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Bonds Jeanne Milliken, Johnson James H, Ordonez Elizabeth
Archives of Community Medicine and Public Health, Volume 8, pp 110-112;

Community Health Workers support frontline public health professionals during times of public health pandemics by providing communities with trusted messengers that are a support system and liaison to medical and social services. North Carolina deployed Community Health Workers during the COVID-19 pandemic using funding under the Patient Protection and Affordable Care Act with success. We offer recommendations for a more robust program going forward using what was learned during the pandemic.
Iqra Munawar, Austin L Seals, John W Sanders, David M Herrington, Thomas F Wierzba
Published: 1 November 2021
Open Forum Infectious Diseases, Volume 8;

Background: Public health officials are concerned that adults may refuse to be vaccinated with an approved COVID-19 vaccine thereby limiting the community health benefit. Here, we studied the self-reported intent to be vaccinated of persons in North Carolina (NC) and then measured whether they did or did not get vaccinated. Methods: The Community COVID-19 Research Partnership (CCRP) is a large prospective study exploring COVID-19 epidemiology and sequelae in participants of several mid-Atlantic and Southern States. All participants complete an online daily survey where they are asked questions about COVID-like symptoms, infections, and their vaccination status. In addition to the daily survey, in December 2020, we implemented a short online cross-sectional survey questioning NC participants on whether they intended to be vaccinated. After completing the cross-sectional survey, we used daily survey data through 15 May 2021 to see if participants reported receiving vaccine. Unvaccinated participants who did not complete the daily survey 30 days or more prior to 15 May 2021 were excluded. Results: 18,874 participants completed the cross-sectional survey and reported vaccination status. Of these participants, 90% were white, 68% were female, 26% were healthcare workers, and 2% self-reported COVID-19 diagnosis The median age was 54 years (IQR: 41 – 65). 79%, 13%, 9%, and 2% answered yes, unsure, no, and prefer not to answer, respectively, about intention to be vaccinated (Table). 99% of the participants who intended to receive the COVID-19 vaccine reporting being vaccinated. Those who were unsure or intended not to get vaccinated had vaccination rates of 80% and 53%, respectively. 78% of the participants who preferred not to answer were vaccinated. Table: Vaccine intent versus vaccine status – COVID-19 Community Research Partnership, North Carolina, December 2020 – May 2021 Conclusion: More than three-quarters of NC participants intended to get vaccinated and by mid-May 2021, the vast majority had received at least one dose. Similarly, those who were unsure or preferred not to say were mostly vaccinated. Even among those who reported they would not get vaccine in January, more than half had received vaccine by May. The nature of our sample makes it difficult to generalize results to the population of NC; nevertheless, further investigation as to the causes of the shift in attitudes is warranted. Disclosures: All Authors: No reported disclosures
Vanessa R. Coffman, Devon Hall, Meredith C. McCormack, Christopher D. Heaney
Published: 1 February 2018
ISEE Conference Abstracts, Volume 2017;

Background/Aim: Although swine worker respiratory disease is established, evidence is mainly from predominantly Caucasian farm-owner-operator cohorts whose work exposures may differ from laborers hired to perform day-to-day intensive swine production jobs in confinement barns. The Rural Empowerment Association for Community Help (REACH) has initiated community-based participatory research (CBPR) with Hispanic laborers hired to work in industrial hog operations (IHOs) in eastern North Carolina. Together with REACH, we investigated whether such IHO workers’ occupational exposures were related to respiratory health outcomes. Methods: During 2013-14, we completed a 4-month CBPR panel study, involving baseline and 8 bi-weekly visits to collect demographic, personal, and work exposure data and spirometry measurements. We assessed the relation of IHO work activities with respiratory outcomes at baseline (linear regression) and longitudinally (fixed-effects ordinal logistic regression), adjusting for potential confounders. Results: One hundred and three IHO workers were enrolled (88% Hispanic; 46% male; age mean[±SD] 38±11 years) and completed 782 bi-weekly visits. Asthma prevalence was 8.7% and 92.6% were non-smokers. At baseline, total number of years of IHO work was negatively associated with forced expiratory volume (L) in the first second (FEV1) (ß=-0.031; 95% confidence interval [CI]: -0.060, -0.001). Longitudinally, positive associations were observed between pressure washing barns and coughing (odds ratio [OR]=3.8; 95%CI: 1.2, 12.3), herd changes and nasal congestion (OR=7.4; 95%CI: 1.2, 44.6) and confinement barn ventilation fans turned off and difficulty breathing (OR=11.2; 95% CI: 2.8, 44.4), eye irritation (OR=5.8; 95%CI: 1.1, 30.7), and chills (OR=5.1; 95%CI: 3.0, 8.9). Conclusions: In a predominantly Hispanic cohort of IHO workers, we observed relations between IHO work activities and adverse respiratory outcomes, particularly prolonged IHO employment and activities that aerosolize and keep waste in-barn. Challenges in exposure assessment from lack of on-IHO access and worker reluctance to enroll in cohorts can be mitigated using an empowering CBPR approach.
Robert R. Korstad, James L. Leloudis, Billy Barnes
This chapter focuses on a time when the North Carolina Fund was riding high. George Esser and his staff looked to the future with confidence and a deep sense of satisfaction. When representatives of the Ford Foundation reviewed the Fund in late 1966, they heaped praise on the agency's efforts. In less than three years, it had “helped initiate and finance innovative, experimental projects . . . to better educate the young and give job skills to unemployed adults, to improve health and sanitation in backward communities . . . to initiate farm coops, and to begin imaginative projects organizing domestic workers, establishing day care centers . . . training and developing indigenous leaders, and a host of other activities, indispensable to ending poverty.” Even so, the Ford team noted, there was much work yet to be done.
Elizabeth Dawes Knight, Alan Dellapenna
Published: 26 April 2015
by BMJ
Statement of purpose There is untapped potential among public health professionals and public health practitioners without formal public health training to prevent injury sing the National Training Initiative’s Core Competencies in Injury Prevention. This presentation will describe North Carolina’s approach to enhancing the statewide multi-disciplinary injury prevention workforce, the Injury-Free NC Academy. The Academy was developed in response to the NC State Advisory Council’s Strategic Plan for Preventing Injury and Violence recommendation that the state “Develop a statewide injury and violence prevention workforce that meets core injury and violence prevention competencies.” Methods/Approach The results of a survey, the NTI Competencies, and the PREVENT Institute informed the development of the Academy. Trainees are multi-disciplinary, multi-organisational county-based teams who bring a project to work on throughout the Academy. Two in-person training sessions are held six months apart. Coaching is provided throughout the Academy, including during the six month interim period in which teams are working on their project. Second session topics are determined by the evaluation results of session one. All instructional sessions are immediately applied to team projects using activities and coaching. Team interaction, peer learning, and networking are emphasised. Results The three Academies held to date have focused on teen driver safety, overdose prevention, and the prevention of child sexual abuse and sexual violence respectively. The Academy has trained 20 teams working in over 30 of NC’s 100 counties. Teams have included social workers, substance abuse, mental health professionals, community advocates, law enforcement personnel, members of the faith community, school personnel, and others. Training, which is always at full capacity, requires at least four days, more if travel is required. While the training is free, participants pay for their own travel and hotel. Conclusions Academy experience attests to the perceived need for public health training, and that this training appears complementary to and easily integrated into other disciplines. Significance and contribution to the field The Academy provides a low-cost method of enhancing the capacity of the NC multi-disciplinary injury prevention workforce with training in core public health competencies which could be replicated in other states.
Sri Lanka Journal of Bio-Medical Informatics, Volume 1;

