Randomized trial of a portable HEPA air cleaner intervention to reduce asthma morbidity among Latino children in an agricultural community.

BACKGROUND: Data on pediatric asthma morbidity and effective environmental interventions in U.S. agricultural settings are few. We evaluated the effectiveness of HEPA air cleaners on asthma morbidity among a cohort of rural Latino children. METHODS: Seventy-five children with poorly controlled asthma and living in non-smoking homes were randomly assigned to asthma education alone or along with HEPA air cleaners placed in their sleeping area and home living room. The Asthma Control Test (ACT) score, asthma symptoms in prior 2 weeks, unplanned clinical utilization, creatinine-adjusted urinary leukotriene E4 (uLTE4 [ng/mg]), and additional secondary outcomes were evaluated at baseline, six, and 12 months. Group differences were assessed using multivariable-adjusted generalized estimating equations. Incident rate ratios of ever experiencing the metrics of poorer asthma health during follow-up (suboptimal asthma management) were estimated using Poisson regression models in secondary analysis. RESULTS: Mean child age was 9.2 and 8.6 years in intervention and control groups, respectively, and two-thirds of participants were male. Primary analysis of repeated measures of ACT score did not differ between groups (HEPA group mean change compared to controls 10% [95% CI: - 12-39%]). A suggestion of greater decrease in uLTE4 (ng/mg creatinine) was observed (- 10% [95% CI: - 20 -1%]). Secondary analysis showed children with HEPAs were less likely to have an ACT score meeting a clinically defined cutoff for poorly controlled asthma using repeated measures (IRR: 0.45 [95% CI: 0.21-0.97]). In Poisson models, intervention participants had reduced risk of ever meeting this cutoff (IRR: 0.43 [95% CI: 0.21-0.89]), ever having symptoms in the past 2 weeks (IRR: 0.71 [95% CI: 0.52-0.98]), and lower risk of any unplanned clinical utilization (IRR: 0.35 [95% CI: 0.13-0.94]) compared to control participants. DISCUSSION: The HAPI study showed generally improved outcomes among children in the HEPA air cleaner group. However, primary analyses did not meet statistical significance and many outcomes were subjective (self-report) in this unblinded study, so findings must be interpreted cautiously. HEPA air cleaners may provide additional benefit for child asthma health where traditional asthmagens (traffic, tobacco smoke) are not prominent factors, but larger studies with more statistical power and blinded designs are needed. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04919915 . Date of retrospective registration: May 19, 2021.

Modernizing Training in Psychotherapy Competencies With Adaptive Learning Systems: Proof of Concept.

PURPOSE: This proof-of-concept study assessed the feasibility, acceptability, and effectiveness of an intelligent tutoring system (ITS) as a classroom adjunct to improve training bachelor of social work (BSW) students in client engagement strategies. METHODS: We codeveloped the ITS with 11 undergraduate students and pilot tested it with six BSW students enrolled in a class on telephone-based cognitive behavioral therapy (tCBT). Student competencies in tCBT were assessed by expert review of role-plays. We also examined time spent using ITS and relation with competency. RESULTS: The majority of students (81.8%) in Wave 1 and all of the students who submitted role-plays in Wave 2 passed the clinical skills role-play. Students advancing through the ITS more quickly had better tCBT competency ratings than those progressing more slowly. DISCUSSION: One of the most challenging aspects of training is how to competently deliver evidence-based practices. ITS has the potential to streamline and scale such training.

The Family Communication Study: A randomized trial of prospective pediatric palliative care consultation, study methodology and perceptions of participation burden.

BACKGROUND: To describe the study methods, baseline characteristics and burden of study procedures of an intervention designed to reduce family stress symptoms through early support from the palliative care team. Length of stay of ≥8days was the trigger for early palliative care involvement. METHODS: Cluster-randomized trial with children as the unit of randomization. Up to 3 family members per child were recruited. Family stress symptoms were recorded at baseline, discharge from the ICU, and 3months post-enrollment. Questionnaire burden was assessed on a 1-10 point scale at each time point and open-ended comments were analyzed to describe the participants' experience in the study. RESULTS: 380 family members of 220 children (control=115 children and 204 family members; intervention=105 children and 176 family members) were recruited, which represented 50% of all eligible families. Most family participants were parents (86% control; 92% intervention) and female (66% both groups). Retention rates were high through the 3-month follow-up: 93% and 90% for the control and intervention groups respectively. Questionnaire burden was very low: mean (sd) scores were 1.1 (1.6), 0.7 (1.5), and 0.9 (1.6) for the baseline, discharge and follow-up questionnaires, respectively. Comments suggest that participation was beneficial by promoting reflection and self-awareness about stress, coping and resilience, and feeling cared for because the intervention and questionnaires focused on their own well-being. CONCLUSIONS: The participants' comments regarding the focus on them as the point of intervention reflects the value of conducting research with family members of seriously ill children during ICU stays.

