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Hispanic youth represent one of the fastest-growing minority groups. Yet, we know little about Hispanic adolescents' response to empirically-supported interventions for adolescent addiction, including motivational interviewing (MI). This randomized controlled trial (RCT) compared MI to an active educational treatment for adolescent alcohol and cannabis use (alcohol and cannabis education; ACE). Adolescents who regularly use substances (N = 448; n = 347 Hispanic; n = 101 non-Hispanic white; ages 13-18) were randomized to two 1-hr individual sessions of MI or ACE. We examined 6-month outcomes and mechanisms of change across Hispanic and non-Hispanic white youth. Treatment response was comparable across ethnicities (Hispanic vs. non-Hispanic white youth). Additionally, adolescents in the MI condition showed greater reductions in alcohol use compared to those in ACE, with support for motivation and self-efficacy as mechanisms of treatment response. Direct effects of MI on cannabis use were not observed; however, a significant indirect effect of motivation was observed for reductions in cannabis use. Data support the efficacy of MI in reducing adolescent alcohol use, through the vehicle of enhanced motivation and self-efficacy. While consistent treatment response was observed for adolescent alcohol use across ethnicities (Hispanic vs. non-Hispanic white), further exploration into potential underexplored mechanisms of Hispanic adolescents' treatment response is requisite to strengthening prevention and intervention programming for Hispanic adolescents' cannabis use. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Context The Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being Scale (FACIT-Sp) is a 12-item measure of spiritual well-being in chronic illness originally developed in patients with cancer. The overall scale, a two-factor model (meaning/peace, faith), and a three-factor model (meaning, peace, faith) have been proposed for the FACIT-Sp, and consensus on the best factor structure has not been reached. In addition, the factor structure of the FACIT-Sp has not been considered in patients with heart failure. Objectives To examine the factor structure of the FACIT-Sp in heart failure patients. Methods A confirmatory factor analysis framework was used to test three competing models on 217 patients with heart failure using data from the CASA (Collaborative Care to Alleviate Symptoms and Adjust to Illness) trial. The overall scale (single factor), two-factor, and three-factor models were tested using baseline data, then confirmed with 12-month data. Model modifications were made based on empirical inspection of baseline data and replicated using 12-month data. Cronbach's alpha and correlations with measures of quality of life and psychological health were examined. Results All three models had strong factor loadings on all items except the negatively worded items. The two-factor and three-factor models fit reasonably well after modifications, but the single factor did not fit well (1/2/3-factor: RMSEA 0.14/0.09/0.06, CFI 0.85/0.93/0.97, SRMR 0.09/0.05/0.04). Internal consistency was sufficient for all factors. Conclusion The two-factor and three-factor models were supported in heart failure patients. The three-factor model demonstrated better statistical fit but was not more interpretable. Key message This study investigated the factor structure of the FACIT-Sp in patients with heart failure. The two-factor and three-factor models were supported, but the single factor model was not. Negatively worded items did not perform well.

The COVID-19 pandemic has created disruptions and ethical tensions in palliative care research; however, ethical principles must continue to be applied for evaluating the safety of conducting research with seriously ill patient participants and nurse participants in an acute care setting. This randomized controlled trial is conducted in the acute care hospital and tests the effects of a narrative intervention versus usual care on the primary outcome of patients' perception of quality of communication with their nurses and the secondary outcome of biopsychosocial well-being. In accordance with local and institutional COVID-19 guidance, research activities were temporarily suspended in March 2020, and when allowed to resume, some aspects of the protocol were adapted to maximize safety for all stakeholders: patients/families, nurses, and the research team. This article (a) considers case perspectives of all stakeholders involved in a randomized controlled trial conducted in the acute care hospital setting during the COVID-19 pandemic, (b) describes the ethical dilemma and ethical principles in the context of the case, (c) discusses lessons learned while resuming clinical research activities, and (d) provides an ethical framework for the decision-making processes around vulnerability and safety in conducting research during a pandemic with persons living with serious illness.

BACKGROUND In the health care setting, electronic health records (EHRs) are one of the primary modes of communication about patients, but most of this information is clinician centered. There is a need to consider the patient as a person and integrate their perspectives into their health record. Incorporating a patient’s narrative into the EHR provides an opportunity to communicate patients’ cultural values and beliefs to the health care team and has the potential to improve patient-clinician communication. This paper describes the protocol to evaluate the integration of an adapted person-centered narrative intervention (PCNI). This adaptation builds on our previous research centered on the implementation of PCNIs. The adaptation for this study includes an all-electronic delivery of a PCNI in an outpatient clinical setting. OBJECTIVE This research protocol aims to evaluate the feasibility, usability, and effects of the all-electronic delivery of a PCNI in an outpatient setting on patient-reported outcomes. The first objective of this study is to identify the barriers and facilitators of an internet-based–delivered PCNI from the perspectives of persons living with serious illness and their clinicians. The second objective is to conduct acceptability, usability, and intervention fidelity testing to determine the essential requirements for the EHR integration of an internet-based–delivered PCNI. The third objective is to test the feasibility of the PCNI in an outpatient clinic setting. METHODS Using a mixed method design, this single-arm intervention feasibility study was delivered over approximately 3 to 4 weeks. Patient participant recruitment was conducted via screening outpatient palliative care clinic schedules weekly for upcoming new palliative care patient visits and then emailing potential patient participants to notify them about the study. The PCNI was delivered via email and Zoom app. Patient-reported outcome measures were completed by patient participants at baseline, 24 to 48 hours after PCNI, and after the initial palliative care clinic visit, approximately 1 month after baseline. Inclusion criteria included having the capacity to give consent and having an upcoming initial outpatient palliative care clinic visit. RESULTS The recruitment of participants began in April 2021. A total of 189 potential patient participants were approached via email, and 20 patient participants were enrolled, with data having been collected from May 2021 to September 2022. A total of 7 clinician participants were enrolled, with a total of 3 clinician exit interviews and 1 focus group (n=5), which was conducted in October 2022. Data analysis is expected to be completed by the end of June 2023. CONCLUSIONS The findings from this study, combined with those from other PCNI studies conducted in acute care settings, have the potential to influence clinical practices and policies and provide innovative avenues to integrate more person-centered care delivery. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/41787