<!-- @page { margin: 0.79in } P { margin-bottom: 0.08in } --> The latter parts of 2007 and early months of 2008 witnessed an alarming number of deaths due to a Leptospirosis outbreak in Sri Lanka(1). An unusual number of patients presenting with symptoms of fever, headache or myalgia concentrated in particular geographic areas (North Central and North Western Province in Sri Lanka) could have signalled the epidemiologists of an abnormal event with the help of a quicker surveillance programme leading to possible implementation of optimal strategies which could possibly have minimized the early deaths and even prevented the progression of the outbreak. The present day paper-based disease surveillance and notification systems in Sri Lanka(2), confined to a set of notifiable diseases, often require 15-30 days to communicate data and for the central Epidemiology Unit to process it. This latency does not allow for timely detection of disease outbreaks and it limits the ability of the health system to effectively respond and mitigate their consequences. Therefore it negatively affects the health status of the work force and productivity of the country. The Real Time Bio-surveillance Program (RTBP) is a pilot study aiming to introduce modern technology to the Health Department of Sri Lanka to complement the existing disease surveillance and notification systems. The processes involve digitizing all clinical health records and analysing them in near real-time to detect unusual events to forewarn health workers before the diseases reach epidemic states. Similar studies have been conducted on bio terrorism surveillance in Winnipeg, Canada(3), pandemic surveillance in Morocco(4) and North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) in North Carolina(5). The infrastructure of the project RTBP is composed of an interconnected network between health care workers via mHealthSurvey mobile phone application, T-Cube web interface (TCWI) and Sahana Messaging/Alerting Module. Health records from health facilities, namely demographic information, symptoms, suspected and diagnosed diseases are collected through the mHealthSurvey, a mobile phone application(6), that feed in to the TCWI(7), a browser based software tool that detects adverse events; health officials are notified of the adverse events using the Sahana Alerting module that transports via Short Message Service (SMS), Email, and Web(10). Evaluation of the RTBP involves a replication study and parallel cohort study. This pilot study indicates the need for more robust mobile application for data collection with complete ontology, semantics and vocabulary in disease-syndrome information to reduce noise and increase reliability in the datasets. More rigorous capacity building and frequent use is required for health officials to take advantage of the full potential of TCWI. This paper discusses the technologies used in the pilot and the initial findings in relation to usability of the system. Keywords: Bio-surveillance, Epidemiology, Information Communication Technology, m-Health, Disease Outbreak, Event Detection, Alerting, Sri Lanka Sri Lanka Journal of Bio-Medical Informatics 2010;1(3):139-154 DOI: 10.4038/sljbmi.v1i3.1774
Published: 1 January 2020
In this podcast, Sherman James describes what he terms as “John Henryism,” in order to examine how social stratification and working class, poor, and minority groups’ dispositions toward improving their social and economic situation can be associated with health problems. John Henryism, James explains, is a “strong personality disposition to engage in high-effort coping with social and economic adversity. For racial and ethnic minorities […] who live in wealthy, predominantly white countries–say, the United States–that adversity might include recurring interpersonal or systemic racial discrimination.” John Henry is a figure from American folklore, a railroad worker famous for his physical strength. The figure is thought to be based on a manual worker, perhaps an emancipated slave. Henry’s boss challenged him to compete against a mechanical steam drill, a challenge he won, but as James explains, “he died from complete mental and physical exhaustion following his victory.” Coronavirus has shone a light on the disproportionate toll such a pandemic can have on communities of color in the United States. James discusses the increased likelihood these communities have of catching and dying from the virus and introduces ideas that would allow deprived communities to pursue their goals, without increasing the destruction of their wellbeing. DE: DAVID EDMONDS SJ: SHERMAN JAMES DE: This is Social Science Bites with me, David Edmonds. Social Science Bites is a series of interviews with leading social scientists and is made in association with SAGE Publishing. Several decades ago, an American epidemiologist now based at Duke University came up with a hypothesis that certain groups were susceptible to health problems because of the stress of high effort of trying too hard. The epidemiologist is Sherman James. And he gave the hypothesis a name, John Henryism. Sherman James, welcome to Social Science Bites. SJ: Thank you very much, David. DE: The topic we’re talking about today is John Henryism. Who was John Henry? SJ: John Henry was a unskilled manual laborer, perhaps an emancipated slave. The legendary John Henry was a railroad worker. And he was renowned throughout the South for his amazing physical strength as being the best steel driver of anyone. And so one day, he was challenged by the captain, by the work boss to compete against a mechanical steam drill. He accepted the challenge. And there was an epic battle of man, John Henry, against the machine. And John Henry actually beat the machine. But he died from complete physical and mental exhaustion following his victory. DE: And this is when, late 19th century? SJ: Yes, roughly the early 1870s. DE: So that’s the folklore John Henry. But you also met somebody with the same name. SJ: I did. I met a man, an African-American man by the name of John Henry Martin. I did not know his full name. All I knew initially was that his name was John Martin. And he had this amazing story of having been born into a very, very poor family, a sharecropping family, in the early 1900s. And he decided that he did not want to be a sharecropper like his father, and have his labor exploited, and remain in debt his entire life. And so with his wife’s encouragement, he took out a bank loan to buy 75 acres of land. And he had 40 years to pay off the bank loan. But he wanted to pay it off in one year because he did not want to be vulnerable in that way. He worked night and day and managed to pay off that 75 acres of fertile North Carolina land in five years. But he suffered from high blood pressure, osteoarthritis, which left him with a disability. He was hardly able to walk when I met him. And he had in his 50s a case of peptic ulcers disease that was so severe that 40% of his stomach had to be removed. And after I listened to this amazing story of how he had overcome enormous odds to become an independent farmer, a landowner, someone capable of managing his own life, his wife came to the door, and she said, John Henry, it’s time for lunch, and bring your guest with you. And I looked at him with astonishment. And I said, your name is John Henry. And he said, John Henry Martin is my name. And I was just blown away by that. And I thought, holy cow. And as I thought about his life story, I realized that his story not only echoed the folktale of John Henry, the legendary steel driver, but it also echoed the life experiences of so many working-class African-Americans that I knew. DE: So these two John Henry’s were both battling against the odds. They were both fighters working astonishingly hard. The second John Henry, the one you met, had serious physical problems, became seriously ill. What then is John Henryism? SJ: So John Henryism is defined as a strong personality disposition to engage in high-effort coping with social and economic adversity. Now, that adversity might include financial hardship, work demands, job loss, or job insecurity. For racial and ethnic minorities– for example, John Henry Martin– who live in wealthy, predominantly white countries– say, the United States– that adversity might include recurring interpersonal or systemic racial discrimination. So it’s high-effort coping with adversity and determination to succeed despite being faced with enormous odds. DE: So it’s the high effort but also the physical repercussions of that. Spell out what those repercussions are. SJ: Yes. So that high-effort coping when engaged in over years, perhaps decades, can produce excessive wear and tear on multiple physiological systems– the cardiovascular system, the immune system, the metabolic system. So it can have widespread physiological consequences. And in terms of cardiovascular health, it can really damage blood vessels. And it can damage the heart. And this is a consequence of this enormous outpouring of energy and the release...
Sa Cage, Cage Sa, Warner Bj, Ballard B, Gallegos Dm, Goza Jp, Warner Lk
Research & Investigations in Sports Medicine, Volume 8, pp 693-696;

Cage SA1,2*, Warner BJ2,3, Ballard B1, Gallegos DM4, Goza JP5 and Warner LK6 1University of Texas at Tyler, USA 2University of North Carolina, USA 3Grand Canyon University, USA 4University of Texas Health East Texas, USA 5Collin College, USA 6AlphaMeD, USA *Corresponding author: Cage SA, University of Texas at Tyler, USA Submission: September 08, 2021;Published: October 20, 2021 DOI: 10.31031/RISM.2021.08.000676 ISSN 2578-0271 Volume8 Issue1 Following the widespread transmission of the novel coronavirus responsible for COVID-19, the first COVID-19 vaccine received emergency use authorization in December 2020. The purpose of this study is to describe the attitudes toward available COVID-19 vaccines among athletic trainers. 258 certified athletic trainers (age=43±12 years; years of certified experience=19±12 years) completed an electronic survey via email that collected data on demographics, face mask usage, and attitudes toward available COVID-19 vaccines. Data were downloaded and analyzed using a commercially available statistics package (SPSS Statistics Version 26, IBM, Armonk, NY). Measures of central tendency (means, standard deviations, frequencies) were calculated for all survey items. The majority of respondents reported that they were comfortable with the current level of authorization for available COVID-19 vaccines. Most athletic trainers stated that they would receive a COVID-19 vaccination when it was available, but that they would rather it be a voluntary choice rather than mandated by an employer or government body. The majority of athletic trainers reported personal, household, and vulnerable population safety as the primary considerations for receiving a COVID-19 vaccination. In general, these factors were more important to participants than were public perception or concerns over infringements of personal liberties. Given that athletic trainers continue to work in day-to-day patient care, it is important to consider the best means of educating athletic trainers on the potential benefits of COVID-19 vaccinations. Keywords: Deterrent factors; Physical activities; Student nurse; Women Coronavirus disease 2019 (COVID-19) is a highly infectious respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 was first reported in late 2019 in Wuhan, China [1]. Symptoms include fever, cough, fatigue, loss of smell, loss of taste, body aches, shortness of breath, nausea, vomiting, and diarrhea [1]. In severe cases, patients have experienced potentially fatal pneumonia, septic shock, metabolic acidosis, and coagulation dysfunction [2]. Efforts during the first several months of the COVID-19 pandemic focused on mitigating its spread, including testing, contact tracing, enhanced hygiene efforts, use of face coverings, and social distancing [3-6]. In December 2020, the first vaccine against COVID-19 received Emergency Use Authorization (EUA) from the United States Food and Drug Administration [7]. As the global COVID-19 pandemic progressed, many communities and organizations enacted legislation and rulings aimed at limiting the transmission of COVID-19. The National Collegiate Athletic Association (NCAA) opted to cancel all remaining championships for the 2020 spring semester [8]. The majority of institutions and athletic conferences followed suit and cancelled the remainder of their seasons [9], including many secondary schools, who postponed or suspended athletic activities and face-to-face instruction [10,11]. Subsequently, a study reported that many athletic trainers were suffering from increased levels of depression and anxiety [12]. These findings suggested that some athletic trainers experienced adverse mental health effects as a result of the pandemic while participating in their role as frontline healthcare workers. Further research is underway to evaluate the epidemiology, diagnosis, treatment, and prevention of COVID-19 [1-4]. To date, no publications appear to be available on attitudes toward recently authorized COVID-19 vaccines. Therefore, the purpose of this study is to describe the attitudes of athletic trainers toward COVID-19 vaccination. Design This cross-sectional study collected data by internet-based survey as approved by the University of Texas at Tyler IRB. Participants Participants were recruited by emailing the head athletic trainers at NCAA Division I, Division II, and Division III institutions, Commission on Accreditation of Athletic Training Education (CAATE) accredited program directors, and members of various regional and local athletic training organizations using publicly available databases. Recruiting was completed using the snowball technique; participants were asked to forward the study invitation to certified colleagues. A total of 258 certified athletic trainers completed the study (age = 43±12 years; years of certified experience = 19±12 years). Participant demographics are listed in Table 1. Table 1: Participant demographic information. Data collection An email was sent in January 2021 to all prospective participants inviting them to participate in a survey accessible via hyperlink to a web-based server (Qualtrics Inc., Provo, UT). The email contained information about the investigators, the purpose of the study, and the nature of the survey. A follow-up email was sent two weeks after the initial email, and the survey was closed a week later prior to statistical analysis. Instrument Following the questions on informed consent and demographics, the survey posed questions about the...
, David Callaway, Jeremy N. Driscoll, Stephanie Murphy
Disaster Medicine and Public Health Preparedness, Volume 16, pp 2076-2082;

