Cardiovascular Disease and Stroke-Focused Competency Assessment Tools for Community Health Workers in the United States: A Scoping Review.

Cardiovascular disease (CVD) and stroke are major contributors to chronic disease burden in the United States. Despite the high prevalence of stroke, 90% of all stroke events are preventable and can be attributed to seven key modifiable risk factors (MRFs)-high blood pressure (BP), high cholesterol, diabetes mellitus (DM), smoking, obesity, unhealthy diet, and physical inactivity. In the United States, stroke prevention interventions led by community health workers (CHWs) have been proven to be highly effective in preventing the onset of MRFs. We conducted a scoping review of the competency assessment methods used in CVD and stroke-focused CHW training programs. We searched six online databases: PubMed, Cochrane, CINAHL, Embase, Web of Science, and HaPI, from all available years until January 2021. Of the 1,774 initial articles found, we identified 30 eligible articles to be included in the review. Nine of these studies used previously validated instruments, whereas the remaining 21 studies used tools from the training curriculum or independently developed instruments. Only five of these validated tools reported psychometric properties; none of them were designed for the CHW population. Our scoping review of literature revealed that CHW-specific competency assessment methods were limited, with few or no domain-referenced tools on CVD or stroke risk factors that complied with established measurement standards. We conclude that there is an urgent need for the development of a comprehensive and valid assessment instrument in CVD and stroke prevention to evaluate CHW performance and optimize their credibility, representing important first steps toward integrating CHWs into health care systems.

Substance Use Among Youth During the COVID-19 Pandemic: a Systematic Review.

PURPOSE OF REVIEW: To review the literature on the trends in substance use among youth during the coronavirus SARS-CoV-2 (COVID-19) pandemic. RECENT FINDINGS: The pandemic has given rise to concerns about the mental health and social well-being of youth, including its potential to increase or exacerbate substance use behaviors. This systematic review identified and included 49 studies of use across alcohol, cannabis, tobacco, e-cigarettes/vaping, and other drugs, and unspecified substances. The majority of studies across all categories of youth substance use reported reductions in prevalence, except in the case of other drugs and unspecified drug and substance use, which included three studies that reported an increase in use and three studies that reported decrease in use. Overall, the results of this review suggest that the prevalence of youth substance use has largely declined during the pandemic. Youth substance use in the post-pandemic years will require monitoring and continued surveillance.

Trends in substance use and primary prevention variables among adolescents in Lithuania, 2006-19.

BACKGROUND: Since the implementation of the Icelandic Model for Primary Prevention of Substance Use in Iceland (IPM), substance use has decreased steadily among 14-16-year-old adolescents and primary prevention factors have improved. Although the IPM is being implemented in several other regions around the world, information documenting its effectiveness in other country contexts is lacking. This study assessed trends in substance use and primary prevention variables in three cities in Lithuania following the implementation of the IPM. METHODS: Data collected from repeated, comparative cross-sectional self-report surveys conducted among a total of 30 572 10th graders in the cities of Kaunas, Klaipeda and Vilnius, Lithuania, from 2006 to 2019, were analyzed. Cochran-Armitage test for linear trend and analysis of variance for linear trend was used to assess time-trends in prevalence of substance use and mean levels of primary prevention variables over time. RESULTS: Following the implementation of IPM rates of cigarette smoking and the use of alcohol, cannabis and amphetamine has decreased among 10th graders in Lithuania's three largest cities and simultaneously preventive variables targeted have improved. Similar to Iceland, primary prevention variables were related to substance use in the expected direction, with the exception of organized sports participation, which was not associated with less likelihood of alcohol, cannabis and amphetamine use. CONCLUSION: Trends in substance use and primary prevention variables following the implementation of the IPM are similar in the three cities in Lithuania as in Iceland. Further research is needed to better understand the mechanisms underlying these trends.

Testing risk and protective factor assumptions in the Icelandic model of adolescent substance use prevention.