Justice-involved youth are at a higher risk of negative outcomes from sexual activity and alcohol use relative to their non-justice involved peers. In the current study, we tested the extent to which variability in neurocognitive response (i.e., activation in the right superior parietal lobule; rSPL) during a risky decision-making task moderated the success of a sexual risk reduction intervention. In a cluster randomized trial blocked by gender, justice-involved adolescents (N = 269) first completed a risky decision-making task during a magnetic resonance imaging (MRI) session, then were assigned to an information-only control (GINFO) or sexual risk reduction intervention incorporating alcohol risk reduction content (GPI + GMET) and then re-contacted every three months for one year. Youth in the GPI + GMET intervention reported less sexual risk behavior 12 months after intervention than those in the control. Although neurocognitive activation was associated with sexual risk behavior, it did not moderate intervention outcomes. This risk-reduction intervention appears to work equally well across a range of neurocognitive responses.

Objective To identify clinical phenotypes of knee osteoarthritis (OA) using measures from the following domains: 1) multimorbidity; 2) psychological distress; 3) pain sensitivity; and 4) knee impairment or pathology. Design Data were collected from 152 people with knee OA and from 31 pain-free individuals. In participants with knee OA, latent profile analysis (LPA) was applied to the following measures: normalized knee extensor strength, Functional Comorbidity Index (FCI), Pain Catastrophizing Scale (PCS), and local (knee) pressure pain threshold. Comparisons were performed between empirically derived phenotypes from the LPA and healthy older adults on these measures. Comparisons were also made between pheonotypes on pain intensity, functional measures, use of health care, and history of knee injury. Results LPA resulted in a four-group solution. Compared with all other groups, group 1 (9% of the study population) had higher FCI scores. Group 2 (63%) had elevated pain sensitivity and quadriceps weakness relative to group 4 and healthy older adults. Group 3 (11%) had higher PCS scores than all other groups. Group 4 (17%) had greater leg strength, except relative to healthy older adults, and reduced pain sensitivity relative to all groups. Groups 1 and 3 demonstrated higher pain and worse function than other groups, and group 4 had higher rates of knee injury. Conclusion Four phenotypes of knee OA were identified using psychological factors, comorbidity status, pain sensitivity, and leg strength. Follow-up analyses supported the replicability of this phenotype structure, but future research is needed to determine its usefulness in knee OA care.

BACKGROUND: Adolescent obesity is associated with significant comorbidities including decreased quality of life (QOL). QOL improves after metabolic and bariatric surgery (MBS), but recent studies have demonstrated that certain gastrointestinal symptoms (GIS) worsen after surgery, including reflux symptoms, nausea, bloating and diarrhea. OBJECTIVE: The aim of this study was to evaluate QOL and the effect of these symptoms on QOL after bariatric surgery. SETTING: Five academic centers performing adolescent MBS in the United States. METHODS: We prospectively studied 228 adolescents undergoing MBS using the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) cohort. Gastrointestinal symptoms and QOL scores were assessed before surgery, at 6-months and yearly to 5 years after surgery. Analysis involved linear models examining QOL and the association between GIS and QOL adjusting for a priori determined covariates. RESULTS: Adjusting for body mass index (BMI) change over time, the physical component score (PCS) of the Short Form-36 (SF-36) increased after surgery from 44.2 at baseline to 54.4 at 5 years (p

Introduction: To identify longitudinal sleep trajectories in early childhood and examine the influence of sleep duration on obesity risk via BMI percentile (BMIp). Methods: Sleep, physical activity, and television viewing were measured in a cohort of 301 children, starting in 2001–2002, when children were 3 years and followed them through age 6. Nighttime sleep, daytime naps, and sleep duration were calculated. A series of latent growth curve models were used to estimate predictors of rate of change in sleep duration and BMIp overtime. A parallel process latent growth model examined the longitudinal relationship between sleep duration and BMIp simultaneously. Results: Most children (>80%) slept >10 hours per night across ages 3 to 6 years, despite the majority of children (>66%) having bedtimes after 9 pm. Sleep duration decreased on average by 0.22 (95% CI 0.20–0.24) hours each year of age (p

Background In the health care setting, electronic health records (EHRs) are one of the primary modes of communication about patients, but most of this information is clinician centered. There is a need to consider the patient as a person and integrate their perspectives into their health record. Incorporating a patient’s narrative into the EHR provides an opportunity to communicate patients’ cultural values and beliefs to the health care team and has the potential to improve patient-clinician communication. This paper describes the protocol to evaluate the integration of an adapted person-centered narrative intervention (PCNI). This adaptation builds on our previous research centered on the implementation of PCNIs. The adaptation for this study includes an all-electronic delivery of a PCNI in an outpatient clinical setting. Objective This research protocol aims to evaluate the feasibility, usability, and effects of the all-electronic delivery of a PCNI in an outpatient setting on patient-reported outcomes. The first objective of this study is to identify the barriers and facilitators of an internet-based–delivered PCNI from the perspectives of persons living with serious illness and their clinicians. The second objective is to conduct acceptability, usability, and intervention fidelity testing to determine the essential requirements for the EHR integration of an internet-based–delivered PCNI. The third objective is to test the feasibility of the PCNI in an outpatient clinic setting. Methods Using a mixed method design, this single-arm intervention feasibility study was delivered over approximately 3 to 4 weeks. Patient participant recruitment was conducted via screening outpatient palliative care clinic schedules weekly for upcoming new palliative care patient visits and then emailing potential patient participants to notify them about the study. The PCNI was delivered via email and Zoom app. Patient-reported outcome measures were completed by patient participants at baseline, 24 to 48 hours after PCNI, and after the initial palliative care clinic visit, approximately 1 month after baseline. Inclusion criteria included having the capacity to give consent and having an upcoming initial outpatient palliative care clinic visit. Results The recruitment of participants began in April 2021. A total of 189 potential patient participants were approached via email, and 20 patient participants were enrolled, with data having been collected from May 2021 to September 2022. A total of 7 clinician participants were enrolled, with a total of 3 clinician exit interviews and 1 focus group (n=5), which was conducted in October 2022. Data analysis is expected to be completed by the end of June 2023. Conclusions The findings from this study, combined with those from other PCNI studies conducted in acute care settings, have the potential to influence clinical practices and policies and provide innovative avenues to integrate more person-centered care delivery. International Registered Report Identifier (IRRID) DERR1-10.2196/41787

