Reported Impact of COVID-19 Workload and Stressors on School Nurses' Provision of Care During the 2021-2022 School Year: A Secondary Analysis of U.S. School Nurse Survey Data.

Many school nurses experienced increased work burden and stress during the COVID-19 pandemic. This analysis examined data from a Centers for Disease Control and Prevention cross-sectional, nationwide survey of school nurses in March 2022 to examine associations between school nurses' ability to conduct their core responsibilities and selected nurse and school factors among school nurses during the 2021-2022 school year and COVID-19 pandemic. Perceived adequate staffing and financial compensation reduced the odds of reported difficulties across all core school nursing tasks. Nurses without a registered nurse license and with higher caseloads were more likely to report difficulty in implementing specific tasks. The impact of these factors varied, with inadequate financial compensation having the largest association with school nurses' difficulty implementing all the core responsibilities. The study results improve our understanding of school nurses' challenges in implementing core school nursing responsibilities during the COVID-19 pandemic in the 2021-2022 school year.

Adverse childhood experiences, risk of opioid misuse and its pathway among students at a public university.

OBJECTIVE:  We examine role of ACEs and pathways to risk of opioid misuse among young adults. Participants and Methods: A cross-sectional survey of validated measures of ACEs, risk of opioid misuse, and health conditions with a sample of 1,402 students from a large public university followed by multivariate logistic regression and pathway analysis. Results: Majority (61%) of participants reported at least one ACE. A dose-response relationship between numbers of ACEs with risk for opioid misuse was present. Compared to participants with no ACEs, participants with ≥4 ACEs and 0-3 ACEs were 2.93 (95% CI: 1.95, 4.39; p < 0.001) and 1.96 (95% CI: 1.46, 2.65; p < 0.001) times more likely to be at risk for opioid misuse, respectively. Having at least one existing or past health condition significantly mediated the association. Conclusions: Our findings suggest need to include assessment of ACEs as a screening criterion for opioid prescription and administration among college-aged individuals.

Electronic Vapor Product Use and Levels of Physical Activity Among High School Students in Georgia.

Introduction: Using a cross-sectional population-based survey, electronic vapor product (EVP) use was evaluated in relation to physical activity levels among high school students in Georgia. Methods: We used self-reported EVP and cigarette use from the Georgia Student Health Survey 2.0 data from 2018 (N =362 933) and used multi-level multinomial logistic regression models to estimate relative risks of the type of product use relative to no-use by levels of physical activity. Results: Nearly 7% of the students were EVP-only users. The relative risks of being an EVP-only user were 11% and 23% higher for those who were physically active 2-3 days/week and 4-5 days/week, respectively, compared to those who were physically active <=1 day/week. Conclusions: Being physically active was positively associated with EVP use among adolescents. Health promotion education and health policies should be developed as a means of reducing EVP use among adolescents.

School climate-related determinants of physical activity among high school girls and boys.

INTRODUCTION: In the United States, physical activity (PA) among adolescents is declining; 75% of high school students do not meet daily PA guidelines. Low rates of PA are more prevalent among high school girls. Schools provide an optimal environment to target and promote PA. However, school climate has not yet been studied for its importance in promoting PA among high school students, particularly girls. METHODS: A cross-sectional analysis was conducted using the Georgia Student Health Survey (GSHS) 2.0 data on perceptions of different school climate measures and self-reported weekly PA levels to study gender differences in the association of PA with school climate. RESULTS: Data from a total of 362,926 students (48% males and 52% females) were analyzed. For both genders, the odds of being physically active increased with a more positive report of supportive school environments, school connectedness, peer social support, school physical environments, cultural acceptance, school safety, and adult social support. Peer victimization was associated with increased odds of PA among females but lower odds for males. CONCLUSION: Results suggest that improving school climate can increase PA among adolescents. As new or existing school-based interventions and policies are considered by states and local governments, improving the school climate should be part of the overall strategy. Future research is needed on peer victimization among physically active females. IMPLICATIONS AND CONTRIBUTIONS: This study evaluated gender differences in the association between measures of school climate and PA among high school students. School climate or policies fostering positive environments including feelings of safety, connectedness, and peer support may increase adolescent PA; addressing peer victimization and fights may reduce gender disparities in PA.

Online-Delivered Over Staff-Delivered Parenting Intervention for Young Children With Disruptive Behavior Problems: Cost-Minimization Analysis.

