Health behavior change in advance care planning: an agent-based model.

BACKGROUND: A practical and ethical challenge in advance care planning research is controlling and intervening on human behavior. Additionally, observing dynamic changes in advance care planning (ACP) behavior proves difficult, though tracking changes over time is important for intervention development. Agent-based modeling (ABM) allows researchers to integrate complex behavioral data about advance care planning behaviors and thought processes into a controlled environment that is more easily alterable and observable. Literature to date has not addressed how best to motivate individuals, increase facilitators and reduce barriers associated with ACP. We aimed to build an ABM that applies the Transtheoretical Model of behavior change to ACP as a health behavior and accurately reflects: 1) the rates at which individuals complete the process, 2) how individuals respond to barriers, facilitators, and behavioral variables, and 3) the interactions between these variables. METHODS: We developed a dynamic ABM of the ACP decision making process based on the stages of change posited by the Transtheoretical Model. We integrated barriers, facilitators, and other behavioral variables that agents encounter as they move through the process. RESULTS: We successfully incorporated ACP barriers, facilitators, and other behavioral variables into our ABM, forming a plausible representation of ACP behavior and decision-making. The resulting distributions across the stages of change replicated those found in the literature, with approximately half of participants in the action-maintenance stage in both the model and the literature. CONCLUSIONS: Our ABM is a useful method for representing dynamic social and experiential influences on the ACP decision making process. This model suggests structural interventions, e.g. increasing access to ACP materials in primary care clinics, in addition to improved methods of data collection for behavioral studies, e.g. incorporating longitudinal data to capture behavioral dynamics.

Financial distress and depressive symptoms among African American women: identifying financial priorities and needs and why it matters for mental health.

Prior research found that financial hardship or distress is one of the most important underlying factors for depression/depressive symptoms, yet factors that contribute to financial distress remain unexplored or unaddressed. Given this, the goals of the present study were (1) to examine the relationship between perceived financial distress and depressive symptoms, and (2) to identify financial priorities and needs that may contribute to financial distress. Surveys from 111 African American women, ages 18-44, who reside in Allegheny County, PA, were used to gather demographic information and measures of depressive symptoms and financial distress/financial well-being. Correlation and regression analyses revealed that perceived financial distress was significantly associated with levels of depressive symptoms. To assess financial priorities and needs, responses to two open-ended questions were analyzed and coded for common themes: "Imagine you won a $10,000 prize in a local lottery. What would you do with this money?" and "What kinds of programs or other help would be beneficial to you during times of financial difficulties?" The highest five priorities identified by the participants were paying bills and debt, saving, purchasing a home or making home repairs, and/or helping others. The participant's perceived needs during times of financial difficulty included tangible assistance and/or financial education. The findings from this study can be used to create new and/or enhance existing programs, services, and/or interventions that focus on the identified financial priorities and needs. Collaborative efforts among professionals in different disciplines are also needed, as ways to manage and alleviate financial distress should be considered and discussed when addressing the mental health of African American women.

School closure as an influenza mitigation strategy: how variations in legal authority and plan criteria can alter the impact.

BACKGROUND: States' pandemic influenza plans and school closure statutes are intended to guide state and local officials, but most faced a great deal of uncertainty during the 2009 influenza H1N1 epidemic. Questions remained about whether, when, and for how long to close schools and about which agencies and officials had legal authority over school closures. METHODS: This study began with analysis of states' school-closure statutes and pandemic influenza plans to identify the variations among them. An agent-based model of one state was used to represent as constants a population's demographics, commuting patterns, work and school attendance, and community mixing patterns while repeated simulations explored the effects of variations in school closure authority, duration, closure thresholds, and reopening criteria. RESULTS: The results show no basis on which to justify statewide rather than school-specific or community-specific authority for school closures. Nor do these simulations offer evidence to require school closures promptly at the earliest stage of an epidemic. More important are criteria based on monitoring of local case incidence and on authority to sustain closure periods sufficiently to achieve epidemic mitigation. CONCLUSIONS: This agent-based simulation suggests several ways to improve statutes and influenza plans. First, school closure should remain available to state and local authorities as an influenza mitigation strategy. Second, influenza plans need not necessarily specify the threshold for school closures but should clearly define provisions for early and ongoing local monitoring. Finally, school closure authority may be exercised at the statewide or local level, so long as decisions are informed by monitoring incidence in local communities and schools.

Preparedness for pandemics: does variation among states affect the nation as a whole?

OBJECTIVE: Since states' public health systems differ as to pandemic preparedness, this study explored whether such heterogeneity among states could affect the nation's overall influenza rate. DESIGN: The Centers for Disease Control and Prevention produced a uniform set of scores on a 100-point scale from its 2008 national evaluation of state preparedness to distribute materiel from the Strategic National Stockpile (SNS). This study used these SNS scores to represent each state's relative preparedness to distribute influenza vaccine in a timely manner and assumed that "optimal" vaccine distribution would reach at least 35% of the state's population within 4 weeks. The scores were used to determine the timing of vaccine distribution for each state: each 10-point decrement of score below 90 added an additional delay increment to the distribution time. SETTING AND PARTICIPANTS: A large-scale agent-based computational model simulated an influenza pandemic in the US population. In this synthetic population each individual or agent had an assigned household, age, workplace or school destination, daily commute, and domestic intercity air travel patterns. MAIN OUTCOME MEASURES: Simulations compared influenza case rates both nationally and at the state level under 3 scenarios: no vaccine distribution (baseline), optimal vaccine distribution in all states, and vaccine distribution time modified according to state-specific SNS score. RESULTS: Between optimal and SNS-modified scenarios, attack rates rose not only in low-scoring states but also in high-scoring states, demonstrating an interstate spread of infections. Influenza rates were sensitive to variation of the SNS-modified scenario (delay increments of 1 day versus 5 days), but the interstate effect remained. CONCLUSIONS: The effectiveness of a response activity such as vaccine distribution could benefit from national standards and preparedness funding allocated in part to minimize interstate disparities.

The impact of dental benefits on the utilization of dental services by low-income children in western Pennsylvania.

PURPOSE: This study examines the impact of dental coverage provided through a health insurance program for low-income children on the use of dental services in Western Pennsylvania. METHODS: A before-after design with a control group was used. Telephone interviews were conducted with the families of newly enrolled children at the time of enrollment, at 6 months and at 12 months after enrollment. Both structured and open-ended questions were asked about the use of health care services, unmet need/delayed care and causes and consequences of unmet need/delayed care. A second group of families were interviewed 12 months after the study group was initially interviewed to form a comparison sample. The study population consisted of 750 children who were continuously enrolled in the program for 12 months and 460 comparison children. RESULTS: After enrollment, the proportion of children with a regular source of dental care increased 42%, while the proportion of those who had a preventive dental visit increased 50%. The proportion of children reporting unmet need/delayed care for dental services fell from 43% to 10%. The program had a larger impact on the use of dental services than on the use of medical services. CONCLUSIONS: The extension of dental benefits to SCHIP-eligible children in Western Pennsylvania had a positive impact on children by increasing their access to dental care and to preventive dental services.

Disparities and access to healthy food in the United States: A review of food deserts literature.

Increasingly, studies are focusing on the role the local food environment plays in residents' ability to purchase affordable, healthy and nutritious foods. In a food desert, an area devoid of a supermarket, access to healthy food is limited. We conducted a systematic review of studies that focused on food access and food desert research in the United States. The 31 studies identified utilized 9 measures to assess food access. Results from these studies can be summarized primarily into four major statements. Findings from other countries offer insight into ways, in which future research, policy development and program implementation in the U.S. may continue to be explored.