Background Health literacy (HL) is the “ability to find, understand, evaluate and put information to use to improve decision making and, ultimately, improve health and quality of life.” Parents with limited HL are less likely to follow recommended parental oral health behaviors. Purpose We tested a theoretical framework designed to clarify mechanisms through which HL may influence parental oral health behavior. The framework proposed that HL: (a) has a direct effect on parental oral health knowledge, beliefs (i.e. self-efficacy; perceived susceptibility, severity, benefits, barriers), and behavior; (b) influences beliefs indirectly through knowledge; and (c) influences behavior indirectly through knowledge and beliefs. Methods We analyzed cross-sectional data from a randomized controlled trial designed to reduce dental decay in American Indian children (N = 521). Parents completed survey questions assessing sociodemographic characteristics, HL, and parental oral health knowledge, beliefs, and behavior. Path analysis was used to test the framework. Results HL exerted significant direct effects on knowledge and beliefs but not behavior. HL had significant indirect effects on all beliefs through knowledge. Significant indirect effects of HL on behavior occurred through self-efficacy (estimate: 0.99, 95% CI: 0.42, 1.83, p = .005), perceived barriers (estimate: 0.73, 95% CI: 0.29, 1.43, p = .010), knowledge to self-efficacy (estimate: 0.57, 95% CI: .31, 0.98, p = .001), and knowledge to perceived barriers (estimate: 0.24, 95% CI: 0.09, 0.47, p = .012). Conclusions HL exerted an indirect effect on parental oral health behavior, with knowledge, self-efficacy, and perceived barriers being the primary constructs linking HL to behavior.

Background Delayed time to listing (TTL) for pediatric transplant patients is associated with increased risks of mortality and morbidity. The full range of health disparities, sociodemographic factors, and other barriers associated with delays in listing in the pediatric transplant candidate evaluation process has not been fully examined. Methods Retrospective chart reviews were conducted for 183 kidney, liver, and heart transplant candidates ages 0-18 who were referred for evaluation during 2012-2015. Demographic information and potential barriers (e g., social/medical factors, financial concerns) were gathered from pre-transplant evaluations and included in a comprehensive model to evaluate mechanisms that explain differences in TTL. Descriptive statistics, logistic regression models, Cox proportional hazards models, and path analysis were used for analyses. Results Candidates included 26.8% heart, 33.3% liver, and 39.9% kidney patients. The most common barrier to listing was financial (71.6%), followed by caregiver psychological or substance use (57.9%), and medical problems (49.7%). Higher age, kidney, and liver organ type (relative to the heart), and presence of social, medical, administrative/motivation, and financial barriers were all directly associated with longer TTL. Public insurance was indirectly associated with TTL through social, administrative/motivation, and financial barriers. Organ type was indirectly associated with TTL through financial barriers. Conclusions Results suggest social problems, administrative issues, and financial issues act as mechanisms through which insurance type and liver transplant candidates face increased risk of delays in transplant listing time. There are numerous clinical implications and interventions that are warranted to reduce TTL among pediatric transplant candidates with co-occurring barriers.

In cross-sectional studies, parental health literacy (HL) is associated with children’s oral health. It is unclear, however, whether HL influences pediatric outcomes. We examined the relationship of HL with change over time in parental oral health knowledge, beliefs, and behaviors, as well as pediatric oral health outcomes. We used longitudinal data from a study designed to reduce dental decay in American Indian children (N = 579). At baseline and annually for three years, parents answered questions assessing HL, oral health knowledge, beliefs, and behaviors, and pediatric oral health status. The number of decayed, missing, and filled tooth surfaces (dmfs) was computed based on annual dental evaluations. Linear mixed models showed that HL was significantly associated with all constructs, except dmfs, at their reference time points and persistently across the three-year study period. HL predicted change over time in only one variable, parents’ belief that children’s oral health is determined by chance or luck. HL is strongly associated with oral health knowledge, beliefs, behaviors, and status prospectively but is not a key driver of change over time in these oral health constructs.

Objectives: To examine the relationship between ethnic identity and oral health knowledge, beliefs, behavior, and outcomes in American Indian families. Methods: Secondary data were analyzed for 579 parent–child dyads in a randomized controlled trial aimed at reducing early childhood caries in a Northern Plains tribal community. Data included demographic characteristics, parental ethnic identity, oral health knowledge, beliefs, and behavior, and parental/pediatric oral health outcomes. Ethnic identity was assessed using two measures: perceived importance of tribal identity and tribal language proficiency. We examined the association of baseline ethnic identity with baseline and longitudinal oral health measures. Results: At baseline, importance of tribal identity was significantly associated with several oral health beliefs, and one’s locus of control measure (external-chance). Baseline scores on importance of tribal identity were also associated with one’s oral heath belief (perceived severity), the same locus of control measure, and oral health knowledge and behavior over the three years of study follow up. Tribal language proficiency was not associated with any study measures at baseline, although it was associated with parental oral health status over the three years. Conclusions: Ethnic identity was associated with a range of oral health constructs expected to influence American Indian children’s oral health.

