Background: The cystic fibrosis (CF) regimen is time-consuming and burdensome leading to barriers to self-management. This mixed-methods study developed the Daily Care Check-in (DCC) that is specific to the barriers faced by people with CF (PWCF) and evaluated its validity. Methods: Qualitative methods were used to identify barriers to self-management and develop items, with "think aloud" cognitive interviews conducted to refine the items. A multisite, cross-sectional study was conducted to test the internal consistency, test-retest reliability, and validity of the DCC scores, comparing them to objective medication adherence (composite medication possession ratio (cMPR)) and psychosocial measures (self-efficacy, medication beliefs, executive functioning, depressive and anxiety symptoms, treatment burden, and treatment complexity). Results: The DCC (18 items) includes two scales: Occurrence (score range 0-18) and Interference (score range 0-90). 405 participants completed the DCC, 344 (85 %) completed the survey, and 365 (90 %) had a cMPR calculated. On average, 6.8 barriers were reported (SD = 4.2 Occurrence Scale), and the Interference Scale had a mean score of 18.4 (SD = 14.0). Reliability was acceptable to good. cMPR was negatively correlated with the DCC (rho=-0.26, Occurrence and rho = -0.31, Interference, p-values<0.0001). A priori hypotheses between the DCC and the other measures were supported and demonstrated construct validity. Conclusions: This study provides evidence supporting the validity of the DCC for assessing the presence and impact of barriers to CF self-management, including medication adherence. Formal screening of self-management barriers (e.g., using the DCC) should be considered to facilitate conversations with the care team and identify tailored interventions to support CF self-management.

Background: Urban minority preschool children are disproportionately affected by asthma with increased asthma morbidity and mortality. It is important to understand how families manage asthma in preschool children to improve asthma control. Objective: To evaluate family asthma management and asthma outcomes among a low-income urban minority population of Head Start preschool children. Methods: The family asthma management system scale (FAMSS) evaluates how families manage a child's asthma. A total of 388 caregivers completed the FAMSS at baseline. Asthma outcomes were evaluated at baseline and prospectively at 6 months, including asthma control (based on the Test for Respiratory and Asthma Control in Kids), courses of oral corticosteroids (OCSs) required, and caregiver health-related quality of life (Pediatric Asthma Caregiver's Quality of Life Questionnaire [PACQLQ]). Multiple regression models evaluated the relationship between the FAMSS total score, FAMSS subscales, and asthma outcomes. Results: Higher FAMSS total scores were associated with fewer courses of OCSs required (b = -0.23, P < .01) and higher PACQLQ scores (b = 0.07, P < .05). At baseline, higher integration subscale scores (b = -0.19, P < .05) were associated with fewer courses of OCSs required, and higher family response scores were associates with higher PACQLQ scores (b = 0.06, P < .05). Nevertheless, higher collaboration scores were associated with lower PACQLQ at baseline (b = - 0.06, P < .05) and 6 months (b = -0.07, P < .05). Conclusion: Among this population of low-income minority preschool children, understanding how a family manages their child's asthma may help identify gaps for education to possibly improve caregiver asthma-related quality of life and reduce courses of OCSs. (C) 2021 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Children spend the majority of their time indoors, and a substantial portion of this time in the school environment. Air pollution has been shown to adversely impact lung development and has effects that extend beyond respiratory health. The goal of this study was to evaluate the indoor environment in public schools in the context of an ongoing urban renovation program to investigate the impact of school building renovation and replacement on indoor air quality. Indoor air quality (CO2, PM2.5, CO, and temperature) was assessed for two weeks during fall, winter, and spring seasons in 29 urban public schools between December 2015 and March 2020. Seven schools had pre- and post-renovation data available. Linear mixed models were used to examine changes in air quality outcomes by renovation status in the seven schools with pre- and post-renovation data. Prior to renovation, indoor CO measurements were within World Health Organization (WHO) guidelines, and indoor PM2.5 measurements rarely exceeded them. Within the seven schools with pre- and post-renovation data, over 30% of indoor CO2 measurements and over 50% of indoor temperatures exceeded recommended guidelines from the American Society of Heating, Refrigerating, and Air Conditioning Engineers. Following renovation, 10% of indoor CO2 measurements and 28% of indoor temperatures fell outside of the recommended ranges. Linear mixed models showed significant improvement in CO2, indoor PM2.5, and CO following school renovation. Even among schools that generally met recommendations on key guidelines, school renovation improved the indoor air quality. Our findings suggest that school renovation may benefit communities of children, particularly those in low-income areas with aging school infrastructure, through improvements in the indoor environment.