Iceland has witnessed a dramatic decline in adolescent substance use that may be partly the result of efforts related to the Icelandic prevention model (IPM). We sought to test risk and protective factor assumptions of the IPM using a prospective cohort study with 12 months separating baseline from follow-up. Participants were students in grades 8 and 9 in the national Icelandic school system enrolled in the spring of 2018 and 2019 (N=2165). Participants self-reported their experiences of cigarette smoking, alcohol consumption, and cannabis use and seven risk and protective factors. Analyses were conducted with generalized linear modeling with extension to general estimating equations with correlated outcomes data. Both individual main-effects models and collective models including all main-effects were tested. Out of 28 individual main-effects models, 23 produced findings consistent with study premises (P<0.05). Multiple main-effects models largely sustained the findings of the individual main-effects models. Findings support the assumption that the risk and protective factors commonly emphasized in the IPM are associated with the four different substance use outcomes in the hypothesized direction. Communities that plan to implement the IPM among adolescents might consider these factors in their work.

Longitudinal association between social media use and psychological distress among adolescents.

This study aimed to examine in a longitudinal cohort design whether social media use among adolescents is related to symptoms of social anxiety, depressed mood, and physical symptoms of anxiety over time. As part of the LIFECOURSE study of risk and protective factors for healthy adolescent development, three waves of school-based surveys of adolescents born in Iceland in 2004 were analyzed. Of the 3914 eligible adolescents, 2378 gave informed consent. Complete responses for this study were collected from 2211 students at the first wave, with 2052 responding roughly 12 months later, and 2097 responding in year 3. Linear mixed-effects models were used to analyze time spent on social media in relation to psychological distress over time. More time spent on social media was weakly but significantly associated with increased symptoms of depressed mood, social anxiety and symptoms of physical anxiety over time. However, the effect size of these relationships suggest they may not be of clinical relevance. The relationship between time spent on social media and symptoms of depressed mood and physical symptoms of anxiety grew stronger over time, although it is not known if this relationship is causal. The relationship between time spent on social media and all outcomes of psychological distress were stronger for girls than boys and increased social media use had a positive relationship with symptoms of depressed mood over time. The relationships found in this study were relatively small and future studies need to focus on the clinical and public health significance of these effects.

Application of the Consolidated Framework for Implementation Research to examine nurses' perception of the task shifting strategy for hypertension control trial in Ghana.

BACKGROUND: The burden of hypertension in many low-and middle-income countries is alarming and requires effective evidence-based preventative strategies that is carefully appraised and accepted by key stakeholders to ensure successful implementation and sustainability. We assessed nurses' perceptions of a recently completed Task Shifting Strategy for Hypertension control (TASSH) trial in Ghana, and facilitators and challenges to TASSH implementation. METHODS: Focus group sessions and in-depth interviews were conducted with 27 community health nurses from participating health centers and district hospitals involved in the TASSH trial implemented in the Ashanti Region, Ghana, West Africa from 2012 to 2017. TASSH evaluated the comparative effectiveness of the WHO-PEN program versus provision of health insurance for blood pressure reduction in hypertensive adults. Qualitative data were analyzed using open and axial coding techniques with emerging themes mapped onto the Consolidated Framework for Implementation Research (CFIR). RESULTS: Three themes emerged following deductive analysis using CFIR, including: (1) Patient health goal setting- relative priority and positive feedback from nurses, which motivated patients to make healthy behavior changes as a result of their health being a priority; (2) Leadership engagement (i.e., medical directors) which influenced the extent to which nurses were able to successfully implement TASSH in their various facilities, with most directors being very supportive; and (3) Availability of resources making it possible to implement the TASSH protocol, with limited space and personnel time to carry out TASSH duties, limited blood pressure (BP) monitoring equipment, and transportation, listed as barriers to effective implementation. CONCLUSION: Assessing stakeholders' perception of the TASSH implementation process guided by CFIR is crucial as it provides a platform for the nurses to thoroughly evaluate the task shifting program, while considering the local context in which the program is implemented. The feedback from the nurses informed barriers and facilitators to implementation of TASSH within the current healthcare system, and suggested system level changes needed prior to scale-up of TASSH to other regions in Ghana with potential for long-term sustainment of the task shifting intervention. TRIAL REGISTRATION: Trial registration for parent TASSH study: NCT01802372. Registered February 27, 2013.