STUDY OBJECTIVES: Given the uncertainty COVID-19 has caused for individuals with prior medical conditions, we examined the extent to which cancer survivors consider themselves at risk for the global COVID-19 pandemic (henceforth COVID), both in general and due to their cancer history. Additionally, we evaluated whether perceived vulnerability to COVID among cancer survivors predicts their cognitive/affective and behavioral responses to the pandemic. DESIGN/SAMPLE: Cancer survivors who completed primary cancer treatment (median months since treatment=33.00) and were enrolled in prior behavioral trials with our research team (N=146) completed two surveys in May-July 2020 (95.89% retention). METHODS: Participants rated perceived next-year risk of infection and of dying from COVID. We adapted established scales to assess perceived vulnerability to COVID generally versus as a cancer survivor, catastrophizing about possible COVID symptoms, COVID-related contamination fears, and adherence to COVID prevention behaviors. FINDINGS: In May 2020, on a 1–100 scale with 0=no chance and 100=definitely will occur, cancer survivors reported a chance in the next year of contracting COVID of M=39.94 (SD=23.90), and dying from COVID of M=24.46 (SD=24.84). Cancer survivors reported somewhat greater vulnerability to COVID compared to same-aged peers, increased contamination fears, and high adherence to COVID prevention measures. Similar findings emerged six weeks later, suggesting stability over time. In simple linear regression models, both general and cancer survivor-specific perceived COVID vulnerability predicted COVID symptom catastrophizing and contamination fears; in multivariable models, only general vulnerability remained a significant predictor. General perceived vulnerability and contamination fears predicted greater adherence to COVID prevention behaviors. CONCLUSIONS: Cancer survivors perceived elevated vulnerability to COVID even years after treatment, which predicted adherence to COVID prevention behaviors. Future research should identify the optimal balance between supporting cancer survivors’ concerns and minimizing negative impacts on quality of life.

Depression, pain, and fatigue are common and bothersome symptoms in heart failure, a serious illness in older adults. Understanding longitudinal pathways among depression, pain, and fatigue in heart failure could inform treatment and improve quality of life.We completed secondary, longitudinal data analyses of a sample of older adults with heart failure (baselineDepressive symptoms were associated with new onset of pain symptoms; however, this association was mediated by fatigue. Pain was not associated with new depression or fatigue symptoms in this sample.In patients with heart-failure, worsening pain symptoms appear to be directly related to levels of depression and fatigue. These findings demonstrate that depression and fatigue may be key to reducing pain symptoms in this population.

Objective: This experiment examined whether people respond differently to information about where they stand relative to peer behaviour or to expert behavioural recommendations, and whether respons...

Background Individual health behaviors (ie, eating habits and sedentary lifestyle) are associated with type 2 diabetes (T2D). Health behavior profiles specific to adolescents with T2D have not been described. Objective To identify health behavior profiles in adolescents with T2D and examine how these profiles change over time. Methods Diet (via food frequency questionnaire) and activity behaviors (via 3-day physical activity recall) examined at baseline, 6 months, and 24 months from participants in the the Treatment Options for T2D in Adolescents and Youth (TODAY) study were used for this analysis. Latent profile analysis identified profiles of health behaviors within three time points, and latent transition probabilities were estimated to examine the change from baseline to 6 months (n = 450) and baseline to 24 months (n = 415). Multinomial logistic regressions were used to examine if the assigned TODAY treatment group (Metformin [Met], Met + Rosiglitazone [Rosi], or Met + Lifestyle) predicted change in health behavior profiles. Results Three profiles emerged: "most sedentary," "healthy eaters," and "active and eat most." At 6 months, 50% of males and 29% of females in the Met + Lifestyle treatment group improved in their health behavior profile. Among males only, the Met + Lifestyle treatment group were more likely to improve their profiles from baseline to 6 months (P = .01). Conclusions Three health behavior profiles emerged and shifted over time. A high quality, lifestyle intervention had little effect on improving health behavior profiles. Optimizing outcomes in youth with T2D might require more robust and multifaceted interventions beyond family-level lifestyle, including more extensive psychosocial intervention, novel medication regimen, or bariatric surgery.

In this chapter, we follow a young Latina woman named Lourdes as she attempts to balance her own aspirations for a career with her own growth as a young adult in a new sexual relationship. Neither she nor her partner know enough about contraception to take steps they think are important to avoid having children right now. Her solution is one that is growing increasingly common—she combines participation in a face-to-face youth development program with a text-messaging program to carefully consider and choose the contraceptive option that is most appropriate for her. Lourdes’ story offers a case study of a growing number of sexual and reproductive health programs that include or may exclusively use mobile and digital technologies such as smartphones to communicate critical information about contraception. We explore the Youth All Engaged! (YAE!) Text messaging curriculum, developed as a series of text messages intended to supplement and enhance face-to-face curricula on sexual health. Specifically, we investigate whether a particular dose of the YAE! program is more beneficial to increase adoption of contraception and avoidance of pregnancy. Looking at data from 854 14–18 year old youth participating in the YAE! program in addition to a face-to-face youth development program sponsored by the Boys & Girls Clubs of Metropolitan Denver, we learned that youth who participated less frequently in face-to-face sessions but engaged with YAE! text messages had greater self-efficacy for condom use; this finding did not extend to youth with greater in-person participation. Given the almost universal use of cell phones among youth, we believe there is ample opportunity to reach them using text messages to support sexual health. The data from this case study suggest that text messaging can be beneficial, particularly for youth who may not be able to participate as fully in face-to-face sexual health interventions.

BACKGROUND: Incorporating a patient’s personal narrative into the electronic health record is an opportunity to more fully integrate the patient’s values and beliefs into care, thus creating opportunities to deliver high-quality/high-value, person-centered care. OBJECTIVES: The aim of the study was to present a study protocol of a narrative intervention to (a) compare the effects of the narrative intervention to usual care on primary outcome of person’s (patient) perceptions of quality of communication, (b) compare the effects of the narrative intervention on secondary outcomes of biopsychosocial well-being, and (c) examine the feasibility and acceptability of the narrative intervention from the perspective of both persons: the patient and the acute care bedside nurse. METHODS: A randomized control trial is being conducted with a targeted enrollment of 80 patient participants and 80 nurse participants. The patient participants include individuals who are admitted to the acute care hospital for either heart failure or end-stage renal disease. An acute care beside nurse who has cared for the patient participant is also enrolled. Through a 1:1 random allocation scheme, stratified by illness, we will enroll 40 in the narrative intervention group and 40 in the usual care group. Patient participants will be assessed for patient-reported outcomes of patient’s perception of quality of communication and biopsychosocial well-being. RESULTS: The study began in October 2019; 53 potential patient participants have been approached, 21 have enrolled, and 20 have completed the data collection process. DISCUSSION: The testing and integration of a person-centered narrative into the electronic health record is a novel approach to provide opportunities for improvement in communication between patients and nurses. The results from this study will provide important preliminary knowledge to inform future randomized clinical trials of narrative interventions leading to advances in how to best provide high-value, high-quality, person-centered care for persons living with serious illness.

