictions. Sites received ongoing technical assistance and a stipend to support implementation. We conducted a mixed-methods evaluation consisting of quantitative performance monitoring data and qualitative interviews with site staff to assess implementation. FINDINGS: Site teams delivered 21 cancer survivorship ECHO sessions to rural providers resulting in 329 participant encounters. Almost all (93%) ECHO participants reported enhanced knowledge of cancer survivorship issues, and 80% reported intent to apply learnings to their practices. Site teams engaged 16 patient navigators who navigated 164 cancer survivors during the study period. Successful implementation required strong partnerships, clear avenues for recruitment of rural providers and cancer survivors, and activities tailored to local needs. Fostering ongoing relationships among sites through community of practice calls also enhanced implementation. CONCLUSIONS: Sites successfully implemented a novel approach for enhancing care for cancer survivors in rural communities. Pairing Project ECHO to address structural barriers and PN to address individual factors affecting survivorship may help bridge the health equity gap experienced by cancer survivors in rural communities.

The Effectiveness of Active Learning Strategies in Gatekeeper Training on Behavioral Outcomes.

Background: Studies of suicide prevention gatekeeper trainings (GKT) show temporary enhancements in short-term behavioral outcomes and limited enhancements in intermediate behavioral outcomes. Aims: We aimed to examine the impact of two training enhancements (role-play and booster) on intermediate GKT outcomes. Method: The study used a factorial randomized controlled design to assign participants to one of four groups. Three indicators of gatekeeper behavior at 6-month follow-up were the primary outcomes of interest. We used propensity score-based techniques to address observed imbalances. Results: At 6 months, among participants assigned to role-play, a significantly larger proportion of those assigned to booster performed identifications and referrals followed by a notification to the referral source, and followed by escorting the youth to the resource. Limitations: While observed imbalances were addressed, unobserved differences may persist. The validity of self-reported indicators to measure actual behavior remains unknown. Conclusion: Results suggest that active learning strategies can, in combination, enhance the effectiveness of trainings. The strategies seem to increase the comprehensiveness of gatekeeper behaviors.

Long-term impact of the Garrett Lee Smith Youth Suicide Prevention Program on youth suicide mortality, 2006-2015.

BACKGROUND: Comprehensive suicide prevention programs funded through the Garrett Lee Smith Memorial Youth Suicide Prevention Program (GLS) have previously been shown to be associated with lower youth suicide mortality rates 1 year following program implementation. However, longer term effects of GLS have yet to be examined. METHODS: The impact of GLS implementation on youth suicide mortality through 2015 was estimated for U.S. counties initially exposed to state and tribal GLS activities between 2006 and 2009. The analytic approach combined propensity score-based techniques to address potential confounding arising from differences between counties exposed and not exposed to the program along an extensive set of characteristics, including historical suicide rates. RESULTS: Counties exposed to GLS during a single year had youth suicide mortality rates lower than expected and for longer than previously reported following implementation of GLS activities. Youth suicide mortality rates in counties implementing GLS were estimated to be 0.9 per 100,000 youths lower than control counties (p = .029) 1 year after the implementation, and 1.1 per 100,000 youths lower than control counties (p = .010) 2 years after the implementation. Further, persistent implementation during multiple years was associated with larger effects during longer periods. Additionally, among rural counties, the youth suicide rates 2 years after exposure were estimated to be 2.4 per 100,000 youths lower than in the absence of the program (p = .003). There was no significant evidence of a decrease in youth suicide rates three or more years after the GLS activities were discontinued. CONCLUSIONS: The effects of GLS comprehensive suicide prevention program were found to be stronger and longer lasting than previously reported, particularly in rural counties. In the face of well-documented increases in national suicide prevention rates, these results support the widespread and persistent implementation of comprehensive, community-based youth suicide prevention programs.

Comparing the Effectiveness of Brief Versus In-Depth Gatekeeper Training on Behavioral Outcomes for Trainees.

BACKGROUND: A common suicide prevention strategy is training gatekeepers to identify at-risk individuals and refer them to services. AIMS: The study aimed to examine whether differences in training outcomes were observed for brief versus in-depth gatekeeper trainings for trainees from varied professional settings while controlling for differences in trainee characteristics and community context. METHOD: Trainees' identification and referral behavior 3 months after gatekeeper training was compared with a sample of respondents matched on individual- and community-level variables using propensity score-based techniques. The value was estimated, in terms of additional identification and associated costs, of adopting in-depth training. RESULTS: A higher proportion of trainees who participated in in-depth trainings from K-12 and community settings identified at-risk youth, and a higher proportion of in-depth trainees from mental health settings referred youth to services compared with participants of brief trainings from the same setting and with similar characteristics. The effect of training type on outcomes varied by professional role and community context. LIMITATIONS: Self-report measures were used to assess outcomes. Similar measures are used in other studies; their validity has not been conclusively established. CONCLUSION: Findings suggest certain individuals may benefit from in-depth training more than others, which favors targeting this intervention to particular gatekeepers.

Examining the Unanticipated Adverse Consequences of Youth Suicide Prevention Strategies: A Literature Review with Recommendations for Prevention Programs.