Development and Guiding Principles of the Icelandic Model for Preventing Adolescent Substance Use.

Adolescent substance use-the consumption of alcohol, tobacco, and other harmful drugs-remains a persistent global problem and has presented ongoing challenges for public health authorities and society. In response to the high rates of adolescent substance use during the 1990s, Iceland has pioneered in the development of the Icelandic Model for Primary Prevention of Substance Use-a theory-based approach that has demonstrated effectiveness in reducing substance use in Iceland over the past 20 years. In an effort to document our approach and inform potentially replicable practice-based processes for implementation in other country settings, we outline in a two-part series of articles the background and theory, guiding principles of the approach, and the core steps used in the successful implementation of the model. In this article, we describe the background context, theoretical orientation, and development of the approach and briefly review published evaluation findings. In addition, we present the five guiding principles that underlie the Icelandic Prevention Model's approach to adolescent substance use prevention and discuss the accumulated evidence that supports effectiveness of the model. In a subsequent Part 2 article, we will identify and describe key processes and the 10 core steps of effective practice-based implementation of the model.

Implementing the Icelandic Model for Preventing Adolescent Substance Use.

This is the second in a two-part series of articles about the Icelandic Model for Primary Prevention of Substance Use (IPM) in this volume of Health Promotion Practice. IPM is a community collaborative approach that has demonstrated remarkable effectiveness in reducing substance use initiation among youth in Iceland over the past 20 years. While the first article focused attention on the background context, theoretical orientation, evaluation and evidence of effectiveness, and the five guiding principles of the model, this second article describes the 10 core steps to practical implementation. Steps 1 to 3 focus on building and maintaining community capacity for model implementation. Steps 4 to 6 focus on implementing a rigorous system of data collection, processing, dissemination, and translation of findings. Steps 7 to 9 are designed to focus community attention and to maximize community engagement in creating and sustaining a social environment in which young people become progressively less likely to engage in substance use, including demonstrative examples from Iceland. And Step 10 focuses on the iterative, repetitive, and long-term nature of the IPM and describes a predictable arc of implementation-related opportunities and challenges. The article is concluded with a brief discussion about potential variation in community factors for implementation.

Interventions to Support Behavioral Self-Management of Chronic Diseases.

A majority of the US adult population has one or more chronic conditions that require medical intervention and long-term self-management. Such conditions are among the 10 leading causes of mortality; an estimated 86% of the nation's $2.7 trillion in annual health care expenditures goes toward their treatment and management. Patient self-management of chronic diseases is increasingly essential to improve health behaviors, health outcomes, and quality of life and, in some cases, has demonstrated effectiveness for reducing health care utilization and the societal cost burden of chronic conditions. This review synthesizes the current state of the science of chronic disease self-management interventions and the evidence for their effectiveness, especially when applied with a systematic application of theories or models that account for a wide range of influences on behavior. Our analysis of selected outcomes from randomized controlled trials of chronic disease self-management interventions contained in 10 Cochrane systematic reviews provides additional evidence to demonstrate that self-management can improve quality of life and reduce utilization across several conditions.

Developing a Tailored Website for Promoting Awareness about Obstructive Sleep Apnea (OSA) Among Blacks in Community-Based Settings.