Objective Studies of dehydroepiandrosterone (DHEA) therapy in older adults suggest sex-specific effects on bone mineral density (BMD) and body composition, but the ability of a single study to reach this conclusion was limited. We evaluated the effects of DHEA on sex hormones, BMD, fat mass and fat-free mass in older women and men enrolled in four similar clinical trials. Design Pooled analyses of data from four double-blinded, randomized controlled trials. Participants Women (n = 295) and men (n = 290) aged 55 years or older who took DHEA or placebo tablet daily for 12 months. Measurements Twelve-month changes in BMD, fat mass, fat-free mass and serum DHEA sulphate (DHEAS), (17)estradiol, testosterone and insulin-like growth factor-1 (IGF-1). Results Women on DHEA had increases (mean ± SD; all P Conclusions Dehydroepiandrosterone therapy may be an effective approach for preserving bone and muscle mass in women. Key questions are (a) the extent to which longer duration DHEA can attenuate the loss of bone and muscle in women, and (b) whether DHEA has a more favourable benefit-to-risk profile for women than oestrogen therapy.

Objective To examine associations between health behavior patterns and childhood obesity, and the mediating effect of sleep duration. Design Population-based survey. Participants Secondary analysis of data from the Infant Feeding Practices Study (age 6 years, n = 1073). Measurements Mothers self-reported their child’s health behaviors including physical activity (PA), screen time, sleep duration, and diet. Latent class analysis determined the child’s patterns based on health behaviors. Sleep was examined as a mediator between the class membership variable and %BMI p95 . Results A 3-class model fit the data best, with classes labeled as “Poorest eaters” (low fruit/vegetable consumption, high fast food), “Healthy” (low screen time, highest fruit/vegetable consumption) and “Active, super-eaters, highest screen time” (highest PA and screen time, ate the most). “Poorest eaters” had an increased %BMI p95 (β = 4.11, P = .006) relative to the “Healthy” class. The “Poorest eaters” and “Active, super-eaters, highest screen time” classes had shorter sleep duration (β = −0.51, P P p95 that was 2.93 U lower ( P Conclusions Our results indicate that health behavior patterns mediated by sleep duration may influence a child’s %BMI p95 . The bi-directionality of the relationship between health behaviors and sleep remains unclear. Our findings suggest the importance of a constellation of health behaviors on childhood obesity. Interventions should include a multitude of health behaviors and consider the possibility that improving diet and activity behaviors may facilitate improved sleep and lowered obesity risk among children.

Introduction Reliable and valid instruments to measure counseling effectiveness related to eating, activity, and inactivity are lacking. HeartSmartKids (HSK; HeartSmartKids, LLC, Boulder, Colorado) is a bilingual decision-support technology that can be used to assess and counsel families on cardiovascular risk factors in children. The purpose of this study was to establish preliminary test–retest reliability and convergent validity of HSK questions relative to a previously validated questionnaire, HABITS. Method Data were collected from children (ages 9-14 years) during an intervention study. A multitrait/multimethod correlation matrix framework was used to examine the test–retest reliability (n = 35) and convergent validity (n = 103) of HSK relative to HABITS. Results HSK had moderate/strong test–retest reliability and good convergent validity between HSK and HABITS. Discussion This study provides preliminary test–retest reliability and convergent validity of a useful clinical tool that can be used to quickly assess children's nutrition (e.g., fruit/vegetable consumption, snacks, sugar-sweetened beverages, breakfast) and activity habits to guide behavior change counseling. Additional work should be done validating HSK with objective measures.

Medication adherence is a challenge for people living with HIV (PLWH), who may experience a gap between their intentions and everyday behaviors. We measured PLWH's (n = 87) daily experiences and tested a model to explain the intention-behavior gap. Participants completed baseline questionnaires, then used a smartphone-based survey and an electronic pill bottle to provide daily data for the next 10 weeks. These PLWH, with generally well-controlled HIV, were nevertheless adherent on only 73% of study days. Multilevel analyses were used to test predicted relationships between variables (n = 58). Four of five theory-based daily measures predicted motivation for antiretroviral therapy (betas = 0.06-0.10), and motivation, in turn, predicted adherence. Consistent with our theory, control beliefs, mood, and social support had indirect effects on adherence. However, stress and coping did not. Daily experiences affect adherence, even in PLWH with well-controlled HIV. Providers should ask about everyday changes in motivation.

Objectives Parental beliefs about child television viewing may affect the way parents regulate child television viewing. Despite this, little research has focused on the development of measures of parental beliefs about child television viewing, particularly among ethnic minority parents and parents of young children. This study's objective was to develop and test a culturally-based measure of parental beliefs about television viewing in low-income Mexican American mothers of preschoolers. Methods Using a cross-sectional study design, 22 items reflecting parental beliefs about influences of TV on children were developed and assessed for psychometric properties in a sample of 312 low-income Mexican American mothers of preschoolers. Results Using exploratory factor analysis, we identified four factors reflecting four domains of parental beliefs: positive general beliefs, positive sleep-related beliefs, positive functional beliefs, and negative general beliefs. Internal reliabilities were acceptable (Cronbach's alpha = 0.70-0.89) for all factors except negative general beliefs (Cronbach's alpha = 0.61). Positive sleep-related beliefs and Positive Functional Beliefs were correlated with children's average daily hours of TV (r = 0.16, p

Most applications of person-centered methodologies have relied on data-driven approaches to class enumeration. As person-centered analyses grow in popularity within organizational research, confirmatory approaches may be sought to provide more stringent theoretical tests and to formalize replication efforts. Confirmatory latent class analysis (LCA) is achieved through placement of modeling constraints, yet there is variation in the types of potential constraints and a lack of standardization in evaluating model fit in published work. This article provides a comprehensive framework for operationalizing model constraints and demonstrates confirmatory LCA via two illustrations: (a) a dual sample approach ( n = 1,366 and n = 1,367 in exploratory and validation samples, respectively) and (b) confirmatory testing of a hypothesized latent class structure ( n = 1,483). We depict operationalization of threshold boundary and/or equality constraints under both illustrations to generate a confirmatory latent class structure, and explain methods of model evaluation and comparison to alternative models. The confirmatory model was well supported under the dual sample approach, and partially supported under the hypothesis-driven approach. We discuss decision making at various points of model estimation and end with future methodological developments.

