Later circadian timing and increased sleep timing variability are associated with attenuations in overnight blood pressure dipping among chronic nightshift workers.

OBJECTIVE: Determine relationships between overnight blood pressure, circadian phase, and sleep variability among dayshift and chronic nightshift nurses. METHODS: Twenty participants working dayshift (n = 10) or nightshift (n = 10) schedules participated in a 7-day cross-sectional study. Participants underwent an evening in-laboratory melatonin assessment and wore ambulatory blood pressure devices to assess 24-hour blood pressure patterns. Overnight blood pressure dipping was calculated from sleeping/waking systolic blood pressure ratio and salivary dim-light melatonin onset determined circadian phase. Sleep variability was assessed using the standard deviation of 7-day sleep onset. RESULTS: Nightshift workers had later circadian phase, greater sleep onset variability, and an attenuated overnight blood pressure dipping pattern. Later circadian phase was associated with attenuated dipping patterns and sleep onset variability was negatively correlated with blood pressure dipping magnitude in nightshift, but not dayshift workers. CONCLUSIONS: Chronic circadian disruption via higher sleep onset variability among nightshift workers may contribute to attenuated blood pressure dipping and cardiovascular risk in this population.

Describing Physical Activity Patterns of Truck Drivers Using Actigraphy.

Background: Truck driving is a highly sedentary occupation that places workers at risk for chronic health conditions, such as obesity and high blood pressure. The primary purpose of this study was to objectively describe truck drivers' typical physical activity (PA) patterns. Methods: We used ∼7-10-day baseline PA actigraphy data samples from drivers in the Safety & Health Involvement For Truckers (SHIFT) study (n = 394). Driver PA patterns (e.g., average number of ≥10 minute Freedson bouts per week, time in bouts, and common days/times for PA) were summarized with descriptive analyses. We also compared objective accelerometer data to self-reports. Results: Drivers' weekly PA averaged 14.4 minutes (SD = 37.0), and most PA occurred between 5-6 pm on Tuesdays and Wednesdays. Drivers overestimated self-reported weekly exercise by over 60 min/week compared to accelerometer data. Conclusion: Our results suggest that objective PA assessment may be warranted over self-report when possible, and timing may be key in future PA intervention work with truck drivers.

The Tech4Rest Randomized Controlled Trial: Applying the Hierarchy of Controls to Advance the Sleep, Health, and Well-being of Team Truck Drivers.

OBJECTIVE: The aim of the study was to evaluate the effectiveness of interventions to improve sleep, reduce fatigue, and advance the well-being of team truck drivers. METHODS: In a randomized controlled trial ( k = 24 teams; N = 49 drivers; 61.3% of planned sample), intervention teams were exposed to baseline (3-4 weeks), cab enhancements (active suspension seat, therapeutic mattress; 3-4 weeks), and cab enhancements plus a behavioral sleep-health program (1-2 months). Control teams worked as usual during the same period. RESULTS: Trends in sleep-related outcomes favored the intervention. Large and statistically significant intervention effects were observed for objectively measured physical activity (a behavioral program target). The discussion of results addresses effect sizes, statistical power, intervention exposure, and work organization. CONCLUSIONS: Trends, effect sizes, and significant findings in this rare trial provide valuable guidance for future efforts to improve working conditions and outcomes for team drivers.

Effects of Low-Intensity Aerobic Exercise on Neurophysiological and Behavioral Correlates of Cognitive Function.

Acute aerobic exercise exerts a small beneficial effect on cognition. Previous research primarily examines cognitive changes following a bout of exercise, while little is currently known about changes in cognitive performance during exercise. The primary purpose of this study was to examine the effects of low-intensity cycling on cognitive function indexed by behavioral (response accuracy; reaction time) and neurocognitive (P3 mean amplitude; P3 centroid latency) responses. Twenty-seven (Mage = 22.9 ± 3.0 years old) individuals were counterbalanced into low-intensity exercise (EX) and seated control (SC) conditions spread across two testing sessions. During each condition, participants completed a 10 min resting baseline period, 20 min of either sustained cycling or seated rest, and a 20 min recovery period. Primary outcomes were assessed at 10 min intervals (five blocks total) throughout each condition via a modified visual oddball task while electroencephalography (EEG) responses were measured. Across time blocks, both conditions exhibited faster reaction times on frequent trials but reduced accuracy to rare trials, suggesting a speed-accuracy tradeoff. There were no differences between conditions in P3 centroid latency, whereas a significant reduction in P3 amplitude was observed during the 20 min exercise period compared to the control condition. Taken together, results suggest that exercise at lower doses may have minimal influence on behavioral outcomes of cognitive performance but may impact more basic measures of brain function. Information gathered from this study may aid in the development of appropriate exercise prescriptions for populations looking to specifically target cognitive function deficits.

