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Mental and behavioral health difficulties are prevalent among children, and research suggests that the vast majority of these children do not receive needed services. Treatment disparities are even larger among rural youth given the scarcity of qualified specialty mental health providers, increased barriers to care, and greater mental health-related stigma compared to their urban counterparts. Many parents seek help and resources from their child’s primary care provider (PCP); however, the comprehensive management of psychosocial and behavioral concerns are often not feasible in traditional primary care settings. Integrating behavioral health services into pediatric primary care clinics has the potential to increase access to needed services, improve comprehensiveness and quality of care for patients, and reduce burdens on PCPs. Research on integrated behavioral health (IBH) models have indicated that it is a cost-effective service leading to improved treatment outcomes compared to usual primary care and that parents and physicians are generally satisfied and interested in this service delivery model. However, little is known about parents’ attitudes toward IBH and factors that may influence the acceptability of this type of care. Previous research has identified several factors associated with parent acceptability of mental health services for their child including symptom severity, attitudes toward child therapy, parenting stress, stigma, perceived barriers to care, and past experiences with services. However, it is unclear how these factors influence attitudes toward IBH, especially in rural areas. The current study examined parents’ attitudes toward co-located and integrated models of care, identified factors that affect acceptability of IBH, and explored differences between rural and urban parents’ attitudes. Results demonstrated that both rural and urban parents hold generally favorable attitudes toward IBH models and that parent attitudes toward general child therapy was strongly associated with IBH acceptability. Demographic variables (e.g., parent age, child age, minority status, socioeconomic status), need characteristics (e.g., parenting stress, child psychosocial symptoms), and other enabling factors (e.g., mental health-related stigma, prior service use, barriers to care) were not predictive of parent IBH acceptability. Urban parents rated co-located models of care as more acceptable and reported higher levels of parent psychosocial symptoms, stigma, and barriers to care compared to rural parents. These findings support efforts to continue integrating behavioral health services into pediatric primary care and highlight parent therapy attitudes as an important target for intervention to improve parent IBH acceptability. Findings also shed light on the need for more mixed-method research to understand the impact rural identity has on the acceptability and use of behavioral health services.

Diarrheal diseases are a global public health burden, killing 1.8 million people annually. Diarrhea disproportionately affects children and those in poverty. Most diarrheal cases can be prevented through safe drinking water, basic hygiene and/or sanitation measures, with drinking water interventions having the most impact on reducing diarrheal disease. A meta-evaluation was completed of studies evaluating a specific household water treatment method, the biosand water filter. Results from the meta-evaluation illustrate that biosand water filters improve drinking water quality and reduce diarrheal disease. However, there is no generally agreed upon field method for determining biosand water filter effectiveness that is useable in low-resource communities. A pilot study was conducted of potential field use indicators, including the Colilert coliform Presence/ Absence test, hydrogen sulfide, alkalinity, hardness, pH, and fluorescently-labeled latex microspheres. The study included both laboratory and field testing. The Colilert Presence/ Absence test had the highest correlation to the United States Environmental Protection Agency standard method (IDEXX Quanti-trays), but more data is needed before making a recommendation. This study adds to understanding about evaluation of biosand water filters and provides preliminary data to address the need for a field use indicator for biosand water filters.