Blacks are at greater risk for lower sleep quality and higher risk for obstructive sleep apnea (OSA) than other racial groups. In this study, we summarize the development of a tailored website including visuals, key messages, and video narratives, to promote awareness about sleep apnea among community-dwelling blacks. We utilized mixed methods, including in-depth interviews, usability-testing procedures, and brief surveys (n = 9, 55% female, 100% black, average age 38.5 years). Themes from the qualitative analysis illuminated varied knowledge regarding OSA symptoms and prevalent self-reported experience with sleep disturbance and OSA symptoms (e.g., snoring). On a scale from 1 (not at all) to 5 (very high), participants provided favorable ratings of website usefulness (mean = 4.9), user friendliness (mean = 4.9) and attractiveness (mean = 4.3). Our findings suggest although tailored health communication has potential for serving as a tool for advancing health equity, usability-testing of health materials is critical to ensure that culturally and linguistically tailored messages are acceptable and actionable in the intended population.

Maternal smoking during pregnancy and academic achievement of offspring over time: A registry data-based cohort study.

Few studies have assessed the cumulative impact of maternal smoking during pregnancy (MSDP) on scholastic outcomes over time. We examined the relations between MSDP and academic achievement in the 4th, 7th and 10th grades using registry data collected at birth, during the neonatal period, and at each grade level from the 2000, LIFECOURSE study birth cohort in Reykjavik, Iceland (N = 1151, girls = 49.3%). Latent growth modeling showed that MSDP influenced Icelandic achievement scores, standardized to a range from 0 to 60, at baseline (ß = -0.04), and over time (ß = -0.05). Likewise, MSDP was negatively associated with standardized mathematics scores at baseline (ß = -0.09) and continued to exert a negative impact on mathematics scores over time (ß = -0.08) after controlling for gender, income, cohabitation, and baseline mathematics and Icelandic achievement scores. Results provide evidence of the persistent negative impact of MSDP on academic achievement in offspring. Findings support the proposition that children whose mothers smoke during the first trimester of pregnancy are, on average, at greater risk for poor scholastic outcomes over time than children whose mothers do not smoke during their first trimester. To our knowledge, this is the first study using a longitudinal cohort design to assess whether the impacts of maternal smoking during pregnancy may persist over time. This study contributes to the current state of knowledge by providing an assessment that focuses on the impact of smoking during pregnancy on academic achievement from childhood into early adolescence.

Cumulative risk over the early life course and its relation to academic achievement in childhood and early adolescence.

Early-life risk factors, such as family disruption, maltreatment, and poverty, can negatively impact children's scholastic abilities; however, most previous studies have relied on cross-sectional designs and retrospective measurement. This study investigated the relation between cumulative risk factors during the early life course and subsequent academic achievement in a cohort of children and adolescents. Data for this study were based on registry-data material from the LIFECOURSE study of 1151 children from the 2000 birth cohort in Reykjavik, Iceland, assembled in 2014-2016. Multiple lifetime risk factors, including maternal smoking during pregnancy, parent's disability status, being born to a young mother, number of children in the household, family income, number of visits to school nurses, and reports of maltreatment, were assessed. Latent class analysis and Analysis of Covariance (ANCOVA) were used to predict academic achievement in the 4th and 7th grades. Individuals with no risk factors reported the highest average academic achievement in the 4th (M=66 points, SD=17) and 7th grades (M=67 points, SD=15). There was a significant main effect for 4th-grade risk factors and academic achievement (F [7, 1146]=12.06, p<0.001) and a similar relationship between the risk factor profile and achievement scores in 7th grade (F [7, 1146]=15.08, p<0.001). Each additional risk factor was associated with a drop in academic achievement at both grade levels. We conclude that academic achievement declines in proportion to the number of risk factors in early life.

The increase in symptoms of anxiety and depressed mood among Icelandic adolescents: time trend between 2006 and 2016.