COMMunity of Practice And Safety Support for Navigating Pain (COMPASS-NP): study protocol for a randomized controlled trial with home care workers.

BACKGROUND: Chronic pain is a prevalent and costly problem that often has occupational origins. Home care workers (HCWs) are at high risk for work-related injuries, pain, and disability. Current treatments for chronic pain emphasize medications, which are an inadequate stand-alone treatment and can produce significant adverse effects. METHODS: In this translational study, we will adapt an established work-based injury prevention and health promotion program (COMmunity of Practice And Safety Support: COMPASS) to address the needs of HCWs experiencing chronic pain. COMPASS employs peer-led, scripted group meetings that include educational content, activities, goal setting, and structured social support. The translated intervention, named COMPASS for Navigating Pain (COMPASS-NP), will be delivered in an online group format. Safety protections will be strengthened through an ergonomic self-assessment and vouchers for purchasing ergonomic tools. Educational content will integrate a self-management approach to chronic pain using proven cognitive-behavioral therapy (CBT) principles. We will use a mixed-methods hybrid type 2 evaluation approach to assess effectiveness and implementation. A cluster-randomized waitlist control design will involve 14 groups of 10 HCWs (n = 140) recruited from Washington, Oregon, and Idaho. Half of the groups will be randomly selected to complete the intervention during the first 10 weeks, while the waitlist groups serve as controls. During weeks 10-20, the waitlist groups will complete the intervention while the original intervention groups complete a follow-up period without further intervention. Our primary hypothesis is that COMPASS-NP will reduce pain interference with work and life. Secondary outcomes include injury and pain prevention behaviors, pain severity, changes in medication use, risk for opioid misuse, well-being, physical activity, and sleep. Qualitative data, including phone interviews with group facilitators and organizational partners, will evaluate the implementation and guide dissemination. DISCUSSION: The results will advance the use and knowledge of secondary prevention interventions such as ergonomic tools and cognitive behavior therapy, to reduce injury, pain, and disability and to encourage appropriate uses of analgesic medications among HCWs. TRIAL REGISTRATION: ClinicalTrials.gov NCT05492903. Registered on 08 August 2022.

Primary Prevention of Weight Gain Among New Bus Operators: Results of the "Success & Health Impacts For Transit operators during Onboarding" (SHIFT Onboard) Pilot Study.

OBJECTIVE: This study aimed to test the feasibility and efficacy of an enhanced onboarding intervention to prevent weight gain and support the early job success of new bus operators. METHODS: Control participants ( n = 9) completed usual practice new employee training and onboarding. Intervention participants ( n = 14) completed five supplemental trainings and four online challenges during their first year. Primary outcomes were body weight, dietary behaviors, physical activity, and sleep duration/quality. Early job success was evaluated with measures of newcomer adjustment. RESULTS: The difference between intervention and control participants in body weight change at 12-month was -6.71 lb (Cohen's d = -1.35). Differences in health behavior changes were mixed, but newcomer adjustment changes favored the intervention group. CONCLUSIONS: Results support the feasibility of enhanced onboarding for bus operators to prevent worsening health while simultaneously advancing their success as new employees.

The Impact of COVID-19 on Transit Workers: Perceptions of Employer Responses and Associations with Health Factors.