BACKGROUND: High-prevalence childhood mental health problems like early-onset disruptive behavior problems (DBPs) pose a significant public health challenge and necessitate interventions with adequate population reach. The treatment approach of choice for childhood DBPs, namely evidence-based parenting intervention, has not been sufficiently disseminated when relying solely on staff-delivered services. Online-delivered parenting intervention is a promising strategy, but the cost minimization of this delivery model for reducing child DBPs is unknown compared with the more traditional staff-delivered modality. OBJECTIVE: This study aimed to examine the cost-minimization of an online parenting intervention for childhood disruptive behavior problems compared with the staff-delivered version of the same content. This objective, pursued in the context of a randomized trial, made use of cost data collected from parents and service providers. METHODS: A cost-minimization analysis (CMA) was conducted comparing the online and staff-delivered parenting interventions. Families (N=334) with children 3-7 years old, who exhibited clinically elevated disruptive behavior problems, were randomly assigned to the two parenting interventions. Participants, delivery staff, and administrators provided data for the CMA concerning family participation time and expenses, program delivery time (direct and nondirect), and nonpersonnel resources (eg, space, materials, and access fee). The CMA was conducted using both intent-to-treat and per-protocol analytic approaches. RESULTS: For the intent-to-treat analyses, the online parenting intervention reflected significantly lower program costs (t168=23.2; P<.001), family costs (t185=9.2; P<.001), and total costs (t171=19.1; P<.001) compared to the staff-delivered intervention. The mean incremental cost difference between the interventions was $1164 total costs per case. The same pattern of significant differences was confirmed in the per-protocol analysis based on the families who completed their respective intervention, with a mean incremental cost difference of $1483 per case. All costs were valued or adjusted in 2017 US dollars. CONCLUSIONS: The online-delivered parenting intervention in this randomized study produced substantial cost minimization compared with the staff-delivered intervention providing the same content. Cost minimization was driven primarily by personnel time and, to a lesser extent, by facilities costs and family travel time. The CMA was accomplished with three critical conditions in place: (1) the two intervention delivery modalities (ie, online and staff) held intervention content constant; (2) families were randomized to the two parenting interventions; and (3) the online-delivered intervention was previously confirmed to be non-inferior to the staff-delivered intervention in significantly reducing the primary outcome, child disruptive behavior problems. Given those conditions, cost minimization for the online parenting intervention was unequivocal. TRIAL REGISTRATION: ClinicalTrials.gov NCT02121431; https://clinicaltrials.gov/ct2/show/NCT02121431.

Implementation of a Statewide Policy Mandating School-Based Fitness Assessment Screening, Georgia: 2018.

Objectives. To evaluate the statewide implementation of childhood fitness assessment and reporting in Georgia.Methods. We collected survey data from 1683 (919 valid responses from a random-digit-dialed survey and 764 valid responses from a Qualtrics panel) parents of public school students in Georgia in 2018.Results. Most parents reported that their child participated in fitness assessments at school, yet only 31% reported receiving results. If a child was identified as needing improvement, parents were significantly more likely to change the diet and exercise of both the child and the family.Conclusions. A state-level mandatory fitness assessment for children may be successful in state-level surveillance of fitness levels; parental awareness of the policy, receipt of the fitness assessment information, and action on receiving the screening information require more efforts in implementation.

Cigarette and electronic vapor product use among high school students in Georgia, 2015-2018.

Adolescent use of electronic vapor products (EVP) is increasing; however, changes in EVP use in the context of cigarette smoking is less certain. We analyzed trends in EVP and cigarette use among high school students in the state of Georgia. We used self-reported EVP and cigarette use from the annual Georgia Student Health Survey 2.0 for 2015 to 2018 (N = 1,405,108). Users were categorized as exclusive EVP users, exclusive cigarette users, or dual users. We assessed current (≥1 day in past 30 days) use of EVPs, cigarettes, and dual users of both products, as well as number of days the products were used among current users. We compared current users, as well as number of days used, across adjacent years using tests for proportion and Wilcoxon t-tests, respectively. The proportion of current exclusive EVP users and dual users increased during 2017-2018 (4.2% to 6.9% and 1.6% to 3.7%, p < 0.001, respectively) after declining during 2015-2017, while the proportion of exclusive cigarette users declined during 2015-2018 (2.0% to 1.0%, p < 0.001). Similarly, the mean number of days of EVP use increased among exclusive EVP and dual users, and mean number of days of cigarette use increased among dual users during 2017-2018 (p < 0.001). These findings reinforce the importance of continued efforts to reduce all forms of tobacco products use among Georgia high school students.