Objective: In this manuscript, we discuss the implementation and deployment of mobile integrated health and community paramedicine (MIH/CP) testing sites to provide screening, testing, and community outreach during the first months of the 2019 coronavirus disease (COVID-19) pandemic in the metropolitan region of Charlotte, North Carolina. This program addresses the need for an agile testing strategy during the current pandemic. We disclose the number of patients evaluated as “persons under investigation” and the proportion with positive severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) results from these sites. We describe how the programs were applied to patient care and include considerations on how additional staffing, scalability, and flexibility of these services may be applied to future patient and health care crises.Methods: This is a descriptive report of the implementation of MIH/CP test sites in our health care system’s early response to the COVID-19 pandemic in March 2020. Retrospective data on the number of patients and their associated demographics are reported here as raw data. No statistical analysis was performed.Results: Between March 15, 2020, and April 15, 2020, our 6 MIH/CP test sites evaluated 4342 patients. Of these, 401 patients (9.2%) had positive test results, 62.8% of whom were women. The estimated duration of each patient encounter under investigation was 3 to 5 minutes. The paramedics were able to perform a brief history, specific physical examination, and screening for signs of hypoxemic respiratory failure. There were no cases of accidental exposure or failure of personal protective equipment for the MIH/CP paramedics.Conclusions: In our health care system, we pivoted the traditional MIH/CP model to rapidly initiate remote drive-through testing for COVID-19 in pre-screened individuals. This model allowed us to test patients with suspected COVID-19 patients away from traditional health care sites and mitigate exposure to health care workers and other patients.
, Zo Mpofu
Journal of Public Health Management and Practice, Volume 28;

Buncombe County, North Carolina, was recognized in 2014 as a Robert Wood Johnson Foundation Culture of Health Prize Winner for its work fostering collaboration and partnership to address community health needs. As part of this work, Buncombe County Health and Human Services (HHS) convened a cross-sector Public Health Advisory Council that supported community-based initiatives and ensured that community members were involved in identifying and implementing solutions to issues such as poverty and child well-being. Leveraging existing relationships and past efforts, Buncombe County has continued to build collaborative networks for systems change using a collective impact framework. Bringing together partners across sectors, including the faith community, Black fraternities and sororities, community health workers, consulates, and others, Buncombe County HHS is supporting efforts to train and equip community members to lead health promotion efforts and community conversations on historical trauma and racial healing; engage community members in the policymaking process through town halls; and archive the community's pandemic journey through storytelling. The collective impact framework has shaped an environment that supports community change by centering community aspirations and values. This environment informed recent declarations by Buncombe County HHS and the Board of Commissioners that racism is a public health crisis, as well as a resolution by the city of Asheville supporting community reparations. This article explores how the collective impact framework has been used in Buncombe County to engage and continually invest in communities of color and reviews steps taken to develop and implement an equity action plan to address structural racism.
Candace Burns, Ann M. Lachat, Kimberly Gordon, Mary Gene Ryan, Maryann Gruden, D. Paxon Barker, Deborah Taormina, Burns Candace, Lachat Ann M., Gordon Kimberly, Ryan Mary Gene, Gruden Maryann, Barker D. Paxon, Taormina Deborah
Published: 1 March 2014
Workplace Health & Safety, Volume 62, pp 96-104;