COVID-19 has had a substantial impact on transit workers' lives, especially among public-facing vehicle operators. The current project examined relationships between workers' knowledge and perceptions of their employer's COVID-19 safety responses, job attitudes, and health. We surveyed transit workers (N = 174) between July and August 2020 and followed up 3 months later. Fifty-seven workers responded to the follow-up survey. Surveys addressed workers' knowledge and perceptions of their employer implementing Centers for Disease Control and Prevention (CDC)-recommended COVID-19 safety responses, COVID-19 risk perceptions, job attitudes, and health factors. Employees reported knowledge of their employer implementing ~8 of 12 CDC-recommended responses. The most reported response was informational poster placements; the least reported was designating a point-person for COVID-19 concerns. Significant associations were found between knowledge of employer safety responses and lower COVID-19 risk perceptions, better job attitudes, and greater mental and global health. Operators (i.e. public-facing workers) reported worse perceptions of employer responses, and higher COVID-19 risk perceptions, work stress, and turnover intentions, compared with non-operators. A time-lagged panel model found that COVID-19 risk perceptions significantly mediated the relationship between public-facing work status and follow-up depression, anxiety, stress, and global health. Results reveal opportunities for transit authorities to broaden and better communicate their responses to emergent occupational safety and health crises.

Rapid changes in overnight blood pressure after transitioning to early-morning shiftwork.

Risk for adverse cardiovascular events increases when blood pressure does not decrease at night ("non-dipping," <10% decrease from daytime blood pressure). Shiftwork alters relationships between behaviors and endogenous circadian rhythms (i.e., circadian disruption along with variable sleep timing), and chronic shiftwork increases cardiovascular disease risk. To determine whether transitioning into shiftwork changes the overnight blood pressure dipping pattern, we leveraged a natural experiment that occurs when newly-hired bus operators transition from a daytime training schedule into an early-morning shiftwork or daywork schedule. Twenty participants were studied in a 90-day protocol upon new employment and underwent cardio-metabolic health assessments, including ambulatory blood pressure monitoring, and weekly sleep-wake diaries. Measurements were repeated after ~30 and 90 days after transitioning to a day or an early-morning shiftwork schedule. Newly-hired shiftworkers displayed dramatic changes in overnight blood pressure, with 62% converting from a healthy dipping blood pressure to the nondipping pattern, resulting in 93% of shiftworkers displaying a nondipping phenotype at 90-days. In contrast, 50% of dayworkers had a nondipping profile at baseline and this decreased to 0% at 90-days, a significant difference from shiftworkers (p = .001). At 90-days, overnight blood pressure dipping was ~7% less in shiftworkers than dayworkers (-6.3% [95%CI -3.7 to -8.8%] vs -13.1% [-10.3 to -15.9%]: p < .01), with changes in dipping associated with changes in sleep timing variability (r2 = .28, p = .03). The observed changes in overnight blood pressure dipping in newly-hired early-morning shiftworkers, which were associated with sleep timing variability, may be an early warning sign of increased cardiovascular risk among shiftworkers.

Bus Operators' Body Weight Changes During Their First 2 Years of Work: A Retrospective Survey.

OBJECTIVE: To empirically assess retrospective reports of weight changes during bus operators' first years on the job, and to investigate experienced and desired training topics for new operators. METHODS: Bus operators (n = 261) completed an online survey on topics of early weight changes and training experiences. RESULTS: Operators reported gaining an average of 7.64 lb (SD = 16.36) during their first year. Further weight gain was not reported during the second year. Most operators reported that health-related topics were not addressed during their initial training. Stress management and healthy eating were the operators' two most desired topics to be included in their initial training. CONCLUSION: Bus operators reported medically meaningful weight gain during their first year of work and a desire for more health-related training. Objective research to document the magnitude of this hazard, and contributing working conditions, is needed.

A Comparison of Safety, Health, and Well-Being Risk Factors Across Five Occupational Samples.

Objective: The aim of this study was to present safety, health and well-being profiles of workers within five occupations: call center work (N = 139), corrections (N = 85), construction (N = 348), homecare (N = 149), and parks and recreation (N = 178). Methods: Baseline data from the Data Repository of Oregon's Healthy Workforce Center were used. Measures were compared with clinical healthcare guidelines and national norms. Results: The prevalence of health and safety risks for adults was as follows: overweight (83.2%), high blood pressure (16.4%), injury causing lost work (9.9%), and reported pain (47.0%). Young workers were least likely to report adequate sleep (46.6%). Construction workers reported the highest rate of smoking (20.7%). All of the adult workers reported significantly lower general health than the general population. Conclusion: The number of workers experiencing poor safety, health and well-being outcomes suggest the need for improved working conditions.

Exploring biopsychosocial correlates of pain, pain management strategies, and risk for opioid misuse among home care workers in Washington State.