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Purpose: Snacking is an important component of dietary intake yet remains understudied, particularly among adolescents who consume 25% of their daily calories from snacks. Previous research provides evidence that adolescents with overweight (OW) and obesity (OB) consume larger and more frequent snacks than adolescents with normal weight (NW). The objective of this study was to compare the food group composition of snacks by weight status as well as to identify snacking patterns and predictors among adolescents in the United States (US). Methods: Anthropometric, dietary, and demographic data from adolescents, 12-19 years old, in the 2005-2016 National Health and Nutrition Examination Survey were analyzed. The mean of the two days of dietary recall was used to measure dietary intake, which serves as a proxy for usual intake. Mean equivalents of the 37 food components present in individual snack foods reported by each adolescent across two days of intake were estimated using the Food Patterns Equivalents Database. Latent Class Analysis (LCA) was used to study the effect of mutually exclusive food component consumption groups. Multivariate logistic regression models were used to analyze membership in relation to dietary quality (Healthy Eating Index 2015 [HEI-2015] scores), weight status (BMI & BMI Z-score), selected snacking parameters (e.g., mean snack calories), and socio-demographic (e.g., race, gender) covariates. Results: Adolescents with two days of reliable dietary recall data and complete anthropometrics were included in the descriptive analysis (n = 6423). Adolescents with NW consumed greater energy, vegetable, whole grains, refined grains, dairy, and solid fat from snacks than adolescents with OW and OB (p < 0.05). LCA identified two main snacking patterns. The “Heavy Snackers” pattern was associated with higher consumption of each food component, total energy and snacking energy while the “Light Snackers” pattern was associated with lower consumption each food component, total energy and snacking energy. After adjustment for energy misreporting, OW or OB classification did not significantly increase the odds of being in either class while being classified with NW decreased the odds of being in the “Heavy Snacker” class. In addition, increasing BMI z-score and HEI-2015 total score increased and decreased the odds of being in the “Heavy Snackers” class respectively. The strongest predictors of a “Heavy Snacker” pattern were male gender, non-Hispanic white race, lower dietary quality, and increased snacking parameters, while female gender, all races except non-Hispanic white, better dietary quality, and decreased snacking parameters were strong predictors of a “Light Snacker” pattern. Conclusion: We can conclude that consuming less foods as snacks contributed positively to weight status and overall diet quality among US adolescents. Findings from this cross-sectional study remain consistent with snacking, diet quality, and weight status associations, but add to existing knowledge with the identification of snack consumption patterns. The dietary patterns derived may provide a useful basis for dietary interventions targeted at snacking among adolescents by recommending light snacking and low consumption of energy dense snack foods. Additional studies are needed to further understand what the main food pattern components are across gender and racial backgrounds and to confirm whether associations between snacking and weight status are due to food quality, quantity, or both. / Epidemiology

Increasing physical activity among individuals in the U.S.A. is a primary health concern. Sedentary life-style is a risk factor for a number of diseases. Life expectancy in the U.S. has increased dramatically over the past several decades, yet frequently, few of these additional years remain disease free. It is now known that life-style factors, including exercise,. are important determinants of the number of healthy, functionally independent years remaining for older adults. Unfortunately, few older adults exercise regularly. Interventions aimed at ameliorating this problem are clearly needed. The Exercise and Older Adults study was designed to assess the effectiveness of an intervention to increase exercise among sedentary and lightly exercising adults ages 55 and older. Unlike other studies which typically involve a supervised aerobic program, this intervention involved the creation of individually tailored exercise programs which participants could maintain without the aid of the researchers. Social learning theory and behavioral principles led to the creation of an intervention combining information, peer modelling, personalized planning, and commitment-making. Subjects came to a single meeting following a three week period of exercise self-monitoring. During the meeting, experimental group subjects were given an exercise information packet, viewed two videotapes about older adults and exercise, created personal exercise plans involving several participation and relapse prevention strategies, and signed a commitment sheet stating that they would try to follow their new exercise plan. Control group subjects received the information packets only. Subjects continued to self-monitor their exercise for six weeks. Repeated Measures Analyses of Covariance did not support the hypothesis that the intervention received by the experimental group was more effective in increasing exercise than the minimal intervention received by the control group. Hierarchical Regression Analyses did not support the hypothesis that self -efficacy and outcome expectancy predict exercise changes. However, both groups in this study increased their exercise significantly and mean differences between groups at the three week follow-up point were significant for several exercise outcomes. Possible reasons for the failure to find statistical significance across time between groups is discussed and future research directions are outlined. / Ph. D.