Professional Practice Candace Burns, PhD, ARNP; Ann M. Lachat, RN, BSN, COHN-S/CM, FAAOHN; Kimberly Gordon, MSN, MA, BAN, RN, COHN-S, FAAOHN; Mary Gene Ryan, MPH, BSN, RN, COHN-S/SM, CSP, FAAOHN; MaryAnn Gruden, RN, CRNP, MSN, COHN-S/CM NP-C; D. Paxon Barker, PhD, MS, RN; Deborah Taormina, MS, RN, NP-BC, COHN-S Approximately 5 million workers employed at 1.3 million work settings are required to wear some form of respiratory protection as part of their jobs. Occupational health nurses can protect the respiratory health of America’s workforce. In 2012, the American Association of Occupational Health Nurses Grants Committee Working Group conducted a nationwide survey of occupational health nurses to assess their knowledge, comfort, skills, and abilities relative to respiratory protection. The Working Group used the survey findings as a foundation for the development of respiratory protection competencies for occupational health nurses and a guide for the development of educational modules. [Workplace Health Saf 2014;62(3):96–104.] Dr. Burns is Director, Occupational Health Nursing Program and Deputy Director, Sunshine Education and Research Center, University of South Florida, Tampa, Florida. Ms. Lachat is Chief Executive Officer, American Board for Occupational Health Nurses, Inc., Hinsdale, Illinois. Ms. Gordon is from University of Iowa, College of Public Health, and Heartland Center for Occupational Health and Safety, Iowa City, Iowa. Ms. Ryan is from MGRyan & Co., Inc., Oxnard, California. Ms. Gruden is Community Liaison, Association of Occupational Health Professionals in Healthcare, Warren-dale, Pennsylvania. Dr. Barker is Associate Professor, Washington Adventists University, Takoma Park, Maryland. Ms. Taormina is Nurse Practitioner, Stanford University Occupational Health Center, Stanford, California. The author has disclosed no potential conflicts, financial or otherwise. The authors gratefully acknowledge the consultation, participation and contributions of Debra Novak, PhD, RN, Senior Service Fellow, CDC/NIOSH/NPPTL. The authors appreciate the assistance of Annette Byrd, RN, MPH, ICC, Education Consultant for AAOHN and Leslie Long, Manager with International AMC. AAOHN acknowledges the contributions of the following owners/members in revising the respiratory protection competencies. Members of the AAOHN Respiratory Protection Education, Competency and Training Project Team: Candace Burns, PhD, ARNP, Team Leader; Debra Novak, PhD, RN, NIOSH Project Officer; Mary Gene Ryan, MPH, BSN, RN, COHN-S/SM, CSP, FAAOHN, and Deborah Taormina, MSN, NP-BC, COHN-S, AAOHN Representatives; Ann Lachat, RN, BSN, FAAOHN, COHN-S/CM, ABOHN Representative; MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM, AOHP Representative; Paxson Barker, PhD, MS, RN, ANA Representative; and Kim Gordon, MSN, MA, RN, COHN-S, FAAOHN, Continuing Education Planner. Delphi Reviewers: David Allcott, MSN, APRN, ANP-BC, COHN-S, COHC, Medical Services Manager, ATK Aerospace Systems; Kathleen Brown, PhD, RN, Professor of Nursing and Director of the Education and Training Unit of the Center for Outcomes Effectiveness Research and Education (COERE), University of Alabama at Birmingham; Barbara Burgel, RN, PhD, COHN-S, FAAN, Clinical Professor of Nursing, University of California–San Francisco School of Nursing; Yolanda Lang, Dr.PH, MSN, CRNP, COHN, FAAOHN, NP Occupational Health, University of Pittsburg Medical Center; Michael R. Cooper, CIH, CSP, MPH, Industrial Hygienist, Occupational Health Branch, California Department of Public Health; Pam Hart, MPH, RN, COHN-S, CSP, Risk Consultant, Wells Fargo Insurance Services; Marjorie McCullagh, PhD, RN, Assistant Professor and Director, Occupational Health Nursing Program, University of Michigan School of Nursing; Emily Wallace, BS, RN, COHN-S, NIOSH-approved Spirometry Instructor; and Cara Winstead, MPH, RN, COHN-S, Occupational Health Nurse, Rex Healthcare. Correspondence: Candace Burns, PhD, ARNP, University of South Florida, College of Nursing-HSC 22, 12901 Bruce B. Downs Blvd., Tampa, FL 33612. E-mail: [email protected] Occupational and environmental health nurses have protected and promoted the health of America’s workers since the turn of the 20th century. By maintaining and improving the health of the nation’s workforce, occupational and environmental health nurses contribute significantly to the health of the nation. These nurses use both general nursing knowledge and skills and specialized occupational health and safety knowledge to provide nursing care in a variety of worksites, including farms, factories, health care facilities, construction sites, and mines. More than 5 million workers at 1.3 worksites may be exposed to respiratory hazards, including physical, biological, and chemical particles and vapors, and are required to wear respiratory protection (Occupational Safety and Health Administration [OSHA], 2011<!----> ). Unfortunately, respiratory protection is not always effective in protecting workers’ health, resulting in specific pulmonary diseases and systemic infections and illnesses that sometimes lead to disability and death. Occupational and environmental health nurses must develop competence in identifying respiratory hazards and developing programs to eliminate the hazard or protect potentially affected workers (Cleaver, Rogers, Schultz, & Liverman, 2011<!----> ). Specifically, occupational and environmental health nurses must conduct workplace assessments, develop health and safety policies, provide effective respiratory protection education programs, and comply with federal, state, and local regulations and standards to reduce the effect of respiratory hazards on the health and safety of workers. For example, a well-documented pattern of marginal respiratory protection practices for health care workers was instituted as far back as the SARS epidemic and most recently the threatened H1N1 epidemic (Banach, Bielang, & Caffee, 2011<!----> ; Daugherty, Perl, & Needham, 2009<!----> ; de Perio et al., 2012<!----> ; Gamage et al., 2005<!----> ; Lautenbach, Saint, Henderson, & Harris, 2010<!----> ; Nichol et al., 2013<!----> ; Wise, de Perio, & Jhung, 2009<!----> ). The National Institute for Occupational Safety and Health (NIOSH) National Personal Protective Technology Laboratory (NPPTL) requested that the Institute of Medicine appoint an ad hoc Committee on Respiratory Protection Curriculum for Occupational Health Nursing Programs and charged it with examining existing respiratory protection curricula in academic occupational health nursing programs and developing recommendations to improve education and training on the selection (including situation assessment), use, care, and maintenance of respirators (Cleaver et al., 2011<!----> ). The nine member Institute of Medicine Committee included individuals with expertise in occupational health nursing and medicine, personal protective equipment design and training, industrial hygiene and occupational health, clinical medicine, and nursing education. The committee used several methods to reach its conclusions and recommendations, including a literature search and review of materials including the American Association of Occupational Health Nurses (AAOHN) core competencies and curriculum. The committee conducted a public workshop in March 2011 to gather information, gain a clearer understanding of existing respiratory protection curricula in occupational health nursing programs, and develop recommendations to improve nursing education on the selection (including situation assessment), use, care, and maintenance of respirators. Presentations from and discussions with experts from graduate academic and continuing education occupational health nursing programs educated the committee about occupational health and safety, respiratory protection, and occupational health nursing practice. Presenters included occupational health nursing and industrial hygiene faculty from graduate academic and continuing education programs, representatives from nursing (e.g., American Nurses Association [ANA]) and occupational health nursing (e.g., AAOHN) professional associations, a representative from the American Board of Occupational Health Nurses (ABOHN), a representative from the NIOSH NPPTL staff, and occupational health and safety stakeholders. NIOSH NPPTL staff also conducted a survey regarding respiratory protection curricula offered by six NIOSH Education and Research Center occupational health nursing graduate programs and the North Carolina Division of Public Health. The committee’s deliberations resulted in seven recommendations (Cleaver et al., 2011<!----> ) (Sidebar 1<!---->). The American Association of Occupational Health nurses (AAOHN) will conduct a survey in collaboration with the National Personal Protective Technology Laboratory (NPPTL) and other professional organizations, inquiring about occupational health nurses’ roles and responsibilities related to respiratory protection and nurses’ education and training needs in this area. Occupational health nurses should achieve and maintain knowledge and skills related to respiratory protection appropriate to their scope of practice. Nursing education programs at all levels should include respiratory protection content appropriate to graduates’ role and scope of practice. Occupational health nurse educators should ensure essential respiratory protection content is included in graduate occupational health nursing programs and integrated into continuing education courses for these nurses. Occupational health nursing education programs should develop, expand, and evaluate innovative teaching methods and resources to establish best practices in respiratory protection. NPPTL should develop and maintain online resources about respiratory protection for the education
Mwangelwa Mubiana-Mbewe, Samuel Bosomprah, Jillian L. Kadota, Aybüke Koyuncu, Thankian Kusanathan, Keith Mweebo, Kebby Musokwatane, Priscilla Lumano Mulenga, Benjamin H. Chi, Michael J. Vinikoor
Published: 1 January 2019
SSRN Electronic Journal;

Background: Suboptimal retention may undermine the individual and public health benefits of immediate lifelong antiretroviral therapy (ART) for HIV-positive pregnant women (i.e., Option B+). We evaluated the effect of an intervention called the B-plus Enhanced Adherence Package (BEAP) on early ART uptake and short-term retention among newly diagnosed HIV-positive pregnant women in Lusaka, Zambia.Methods: Pregnant women at 3 public sector facilities in Lusaka urban district who were 18+ years old, HIV-positive, and ART naïve were enrolled between March 02, 2017 and December 18, 2017 and randomized 1:1 to BEAP versus standard of care (SOC) services. All participants were eligible for Option B+ per national guidelines. BEAP involved early (within 1-2 weeks of eligibility for option B+) phone calls and home visits from a male-female pair of community health workers (CHW) to provide additional counseling, engage male partners in HIV testing, and follow-up any missed ART appointments. CHW documented all BEAP activities. The primary outcome, initiation and retention on ART per pharmacy records at 30 days after Option B+ eligibility, was compared by study arm in an intention to treat (ITT) analysis using logistic regression. In a per protocol analysis we also assessed the impact of BEAP on initiation and retention among those women who were confirmed to have received BEAP services. In pre-planned subgroup analyses, we also evaluated the BEAP's impact according to participant age, parity, baseline HIV partner disclosure status and baseline CD4+ count.Findings: Among 454 women enrolled, 229 were randomized to BEAP and 225 to SOC. The two arms were balanced with respect to age (p=0.16) and gestational age (p=0.09). Within 30 days of Option B+ eligibility, 445 (98.2%) initiated ART; however, only 369 (82.9%) of those women who started ART were still in care at 30 days. In ITT analysis, the proportion initiating and remaining on ART at 30 days was similar between women randomized to BEAP versus SOC (82.5% versus 80.4%; crude relative risk [RR], 1.03; 95% confidence interval [CI], 0.91-1.16). After exclusion of 92 participants (40.2%) due to not receiving BEAP services based on CHW documentation and 1 participant due to ineligibility, BEAP was associated with being on ART at 30 days versus SOC (91.9.0% versus 80.4%; crude RR 1.14; 95% CI, 1.02-1.29). No significant variation was found in the effect of BEAP in subgroup analyses based on parity, age, baseline HIV disclosure status, and/or baseline CD4+ count.Interpretation: Uptake of Option B+ within 30 days of eligibility was nearly universal among HIV-positive pregnant women in urban Zambia. Women who received the BEAP intervention were statistically more likely to be on ART at 30 days compared to those receiving standard services. This difference, though modest, supports the potential of targeted early interventions to optimize the implementation of Option B+.Trial Registration: The trial was also registered at (trials number NCT02459678).Funding Statement: This research has been supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through the United States Centers for Disease Control and Prevention (CDC) under the terms of cooperative agreement number U01GH000530. Additional investigator support was provided by the National Institutes of Health (K24 AI120796).Declaration of Interests: MM declares that the Centre for Infectious Disease Research in Zambia (CIDRZ), received a grant from the Centers for Disease Control and Prevention (CDC) (grant number: GH000530) to carry out this study. The rest of the authors declare no conflict of interest.Ethics Approval Statement: Approval for the study was obtained from the University of Zambia Biomedical Research Ethics Committee (Lusaka, Zambia) and the University of North Carolina at Chapel Hill Instituitional Review Board (Chapel Hill, NC, USA). The study was reviewed in accordance with the Centers for Disease Control and Prevention (CDC) human research protection procedures and was determined to be research, but CDC investigators did not interact with human subjects or have access to identifiable data or specimens for research purposes. Women who were eligible and agreed to participate provided written informed consent.
Published: 1 January 2013
Frontiers in Public Health, Volume 1;