Home care workers (HCWs) are at high risk for musculoskeletal pain and injury, and they are an important population for pain management research and intervention. The purpose of this study was to gather novel data on HCWs' work characteristics, pain experiences, pain management strategies, and risk for opioid misuse. A survey invitation was e-mailed to a random sub-sample of HCWs in Washington State, and 421 responded. Over half (54.2%) reported chronic or currently elevated pain. Pharmacological pain management strategies were used by 67.3% of all respondents with 4.8% reporting prescription opioid use. Biopsychosocial factors like injuries, interpersonal conflict, financial strain, and anxiety were associated with increased opioid misuse risk. Multimodal primary and secondary interventions are recommended to improve HCWs' pain management.

Infliximab Trough Levels Are Not Predictive of Relapse in Patients with IBD in Endoscopic Remission: A Multicenter Cohort Study.

BACKGROUND: Therapeutic drug monitoring (TDM) is important in optimizing use of biologics in inflammatory bowel diseases (IBD). However, the role of proactive TDM during remission remains uncertain. METHODS: This retrospective study included patients receiving infliximab (IFX) therapy at Massachusetts General Hospital or Erasmus University Medical Center. All eligible patients had completed induction phase of IFX and were in clinical and endoscopic remission. Our primary outcome was clinical relapse within 2 years after baseline. Multivariable regression models examined the association between infliximab trough levels during remission and relapse, need for IBD-related surgery or hospitalization. RESULTS: Our study cohort included 110 patients with IBD (72 CD, 38 UC) on IFX maintenance therapy. In total, 12 patients (10.9%) experienced relapse of disease over 2 years. The mean IFX trough level at baseline was 8.0 µg/mL (± 8.6) and did not differ between the institutions. 49.1% of patients had levels < 5 µg/mL and 2.7% had antibodies to infliximab at baseline. There was no difference in the mean IFX trough levels between patients who relapsed (7.5 µg/mL ± 3.7 µg/mL) over 24 months compared to those who did not (8.1 µg/mL ± 7.9 µg/mL, p = 0.815). On multivariable logistic regression analysis, IFX trough levels at baseline were not associated with relapse of disease over 24 months (OR 1.01, 95% CI 0.93-1.09, p = 0.856). CONCLUSION: This retrospective multicenter study provides evidence that IFX trough levels during quiescent disease do not predict relapse over 2 years, suggestive that proactive TDM in this setting is not warranted.

Advancing the Safety, Health, and Well-Being of Commercial Driving Teams Who Sleep in Moving Semi-Trucks: The Tech4Rest Pilot Study.

OBJECTIVE: To test the feasibility, acceptability, and potential effectiveness of engineering and behavioral interventions to improve the sleep, health, and well-being of team truck drivers (dyads) who sleep in moving semi-trucks. METHODS: Drivers (n = 16) were exposed to Condition A: a new innerspring mattress, and Condition B: a novel therapeutic mattress. A subsample of drivers (n = 8) were also exposed to Condition C: use of their preferred mattress (all chose to keep B), switching to an active suspension driver's seat, and completing a behavioral sleep-health program. Primary outcomes were sleep duration, sleep quality, and fatigue. Behavioral program targets included physical activity and sleep hygiene. RESULTS: Self-reported sleep and fatigue improved with mattress A, and improved further with mattress B which altered vibration exposures and was universally preferred and kept by all drivers. Condition C improved additional targets and produced larger effect sizes for most outcomes. CONCLUSIONS: Results support these interventions as promising for advancing team truck drivers' sleep, health, and well-being.

Challenging Aggressive Behaviors Experienced by Personal Support Workers in Comparison to Home Care Workers: Relationships between Caregiver Experiences and Psychological Health.

Personal support workers (PSW) are caregivers for children and adults with intellectual and developmental disabilities (IDDs) or adults experiencing mental illness or other behavioral health conditions. The work can be very meaningful, but many PSWs must prepare for, monitor, and manage challenging behaviors, including aggression. This study was designed to estimate the prevalence of aggression experienced by PSWs in Oregon, and compare it to a previous sample of Oregon home care workers (HCWs). This comparison included an analysis of relationships between exposures to aggression and psychological health factors. PSWs in Oregon (N = 240) were surveyed electronically at a single time point. PSWs generally reported higher rates of exposure to aggression compared to HCWs. Experiences with aggression were positively associated with fatigue and weakly associated with depression, but not stress. PSWs' self-reported lost work time injury rate was elevated compared to the US average, but it was comparable to previous self-reported injury rates from HCWs. Physical demands of work were the most prevalent reported primary safety concern, followed by challenging behaviors (including aggression). Developing tailored training to help PSWs understand, plan for, minimize, and manage challenging behaviors is a social priority.

