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The school closures necessitated by the COVID-19 pandemic created a rapid shift to alternative modes of educational delivery, primarily online learning and teacher-supported home-schooling. This shift has revealed deep inequities in education systems worldwide, as many children lost access to teachers and schooling. An effective response to these changes has tested teachers' personal capacities and individual and collective agency intensely. The research lab we report on within this paper aimed to develop a better understanding of teacher agency in meeting the challenges of the pandemic and the physical and relational enablers and constraints of their environment. Drawing on case study reports from six international contexts and a series of online discussions with research lab participants, this study explores teachers' enactment of agency in the context of various circumstances and environments. The authors argue that it is imperative that education systems support the enhancement of teachers' personal and collective agency in the face of continued disruption to schooling and ongoing challenges to educational equity.

Mediation analysis refers to the process of making inferences on effects of third variables that intervene in the relationship between an exposure and response variable. The relationships among variables can be modelled by generalized linear models (GLM). However, GLM are not sufficient to describe relationships among variables when there are nonlinear relationships and potential interaction effects. A general mediation analysis method was developed using not only GLMs, but also multiple additive regression trees and smoothing splines by Yu and Li (2017). The method is implemented in the R package, mma. In this paper, we developed SAS macros so that functions in the mma package can be called and the mediation analysis performed in the SAS environment. Funding statement: Research reported in this publication was supported by the National Institute On Minority Health And Health Disparities of the National Institutes of Health under Award Number R15MD012387. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

The objective was to evaluate a multidisciplinary guideline-driven disease management program focused on achievement of asthma control among sustained patients with confirmed asthma in Louisiana and to assess factors affecting achievement of asthma control. Data were extracted from the electronic health records of 1596 adults with confirmed asthma, sustained care for1 year in the outpatient setting, and ≥2 recorded Asthma Control Test (ACT) scores. Multivariable logistic regression modeling was used to assess the association of demographic variables, comorbidities, and process measures with the best achieved asthma control as represented by the highest ACT score. Most subjects were female (81.1%) and African American (63.9%). Approximately half of them (48.9%) were able to achieve asthma control (ACT ≥20). The most prevalent comorbidities were hypertension (79.8%), rhinitis (55.3%), and obesity (50.5%). Most patients received pulmonary function testing (PFT) (88.6%), controller medication therapy (85.5%), or written asthma action plans (92.7%). Asthma control was positively associated with presence of PFT (OR = 1.63, 95% CI: 1.13, 2.37) and being a "never" smoker (OR = 1.49, 95% CI: 1.08, 2.04). Asthma control was less likely to be achieved by patients who were African American (OR = 0.68, 95% CI: 0.52, 0.87), had more comorbidities (OR = 0.89, 95% CI: 0.83, 0.96), or were on more medications (OR = 0.79, 95% CI: 0.72, 0.88). Asthma control was achieved in 48.9% of an adult, primarily African American population with the implementation of comprehensive guideline-driven care. Furthermore, this is the first study to observe that the presence of PFT may be associated with asthma control.

Little is known about the relationship between freestanding children's hospitals and outcomes in children with critical illness. The purpose of this study was to evaluate the association of freestanding children's hospitals with outcomes in children with critical illness.Propensity score matching was performed to adjust for potential confounding variables between patients cared for in freestanding or nonfreestanding children's hospitals. We tested the sensitivity of our findings by repeating the primary analyses using inverse probability of treatment weighting method and regression adjustment using the propensity score.Retrospective study from an existing national database, Virtual PICU Systems (LLC) database.Patients less than 18 years old admitted to one of the participating PICUs in the Virtual PICU Systems, LLC database were included (2009-2014).None.A total of 538,967 patients from 140 centers were included. Of these, 323,319 patients were treated in 60 freestanding hospitals. In contrast, 215,648 patients were cared for in 80 nonfreestanding hospitals. By propensity matching, 134,656 patients were matched 1:1 in the two groups (67,328 in each group). Prior to matching, patients in the freestanding hospitals were younger, had greater comorbidities, had higher severity of illness scores, had higher incidence of cardiac arrest, had higher resource utilization, and had higher proportion of patients undergoing complex procedures such as cardiac surgery. Before matching, the outcomes including mortality were worse among the patients cared for in the freestanding hospitals (freestanding vs nonfreestanding, 2.5% vs 2.3%; p0.001). After matching, the majority of the study outcomes were better in freestanding hospitals (freestanding vs nonfreestanding, mortality: 2.1% vs 2.8%, p0.001; standardized mortality ratio: 0.77 [0.73-0.82] vs 0.99 [0.87-0.96], p0.001; reintubation: 3.4% vs 3.8%, p0.001; good neurologic outcome: 97.7% vs 97.1%, p = 0.001).In this large observational study, we demonstrated that ICU care provided in freestanding children's hospitals is associated with improved risk-adjusted survival chances compared to nonfreestanding children's hospitals. However, the clinical significance of this change in mortality should be interpreted with caution. It is also possible that the hospital structure may be a surrogate of other factors that may bias the results.