Background Many persons living with HIV (PLWH) are nonadherent to medication. Trait level measures that ask about predictors of adherence in the abstract may not adequately capture state level daily variability that more directly impacts adherence. Objectives This preliminary study was designed to test six predictors of electronically monitored adherence at both the state and trait levels and to compare their relative effects. Methods Using a smartphone, 87 PLWH completed randomly cued daily surveys on thoughts, mood, stress, coping, social support, and treatment motivation. All participants also completed baseline surveys on each construct. These state and trait variables were tested as prospective predictors of next-day adherence in multilevel models, and their relative importance was quantified. The analysis sample consisted of 53 PLWH who stored their most frequent antiretroviral medication in a bottle that time-stamped openings to measure adherence. Results Higher state level motivation, OR = 1.55, 95% CI [1.07, 2.24], and negative mood, OR = 1.33, 95% CI [1.07, 1.63], predicted greater adherence the following day. Importantly, these effects were only found at the state level. Trait level control beliefs predicted greater adherence, OR = 1.65, 95% CI [1.17, 2.35], but contrary to prediction, validated trait level measures of mood, stress, coping, social support, and motivation did not. Discussion Trait and state level measures predicted adherence, but there were differences between them. Motivation for treatment and negative mood predicted adherence when measured the preceding day, but not as aggregate measures. At the trait level, only control beliefs predicted adherence. Researchers should consider state level variations in mood and motivation as possible explanations for nonadherence. Interventions could be developed to target state level variables.

INTRODUCTION: Justice-involved adolescents are at high risk for sexually transmitted infections; one primary reason is co-occurring substance use. This study investigates the additive benefit of including alcohol and cannabis use content to a theory-based sexual risk reduction intervention, delivered using group-based motivational enhancement therapy. STUDY DESIGN: This study had a cluster randomized design, with randomization of single-sex clusters to one of three interventions. SETTING/PARTICIPANTS: Participants were male and female justice-involved adolescents (N=460) residing in youth detention facilities. Data were collected from 2010 to 2014; analyses were completed in 2018–2019. INTERVENTION: Adolescents were randomized to one of three motivational enhancement therapy interventions: sexual risk reduction intervention, sexual risk reduction intervention with alcohol content, or sexual risk reduction intervention with alcohol and cannabis content. MAIN OUTCOME MEASURES: The primary outcome was risky sexual behavior (aggregation of condom use and frequency of intercourse), measured every 3 months for 1 year. Secondary outcomes were theoretical mechanisms on which the intervention was based (condom use attitudes, self-efficacy, peer norms, and behavioral intentions), collected at baseline and post-test. RESULTS: Risky sexual behavior significantly decreased from baseline to 3-month follow-up (t=10.59, p0.29 for all). Comparisons to a historical information-only, sexual risk reduction control arm conducted with a similar juvenile justice sample confirm effectiveness of all three motivational enhancement therapy–based interventions. CONCLUSIONS: All three interventions were associated with decreased sexual risk up to 1 year later, suggesting that the intervention modality (motivational enhancement therapy) may resonate with this population beyond the specific substance use content. This single-session manualized intervention can be readily disseminated to juvenile justice settings. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT01170260.

Objective: To identify sleep patterns in early childhood and examine the influence of these patterns on health behaviors and obesity. Methods: Prospective cohort study of healthy 3-year old children (n=301) measured annually through age 6. Parent-reported total sleep duration (TSD) was calculated as night-time sleep plus daytime naps . Insufficient sleep was defined as TSD A latent growth curve model was estimated to establish the trajectory of TSD over four years. At each time period, univariate regression models were estimated to: (a) identify modifiable and demographic (i.e., race/ethnicity, gender) predictors of insufficient sleep and (b) test the association of insufficient sleep with health behaviors (i.e., diet, screen time) and obesity status (adjusting for time-specific daily energy intake, screen time, and moderate-vigorous physical activity (MVPA)). Results: The analytical cohort was 49% female, predominately white (82%) with 36% reporting household incomes below $50,000. At age 3, 21% were defined as overweight or obese and at age 6, 32% of the cohort were defined as overweight or obese. Children had a similar bed and wake time across the four-year study with an average bedtime at 9:27PM and waketime at 8:01AM. Growth curve modeling showed decreases of 39.6 minutes in TSD from age 3 to age 6; though statistically significant (p Conclusions: Sleep patterns appear to be established by age 3 years with little change throughout young childhood, and with implications for early obesity development. Early intervention to improve sleep may be necessary during this time, especially for children from racial/ethnic minority backgrounds, prior to the establishment of sleep patterns, to prevent negative consequences of insufficient sleep.

Background: Many patients evaluated for acute coronary syndrome (ACS) in emergency departments (EDs) continue to experience troubling symptoms after discharge—regardless of their ultimate medical diagnosis. However, comprehensive understanding of common post-ED symptom trajectories is lacking. Objectives: The aim of this study was to identify common trajectories of symptom severity in the 6 months after an ED visit for potential ACS. Methods: This was a secondary analysis of data from a larger observational, prospective study conducted in five U.S. EDs. Patients (N = 1005) who had electrocardiogram and biomarker testing ordered, and were identified by the triage nurse as potentially having ACS, were enrolled. Symptom severity was assessed in the hospital after initial stabilization and by telephone at 30 days and 6 months using the validated 13-item ACS Symptom Checklist. Growth mixture modeling was used for the secondary analysis. The eight most commonly reported symptoms (chest discomfort, chest pain, chest pressure, light-headedness, shortness of breath, shoulder pain, unusual fatigue, and upper back pain) were modeled across the three study time points. Models with increasing numbers of classes were compared, and final model selection was based on a combination of interpretability, theoretical justification, and statistical fit indices. Results: The sample was 62.6% male with a mean age of 60.2 years (SD = 14.17 years), and 57.1% ruled out for ACS. Between two and four distinct trajectory classes were identified for each symptom. The seven different types of trajectories identified across the eight symptoms were labeled “tapering off,” “mild/persistent,” “moderate/persistent,” “moderate/worsening,” “moderate/improving,” “late onset, “and “severe/improving.” Trajectories differed on age, gender, and diagnosis. Discussion: Research on the individual nature of symptom trajectories can contribute to patient-centered, rather than disease-centered, care. Further research is needed to verify the existence of multiple symptoms trajectories in diverse populations and to assess the antecedents and consequences of individual symptom trajectories.