BACKGROUND: The prevalence of burnout and depressive symptoms is high among physician trainees. RESEARCH QUESTION: What is the burden of burnout and depressive symptoms among fellows training in pulmonary and critical care medicine (PCCM) and what are associated individual fellow, program, and institutional characteristics? STUDY DESIGN AND METHODS: We conducted a cross-sectional electronic survey of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States to assess burnout and depressive symptoms. Burnout symptoms were measured using the Maslach Burnout Index two-item measure. The two- item Primary Care Evaluation of Mental Disorders Procedure was used to screen for depressive symptoms. For each of the two outcomes (burnout and depressive symptoms), we constructed three multivariate logistic regression models to assess individual fellow characteristics, program structure, and institutional polices associated with either burnout or depressive symptoms. RESULTS: Five hundred two of the 976 fellows who received the survey completed it-including both outcome measures-giving a response rate of 51%. Fifty percent of fellows showed positive results for either burnout or depressive symptoms, with 41% showing positive results for depressive symptoms, 32% showing positive results for burnout, and 23% showing positive results for both. Reporting a coverage system in the case of personal illness or emergency ( adjusted OR [aOR], 0.44; 95% CI, 0.26-0.73) and access to mental health services (aOR, 0.14; 95% CI, 0.04-0.47) were associated with lower odds of burnout. Financial concern was associated with higher odds of depressive symptoms (aOR, 1.13; 95% CI, 1.05-1.22). Working more than 70 hours in an average clinical week and the burdens of electronic health record (EHR) documentation were associated with a higher odds of both burnout and depressive symptoms. INTERPRETATION: Given the high prevalence of burnout and depressive symptoms among fellows training in PCCM, an urgent need exists to identify solutions that address this public health crisis. Strategies such as providing an easily accessible coverage system, access to mental health resources, reducing EHR burden, addressing work hours, and addressing financial concerns among trainees may help to reduce burnout or depressive symptoms and should be studied further by the graduate medical education community.

BACKGROUND: Participant retention is a major challenge in clinical research, especially in studies with multiple, longitudinal research assessments. Despite the importance of retention methods, there is little empirical research on how cohort retention efforts are perceived by study participants. RESEARCH QUESTION: To evaluate the association between the number of attempts undertaken to contact participants for research assessments in a longitudinal cohort study and participants' feeling of being bothered regarding such contact attempts. STUDY DESIGN AND METHODS: Secondary analysis of 315 ARDS survivors participating in a prospective study using comprehensive strategies for participant follow-up at 6 and 12 months that achieved > 95% participant retention. After completing a 242-question research assessment lasting 20 to 40 min, participants were surveyed for feedback. RESULTS: At 6 and 12 months, only 5% and 8% of participants, respectively, reported being bothered "more than a little bit" by the study contact attempts, with an OR of 1.06 (95% CI, 1.02-1.10) for each contact attempt. Participants' mental health symptoms at follow-up assessment were not associated with reports of being bothered. INTERPRETATION: Comprehensive cohort retention efforts can achieve > 95% retention rates in a national longitudinal study, with most participants reporting little or no bother by contact attempts. Despite a high frequency of mental health symptoms in this population, such symptoms were not associated with participant feedback regarding contact attempts. Careful training of research staff may be important in achieving such results.

Objective: The purpose of this study was to evaluate associations between executive functioning and caregiver adherence monitoring with objective antihypertensive medication adherence over 24 months in adolescents with chronic kidney disease (CKD). Methods: Adolescents (N = 97, 11-20 years old) with CKD taking antihypertensive medication and their caregivers were recruited from three pediatric nephrology clinics. At baseline, adolescents and caregivers reported on adolescents' executive functioning and caregivers reported on their adherence monitoring. Antihypertensive medication adherence was objectively assessed via electronic monitoring at baseline and every 6 months after for 24 months. Associations between executive functioning, caregiver monitoring, and longitudinal adherence were evaluated with linear mixed models. Results: Up to 38% of adolescents had elevated executive functioning scores indicating more severe impairments, with rates varying by scale and reporter (adolescent vs. caregiver). Caregiver monitoring showed a significant, negative association with adherence. but adolescents' executive functioning was not significantly associated with adherence. Neither variable was associated with the rate of change in adherence over time. Conclusions: Given that adolescents' executive functioning was not associated with antihypertensive medication adherence or changes in adherence over time. adherence to daily pill-form medications may involve less cognitive effort than more complex medical regimens. Higher levels of caregiver monitoring were unexpectedly associated with lower adherence levels. This unanticipated finding may reflect increased caregiver monitoring efforts when faced with adolescents' medication nonadherence, but this finding warrants further investigation. Adolescents with CKD who are nonadherent may benefit from medication adherence-promoting strategies beyond increasing caregiver monitoring.