Models of care coordination can significantly improve health outcomes for older adults with chronic illnesses if they can engage participants. The purpose of this study was to examine the impact of nursing contact on the rate of participants’ voluntary disenrollment from a care coordination program. In this retrospective cohort study using administrative data for 1,524 participants in the Health Quality Partners Medicare Care Coordination Demonstration Program, the rate of voluntary disenrollment was approximately 11%. A lower risk of voluntary disenrollment was associated with a greater proportion of in-person (vs. telephonic) nursing contact (Hazard Ratio [HR] 0.137, confidence interval [CI] [0.050, 0.376]). A higher risk of voluntary disenrollment was associated with lower continuity of nurses who provided care (HR 1.964, CI [1.724, 2.238]). Findings suggest that in-person nursing contact and care continuity may enhance enrollment of chronically ill older adults and, ultimately, the overall health and well-being of this population

Background: Alcohol intake is a leading modifiable cause related to cancer-specific deaths. Various alcohol intake patterns have shown to impact cancer progression differently, however, many studies only evaluated simplified patterns (such as heavy vs. non-heavy drinking) of alcohol intake for cancer survivors. The objective of this study is to provide population-based prevalence of the complex alcohol drinking patterns for cancer survivors, and compare it with that of non-cancer individuals. Additionally, we evaluated the impact of cancer related factors (binary, alcohol-related cancer type, and length of cancer history) to the alcohol intake patterns adjusted for the selected factors. Methods: A total of 193,197 individuals, including 16,504 cancer survivors, with age ≥18 years old in the 2012–2017 National Health Interview Survey (NHIS) were included in this study. The population-based prevalence of alcohol patterns was estimated. To evaluate cancer related factors associated with the alcohol intake patterns, we applied multinomial logistic models with the appropriate sampling weights and adjusted the selected demographic factors and smoking status. Results: There were 62.1% of cancer survivors and 66.0% of non-cancer individuals who were current alcohol drinkers in the past year. The prevalence of heavy drinking was identical for 5.2% of cancer and non-cancer individuals. For frequent binge drinking, cancer survivors tended to have less frequent binge than non-cancer individuals (2.8% vs . 4.9%). After adjusting for the selected demographic factors and smoking status, the cancer survivors were less likely to have the intermediate level of alcohol intake (light/moderate or occasional binge drinking) compared with non-cancer individuals, but no difference for the excessive alcohol intake (heavy or frequent binge drinking) was observed for those with and without cancer. As for cancer type, those with non-alcohol related cancer tended to be a current drinker compared with those with alcohol-related cancer. Compared with cancer survivors with a short cancer history (2–4 years), survivors with a cancer history of 5–9 years were more likely to be current drinkers after adjusting for the selected factors. Cancer status, alcohol-related cancer type and length of cancer history had no impact on excessive alcohol intake. Conclusions: In summary, cancer survivors have similar excessive alcohol drinking patterns but were less likely to have the intermediate level of alcohol intake compared to non-cancer individuals. Alcohol intake may enhance cancer progression, interfere with cancer treatments and increase cancer-related mortality. To improve cancer survivors’ health, custom alcohol interventions and cessation programs should be conducted to minimize alcohol intake for cancer survivors, especially for excessive alcohol drinkers.