Objective Knee osteoarthritis (OA) is a broadly applied diagnosis that may describe multiple subtypes of pain. The purpose of this study was to identify phenotypes of knee OA, using measures from the following pain-related domains: 1) knee OA pathology, 2) psychological distress, and 3) altered pain neurophysiology. Methods Data were selected from a total of 3,494 participants at visit 6 of the Osteoarthritis Initiative study. Latent class analysis was applied to the following variables: radiographic OA severity, quadriceps strength, body mass index, the Charlson Comorbidity Index (CCI), the Center for Epidemiologic Studies Depression Scale, the Coping Strategies Questionnaire-Catastrophizing subscale, number of bodily pain sites, and knee joint tenderness at 4 sites. The resulting classes were compared on the following demographic and clinical factors: age, sex, pain severity, disability, walking speed, and use of arthritis-related health care. Results A 4-class model was identified. Class 1 (4% of the study population) had higher CCI scores. Class 2 (24%) had higher knee joint sensitivity. Class 3 (10%) had greater psychological distress. Class 4 (62%) had lesser radiographic OA, little psychological involvement, greater strength, and less pain sensitivity. Additionally, class 1 was the oldest, on average. Class 4 was the youngest, had the lowest disability, and least pain. Class 3 had the worst disability and most pain. Conclusion Four distinct pain phenotypes of knee OA were identified. Psychological factors, comorbidity status, and joint sensitivity appear to be important in defining phenotypes of knee OA–related pain.

Fatigue symptoms are very common among persons living with HIV (PLWH). Fatigue is related to functional and psychological problems and to treatment nonadherence. Using secondary data from ecological momentary assessment, we examined fatigue as a predictor of PLWH everyday experiences. In bidirectional analyses based on the shape shifters model, we also examined these experiences as predictors of fatigue. Data were examined from 67 PLWH who completed daily surveys on a handheld computer. Brief validated scales were used to assess participants' control beliefs, mood, stress, coping, social support, experience of stigma, and motivation. At the beginning and end of the study, fatigue was measured with two CES-D items that have been used in past HIV symptom research. Multilevel models and logistic regression were used to test reciprocal predictive relationships between variables. Moderate to severe fatigue affected 45% of PLWH in the study. Initial fatigue predicted PLWH subsequent overall level of control beliefs, mood, stress, coping, and social support, all p

Objective The purpose of this study was to evaluate school-based health center (SHBC) provider adherence to guidelines for identification and assessment of childhood obesity after participation in a virtual Health Disparities Learning Collaborative with and without HeartSmartKids™, decision-support technology with tailored patient education. Design and Setting A cluster randomized comparative effectiveness trial was conducted with 24 SBHCs from six states. Participants The sample consisted of 33 SBHC providers and review of medical charts at three time points. Chart data were collected at baseline ( n = 850), after training ( n = 691) and 6 months after training ( n = 612). Main Outcome Measures Charts from a random sample of youth 5–12 years making well-child visits were examined for the documentation of: BMI percentile, accurate weight diagnosis based upon BMI percentile, blood pressure percentile, and ordering appropriate laboratory assessment of obese youth ≥10 years old. Results Percentage of overweight/obese children in this study was 40.4–47.2%. For both the HeartSmartKids™ and non-HeartSmartKids™ groups, provider adherence significantly improved after training for BMI percentile and blood pressure percentile documentation, as well as correct diagnosis for overweight and obese. Implementation of the HeartSmartKids™ was variable at the technology sites and differences in identification and assessment were not found between groups. Conclusion The virtual collaborative approach to quality improvement resulted in improved adherence to guidelines for identification and assessment of overweight/obese children. The impact of the training with and without HeartSmartKids™ on patient outcomes needs to be evaluated. Coaching on implementation of technology needs to be included in future work.

Objective: (a) To investigate the factor structure of the Connor-Davidson Resilience Scale (CD-RISC) in critical care nurses, using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) and (b) to assess reliability and known group differences of the CD-RISC on critical care nurses. Methods: CD-RISC surveys were collected on 744 critical care nurses across the United States. An abridged version of the CD-RISC was used for the EFA and CFA. Further reliability and known group differences were also tested. Results: EFA identified 3 factors with eigenvalues >1.0 and an explained variance of 59%. The factors were labeled personal competence, perseverance, and leadership, and each factor had salient loadings. The 3-factor CFA provided good fit to the data, χ2 = 243.1, p < .001; RMSEA = .062; CFI = .935, although correlations among the 3 factors were high (.78–.86). A 1-factor model was subsequently tested but did not produce a better fit, and model comparison analyses supported retention of the 3-factor model. Known group differences was supported as intensive care unit (ICU) nurses with a diagnosis of posttraumatic stress disorder (PTSD) had significantly lower total resilience scores (M = 75.43) compared to those without a diagnosis of PTSD (M = 83.21; t = 5.01; p < .001). Discussion: The current investigation found that the 3-factor structure provided the best fit for the data on the abridged version of the CD-RISC in a population of ICU nurses. Analyses also supported the reliability and known group differences of the 16-item measure. Further research is needed to examine trait and capacity features of resilience as it relates to this population.