Racial/ethnic identity and subjective physical and mental health of Latino Americans: an asset within?

Social Identity Theory indicates that ethnic identity could benefit minority members in a society because of its promotion of a sense of belonging, or of its buffering of the damage of discrimination. Despite growing investigation about Latinos' overall health, few studies have simultaneously examined the influence of multiple cultural strength factors, especially racial/ethnic identity, social support, and religious attendance, on these outcomes. Using the National Latino and Asian American Study, we examine the potential predictive value of these cultural strength factors on Latinos' Self-Rated Mental and Physical Health (SRMH and SRPH). Two separate two-step regression models revealed significant positive effects of racial/ethnic identity on both mental and physical health of Latinos, above and beyond the effect of known demographic and acculturation factors, such as discrimination. Religious attendance had a positive effect on SRMH but not on SRPH. The deteriorating roles of discrimination, in mental health only, and that of Length in the US in both outcomes, however, was primarily not altered by entry of these cultural strength factors. The independent direct effect of racial/ethnic identity among Latinos nationwide may suggest that this cultural strength is an internalized protective asset. Longitudinal data is needed to explore its underlying mechanism and long-term impact.

Examining palliative care team involvement in automatic consultations for children on extracorporeal life support in the pediatric intensive care unit.

BACKGROUND: Extracorporeal life support (ECLS) is an advanced form of life-sustaining therapy that creates stressful dilemmas for families. In May 2009, Seattle Children's Hospital (SCH) implemented a policy to involve the Pediatric Advanced Care Team (PACT) in all ECLS cases through automatic referral. OBJECTIVE: Our aim was to describe PACT involvement in the context of automatic consultations for ECLS patients and their family members. METHODS: We retrospectively examined chart notes for 59 consecutive cases and used content analysis to identify themes and patterns. RESULTS: The degree of PACT involvement was related to three domains: prognostic uncertainty, medical complexity, and need for coordination of care with other services. Low PACT involvement was associated with cases with little prognostic uncertainty, little medical complexity, and minimal need for coordination of care. Medium PACT involvement was associated with two categories of cases: 1) those with a degree of medical complexity but little prognostic uncertainty; and 2) those that had a degree of prognostic uncertainty but little medical complexity. High PACT involvement had the greatest medical complexity and prognostic uncertainty, and also had those cases with a high need for coordination of care. CONCLUSIONS: We describe a framework for understanding the potential involvement of palliative care among patients receiving ECLS that explains how PACT organizes its efforts toward patients and families with the highest degree of need. Future studies should examine whether this approach is associated with improved patient and family outcomes.

Palliative care in the pediatric ICU: challenges and opportunities for family-centered practice.

The culture of pediatric intensive care units (PICUs) is focused on curative or life-prolonging treatments for seriously ill children. We present empirically-based approaches to family-centered palliative care that can be applied in PICUs. Palliative care in these settings is framed by larger issues related to the context of care in PICUs, the stressors experienced by families, and challenges to palliative care philosophy within this environment. Innovations from research on family-centered communication practices in adult ICU settings provide a framework for development of palliative care in PICUs and suggest avenues for social work support of critically ill children and their families.

Institutional predictors of developmental outcomes among racially diverse foster care alumni.

Child welfare practitioners are confronted with the responsibility of relying on best practice to ensure children in foster care transition successfully into adulthood after leaving the foster care system. Yet, despite recent reforms and efforts to address their needs, research clearly shows that foster care alumni are still more likely to experience negative developmental outcomes compared to adults in the general population. The purpose of this study was to better understand how child-serving systems of care adequately prepare racially diverse foster care alumni to thrive. Controlling for gender, age, placement instability, and circumstances of exit from foster care, study findings highlighted salient racial and ethnic differences relative to which factors predicted the odds of mental health, education, and employment outcomes. Implications for developing and implementing culturally sensitive, evidence-based prevention and intervention programs to promote positive developmental outcomes among racially diverse foster care alumni are discussed.