Does Experiencing an Injury Claim Impact Small Construction Company Leaders' Participation in a Fall Protection Survey?

OBJECTIVES: Workers in small and medium residential construction companies (≤50 employees) have a high risk of fall-related fatality or disability. However, little is known about effective ways to engage with this subsector for research and training. We tested whether insurance-documented fall-related claims during the past 12 months and lower familiarity with equipment motivated companies' representatives to engage with a fall protection survey. METHODS: Oregon's largest workers compensation insurer drew a random anonymous sample of small and medium residential construction that did (n = 197) and did not (n = 195) have a recent fall-related claim. Samples were stratified by size, trade, and region. Company representatives were emailed a 34-item questionnaire about equipment familiarity to enter a raffle to win fall-prevention equipment. We coded survey engagement binarily, indicating whether a participant completed at least half of the survey. Familiarity with 10 pieces of equipment was measured with a scale from 0 (never seen it) to 3 (use it frequently) points. RESULTS: The survey was initiated by 88 out of 392 representatives (22.4% response rate). Of those, 63 representatives provided the company identifier which was needed to establish claim status. Survey engagement was higher among representatives from companies with claims compared with those without (57.6 versus 42.4%, P = 0.16). Equipment familiarity was lower among company representatives with lower survey engagement (1.15 versus 1.56, P < 0.05). CONCLUSIONS: The survey had a relatively encouraging response rate for a hard-to-reach sector. The large but not statistically significant difference in survey engagement rates suggests that adverse events motivate companies to engage with fall protection research. Low equipment familiarity in the sample substantiates the need to identify effective engagement methods for fall protection practices.

Acute aerobic exercise increases respiratory sinus arrythmia reactivity and recovery to a sad film among individuals at risk for depression.

Cardiac vagal control (CVC), as indexed by abnormalities in resting, reactivity, and recovery levels of respiratory sinus arrythmia (RSA), has been proposed as an index of impaired self-regulatory capacity in depression. Aerobic exercise has been shown to improve positive and negative affective responses and influence autonomic function; however, it is unknown whether exercise impacts RSA reactivity and subsequent recovery to emotional challenges among individuals at risk for depression. The present study aimed to determine the effects of moderate-intensity aerobic exercise on RSA reactivity and recovery to a sad film. Using a within-subjects design, 47 individuals with variable symptoms of depression completed a 30-min session of exercise and a sedentary control condition on separate days prior to viewing a sad film. On the control day, individuals with elevated depressive symptom severity displayed less vagal withdrawal to the sad film and exhibited impaired post-film RSA recovery. Following exercise, individuals with elevated depressive symptom severity demonstrated a higher degree of vagal withdrawal to the sad film and subsequent post-film recovery that matched individuals with lower depressive symptom severity. These findings suggest that a single session aerobic exercise may be an effective approach to increase emotional and self-regulatory capacity among individual at risk for, or currently experiencing, depression.

Does aerobic fitness moderate age-related cognitive slowing? Evidence from the P3 and lateralized readiness potentials.

Reaction time (RT) slowing occurs among older adults, although it remains unclear whether general or specific aspects of information-processing are implicated in this phenomenon. Aerobic fitness moderates age-related RT slowing, although it is unknown whether fitness benefits earlier versus later stages of information-processing. To test these hypotheses, 40 younger and 43 older adults classified by level of aerobic fitness were tested using a visual oddball paradigm to assess behavioral measures of RT and accuracy along with the P3 wave and lateralized readiness potential (LRP) to index stimulus categorization and response selection and execution processes, respectively. Older adults had slower RT, decreased P3 amplitude, and increased P3 latency and LRP amplitude, suggestive of generalized age-related cognitive slowing decline. While aerobic fitness was significantly correlated with median RT and P3 latency across the entire sample, these correlations did not persist when adjusting for age. Subsequent moderation analysis also failed to support an influence of aerobic fitness on any of the cognitive outcomes. These findings indicate that, at least in simple discrimination tasks, aging is associated with slower processing that occurs proximal to stimulus categorization and extends to motor response and execution processing. These age-related deficits, however, are not moderated by aerobic fitness.