Collaborative efforts between medical and behavioral health professionals is required to simultaneously treat individuals with medical and mental health disorders. However, there is lack of focus on the competencies and trainings needed by behavioral health clinicians (BHCs) transitioning to integrated primary care (IPC) settings. The purpose of this qualitative interpretive phenomenological study was to describe the lived experiences of BHCs who have transitioned from specialty outpatient behavioral healthcare settings to IPC settings. Semi-structured interview questions were used to collect data. Using interpretive phenomenological data analysis approach, themes and the shared meanings and experiences of 8 licensed BHCs were explored. Seven participants had graduate degrees and 1 participant had post-graduate degree. All participants had at least a year of experience working in IPC settings, worked full-time in North Carolina, and had over a year of experience in traditional behavioral healthcare settings. Results indicated that participants shared experiences in 5 themes: (a) clinical experience, (b) effective communication, (c) collaboration with primary care providers(PCPs), (d) continued education and trainings, and (e) care coordination. The outcome of this research will inform institutions, administrators, and credentialing boards to consider implementation of defined competencies for BHCs in community health centers that operate on IPC principles to ensure collaborative efforts between BHCs and PCPs in order to help provide effective holistic and affordable health care in a systems-based approach.

Integrated behavioral health care within primary care has become a popular style of health care delivery within the United States. However, individuals with a behavioral health concern face several barriers in using these services. The purpose of this quantitative study was to identify key factors accounting for individuals' utilization and intensity of behavioral health services. Andersen's behavioral model of health care use and the integrated theory of health behavior change served as the theoretical framework. It was hypothesized that gender, age, race, ethnicity, family size, payer type, poverty level, and certain preexisting medical conditions (obesity, diabetes, hypertension, and tobacco use) would determine behavioral health care utilization and intensity. A secondary data analysis of 315 individuals who used behavioral health services within primary care was performed; the study setting was at the Center for Health, Education, Medicine, and Dentistry, located in Lakewood, New Jersey. Among the individual variables examined, only a preexisting condition of hypertension reached statistical significance, showing that those individuals were more likely to attend multiple sessions, Ï?2 (1) = 5.77, p = .02. Payer type was also found to be predictive of behavioral health care intensity. Medicare recipients were more likely to attend multiple behavioral health care sessions (74%) than were Medicaid recipients (59%) and those who were uninsured (25%). By providing insights about the barriers faced by individuals, study findings may help patient advocates and health care professionals to provide individuals with better health care. This study has implications for positive social change, as study findings may assist the United States health care system in its shift toward an integrated behavioral health care style of health care delivery.

Socialstyrelsen menar att primärvården står inför en utmaning att tillgodose tillgänglig psykologisk behandling till ett växande behov. Ett möjligt tillvägagångssätt skulle kunna vara Integrerad beteendehälsa som eftersträvar att kunna erbjuda korta psykologiska interventioner med hög tillgänglighet. Syftet med föreliggande studie var att jämföra två varianter av Integrerad beteendehälsa; ett sedvanligt upplägg med Brief Interventions och ett upplägg med utökad bedömning och möjligheten till vägledd självhjälp för ett specifikt problem. Det här med avseende på generella symtom och symtom specifika för just det problem som patienter erhållit självhjälp för, alternativt bedömts skulle ha passat för självhjälp avseende ett specifikt problem. Resultaten visade att den generella symtomnivån förbättrades för gruppen som helhet, samt inom respektive grupp. Den problemspecifika symtomnivån sjönk för både patienter som erhållit vägledd självhjälp och för patienter som erhållit Brief Interventions men vars problemprofil visat att de hade passat för en specifik självhjälpsmanual. Någon signifikant skillnad i symtomförändring, oavsett generell eller problemspecifik, kunde inte hittas. I diskussionen problematiseras bland annat den interna validiteten och den naturalistiska miljön lyfts som en styrka. / The national board of health and wellfare are stating that primary care faces a major challenge in providing available psychological treatment to an increasing need. One possible approach is Integrated Behavioral Health, which strives towards offering brief psychological interventions with great access. The purpose of the following study was to compare two different methods of Integrated Behavioral Health; an ordinary set up with Brief Interventions and one set up with extended assesment and the possibility of guided self-help treatment for a particular problem. This regarding general as well as specific symptoms for the particular problem the patient has received guided self-help for, or considered to have been suited for. The results showed that the general level of symptoms improved for all patients, merged into one group, and within the respective group. The level of the problem-specific symptom decreased for patients who received guided self-help and for patients who received Brief Interventions, but whose problem profile showed that they had fit for a specific self-help manual. No significant difference in symptom change, regardless of general or problem- specific, could be found. In the discussion, the internal validity is discussed, and the naturalistic environment is described as a strength.