In-patient obesity diagnosis, use of surgical treatment and associated costs by payer type in the United States: Analysis of the National Inpatient Sample, 2011 through 2014.

This study aims to examine the trend in the diagnosis of obesity and the use of surgical treatment in in-patient settings as well as per person and national costs associated with the surgical treatment of obesity. We conducted cross-sectional and trend analyses of in-patient obesity diagnosis and surgical treatment for obesity using data from the National Inpatient Sample (2011-2014) of adult patients in the United States aged 18 years and older. We studied the rate of in-patient obesity diagnosis among hospitalized patients, the rate of bariatric surgery among patients diagnosed with obesity in the hospital, and the costs associated with surgical treatment. Trend analyses showed a statistically significant increase in the proportion of (a) hospitalized patients diagnosed with obesity, and (b) bariatric surgery among those diagnosed with obesity and among different socio-demographic and insurance groups. Despite the increase in the national in-patient cost, the average in-patient cost per hospitalization associated with bariatric surgery decreased from 2012 to 2014. With the increase in the rate of diagnosed obesity and bariatric surgery among hospitalized patients and the decrease in the average in-patient cost, future research should address the short- and long-term cost-effectiveness of bariatric surgery on chronic diseases.

There's no such thing as a free TB diagnosis: Catastrophic TB costs in Urban Uganda.

Identifying and reducing TB-related costs is necessary for achieving the End TB Strategy's goal that no family is burdened with catastrophic costs. This study explores costs during the pre-diagnosis period and assesses the potential for using coping costs as a proxy indicator for catastrophic costs when comprehensive surveys are not feasible. Detailed interviews about TB-related costs and productivity losses were conducted with 196 pulmonary TB patients in Kampala, Uganda. The threshold for catastrophic costs was defined as 20% of household income. Multivariable regression analyses were used to assess the influence of patient characteristics on economic burden, and the positive predictive value (PPV) of coping costs was estimated. Over 40% of patients experienced catastrophic costs, with average (median) pre-diagnosis costs making up 30.6% (14.1%) of household income. Low-income status (AOR = 2.91, 95% CI = 1.29, 6.72), hospitalisation (AOR = 8.66, 95% CI = 2.60; 39.54), and coping costs (AOR = 3.84, 95% CI = 1.81; 8.40) were significantly associated with the experience of catastrophic costs. The PPV of coping costs as an indicator for catastrophic costs was estimated to be 73% (95% CI = 58%, 84%). TB patients endure a substantial economic burden during the pre-diagnosis period, and identifying households that experience coping costs may be a useful proxy measure for identifying catastrophic costs.

Longitudinal evaluation of the impact of school characteristics on changes in physical activity opportunities.

BACKGROUND: Even as many states adopt physical activity policies to promote physical activity and prevent childhood obesity, little is known about differences in policy implementation based on school characteristics. We studied association of school characteristics and changes in physical activity opportunities at the school level during the implementation of a statewide physical activity policy in the state of Georgia. METHODS: A web-based school survey was administered to elementary schools at two time points (before and during policy execution). Matched respondents (289 classroom teachers, 234 administrators) reported the frequency and duration of recess and integrated physical activity time. We used paired t-test to assess changes in physical activity opportunities and chi-square tests to assess the association of change in physical activity opportunities with school characteristics. We then constructed a multiple linear regression model following a change score method to identify school-level factors that predict the magnitude of change in physical activity opportunities. RESULTS: There was an overall significant increase in total physical activity opportunities across time; however, schools with higher poverty showed a decrease in physical activity time by 5.3 minutes per day (95% CI: -9.2, -1.3). Further, the changes in physical activity time for schools in suburban Georgia were smaller (-5.7, 95% CI: -9.5, -1.9) compared to schools located in towns. CONCLUSIONS: The change in physical activity opportunities was not the same across schools and school characteristics predicted the magnitude of change. Additional efforts at the local level might be needed for equitable policy implementation based on schools' geographical location and poverty level of the student population.

The Protecting Strong African American Families Program: a Randomized Controlled Trial with Rural African American Couples.