Building a community-academic partnership: implementing a community-based trial of telephone cognitive behavioral therapy for rural latinos.

Concerns about the appropriate use of EBP with ethnic minority clients and the ability of community agencies to implement and sustain EBP persist and emphasize the need for community-academic research partnerships that can be used to develop, adapt, and test culturally responsive EBP in community settings. In this paper, we describe the processes of developing a community-academic partnership that implemented and pilot tested an evidence-based telephone cognitive behavioral therapy program. Originally demonstrated to be effective for urban, middle-income, English-speaking primary care patients with major depression, the program was adapted and pilot tested for use with rural, uninsured, low-income, Latino (primarily Spanish-speaking) primary care patients with major depressive disorder in a primary care site in a community health center in rural Eastern Washington. The values of community-based participatory research and community-partnered participatory research informed each phase of this randomized clinical trial and the development of a community-academic partnership. Information regarding this partnership may guide future community practice, research, implementation, and workforce development efforts to address mental health disparities by implementing culturally tailored EBP in underserved communities.

Telephone-based cognitive-behavioral therapy for Latino patients living in rural areas: a randomized pilot study.

OBJECTIVE: This pilot study tested the effectiveness of culturally tailored, telephone-based cognitive-behavioral therapy (CBT) for improving depression outcomes among Latino primary care patients living in rural settings. METHODS: A total of 101 Latino patients at a rural family medical center who met criteria for probable major depression were randomly assigned to enhanced usual care or eight sessions of CBT delivered by phone by trained bilingual therapists from the community. Blinded study assistants assessed depression symptom severity, using the Hopkins Symptom Checklist (SCL) depression items and the Patient Health Questionnaire-9, and patient satisfaction after six weeks, three months, and six months. Mixed-effects models were used to estimate intervention effects over time. For cross-sectional analyses, attrition weights were used to account for missing data. RESULTS: In intent-to-treat analyses, patients who received CBT by phone were more likely to experience improvement in depression scores over the six-month follow-up period compared with patients who received enhanced usual care (ß=-.41, t=-2.36, df=219, p=.018, for the SCL; and ß=-3.51, t=-2.49, df=221, p=.013, for the PHQ-9). A greater proportion of patients in the CBT group than in the group that received enhanced usual care achieved treatment response at three months (p=.017), as indicated by a 50% improvement in SCL depression score or a score <.75, and reported high satisfaction with treatment (p=.013). CONCLUSIONS: Although limited by small sample size, pilot results suggest culturally tailored, telephone-based CBT has the potential to enhance access to psychotherapy in an underserved Latino population with little access to mental health services.

Examining the premises supporting the empirically supported intervention approach to social work practice.

Federal, state, and local policymakers and funders have increasingly organized human service delivery functions around the selection and implementation of empirically supported interventions (ESIs), under the expectation that service delivery through such intervention frameworks results in improvements in cost-effectiveness and system performance. This article examines the validity of four premises undergirding the ESI approach: ESIs are effective, relevant to common client problems and needs, culturally appropriate, and replicable and sustainable in community-based settings. In reviewing available literature, the authors found insufficient support for the uniform application of an ESI approach to social work practice in the human service sector, particularly as applied within agency contexts serving ethnic minority clients. The authors recommend that greater attention be devoted to the development and dissemination of social work interventions that respond to needs that are broadly understood and shared across diverse cultural groups, have proven clinical efficacy, and can be translated successfully for use across different agency and cultural environments. Such attention to the research and development function of the social work profession is increasingly necessary as policymakers and human service system architects require reduced costs and improved performance for programs serving historically oppressed client populations.

Evidence-based practice in mental health care to ethnic minority communities: has its practice fallen short of its evidence?