IMPORTANCE Asthma is the most common chronic childhood disease, with Black children experiencing worse morbidity and mortality. It is important to evaluate the effectiveness of efficacious interventions in community settings that have the greatest likelihood of serving at-risk families. OBJECTIVE To evaluate the effectiveness of a multilevel home- and school (Head Start)-based asthma educational program compared with a Head Start-based asthma educational program alone in improving asthma outcomes in children. DESIGN, SETTING, AND PARTICIPANT This randomized clinical trial included 398 children with asthma enrolled in Head Start preschool programs in Baltimore, Maryland, and their primary caregivers. Participants were recruited from April 1, 2011, to November 31, 2016, with final data collection ending December 31, 2017. Data were analyzed from March 18 to August 30, 2018. INTERVENTIONS Asthma Basic Care (ABC) family education combined with Head Start asthma education compared with Head Start asthma education alone. Main Outcomes and Measures Asthma control as measured by the Test for Respiratory and Asthma Control in Kids (TRACK) score. Results Among the 398 children included in the analysis (247 boys [62.1%]; mean [SD] age, 4.2 [0.7] years), the ABC plus Head Start program improved asthma control (beta = 6.26; 95% CI, 1.77 to 10.75;P < .001), reduced courses of oral corticosteroids (beta = -0.61; 95% CI, -1.13 to -0.09;P = .02), and reduced hospitalizations (odds ratio, 0.36; 95% CI, 0.21-0.61;P < .001) during a 12-month period. Conclusion and Relevance In this randomized clinical trial, combined family and preschool asthma educational interventions improved asthma control and reduced courses of oral corticosteroids and hospitalizations. Multilevel interventions implemented in community settings that serve low-income minority families may be key to reducing disparities in asthma outcomes.

This study aimed to assess the factors associated with home meal preparation (HMP) and fast-food sources use (FFS) frequencies of low-income African-American adults and their healthy food beliefs and attitudes, food-related psychosocial factors, food acquisition patterns, food sources use, and BMI. We used cross-sectional data from 295 adults living in Baltimore, USA. HMP was inversely associated with FFS, which had lower odds of HMP ≥1 time/day and higher BMI scores. HMP was positively associated with positive beliefs and self-efficacy toward healthy foods, getting food from healthier food sources, and lower FFS. Higher odds of HMP ≥1 time/day were associated with getting food from farmers' market and supermarkets or grocery stores. FFS had an inverse association with positive beliefs and self-efficacy toward healthy foods, and a positive association with less healthy food acquisition scores. Higher odds of FFS ≥1 time/week were associated with getting food from corner stores, sit-down restaurants, and convenience stores.

BACKGROUND:Obesity and other nutrition-related chronic disease rates are high in American Indian (AI) populations, and an urgent need exists to identify evidence-based strategies for prevention and treatment. Multi-level, multi-component (MLMC) interventions are needed, but there are significant knowledge gaps on how to deliver these types of interventions in low-income rural AI communities.METHODS:OPREVENT2 is a MLMC intervention targeting AI adults living in six rural reservations in New Mexico and Wisconsin. Aiming to prevent and reduce obesity in adults by working at multiple levels of the food and physical activity (PA) environments, OPREVENT2 focuses on evidence-based strategies known to increase access to, demand for, and consumption of healthier foods and beverages, and increase worksite and home-based opportunities for PA. OPREVENT2 works to create systems-level change by partnering with tribal stakeholders, multiple levels of the food and PA environment (food stores, worksites, schools), and the social environment (children as change agents, families, social media). Extensive evaluation will be conducted at each level of the intervention to assess effectiveness via process and impact measures.DISCUSSION:Novel aspects of OPREVENT2 include: active engagement with stakeholders at many levels (policy, institutional, and at multiple levels of the food and PA system); use of community-based strategies to engage policymakers and other key stakeholders (community workshops, action committees); emphasis on both the built environment (intervening with retail food sources) and the social environment. This paper describes the design of the intervention and the evaluation plan of the OPREVENT2.TRIAL REGISTRATION:Clinical Trial Registration: NCT02803853 (June 10, 2016).

Higher rates of obesity and obesity-related chronic disease are prevalent in communities where there is limited access to affordable, healthy food. The B'More Healthy Communities for Kids (BHCK) trial worked at multiple levels of the food environment including food wholesalers and corner stores to improve the surrounding community's access to healthy food. The objective of this article is to describe the development and implementation of BHCK's corner store and wholesaler interventions through formal process evaluation. Researchers evaluated each level of the intervention to assess reach, dose delivered, and fidelity. Corner store and wholesaler reach, dose delivered, and fidelity were measured by number of interactions, promotional materials distributed, and maintenance of study materials, respectively. Overall, the corner store implementation showed moderate reach, dose delivered, and high fidelity. The wholesaler intervention was implemented with high reach, dose, and fidelity. The program held 355 corner store interactive sessions and had 9,347 community member interactions, 21% of which were with children between the ages of 10 and 14 years. There was a 15% increase in corner store promoted food stocking during Wave 1 and a 17% increase during Wave 2. These findings demonstrate a successfully implemented food retailer intervention in a low-income urban setting.