Associations of depression severity with heart rate and heart rate variability in young adults across normative and clinical populations.

Limitations of current depression treatments may arise from a lack of knowledge about unique psychophysiological processes that contribute to depression across the full range of presentations. This study examined how individual variations in heart rate (HR) and heart rate variability (HRV) are related to depressive symptoms across normative and clinical populations in 152 young adults (aged 18-35 years). Moderating effects of sex and antidepressant medication status were considered. Electrocardiogram data were collected during "vanilla" baseline and in response to positive and negative emotional cues. Linear regressions and repeated-measures mixed models were used to assess the relationships between Beck Depression Inventory-II (BDI-II) scores, sex, antidepressant use, and cardiovascular outcomes. Baseline models yielded significant main effects of BDI-II and sex on HR and significant interactions between antidepressant medication status and BDI-II on HRV outcomes. The main effects of BDI-II and sex on HR were no longer significant after controlling for cardiorespiratory fitness. Participants who denied current antidepressant use (n = 137) exhibited a negative association and participants who endorsed current antidepressant (n = 15) use exhibited a positive association between BDI-II scores and HRV. Emotional reactivity models were largely non-significant with the exception of a significant main effect of antidepressant medication status on high-frequency HRV reactivity. Results indicated antidepressant medication use may moderate the relationship between depression severity and cardiovascular functioning, but this requires replication given the modest proportion of medicated individuals in this study. Overall, findings suggest cardiovascular processes and cardiorespiratory fitness are linked to depression symptomatology and may be important to consider in depression treatment.

Lower resting cardiac autonomic balance in young adults with current major depression.

Research on cardiac autonomic function in major depressive disorder (MDD) has predominantly examined cardiac vagal control and adopted a model of reciprocal autonomic balance. A proposed bivariate autonomic continuum uses cardiac autonomic balance (CAB) and cardiac autonomic regulation (CAR) models, derived from normalized values of respiratory sinus arrhythmia and pre-ejection period, to more adequately index patterns of autonomic control. The purpose of this study was to assess resting levels of CAB and CAR among young adults with and without a current diagnosis of major depression. One hundred forty-two young adults (n = 65 MDD, n = 77 healthy controls; 20.8 ± 2.6 years) completed a structured diagnostic interview, cardiovascular assessment, and a maximal aerobic fitness test. The findings revealed that CAB, but not CAR, significantly predicted current MDD status (OR = 0.70, 95% CI [0.53, 0.93]), an effect that remained after controlling for aerobic fitness and body mass index. Although CAB was found to be a significant predictor of current MDD status among a sample of young adults, there remained substantial variation in autonomic control that was not captured by the traditional model of reciprocal autonomic balance.

Process Evaluation of a Mobile Weight Loss Intervention for Truck Drivers.

BACKGROUND: In a cluster-randomized trial, the Safety and Health Involvement For Truck drivers intervention produced statistically significant and medically meaningful weight loss at 6 months (-3.31 kg between-group difference). The current manuscript evaluates the relative impact of intervention components on study outcomes among participants in the intervention condition who reported for a postintervention health assessment (n = 134) to encourage the adoption of effective tactics and inform future replications, tailoring, and enhancements. METHODS: The Safety and Health Involvement For Truck drivers intervention was implemented in a Web-based computer and smartphone-accessible format and included a group weight loss competition and body weight and behavioral self-monitoring with feedback, computer-based training, and motivational interviewing. Indices were calculated to reflect engagement patterns for these components, and generalized linear models quantified predictive relationships between participation in intervention components and outcomes. RESULTS: Participants who completed the full program-defined dose of the intervention had significantly greater weight loss than those who did not. Behavioral self-monitoring, computer-based training, and health coaching were significant predictors of dietary changes, whereas behavioral and body weight self-monitoring was the only significant predictor of changes in physical activity. Behavioral and body weight self-monitoring was the strongest predictor of weight loss. CONCLUSION: Web-based self-monitoring of body weight and health behaviors was a particularly impactful tactic in our mobile health intervention. Findings advance the science of behavior change in mobile health intervention delivery and inform the development of health programs for dispersed populations.