Objectives: This study examined longitudinal pathways among depression, pain, and fatigue in the context of a randomized clinical trial (RCT). Further, we tested whether a collaborative symptom and psychosocial care intervention influenced later pain through its impact on depression and fatigue. Methods: We completed secondary, longitudinal data analyses of a sample of older adults with heart failure (Baseline N=317) enrolled in a multi-site RCT. First, we used bootstrapped mediation to assess the directionality of the relationship between depression and pain and to determine if fatigue acts as a pathway between these conditions. For both outcomes (i.e., pain or depression at 12-months), baseline covariates included age, sex, education level, study arm, and baseline levels of the outcome variable, and fatigue at 6-months was assessed as the mediator. After assessing the directionality of the relationship, we examined whether the intervention would reduce the impact of depression or fatigue on the development of pain symptoms. Results: Depressive symptoms were associated with new onset of pain symptoms; however, this association was fully mediated by fatigue. Pain was not associated with new onset of depressive symptoms, and there was no indirect effect of fatigue. The intervention reduced the onset of pain symptoms indirectly by decreasing depressive symptoms. Discussion: Depression influenced new onset of pain symptoms through its influence on fatigue; thus, treatment of depression and fatigue may reduce risk for new onset of pain. A patient centered, collaborative care team intervention may provide a pathway for targeting pain through its impact on depressive symptoms.

Background Health promotion and chronic disease management both require behavior change, but people find it hard to change behavior despite having good intentions. The problem arises because patients' narratives about experiences and intentions are filtered through memory and language. These narratives inaccurately reflect intuitive decision-making or actual behaviors. Objectives We propose a principle—temporal immediacy—as a moderator variable that explains which of two mental systems (narrative or intuitive) will be activated in any given situation. We reviewed multiple scientific areas to test temporal immediacy as an explanation for findings. Methods In an iterative process, we used evidence from philosophy, cognitive neuroscience, behavioral economics, symptom science, and ecological momentary assessment to develop our theoretical perspective. These perspectives each suggest two cognitive systems that differ in their level of temporal immediacy: an intuitive system that produces behavior in response to everyday states and a narrative system that interprets and explains these experiences after the fact. Findings Writers from Plato onward describe two competing influences on behavior—often with moral overtones. People tend to identify with the language-based narrative system and blame unhelpful results on the less accessible intuitive system, but neither is completely rational, and the intuitive system has strengths based on speed and serial processing. The systems differ based on temporal immediacy—the description of an experience as either “now” or “usually”—with the intuitive system generating behaviors automatically in real time and the narrative system producing beliefs about the past or future. Discussion The principle of temporal immediacy is a tool to integrate nursing science with other disciplinary traditions and to improve research and practice. Interventions should build on each system's strengths, rather than treating the intuitive system as a barrier for the narrative system to overcome. Nursing researchers need to study the roles and effects of both systems.

ObjectivesTo (1) examine whether the Information-Motivation-Behavioral Skills Model predicts maternal screen-related parenting practices and (2) evaluate the relationship of American Academy of Pediatrics (AAP)-recommended parenting practices with child television (TV) use behaviors.MethodsIn this cross-sectional study, 312 Spanish-speaking and/or English-speaking female primary caregivers of Mexican descent with a child 3 to 5 years of age were recruited from safety-net pediatric clinics. Participants completed a phone interview and screen media diary. Measures included maternal screen-related beliefs, self-efficacy, parenting practices (time restriction, TV in the child's bedroom, allowing viewing while eating meals and while eating snacks), and child viewing behaviors (amount of TV viewing, frequency of eating while viewing). Two path analytic models were estimated.ResultsPositive general beliefs about TV viewing and positive functional beliefs were negatively associated with maternal self-efficacy to restrict TV time (β = -0.14, P < .05; β = -0.27, P < .001). Greater self-efficacy to restrict time was associated with more maternal restriction of time (β = 0.29, P < .001). Greater positive functional beliefs were associated with less self-efficacy to restrict TV viewing with snacks (odds ratio = 0.56; 95% confidence interval, 0.38-0.81). High self-efficacy to restrict viewing with snacks was associated with less allowing of viewing while snacking (β = -0.16, P < .01). Time restriction, TV in the child's bedroom, and allowing viewing while snacking were associated with child TV viewing behaviors.ConclusionsProviders should consider maternal beliefs, including beliefs regarding the functional use of screens, and self-efficacy to engage in AAP-recommended parenting practices, when counseling on screen use in this population.

Rationale The social, emotional, and mental health benefits associated with gardening have been well documented. However, the processes underlying the relationship between garden participation and improvements in health status have not been sufficiently studied. Methods Using population-based survey data ( n = 469 urban residents), objective street environment data, and area-level measures, this research used a path analytic framework to examine several theoretically based constructs as mediators between gardening history and self-reported health. Results The results showed that garden participation influenced health status indirectly through social involvement with one's community, perceived aesthetic appeal of the neighborhood, and perceived collective efficacy. Gardeners, compared to non-gardeners, reported higher ratings of neighborhood aesthetics and more involvement in social activities, whereas aesthetics and involvement were associated with higher ratings of collective efficacy and neighborhood attachment. Collective efficacy, but not neighborhood attachment, predicted self-rated health. Gardening also directly influenced improved fruit and vegetable intake. The physical and social qualities of garden participation may therefore stimulate a range of interpersonal and social responses that are supportive of positive ratings of health. Conclusion This research suggests that community planners and health professionals should aim to strengthen the social and aesthetic relationships while designing environments and policies as a way to ignite intermediate processes that may lead to improved health status.

Justice-involved adolescents engage in high levels of risky sexual behavior and substance use, and understanding potential relationships among these constructs is important for effective HIV/STI prevention. A regression mixture modeling approach was used to determine whether subgroups could be identified based on the regression of two indicators of sexual risk (condom use and frequency of intercourse) on three measures of substance use (alcohol, marijuana and hard drugs). Three classes were observed among n = 596 adolescents on probation: none of the substances predicted outcomes for approximately 18 % of the sample; alcohol and marijuana use were predictive for approximately 59 % of the sample, and marijuana use and hard drug use were predictive in approximately 23 % of the sample. Demographic, individual difference, and additional sexual and substance use risk variables were examined in relation to class membership. Findings are discussed in terms of understanding profiles of risk behavior among at-risk youth.