BackgroundLimited research exists on the impact of multi‐level, multi‐component (MLMC) interventions. BHCK is an ongoing MLMC obesity prevention program, which targets multiple levels of the urban food environment, addressing child (via youth leaders), adult caregiver (via text messaging, social media), community (via corner store, carry‐out, wholesaler programs), and policy levels to increase healthy food access, purchasing, and consumption among low income African American (AA) youth between the ages of 10–14 in Baltimore City.MethodsWave 1 of BHCK was evaluated through a combination of process and impact measures at different levels. We observed small food stores/carryout to detect change in availability of BHCK healthy promoted products such as produce, whole grain products, lower fat snacks, and lower sugar beverages, low fat entrees/side dishes. In youth, we used the 2004 Block Kids FFQ to estimate impact on dietary intake. Our baseline sample was composed of 299 child‐caregiver dyads (pre‐intervention), with 70% assessed post‐intervention. Estimated difference in food group intake was calculated using the least‐squares mean regression, adjusted by child's age, sex, energy intake, baseline value of the dependent variable, BMI percentile, caregiver's income and education level. Analysis of covariance (ANCOVA) was used to assess difference in intake between intervention and control groups.ResultsDifferent components of the intervention were implemented with moderate to high reach, dose and fidelity observed. Twelve of our original sixteen youth‐leaders conducted a total of 98 nutrition sessions across seven intervention recreation centers, with an average of 10 low‐income AA children in our target age range (10–14) attending each session, and a total of 1600 child interactions in recreation centers and community venues combined. Educational sessions and promotional activities at stores reached 5–10 youth in our target age range per store session. 80% of study families received text‐messages during the program. We found an 8.6% increase in availability of whole wheat bread in intervention stores while control stores decreased 37.8% (p<0.01). FFQ data shows that youth in the intervention group increased consumption of whole grain foods from pre‐ to post‐intervention, whereas youth in the control group decreased. Intervention group had a 0.47 (± 0.04) adjusted mean intake of whole grains, whereas control group showed a 0.41 (±0.43) adjusted mean intake. Additional analyses will examine impact of the BHCK program on access, purchase, and consumption of healthier beverages and snacks.ConclusionsThis study is an example of a successful MLMC intervention. Findings will inform public health strategies to improve dietary quality and access to healthy food in low‐income urban settings. Future directions include scaling up to other cities and sustaining/institutionalizing successful strategies.Support or Funding InformationResearch reported in this work was supported by the Global Obesity Prevention Center (GOPC) at Johns Hopkins, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the Office of the Director, National Institutes of Health (OD) under award number U54HD070725. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Background Prevalence of obesity is disproportionately high among American Indians (AIs) and is associated with increased prevalence of diabetes, hypertension, and cardiovascular disease. Increasing physical activity (PA) is associated with weight loss and maintenance of a healthy body weight. Objective The objective of this study was to decrease obesity and promote healthier bodyweights using a multi‐level, multi‐institutional obesity intervention designed to increase knowledge, build self‐efficacy, and influence intentions for improved behavior change at multiple levels. Primary areas of focus were nutrition, PA, and behaviors related to food consumption and purchasing. The aim of this analysis was to determine whether or not participants in the intervention communities engaged in a greater amount of PA versus comparison at follow‐up. Methods A randomized controlled community‐based program (OPREVENT) was developed, implemented, and evaluated within five AI communities. The five communities were randomly assigned to intervention (n=3) or delayed intervention (comparison; n=2)in New Mexico and Michigan. A modified International Physical Activity Questionnaire‐Short Form (IPAQ‐SF) was administered to 180 randomly selected community members at baseline and follow‐up from intervention and comparison communities. Results Total days per week participating in vigorous PA was significantly different between intervention and comparison at follow‐up ( p <0.05). Total Metabolic Equivalents(METs) of vigorous PA was significantly different between intervention and comparison at follow‐up ( p <0.05). Conclusions OPREVENT was associated with an increase in days per week engaged invigorous PA as well as an increase in total METs vigorous PA in communities that received the OPREVENT program. Support or Funding Information The USDA provided funding for this project. Approval and support was obtained from all participating tribal communities.