This study presents results from a randomized controlled trial of the Protecting Strong African American Families (ProSAAF) program, a family-centered intervention designed to promote strong couple, coparenting, and parent-child relationships in two-parent African American families. A total of 346 African American couples with an early adolescent child participated; all families lived in rural, low-income communities in the southern USA. Intent-to-treat growth curve analyses involving three waves and spanning 17 months indicated that ProSAAF participants, compared with control participants, reported greater improvements in relationship communication, confidence, satisfaction, partner support, coparenting, and parenting. More than 80% of the couples attended all six of the in-home, facilitator-led sessions; costs to implement the program averaged $1739 per family. The findings inform the ongoing debate surrounding prevention programs for low-income and ethnic minority couples.

Cost Effectiveness of a Weight Management Program Implemented in the Worksite: Translation of Fuel Your Life.

OBJECTIVE: Conduct a cost-effectiveness analysis of the Fuel Your Life (FYL) program dissemination. METHODS: Employees were recruited from three workplaces randomly assigned to one of the conditions: telephone coaching, small group coaching, and self-study. Costs were collected prospectively during the efficacy trial. The main outcome measures of interest were weight loss and quality-adjusted life years (QALYs). RESULTS: The phone condition was most costly ($601 to $589/employee) and the self-study condition was least costly ($145 to $143/employee). For weight loss, delivering FYL through the small group condition was no more effective, yet more expensive, than the self-study delivery. For QALYs, the group delivery of FYL was in an acceptable cost-effectiveness range ($22,400/QALY) relative to self-study (95% confidence interval [CI]: $10,600/QALY-dominated). CONCLUSIONS: Prevention programs require adaptation at the local level and significantly affect the cost, effectiveness, and cost-effectiveness of the program.

How much are Ecuadorians Willing to Pay to Reduce Maternal Mortality? Results from a Pilot Study on Contingent Valuation.

CONTEXT: There is an established association between the provision of health care services and maternal mortality. In Ecuador, little is known if the societal value is greater than the resources expended in preventive medicine. AIMS: The purpose of this research is to investigate Ecuadorians' willingness to pay to prevent maternal death and disabilities due to complications of care during childbirth in the context of universal coverage. METHODS AND MATERIALS: The study elicited a "contingent" market on morbidity and mortality outcomes, specific to Ecuador's epidemiologic profiles between a hypothetical market that included a 50% reduction in the risk of maternal mortality from 100 to 50 per 100,000, and a market that included a 50% reduction in the risk of maternal morbidity from 4,000 to 2,000 per 100,000. RESULTS: The average amount participants are willing to pay (WTP) to prevent maternal mortality in the context of universal coverage, was $176 a year (95% CI=$172, $179). The unadjusted mean WTP for a reduction in the maternal morbidity risk was $135 (95% CI=$132, $139). Translated into Value of statistical Life, participant´s from this study valued the prevention of one statistical maternal death at USD $352,000. CONCLUSION: Results suggest that the costs of maternal care do not outweigh the benefit of prevention, and that Ecuadorians are willing to pay a significant amount to reduce the risk of maternal mortality. GLOBAL HEALTH IMPLICATIONS: Reduction of maternal mortality will remain an important global developmental goal in the upcoming years. Having a monetary approximation on the value of these losses may have important implications in the allotting financial and technical resources to reduce it.

A Prospective Programmatic Cost Analysis of Fuel Your Life: A Worksite Translation of DPP.

OBJECTIVE: An accounting of the resources necessary for implementation of efficacious programs is important for economic evaluations and dissemination. METHODS: A programmatic costs analysis was conducted prospectively in conjunction with an efficacy trial of Fuel Your Life (FYL), a worksite translation of the Diabetes Prevention Program. FYL was implemented through three different modalities, Group, Phone, and Self-study, using a micro-costing approach from both the employer and societal perspectives. RESULTS: The Phone modality was the most costly at $354.6 per participant, compared with $154.6 and $75.5 for the Group and Self-study modalities, respectively. With the inclusion of participant-related costs, the Phone modality was still more expensive than the Group modality but with a smaller incremental difference ($461.4 vs $368.1). CONCLUSIONS: This level of cost-related detail for a preventive intervention is rare, and our analysis can aid in the transparency of future economic evaluations.

Cost-effectiveness of Legacy for Children™ for Reducing Behavioral Problems and Risk for ADHD among Children Living in Poverty.