Objective Obese youth are more likely to report difficulties with sleep, depression, and quality of life (QOL). This study aims to characterize sleep problems, QOL, and symptoms of depression by degree of obesity. Method The cross-sectional study was conducted in a specialized obesity clinic. Obese youth and their caregivers (N = 150) were evaluated with the Child Sleep Habits Questionnaire and Pediatric Quality of Life. Youth completed the Children's Depression Inventory. Regression models and correlations were calculated. Results Degree of obesity was predictive of increased sleep difficulties and decreased QOL scores. Children's Depression Inventory scores showed that children with more symptoms of depression had more sleep problems, and these were not associated with the degree of obesity. Adolescents with more difficulties sleeping also reported more symptoms of depression and lower QOL. Conclusions Degree of obesity negatively affected QOL and sleep variables. Patients with greater sleeping difficulties reported more symptoms of depression.

Models of care coordination can significantly improve health outcomes for older adults with chronic illnesses if they can engage participants. The purpose of this study was to examine the impact of nursing contact on the rate of participants' voluntary disenrollment from a care coordination program. In this retrospective cohort study using administrative data for 1,524 participants in the Health Quality Partners Medicare Care Coordination Demonstration Program, the rate of voluntary disenrollment was approximately 11%. A lower risk of voluntary disenrollment was associated with a greater proportion of in-person (vs. telephonic) nursing contact (Hazard Ratio [HR] 0.137, confidence interval [CI] [0.050, 0.376]). A higher risk of voluntary disenrollment was associated with lower continuity of nurses who provided care (HR 1.964, CI [1.724, 2.238]). Findings suggest that in-person nursing contact and care continuity may enhance enrollment of chronically ill older adults and, ultimately, the overall health and well-being of this population.

BACKGROUND When managing patients with disorders that require clinical intervention, a practical assessment of body habitus is valued. The Duffull-Green lean body weight (LBW) equation was derived and validated in adults across a wide body mass index (BMI) range. Whether this predictive equation will perform well in patients at BMI extremes or perform better than a widely used empiric "ideal" body weight (IBW) equation is unknown. MATERIALS AND METHODS Calculated LBW and calculated IBW were each compared with the dual-energy x-ray absorptiometry (DXA)-derived lean body mass (LBM) by simple linear regression. A mixed model was used to determine how well the LBW equation performed over time in patients with more than 1 DXA measurement. RESULTS At time 0, 32 patients were 18-67 years old, and all were obese (BMI: 36-65 kg/m2), while the remaining 7 had parenteral nutrition-dependent intestinal failure (BMI: 17-25 kg/m2). A subset of patients underwent bariatric surgery after time 0 (BMI at follow-up: 22-49 kg/m2). The LBW equation was a predictor of LBM ( R2 = 0.67, P < .0001), while the IBW equation was not ( R2 = 0.04, P = .25). The LBW equation remained a predictor of LBM over time ( P < .0001) without significant interaction by number of months since time 0. CONCLUSION The Duffull-Green LBW equation successfully predicted lean body mass in a patient population with a wide range of BMIs at both a single point in time and after considerable weight loss. In the clinical setting, an equation that performs well in various disease states and body sizes is advantageous.

Purpose. To elucidate factors that impact intention (INT) to be active as well as actual physical activity (PA) behavior in colorectal cancer survivors (CRC-S) using the theory of planned behavior (TpB). Planning for PA was explored as a mediator of the INT-behavior relationship. Chemotherapy-induced neuropathy and fatigue were also explored. Design. A cross-sectional quantitative mailed survey was used. Setting. The study was conducted among community-dwelling adults living in Pennsylvania when diagnosed with colorectal cancer (CRC). Subjects. Subjects comprised 843 CRC-S diagnosed with CRC in Pennsylvania in 2009. Measures. The survey included questions about planning for PA, TpB constructs, medical and social variables, and PA as measured by a modified Godin Leisure Time Questionnaire. Analysis. Descriptive statistics were used to characterize the sample. A mediation analysis was used to determine if planning mediated the relationship between INT and actual PA behavior. A stepwise regression was used to determine predictors of INT and PA. Results. Ninety-six CRC-S responded, with 25% meeting PA recommendations for health promotion, suggesting that CRC-S are insufficiently active. Perceived behavioral control (PBC) and social norm (SN) accounted for 43% of the variance in INT, whereas 30% of the variance in PA was explained by PBC and age. Neuropathy negatively impacted PA behavior (p = .008). Both action and coping planning partially mediated the INT-behavior relationship (β = 20.08, p = .007; β = 22.85, p = .001, respectively). Conclusion. Survivors at risk for inactivity are those with low PBC, low SN, and neuropathy, and those who are older.