Evidence-based practice (EBP) has contributed substantially to the advancement of knowledge in the treatment and prevention of adult mental health disorders. A fundamental assumption, based on documented evidence of effectiveness with certain populations, is that EBP is equally effective and applicable to all populations. However, small sample sizes of ethnic minority populations in randomized clinical trials prevent strong and clear conclusions about the effectiveness and generalizability of EBP with regard to people of color. In addition, the appropriateness of EBPs to ethnic minority communities has rarely been investigated. This article critically examines the applicability and dissemination of adult mental health EBP to diverse ethnic minority populations. It highlights limitations of EBP rooted in its epistemological narrowness, exclusion of communities of color, and lack of cultural competence and examines whether the practice of EBP has overstepped its evidence. This article presents a framework characterized by pathways of epistemological partnership and substantive inclusion of racial and ethnic minority groups to facilitate the promotion of culturally responsive EBPs and to inform mental health practice and policy implementation.

The role of young adolescents' perception in understanding the severity of exposure to community violence and PTSD.

This study seeks to (a) identify and measure the lifetime exposure to community violence of 137 African American and Latino middle school students from a low income neighborhood and apply numerical weights to each violent event; (b) examine the relationship between the objective severity of child self reported violence exposure and the child's subjective perception of the most bothersome event; and (c) examine the relationship between child's exposure and posttraumatic stress disorder (PTSD). Results highlight that students' designation of their most bothersome exposure to community violence did not correspond to the most severe violent event they experienced. Regression analyses reveal the weight of the most severe event explains a larger percentage of the variance in PTSD compared with the relationship to victim, level of exposure, weight of the most bothersome exposure, and cumulative weight of all exposure. This study underscores the importance of assessing a child's perception of violent events.

Community violence in context: risk and resilience in children and families.

Although some community violence research has examined the context of community violence, including the social, economic, and structural organization of neighborhoods, more needs to be learned about family, school, and community-level factors that may promote and lessen the incidence and prevalence of community violence. In addition, further research is needed on various social, environmental, and contextual factors hypothesized to protect youth from exposure. This article (a) reviews and examines the relation between neighborhood context and risk of violence exposure, (b) reviews current literature on predictors of community violence and mental health and behavioral consequences for children and families adversely affected by community violence, (c) examines sources of resilience and community strengths that extend beyond the individual, (d) discusses the contributions and limitations of current conceptualizations of risk and resilience, and (e) highlights directions for future research. Information from this review can inform community and government efforts to lessen community violence through prevention and treatment.

Maternal depression and adolescent behavior problems: an examination of mediation among immigrant Latino mothers and their adolescent children exposed to community violence.

This study examines the psychological and behavioral effects of exposure to community violence of 47 Latino mothers and their young adolescent children. Using data gathered from multiple sources, this study tests the associations between lifetime exposure to community violence, maternal depression, and child behavior problems. More than 80% of the youngsters ranging from age 11 to 14 years and 68% of the mothers reported being exposed to at least one act of community violence either as a victim or as a witness. Analyses reveal that maternal depression is a mediator of child behavior problems, reducing the direct effect of community violence exposure by more than 50%. Findings suggest that maternal depression is a factor more important than child's community violence exposure in contributing to young adolescents' behavioral problems.

Contextualizing community violence and its effects: an ecological model of parent-child interdependent coping.

This article presents an integrated conceptual framework that contextualizes exposure to community violence and the interpersonal and interdependent processes of parent and child response to community violence. This model posits that parental distress, including post-traumatic stress disorder (PTSD) and depression, is a significant mediator of child distress symptomatology and behavior problems. The model advances understanding of the impact of community violence in the lives of parents and children through various mechanisms, including social capital. This article underscores the need for a fundamental shift in the study of community violence, in the delivery of mental health services, and in prevention efforts from focusing on the individual child to concentrating on the parent, family, and community-level factors and processes. This article highlights important areas to address in future research, including investigation and specification of the mechanisms and processes by which neighborhoods affect and influence human development outcomes.

Using conjoint analysis to assess depression treatment preferences among low-income Latinos.

The authors examined the feasibility of conjoint analysis for measuring the depression treatment preferences of low-income, low-literacy Latino primary care patients. Forty-two patients with depression (58 percent of those eligible for the study) completed a survey about preferences for treatment and strategies to reduce barriers to care. They preferred combined counseling and medication to either approach alone and preferred individual over group treatment but did not show a significant preference for treatment setting. The odds of treatment acceptance were increased by the availability of telephone appointments, bus passes, and help with making appointments. Although further validation is required, conjoint analysis appears to be feasible for assessing preferences regarding depression treatment in this underserved population.