Background: Both research and popular media reports suggest that adolescent mental health has been deteriorating across societies with advanced economies. This study sought to describe the trends in self-reported symptoms of depressed mood and anxiety among Icelandic adolescents. Methods: Data for this study come from repeated, cross-sectional, population-based school surveys of 43 482 Icelandic adolescents in 9th and 10th grade, with six waves of pooled data from 2006 to 2016. We used analysis of variance, linear regression and binomial logistic regression to examine trends in symptom scores of anxiety and depressed mood over time. Gender differences in trends of high symptoms were also tested for interactions. Results: Linear regression analysis showed a significant linear increase over the course of the study period in mean symptoms of anxiety and depressed mood for girls only; however, symptoms of anxiety among boys decreased. The proportion of adolescents reporting high depressive symptoms increased by 1.6% for boys and 6.8% for girls; the proportion of those reporting high anxiety symptoms increased by 1.3% for boys and 8.6% for girls. Over the study period, the odds for reporting high depressive symptoms and high anxiety symptoms were significantly higher for both genders. Girls were more likely to report high symptoms of anxiety and depressed mood than boys. Conclusions: Self-reported symptoms of anxiety and depressed mood have increased over time among Icelandic adolescents. Our findings suggest that future research needs to look beyond mean changes and examine the trends among those adolescents who report high symptoms of emotional distress.

Maternal smoking during pregnancy and scholastic achievement in childhood: evidence from the LIFECOURSE cohort study.

Background: Research on the impact of maternal smoking during pregnancy (MSDP) on scholastic achievement in the offspring has shown conflicting findings. The objective of this study was to assess the impact of MSDP on scholastic achievement in a birth cohort of children in 4th, 7th and 10th grades. Methods: We analysed data from the LIFECOURSE study, a cohort study of risk and protective factors in all children born in Reykjavik, Iceland, in the year 2000 (N = 1151, girls = 49.3%). Retrospective registry data for 2014-2015 were merged with prospective survey data that were collected in April 2016. Data on MSDP were assessed during regular antenatal visits at the end of the first trimester. Standardized academic achievement scores were obtained from official school transcripts. Data were analysed using OLS regressions that were entered in three hierarchical blocks. Results: Children of mothers who smoked tobacco during the first trimester consistently revealed between 5% and 7% lower scores on standardized academic achievement in 4th, 7th and 10th grade (∼6-8 points on a normally distributed 120 point scale) than those of mothers who had not smoked tobacco during this period (P < 0.05). These findings held after controlling for several factors associated with the time of birth (e.g. birth weight, maternal age at birth, birth order, parental cohabitation and household income), as well as the year of scholastic assessment (parental cohabitation, household income and parental education). Conclusions: Maternal smoking during pregnancy was negatively related to scholastic achievement in the offspring during 4th, 7th and 10th grade.

Stress and adolescent well-being: the need for an interdisciplinary framework.

Stress and strain among adolescents have been investigated and discussed largely within three separate disciplines: mental health, where the focus has been on the negative effects of stress on emotional health; criminology, where the emphasis has been on the effects of strain on delinquency; and biology, where the focus has been to understand the effects of stress on physiology. Recently, scholars have called for increased multilevel developmental analyses of the bio-psychosocial nature of risk and protection for behaviors of individuals. This paper draws on several different but converging theoretical perspectives in an attempt to provide an overview of research relevant to stress in adolescence and puts forth a new framework that aims to provide both a common language and consilience by which future research can analyze the effects of multiple biological, social and environmental factors experienced during specific developmental periods, and cumulatively over time, on harmful behavior during adolescence. We present a framework to examine the effects of stress on diverse behavioral outcomes among adolescents, including substance use, suicidal behavior, self-inflicted harm, and delinquency.

Association between higher BMI and depressive symptoms in Icelandic adolescents: the mediational function of body image.

BACKGROUND: Weight status and depressive affect in adolescents are positively related constructs, but the nature of this relationship is not well understood, especially in European populations. The objective of this study was to examine the interplay between body mass index (BMI) and depressive symptoms, while accounting for the possible mediational role of body image, in a sample of older adolescents in Iceland. METHOD: We utilized data from a population-based cross-sectional sample of 11 388 junior college students (16-20-year-olds) to conduct structural equation modelling to test the relationship between BMI, body image and depressive symptoms while controlling for socioeconomic status and other background variables. RESULTS: Higher levels of BMI are associated with higher depressive symptoms. However, this association was mediated entirely through perceptions of body image. The association is gender dependent, with the relationship between BMI levels and depressive symptoms being significantly stronger among junior college girls than boys. CONCLUSION: Body image is a key contributor in the relationship between weight status and depressive symptoms among adolescents. Future interventions with adolescents should take this association into account and focus on such factors as physical confidence and self-esteem.