Background Despite reports that persons with heart failure (HF) symptoms delay up to 7 days before seeking treatment, few studies have prospectively explored specific factors influencing treatment-seeking delay in this population. Objective The purpose of this study was to explore how factors related to the symptom experience, such as perception (number and intensity), evaluation (attribution and understanding), and response (behaviors of patients and others) influence delay in seeking treatment for symptoms of acute decompensated HF. Methods Patients hospitalized for acute HF were enrolled into an exploratory, descriptive study. Only those who had HF for 3 months or longer and a previous HF admission were eligible. Data on factors related to the symptom experience, response to symptoms, and delay time were collected by interview during hospitalization. Delay time measured in hours was analyzed using generalized linear modeling. Results The sample of 131 adults was predominately older (77 ± 11.3 years) men (55.7%). The median delay time was 60 hours (2.5 days), with a range of 1 to 336 hours (14 days). Only 34 (25.9%) sought care in less than 12 hours. Three variables were statistically significant determinants of long delay time-waiting to see if the symptoms would abate, receiving a passive response to symptoms from others, and living in a rural environment. These variables explained 13.9% of the variance in delay time. Clinical characteristics were not significant predictors of delay. Conclusions The response of patients (wait-and-see) and others (eg, don't worry) contributed to delay, as did living in a rural environment. Evaluative characteristics of attribution and understanding were not significant determinants of delay, suggesting that patient education alone will not effectively decrease delay. Instead, interventions directed toward decision making in response to symptoms and inclusion of family members in such discussions may be more effective.

Background: Physician stress is at a heightened level in the midst of a changing health care environment and limited research funding conditions. Burnout of physicians has an impact on their personal health, related institutional health care costs, retention of quality faculty, and patient care and safety. The present study was designed to assess levels of burnout and sources of stress in clinical, educational, and research faculty working in a Department of Pediatrics and a large Children’s Hospital setting.Methods: The self-report Maslach Burnout Inventory was given to the 240 faculty members in a large Department of Pediatrics based at a Children’s Hospital as part of a larger faculty development needs survey designed to inform faculty development programming. Participation in the survey was voluntarily, and was presented during a mandatory faculty meeting and then emailed to all faculty so those who were unable to attend could participate. A brief survey on sources of stress, stress-related illness, and wellness programming needs was also administered.Results: Out of the 240 faculty members, 86 surveys were collected and analyzed (36% response rate). 52% were female, 84% were Caucasian. Rank of respondents appeared fairly consistent with overall Departmental distribution (40% Assistant, 22% Associate, 34% Full, 4% Instructor). 48% of respondents were Clinical Educators, with 18% Basic Scientists, 17% Clinical Attendings, and 16% Clinical Scientists, also fairly consistent with overall Departmental distributions. Results suggest 65% of faculty endorse high levels of emotional exhaustion, 56% high levels of depersonalization, and 100% felt low levels of personal accomplishment. According to Maslach Burnout Inventory (MBI) cutoff criteria, 94% of respondents were above the cutoff for Burnout, much higher than recent, published national norms. The most frequently identified top stressors were: lack of connectedness to the institution, administrative responsibilities, time conflicts, clinical workload and general workload. The most frequently identified top stress symptoms experienced were: mood issues, health-related behaviors, and psychosomatic symptoms.Conclusions: Burnout rates at this institution are higher than national norms. From the data collected, faculty development programs to address coping with burnout and prevention such as strategies to promote resilience to stress will be provided. Faculty will be periodically provided with currently available sources of individual and group support and these will be easily available on the internal website. Institutional changes that may affect burnout rates should also be considered.