Public Health Education and Promotion, a new section of the journal Frontiers in Public Health, provides a refreshing forum for those readers who have traversed the familiar landscape of near-intractable health inequities on a national and global level and desire new knowledge on how best to ameliorate health inequities and the social factors that perpetuate them. The new “frontier” in public health hopefully heralds an era of increased and appropriate resource allocation for interventions that improve public health education and consequently begins to shift the needle toward health equity. This article highlights a series of approaches that, asserting an ecological model, can promote and sustain health equity by: • Providing an easily accessible repository of public health data and health information that promotes health literacy at a population level. • Elevating public health research on health equity, aligning it with the best clinical and clinical translational research at leading institutions. • Identifying strategies to ameliorate health inequity, primarily by promoting evidence-based, public health pedagogy in all institutions of higher education while advocating for the development of a diverse public health workforce. Poor health literacy has been strongly linked to health disparities (1– 4). Health literacy is defined in the Institute of Medicine (IOM) report Health Literacy: A Prescription to End Confusion as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (5). Health literacy goes beyond a narrow concept of health education and individual behavior-oriented communication and addresses the environmental, political, and social determinants of health. The body of health literacy research and practice has expanded remarkably in the past decade; however we are still in the nascent stages of understanding the interface between health literacy and public health. Kristen Sorenson and colleagues offered a conceptual framework that integrates the “medical” conceptualization of health literacy with the broader “public health” perspective (6). Their model illustrates the necessary interface between disease promotion and social determinants to address public health literacy, with the individual health promotion found in traditional health literacy. It is now incumbent upon leading scientific journals to provide concrete examples of how health literacy approaches can be used to improve community and population health and reduce health disparities. Readers will have the opportunity to review the current field of public health literacy and health disparities in more detail in a forthcoming edition of this journal. Public health education research needs to be funded at a level commensurate with the urgency to reduce the burden of chronic diseases and health inequity worldwide, and Public Health Education and Promotion has to be at the forefront of disseminating that research to a broad audience. Public health education research has to specifically address the socioeconomic, environmental, and behavioral determinants of disease (7), which has to occur in a collaborative manner among the leading academic medical centers, schools of public health, and institutions such as the National Institutes of Health (NIH) and Centers for Disease Control and Prevention (CDC). The Affordable Care Act (8) recently ushered in a new level of research collaboration through the establishment of the Prevention and Public Health Fund, which has invested substantially in evidence-based activities including research. According to the Department of Health and Human Services, the CDC has continued support for its Prevention Research Centers program (9). This effort directs a national network of 37 academic research centers, at either a school of public health or a medical school with a preventive medicine residency program. The centers are committed to conducting prevention research and are leaders in translating research results into public health practice. These centers have rich capacity for the community-based, participatory prevention research needed to understand the major community changes that can prevent and control chronic diseases. The Agency for Healthcare Research and Quality (AHRQ) has also established Centers for Excellence in Clinical Preventive Services in Illinois, North Carolina, and Colorado which support the HHS National Prevention Strategy by developing evidence around the most efficient and effective ways primary care health systems can deliver clinical preventive services (10). These and other examples of community-based participatory prevention research should be extensively highlighted to promote more widespread adoption. As outlined by the CDC and the NIH Institute for Minority Health, the future health of the nation will be determined to a large extent by how effectively we work with communities to eliminate health disparities among those populations experiencing a disproportionate burden of disease, disability, and death (11). Nonetheless, health professional schools have produced a practitioner workforce more educated in specific disciplines and lacking in formal public health training. In September 2010 the Association of American Medical Colleges (AAMC) and the CDC sponsored a workshop (12), “Patients and Populations: Public Health in Medical Education” which provided a framework for integrating public health content into medical school curricula. It is timely that schools of medicine and allied health provide members of the future physician workforce the knowledge, skills, and attitudes to address health disparities in partnership with community health and public health workers. Unquestionably, a reduction in health disparities will require more interdisciplinary approaches, with a more active interface between public health programs and health professional schools, coupled with a systematic approach that aligns governmental and non-governmental agencies to specifically address health equity. Indeed, the resolution of this country’s persistent health inequities is intrinsically linked to enhanced instruction in public health in our schools of medicine, public health, and allied health (13, 14). Such comprehensive health disparities curricula have been infrequent in contemporary health professional schools and organizations (15). The Liaison Committee for Graduate Medical Education (LCGME) adopted standards for cross-cultural education as early as 2002 (16), and both the AAMC and IOM (17, 18) have provided recommendations for health disparities education. However, health disparities curriculum in health professional schools may fail to evaluate knowledge, skills, and attitudes over time and are less likely to be linked to improved patient heath status and greater community benefit. While there is continued interest in courses on healthcare delivery and healthcare systems, there may be less in other appropriate areas like occupational health and medicine. Health policy development is required in <70% of medical schools despite the fact that 77% of polled Americans most trust physicians to reform the health system (19, 20). These data follow the 1998 Healthy People Curriculum Task Force (21) which recommended that population health perspectives be provided for all medical students. The efforts outlined above have centered on trainees in formal public health programs, however we recognize that reduction in health disparities will require a more interdisciplinary approach, with a more active interface between public health programs and health professional schools (22). There is renewed optimism in achieving the goal of expanding a diverse public health workforce, based on the Liaison Committee on Medical Education (LCME) standards for public health science instruction and the ongoing initiatives in public health instruction throughout US medical schools (14). The AAMC and LCME data (19) indicate that many U.S. medical schools now report a broader range of population-based medicine topics in their curriculum, such as biostatistics, epidemiology, health disparities, health care financing, health care quality improvement, public health systems, and global health issues. Prevention and health maintenance is also a required topic of instruction in most medical schools. In June 2010, the LCME, the body that sets accreditation standards for MD-granting medical schools, revised two of their educational standards (ED-11, ED-15) (23) to explicitly include public health sciences and preventive medicine. The curriculum of a medical education program must include content from the biomedical sciences that supports students’ mastery of the contemporary scientific knowledge, concepts, and methods fundamental to acquiring and applying science to the health of individuals and populations and to the contemporary practice of medicine. The curriculum of a medical education program must prepare students to enter any field of graduate medical education and include content and clinical experiences related to each phase of the human life cycle that will prepare students to recognize wellness, determinants of health, and opportunities for health promotion; recognize and interpret symptoms and signs of disease; develop differential diagnoses and treatment plans; and assist patients in addressing health-related issues involving all organ systems. The University of New Mexico School of Medicine Public Health Certificate – The first year of medical school begins with a public health course: “Health Equity: Principles of Public Health.” The courses includes didactic lectures, case-based discussions, and introduces the social determinants of health through the documentary “Unnatural Causes: Is Inequality
Barbara Fraser
Published: 1 June 2016
Journal: Nature
Nature, Volume 534, pp 162-162;

The publisher has not yet granted permission to display this abstract.
, Ma Kuti, Ra Audu, Sa Muyibi, M Imhansoloeva, Oa Mosuro, Ea Solanke, , Ae Irabor, Mma Ladipo, B Berzins, K Robertson, A Ogunniyi, If Adewole, Bo Taiwo
Published: 31 July 2017
Journal: HIV Medicine
HIV Medicine, Volume 19, pp 72-76;