OBJECTIVE: Youth suicide is a public health problem in the United States. Suicide prevention programs have been shown to be beneficial; however, knowledge of unanticipated adverse consequences of programs is limited. The objective of this review is to present what is known about these consequences so informed decisions and appropriate planning can be made prior to implementation of suicide prevention interventions. METHOD: A narrative but systematic review was conducted assessing what is known about adverse consequences utilizing a comprehensive keyword search of EBSCO and PubMed databases. Study populations beyond youth were included. RESULTS: Unanticipated adverse consequences of suicide prevention interventions were included in 22 publications. Consequences occur at three levels: at the level of the youth, those who identify or intervene with at-risk youth, and at the system level. While rare, unanticipated adverse consequences include an increase in maladaptive coping and a decrease in help-seeking among program targets, overburden or increased suicide ideation among program implementers, and inadequate systemic preparedness. CONCLUSIONS: Overall, the benefits of youth suicide prevention outweigh the unanticipated adverse consequences. Nevertheless, these results may be utilized for informed decision-making regarding suicide prevention programming, and to ensure appropriate infrastructure is in place prior to prevention efforts.

Is container type the biggest predictor of trace element and BPA leaching from drinking water bottles?

The knowledge-base of bottled water leachate is highly contradictory due to varying methodologies and limited multi-elemental and/or molecular analyses; understanding the range of contaminants and their pathways is required. This study determined the leaching potential and leaching kinetics of trace elements, using consistent comprehensive quantitative and semi-quantitative (79 elements total) analyses, and BPA, using isotopic dilution and MEPS pre-concentration with UHPLC-ESI-QTOF. Statistical methods were used to determine confounders and predictors of leaching and human health risk throughout 12days of UV exposure and after exposure to elevated temperature. Various types of water were used to assess the impact of water quality. Results suggest Sb leaching is primarily dependent upon water quality, not container type. Bottle type is a predictor of elemental leaching for Pb, Ba, Cr, Cu, Mn and Sr; BPA was detected in samples from polycarbonate containers. Health risks from the consumption of bottled water increase after UV exposure.

Potential health impacts of consuming desalinated bottled water.

This study compared physicochemical properties, anion and carbon content and major and trace elements in desalinated and non-desalinated bottled water available in Qatar, and assessed the potential health risks associated with prolonged consumption of desalinated water. Results indicate that Qatar's population is not at elevated risk of dietary exposure to As (mean = 666 ng/L), Ba (48.0 µg/L), Be (9.27 ng/L), Cd (20.1 ng/L), Cr (874 ng/L), Pb (258 ng/L), Sb (475 ng/L) and U (533 ng/L) from consumption of both desalinated and non-desalinated bottled water types available in the country. Consumers who primarily consume desalinated water brands further minimize risk of exposure to heavy metals as levels were significantly lower than in non-desalinated bottled water. Desalinated bottled water was not a significant contributor to recommended daily intakes for Ca, Mg and F(-) for adults and children and may increase risk of deficiencies. Desalinated bottled water accounted for only 3% of the Institute of Medicine (IOM) adequate intake (AI) for Ca, 5-6% of the recommended daily allowance for Mg and 4% of the AI for F among adults. For children desalinated water contributed 2-3% of the IOM AICa, 3-10% of the RDA(Mg) and 3-9% of the AIF.

A market basket survey of As, Zn and Se in rice imports in Qatar: health implications.

Qatar is dependent on importation of rice, its staple dish, and is therefore susceptible to compromises of food quality in the global market. This market basket study assesses potential health risks of As exposure from rice consumption in Qatar and examines its contribution to the recommended nutritional intakes (RNI) for Zn and Se. Fifty-six rice types and 12 products sold in Qatar were analyzed by ICP/MS. Mean concentrations and ranges were 96.2±54.1µg/kg (9.76-258µg/kg) for As; 12.5±5.35mg/kg (2.79-29.9mg/kg) for Zn and 103±113µg/kg (<5.94-422µg/kg) for Se. Calculated risk quotient shows rice consumption in Qatar is not a significant route of As exposure but can contribute up to 100% and 50% of the RNI for Se and Zn, respectively. Results indicate that children in Qatar may be at elevated risk of arsenic exposure from rice-based infant cereals but more data is needed to obtain a definitive assessment.

What do the trace metal contents of urine and toenail samples from Qatar׳s farm workers bioindicate?

Qatar׳s farm workers provide a unique population for exposure study: they are young, healthy males. This study combined trace element profiles in urine and toenail with survey information from 239 farm workers to assess the extent to which the biomarkers provide complementary exposure information. Urinary Mo levels (average=114 µg/L) were elevated; average urinary values (µg/L) for all other elements were: V (1.02), Cr (0.55), Mn (2.15), Fe (34.1), Co (0.47), Ni (2.95), Cu (15.0), As (47.8), Se (25.7), Cd (1.09), Ba (22.5), Pb (2.50) and U (0.15). Average toenail concentrations (mg/kg) were: Mn (2.48), Cu (4.43), As (0.26), Se (0.58), Mo (0.07), Cd (0.03), Ba (1.00), Pb (0.51) and U (0.02). No significant association was found between corresponding elements in urine and toenails. Elemental profiles suggest groundwater (with the exception of Mo) and soil-dust-crop exposure pathways cannot account for elemental variations. The main factors moderating trace element contents are related to depuration processes involving participants׳ trace element body burden prior to work in Qatar, and interactions of trace element metabolic cycles which over-ride the exposure footprint. Toenail and urine need to be carefully validated before reliable use as biomarkers of exposure in general populations for most elements in the study.