Self-generated identification codes in longitudinal prevention research with adolescents: a pilot study of matched and unmatched subjects.

Self-generated identification codes (SGICs) are an increasingly utilized methodological feature of longitudinal prevention research among adolescents. This study sought to test the differences between the matched and unmatched groups at baseline on a number of background, health, and well-being and risk behavior measures in a prevention study among 13- to 16-year-old Icelandic adolescents where a SGIC was constructed and used to link individual-level respondent data over two data collection points one year apart. We use pilot data from two Reykjavik city secondary schools collected as part of the population study Youth in Iceland in February 2010 and 2011 (N = 366, SGIC matching rate 61%). Baseline results for the matched and unmatched participants are compared. Findings indicate that the unmatched subjects are both more likely to be substance users than their matched counterparts as well as being more likely to be boys and/or from disrupted families. Five out of the seven scaled measures for risk and protective factors and personality indicators reveal no difference between the matched and unmatched subjects and the significantly different measures reveal small effect sizes between the two groups. However, the effect sizes for substance use are significantly different between the matched and unmatched groups for all seven substance use measures with effect sizes from 0.52 to 1.32. These findings therefore indicate that the measurement validity of adolescent risk behaviors such as substance use may be put in jeopardy when using SGIC and that unmatched subjects may be more likely to distrust the SGIC process.

Who is being reached for a telephone-delivered intervention for patients with uncontrolled hypertension?

BACKGROUND: Telephone-delivered interventions to provide health counseling for complex chronic medical conditions are convenient, acceptable, and cost-effective. However, little is known about which patients are reached, their characteristics, and who benefits most from telephone-delivered counseling. MATERIALS AND METHODS: This study examined whether baseline characteristics are predictive of being easily reached for a monthly, telephone-delivered behavioral intervention to improve treatment adherence in Veterans with uncontrolled hypertension. Participants were to complete a telephone session once a month for 6 months. RESULTS: Participants completed an average of 5.71 out of a possible 6 sessions. Participants who were unmarried, African American, unemployed, or younger or did not complete high school required significantly more call attempts per completed session. CONCLUSIONS: Overall, telephone-delivered counseling is a feasible approach to reaching hypertensive patients. Patients who are married, Hispanic, retired, or older or graduated college may be easier to reach and engage in telephone-delivered counseling. Reaching patients with other sociodemographic characteristics may require more resources or alternate methods.

HIV testing sites' communication about adolescent confidentiality: potential barriers and facilitators to testing.

PURPOSE: This study sought to evaluate HIV testing locations in New York City in terms of staff communication of confidentiality policies for adolescent clients. METHOD: Using the New York State Directory of HIV Counseling and Testing Resources as a sampling frame, this study made telephone contact with 164 public HIV testing locations in New York City and used a semistructured interview to ask questions about confidentiality, parental permission, and parent access to test results. RESULTS: At 48% of locations, either HIV testing was not offered or we were unable to reach a staff member to ask questions about testing options and confidentiality. At the remaining sites, information provided regarding confidentiality, parental consent, and privacy of test results was correct only 69% to 85% of the time. Additionally, 23% of sites successfully contacted offered testing exclusively between 9:00 a.m. and 3:00 p.m. weekdays, when most adolescents are in school. CONCLUSIONS: Our findings point to a need for increased training and quality control at the clinical level to ensure that consumers in need of HIV testing are provided with accurate information and accessible services. Furthermore, these results highlight the need for more "patient-centric" sites with enhanced accessibility for potential clients, particularly youth.