HIV rapid antibody tests are widely used in Africa, but dual testing sometimes produces discordant results. It is not clear if discordant rapid HIV tests should always heighten suspicion by frontline health workers that early HIV infection is present. Some studies have reported that discordant rapid tests have value for identifying early HIV infection in high HIV prevalence populations. It is not known if rapid test performance influenced this conclusion, or if this observation will hold true for low HIV prevalence populations. We therefore explored the occurrence of discordant rapid HIV tests in a low-resource community. A cross-sectional sample of HIV status-unaware adults with recent exposure to unsafe sex was assessed using a validated risk-based tool (University of North Carolina (UNC)-Malawi Risk Screening Score) for acute HIV infection. Participants received rapid testing with Determine™ HIV 1/2 and Uni-Gold™ HIV assays, plus plasma HIV-1 antigen testing with the COBAS® Ampliprep/COBAS® Taqman® HIV-1 assay, followed by western blot in those with detected HIV-1 antigen. Of 408 participants, 1.0% were confirmed to have established HIV infection. The discordance between rapid tests at initial screening was 2.45 and 2.94% when the two assays were used sequentially and simultaneously, respectively. Discordant rapid tests were strongly associated with risk scores > 2 [odds ratio (OR) 10.88; 95% confidence interval (CI) 2.35-50.43], and with detected HIV-1 RNA (OR 26.06; 95% CI 3.91-173.60). When the sample occurrence of discordance between the first and second tests is below 5%, discordant rapid tests in an adult with sexual risk behaviour should trigger strong suspicion of early HIV infection in low HIV prevalence populations.
, Kristen Sullivan, Amy Gatto
Published: 10 September 2010
Psychology, Health & Medicine, Volume 15, pp 515-527;

Recently, national attention has been drawn to the increasing number of adolescents infected with HIV in the US, particularly in the South. According to the Center for Disease Control and Prevention (2007), at least 50% of new HIV infections occur in persons 15–25 years of age, and the majority of these persons are likely infected in their teens. Adolescents with HIV present new challenges to health and social-service providers. Infected teens are typically identified and initially followed by pediatricians and pediatric staff upon diagnosis. The transition to adult infectious disease care can be difficult due to the increased responsibility for self-care and monitoring placed on the young adult. Interviews were conducted with 19 professionals who provide care for children and adults with HIV in North Carolina in order to identify the best practices for transition to adult care. Approximately half of the providers self-identified as pediatric care providers. Nine of those interviewed were nurses and physicians and 10 were social workers. Interviews were transcribed and emergent themes were identified. Findings indicate that promoting medical independence among adolescents, close communication between pediatric and adult providers, and addressing system level concerns, including helping patients' families navigate health insurance and other social services, as well as having a separate clinic for adolescents with HIV, constitute best practices for transitioning youth with HIV from pediatric to adult care.
Published: 27 April 2015
Frontiers in Public Health, Volume 2, pp 163-163;

Village: A group of houses and associated buildings, larger than a hamlet and smaller than a town. Tribe: A social division in a traditional society consisting of families or communities linked by social, economic, religious, or blood ties, with a common culture and dialect. Oxford Dictionary. Effective fall prevention efforts bridge the silos between clinical and community practice. A fall experienced by an older adult is rarely a straightforward event. Typically, falls are due to complex inter-related medical, behavioral, and environmental risk factors (1). For many older adults, medical risk factors such as medication reconciliation, treatment of atrial fibrillation, or physical therapy to address gait and balance impairments are primary in fall prevention (2). However, this is only the beginning of the fall prevention story. Once medical risk factors are managed, the focus of risk management should transition to behavioral and environmental factors (3). This will ensure that the older adult has the ability to safely interact with their environment to prevent a future fall. One of the most robust interventions is strength and balance training to minimize fall risk (4). Two hours of strength and balance training done each week is the minimum dose required to effectively prevent a fall or fall-related injury (5). To achieve this dose of exercise typically requires a behavior change (6). Established protocols to transition from a clinically supervised rehabilitation program to an evidence-based community program will support this behavior change. Once the initial clinical-community transition is complete, to further support behavior change, the older can be embedded into the continuum of the community. For example, the older adult could move from programs that target the more frail and deconditioned, like Stepping On (7), to those that target more robust individuals, like Tai Chi (8). This proposed model supposes that infrastructure is in place to build a continuum of care where none exists. To achieve this model, stakeholders have called for multi-level, multi-component interventions, with the goal of engaging policy makers, healthcare providers, community providers, and older adults themselves. Many have compared these efforts to building a “village” of providers (9). The concept of “village” is appealing, though may be inherently flawed. A village is a group of buildings that simply share the same physical location. These buildings are not necessarily inter-related, inter-dependent, or even connected by a common culture or value system. Besides being in the same physical location, there is no common commitment among members of a village. This scenario of assumed but not confirmed alignment of priorities and goals often plays out in fall prevention. Many public health providers mistakenly assume that healthcare providers integrate fall risk screening and management into their practices. For example, an evidence-based fall prevention exercise program is offered in the community. An older adult is interested in attending the program, and must be cleared by their physician before participating. The older adults request a falls screen from their physician. The physician, however, does not understand her expected role in fall prevention. She has not been trained in fall screening. She assumes that if the patient is asked to be screened then she is at risk of falling, and is not going to be safe in the community program. This is not an atypical behavior; studies have shown that less than 30% of healthcare providers who interact with older adults screen for falls on a routine basis (10). Physical therapists are also uncertain about their roles and responsibilities in the fall prevention continuum. For example, few physical therapists are aware of evidence-based programs that target populations at risk of falling (11). They also may not understand the role of State Fall Prevention Coalitions, or perceive them as partners in creating a continuum. In a survey of PTs interested in disseminating the Otago Exercise Program (OEP), the majority of PTs indicated that support of a program by State-Based Fall Prevention Coalitions was not a facilitator to program implementation (11). A similar story exists from the public health perspective. State-Based Fall Coalitions identified working with healthcare providers to disseminate evidence-based fall prevention programs as a top priority (12). However, it is clear that a disconnect exists between the expectations and actions of healthcare providers by the Coalitions may be resulting in gaps in the continuum. A final example is the complex and misunderstood role of older adults. Though almost all Fall Prevention Coalitions have the goal of education and public awareness, few, if any, actually have older adults as active members of their coalitions (12). Preliminary evidence from pilot studies supports a disturbing trend that even by educating healthcare providers and offering innovative programing, many older adults are likely to refuse when offered an intervention to minimize their risk for falling. A “tribe” differs from a “village” in that there is a shared common culture and values. Everyone has a prescribed job to achieve the common goals. For effective multi-level fall prevention efforts to happen, we may want to shift the paradigm from assuming each stakeholder understands their roles to describing and motivating stakeholders to be part of a shared social movement. What would this look like for future efforts? Current tribe building efforts have demonstrated success. For example, the Oregon State Department of Public Health (DPH) engaging the state chapter of the American Physical Therapy Association to educate physical therapists about the role of public health in fall prevention and providing partnership models. This partnership was designed to facilitate the implementation of the OEP. It was discovered that physical therapists were not familiar with the OEP. Once they were invited to engage with the program, and supported by the Oregon State DPH, OEP adoption and implementation rates increased. The Community Health Worker (CHW) Training described by St. John et al. is another example (13). The goal is to educate CHWs about their role in fall prevention, and in turn to help the CHWs educate their older adult clients. This will ensure that the CHW can contribute to the tribe by contributing to a knowledge base they can use to educate and engage with other healthcare providers who care for their clients (13). Starting with a small group and crossing between disciplines, educating and engaging all key players, and building a common culture of fall prevention will be the key to creating an effective tribe. Every member, no matter how old or young, licensed professional or community provider, has a significant role to play, they just may not know it yet. As we move forward in dissemination and implementation of evidence-based fall prevention programs nationally, the more members we recruit to the tribe, the more successful we will be at addressing the problem of falls. The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. This paper is included in the Research Topic, “Evidence-Based Programming for Older Adults.” This Research Topic received partial funding from multiple government and private organizations/agencies; however, the views, findings, and conclusions in these articles are those of the authors and do not necessarily represent the official position of these organizations/agencies. All papers published in the Research Topic received peer review from members of the Frontiers in Public Health (Public Health Education and Promotion section) panel of Review Editors. Because this Research Topic represents work closely associated with a nationwide evidence-based movement in the US, many of the authors and/or Review Editors may have worked together previously in some fashion. Review Editors were purposively selected based on their expertise with evaluation and/or evidence-based programming for older adults. Review Editors were independent of named authors on any given article published in this volume. This work was funded in part by the University of North Carolina at Chapel Hill Prevention Research Center, supported by Cooperative Agreement Number U48-DP001944, Centers for Disease Control and Prevention Special Interest Project 12-058, and the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under grant #UB4HP19053, Carolina Geriatric Education Center. 1. Tinetti ME, Kumar C. The patient who falls: “it’s always a trade-off”. JAMA (2010) 303:258–66. doi: 10.1001/jama.2009.2024 Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar 2. Prevention of Falls in Older Persons AGS/BGS Clinical Practice Guidelines. (2010). Available from: Google Scholar 3. Stevens JA, Phelan EA. Development of STEADI: a fall prevention resource for health care providers. Health Promot Pract. (2013) 14(5):706–14. doi:10.1177/1524839912463576 CrossRef Full Text | Google Scholar 4. Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev (2012) 9:CD007146. doi:10.1002/14651858.CD007146.pub2 Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar 5. Tiedemann A, Sherrington C, Close JC, Lord SR. Exercise and sports science Australia position statement on exercise and falls prevention in older people. J Sci Med Sport (2011) 14:489–95. doi:10.1016/j.jsams
Roman Johnson, Jennifer R. Bail, Michael Behring, Rachael Orlandella, Victoria Williams, Karina I. Halilova, Teri W. Hoenemeyer
Published: 5 March 2020
Frontiers in Oncology, Volume 10;

A Commentary on Predictors of Colorectal Cancer Screening in Two Underserved U.S. Populations: A Parallel Analysis by Bernardo, B. M., Gross, A. L., Young, G., Baltic, R., Reisinger, S., Blot, W. J., et al. (2018). Front. Oncol. 8:230. doi: 10.3389/fonc.2018.00230 The authors contribute to the literature on geographic colorectal cancer disparities by examining two different populations located in the major colorectal cancer incidence (CRC) hotspots of the Lower Mississippi Delta, West Central Appalachia, and Eastern Virginia/North Carolina regions (1). However, this study could be improved by incorporating more measures reflective of the neighborhood deprivation literature, such as fruit and vegetable consumption (which may decrease colon cancer risk) and extensively underscore the role of the gut microbiome in colon cancer risk (2–5). For example, fruit and vegetable consumption has been shown to reduce the risk of colon cancer (6, 7). In one study, fruit consumption and only one vegetable category, legumes, was inversely associated with colon cancer risk (6). Another study found that consumption of green and white vegetables and fruits was inversely associated with colon cancer risk in men. Simultaneously, consumption of green, red/purple, and white vegetables and fruits was inversely associated with colon cancer risk in women (7). However, in the same study, consumption of orange/yellow vegetables and fruits in men was associated with increased colon cancer risk (e.g., citrus fruits and ginger) (7). Furthermore, diversifying the gut microbiome can aid in preventing colon cancer (8). For instance, eating red meat—a known carcinogen and an inflammatory agent in the bowel—is a common activity in the United States, and largely so in the Midwest and Deep South (8, 9). While there was elaboration on the characteristics of CRC hotspots, the characteristics of CRC non-hotspot areas were not as detailed. For example, the study may have benefited from communicating how cancer incidence and mortality varies within the CRC non-hotspot and hotspot areas (10). Secondly, the fact that some men may hold machismo health beliefs (such as the belief that they can delay healthcare because of their capacity for pain) is an important health belief consideration for explaining the observed differences between men and women in CRC (11). For men, hyper-masculinity ideals may delay or deter them from seeking preventive healthcare services, and, in particular, colonoscopy (11). In a hotspot-originating analysis, mortality rates for African-American (AA) males in the Lower Mississippi Delta Region (comprising 94 counties across Arkansas, Illinois, Kentucky, Louisiana, Mississippi, Missouri, and Tennessee) have remained unchanged, while all other race/gender groups have declined in the last 25 years (12). In this study, traditional risk factors such as AA race and unemployment were linked to higher adjusted relative odds of being within screening guidelines. Interestingly, this gender disparity (38% males within guidelines), is seen in screening in the Southern Community Cohort (SCCS) study, which comprised the subject of this commentary (1, 13). While the authors highlighted the importance of future interventions in underserved areas to increase CRC screenings, specific recommendations regarding how the study's findings translate into specific health behavior change interventions were not provided. Lack of health insurance, low income, and smoking are well-documented colon cancer risk factors screening as well as viable opportunities for preventative intervention (14–16). Furthermore, the Community Guide recommends multicomponent interventions to increase screening for colorectal cancer, and the National Cancer Institute (NCI) provides a list of research-tested intervention programs (RTIPs) specifically aimed at increasing colorectal cancer screening (17, 18). For example, Targeting Cancer in Blacks (TCiB) is a multicomponent, community-based intervention focused on awareness building and behavior modification in unscreened and under-screened AA adults (19). This 18-month intervention, which was disseminated through historically black colleges and universities (HBCUs), resulted in increased cancer screening among AAs in the Southeast United States. An intervention in a rural Washington state community of Hispanic individuals found that use of a promotora cultural worker increased colon cancer screening awareness, knowledge, and screening use in that population (20). The finding that two out of the three CRC hotspot regions exhibited increased odds of CRC screening is intriguing. However, it is also possible that biological differences in CRC severity in hotspot regions exacerbated by race/ethnicity, lower educational attainment, higher obesity prevalence, and unhealthy lifestyles may lead to increased colorectal cancer mortality (21–25). Therefore, future studies should examine potential biological differences in CRC patients who reside in hotspot and non-hotspot areas to improve patient care. Specifically, the potential differences in the gut microbiome matter for individuals at greater risk of colon cancer, especially for those who occupy multiple disadvantaged social profiles and those whose typical diet is more fatty in composition (e.g., black individuals who live in urban environments concentrated with fast food restaurants and low quality produce in grocery stores) as obesity increases colon cancer risk. Health professional recommendations have a positive influence on CRC screening (26). A pivotal role in patient education and motivating screening adherence is played by nurses, given the extended time they spend with patients. Arnold et al. (27) conducted a nurse-led intervention aimed at increasing knowledge and self-efficacy for CRC screening with Fecal Occult Blood Test (FOBT). Nurses used motivational interviewing techniques to identify, solve barriers, and motivate patients to complete FOBTs. Among those receiving nurse support, self-efficacy increased significantly, with patients indicating they could obtain an FOBT, complete it and mail in results. Thus, future interventions aimed at improving CRC screening adherence among those residing in hotspot regions should consider a nurse-led approach. In conclusion, we are heartened by the contribution of Bernardo et al. as it further elucidates our understanding of screening differences by geographical regions. By building further on this research, with an understanding of how to link efficacious interventions, multidisciplinary efforts can improve the health outcomes of the regions' underserved populations. Additionally, research that focuses on geographical screening differences should be translatable into an interdisciplinary, behavioral-based intervention improving health outcomes. - Lifestyle and Diet (28, 29) - Personal History and Genetics (21, 30) - Racial/Ethnic Background (31, 32) - Geographical Environment (33, 34). Each member of the study team contributed portions of the earlier draft manuscripts. The corresponding author prepared the final draft of the manuscript and edited earlier versions of this manuscript. The authors declare that the research conducted have no commercial or financial interests. National Cancer Institute (T32 CA047888) funds the activities of the Cancer Prevention and Control Training Program at the University of Alabama at Birmingham. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The authors acknowledge support from the National Cancer Institute: T32 CA047888. 1. Bernardo BM, Gross AL, Young G, Baltic R, Reisinger S, Blot WJ, et al. Predictors of colorectal cancer screening in two underserved U.S. Populations: a parallel analysis. Front Oncol. (2018) 8:230. doi: 10.3389/fonc.2018.00230 PubMed Abstract | CrossRef Full Text | Google Scholar 2. Lee JE, Chan AT. Fruit, vegetables, and folate: cultivating the evidence for cancer prevention. Gastroenterology. (2011) 141:16–20. doi: 10.1053/j.gastro.2011.05.020 PubMed Abstract | CrossRef Full Text | Google Scholar 3. Smith DM, Cummins S, Taylor M, Dawson J, Marshall D, Sparks L, et al. Neighbourhood food environment and area deprivation: spatial accessibility to grocery stores selling fresh fruit and vegetables in urban and rural settings. Int J Epidemiol. (2009) 39:277–84. doi: 10.1093/ije/dyp221 PubMed Abstract | CrossRef Full Text | Google Scholar 4. Sharkey JR, Horel S, Dean WR. Neighborhood deprivation, vehicle ownership, and potential spatial access to a variety of fruits and vegetables in a large rural area in Texas. Int J Health Geogr. (2010) 9:26. doi: 10.1186/1476-072X-9-26 PubMed Abstract | CrossRef Full Text | Google Scholar 5. Pruitt SL, Davidson NO, Gupta S, Yan Y, Schootman M. Missed opportunities: racial and neighborhood socioeconomic disparities in emergency colorectal cancer diagnosis and surgery. BMC Cancer. (2014) 14:927. doi: 10.1186/1471-2407-14-927 PubMed Abstract | CrossRef Full Text | Google Scholar 6. Vogtmann E, Xiang YB, Li HL, Levitan EB, Yang G, Waterbor JW, et al. Fruit and vegetable intake and the risk of colorectal cancer: results from the Shanghai Men's Health Study. Cancer Causes Control. (2013) 24:1935–45. doi: 10.1007/s10552-013-0268-z PubMed Abstract | CrossRef Full Text | Google Scholar 7. Lee J, Shin A, Oh JH, Kim J. Colors of vegetables and fruits and the risks of colorectal cancer. World J Gastroenterol. (2017) 23:2527–38. doi: 10.3748/wjg.v23.i14.2527 PubMed Abstract | CrossRef Full Text | Google Scholar 8. Rea D, Coppola G, Palma G, Barbieri A, Luciano A, Del Prete P, et al. Microbiota effects on cancer: from risks
Published: 1 January 2014
Frontiers in neuroengineering, Volume 7;

The idea of creating a direct connection between a human brain and a computer has a long history in science fiction. The development of brain computer interfaces (BCI), technologies permitting direct communication between a user's brain and an external device, began to become a reality in the 1970s (Vidal, 1973), and have since captured the attention of scientists and the public alike. Initially conceptualized for military use—the initial work was funded by the National Science Foundation and the Defense Advanced Research Projects Agency (DARPA)—more recently BCIs have shown promise for therapeutic uses, providing hope for restorative and even enhanced human capacities. Utilizing both invasive and non-invasive technologies, scientists are now capable of recording and translating activity from populations of neurons to operate external devices (e.g., O'Doherty et al., 2011). In early 2013, the technology took a leap forward as researchers replaced the external computer connection with a second embodied brain, dubbing the approach “brain-to-brain” interfacing (BTBI). The direct transfer of information between two brains raises new and important ethical issues. Below, we summarize the first two landmark studies in BTBI research, and then discuss ethical concerns relevant to BTBI as they are applied in clinical, research, and non-therapeutic domains. Two studies mark the first major advances in BTBI technology. In the laboratory of Miguel Nicolelis, Pais-Vieira et al. (2013) successfully transferred sensorimotor information from the brain of one rat into that of another. Rats were trained to complete a discrimination task in which illumination of an LED above one of two levers indicated which lever was rewarded. Rats were then grouped into either the “encoder” or “decoder” cohort and implanted with either recording or stimulating electrodes, respectively, in their primary motor cortices. The goal was to transfer task relevant motor information from encoder to decoder rats via electrical stimulation to investigate whether this transfer could allow the decoder to correctly perform the discrimination task in the absence of any other cues. With each correct decoder response, the encoder received an additional reward resulting in a feedback loop for encoders. Without BTBI, decoder performance was at chance; when BTBI was used, however, decoder performance was significantly enhanced, enabling animals to choose the correct lever when receiving neural information from encoders. The investigators found similar performance enhancements with the transfer of somatosensory information (i.e., discriminating aperture width). Pais-Vieira et al. (2013) also coupled the brains of a rat in North Carolina with a rat in Brazil, sending information via Internet, rather than to the adjacent cage. Here, too, decoder rats chose the correct lever more often when BTBI was implemented. A subsequent study by Deadwyler et al. (2013) demonstrated that cognitive information related to the encoding of a memory could also be transferred from one rat's brain to another's. A second group, based in Harvard Medical School, utilized a non-invasive form of BTBI to transfer information from human to rat brains, marking the first interspecies brain interfacing study. Yoo et al. (2013) recorded signals from a human scalp and transformed these signals into tail-movement-evoking stimulation delivered to the brain of an anesthetized rat. Electroencephalography (EEG) was used to record neural activity from humans who were presented with a visual stimulus. When the human participant intentionally focused attention on the stimulus, a steady-state visual evoked potential (SSVEP), a robust electrophysiological signal corresponding to active visual focus, was produced. The SSVEP triggered a stimulation pulse delivered to an anesthetized rodent's scalp using focused ultra-sound (FUS), in which focused acoustic energy is delivered non-invasively to a targeted brain region (but see Davis and van Koningsbruggen, 2013 re: “non-invasive”). Delivery of the SSVEP-invoked FUS pulse reliably evoked rodent tail movement. Yoo et al. (2013) suggest that interspecies BTBI may eventually be used in the reverse direction, from non-human animals to humans, for such things as enhancing our sensory systems (e.g., improving olfaction by linking our olfactory systems to those of a dog) or aiding in search-and-rescue operations, linking our brains with those of the search-and-rescue animal. The very act of linking two brains together to transfer information raises a variety of ethical and safety concerns. Though born of two approaches, extraction and delivery of information, that are each privy to their own suite of ethical issues, BTBIs are a novel means of information transfer which bypasses the customary sensory means for the brain to apprehend information from another individual. Table 1 summarizes ethical issues associated with each aspect of BTBI technology. Such a novel approach demands careful consideration, especially as we develop human-to-animal and human-to-human BTBI technologies. Here we will discuss three categories of concern: potential violations of privacy, human enhancement, and agency and identity. Table 1. Ethical concern by component of brain-to-brain interfacing. Similar to any technology that can extract meaningful information from an individual's brain/body (e.g., fMRI, genetics, EEG), BTBI raises concerns of privacy. While considerable effort has been made to protect genetic information, few safeguards have been created for neural data. Priorities in mapping the human connectome, as with the new US Brain Initiative and the EU's Human Brain Project, foreground the potential for brain-based data to be as powerful and identifiable as genetic data. In addition, fMRI technologies are already being used to reconstruct videos observed by participants (Nishimoto et al., 2011), decode the category of objects viewed by participants (Haxby et al., 2001), and decipher whether or not subjects are lying (Davatzikos et al., 2005). BTBIs add another dimension to the neural privacy concern; not only is information extracted and decoded from the transmitting brain, it is introduced to a receiving brain, presumably without the ability of that brain to refuse or inhibit the impulse. The specter of introducing various kinds of information coercively is also a plausible ethical concern. Because BTBI-related neural information can be transferred over the Internet (as in Pais-Vieira et al., 2013, above), conceivably, one could “hack” another's neural device as has been done with heart pacemakers (Halperin et al., 2008). In addition, these transmissions could be communicated discretely, with items such as “epidermal electronics” (Kim et al., 2011)—extremely thin grids of electrical sensors applied directly to the outside of the skin, similar to a temporary tattoo—placed on the forehead under hair, for instance. BTBI connections, especially through wireless transmissions, could eventually allow soldiers or police—or criminals—to communicate silently and covertly during operations. Another concern, though still far in the future, is the eventual possibility to use this technology coercively. If thoughts can be planted, or behavior compelled, through interfaces that send stimulation or information directly to the brain, it is theoretically possible at some point that such technology might be used without consent to control the behaviors of prisoners, for example. While the current state of the technology is too primitive for such use now, vigilance is imperative as this research continues. As is the case with other neural interventions, such as transcranial direct current stimulation (TDCS) (Coffman et al., 2013) and pharmacological substances (Greely et al., 2008), BTBI has the potential to be used to enhance human cognition (Bostrom and Sandberg, 2009) or well being (Earp et al., 2014). For example, coupling brains could one day provide an advantage to students, enhancing speed of knowledge or skill acquisition. BTBI facilitated learning could widen the gap of social inequities in education and other areas even further, as it is likely that very few will be able to afford initial prototypes. Though progress in brain interfacing technology must first overcome several technological obstacles (Lebedev and Nicolelis, 2006), the future promises advances that will encourage individuals to experiment with these technologies for enhancement purposes, perhaps even creating home-made brain interfacing devices as has already been done with TDCS (Fitz and Reiner, 2013) despite substantial concern regarding the readiness of TCDS technology (Horvath et al., 2014). Do-it-yourself kits for creating TDCS-like devices are already pre-selling from some websites ( and instructional videos for home-made TDCS devices can be found on YouTube. Using EEG, Presacco et al. (2012) recently demonstrated success decoding detailed information about limb movements recorded as participants walked on a treadmill. Likewise, Choi (2013) decoded with high accuracy the shoulder and arm joint movements of participants based on non-invasive recordings. If this information could be transferred via stimulation to the relevant regions of a second individual's (or non-human animal's) brain, it may be possible to control the limbs of the receiving subject via encoder's neural activity. For example, a recent article (Sakurada et al., 2013) reports experiments in which EEG was used to control a Brain-Machine Interface (BMI) suit worn by the user, allowing the suit to grasp a ball and subsequently drop the ball in a target location. Some have argued that such use of BCIs outside the context of therapeutics violate individual authenticity, disrespects the “limits of nature,” and puts us
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