This paper describes the programmatic costs required for implementation of the Legacy for Children™ (Legacy) program at two sites (Miami and Los Angeles) and enumerate the cost-effectiveness of the program. Legacy provided group-based parenting intervention for mothers and children living in poverty. This cost-effectiveness analysis included two behavioral outcomes, behavioral problems, and attention-deficit/hyperactivity disorder (ADHD), and programmatic costs collected prospectively (2008 US$). Incremental costs, effects, the incremental cost-effectiveness ratio (ICER), and cost-effectiveness acceptability curves were estimated for the intervention groups relative to a comparison group with a 5 year analytic horizon. The intervention costs per family for Miami and Los Angeles were $16,900 and $14,100, respectively. For behavioral problems, the incremental effects were marginally significant (p=0.11) for Miami with an ICER of $178,000 per child at high risk for severe behavioral problems avoided. For ADHD, the incremental effects were significant (p=0.03) for Los Angeles with an ICER of $91,100 per child at high risk for ADHD avoided. Legacy was related to improvements in behavioral outcomes within two community-drawn sites and the costs and effects are reasonable considering the associated economic costs.

Linking costs to health outcomes for allocating scarce public health resources.

INTRODUCTION: Resources for public health (PH) are scarce and policymakers face tough decisions in determining their funding priorities. The difficulty of making these decisions is compounded by current PH accounting systems, which are ill-equipped to link fiscal resources to PH outcomes. This paper examines the types of revenues and expenditures, health services, and health outcomes that are being tracked at the local and state PH levels. The authors provide recommendations for strengthening the ability of local and state governments to link expenditures to PH outcomes, both within and across jurisdictions. FRAMEWORK AND NEXT STEPS: The source of revenue data for most local jurisdictions is the accounting systems used for the budgeting and auditing of fiscal activities, and these are primarily linked to specific PH programs. In contrast, expenditure data are mostly generic and typically span multiple PH programs with no link to specific PH activities. Many challenges exist to then link PH activities to health outcomes data, which are often collected through separate reporting systems at the local, state, and national levels. Policy change at the state level and implementation strategies that are standardized across local health departments are required to assess the costs and health outcomes of PH activities. CONCLUSION: Information linking PH expenditures to health outcomes of PH services could greatly inform the decision-making process. This information will allow investments in PH to be better understood and will provide a strong foundation for the PH services and systems research community to understand variation and drive improvement. Ultimately, these data could be used to improve accountability at the local and state PH department levels.

Cost-effectiveness of the strong African American families-teen program: 1-year follow-up.

INTRODUCTION: Alcohol use poses a major threat to the health and well being of rural African American adolescents by negatively impacting academic performance, health, and safety. However, rigorous economic evaluations of prevention programs targeting this population are scarce. METHODS: Cost-effectiveness analyses were conducted of SAAF-T relative to an attention-control intervention (ACI), as part of a randomized prevention trial. Outcomes of interest were the number of alcohol use and binge drinking episodes prevented, one year following the intervention. Incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves (CEACs) were used to determine the cost-effectiveness of SAAF-T compared to the ACI intervention. RESULTS: For the 473 participating youth completing baseline and follow-up assessments, the incremental per participant costs were $168, while the incremental per participant effects were 3.39 episodes of alcohol use prevented and 1.36 episodes of binge drinking prevented. Compared to the ACI intervention, the SAAF-T program cost $50 per reduction in an alcohol use episode and $123 per reduced episode of binge drinking. For the CEACs, at thresholds of $100 and $440, SAAF-T has at least a 90% probability of being cost-effective, relative to the ACI, for reductions in alcohol use and binge drinking episodes, respectively. CONCLUSIONS: The SAAF-T intervention provides a potentially cost-effective means for reducing the African American youths' alcohol use and binge drinking episodes.

A comparison of willingness to pay to prevent child maltreatment deaths in Ecuador and the United States.

Estimating the benefits of preventing child maltreatment (CM) is essential for policy makers to determine whether there are significant returns on investment from interventions to prevent CM. The aim of this study was to estimate the benefits of preventing CM deaths in an Ecuadorian population, and to compare the results to a similar study in a US population. The study used the contingent valuation method to elicit respondents' willingness to pay (WTP) for a 1 in 100,000 reduction in the risk of CM mortality. After adjusting for differences in purchasing power, the WTP to prevent the CM mortality risk reduction in the Ecuador population was $237 and the WTP for the same risk reduction in the US population was $175. In the pooled analysis, WTP for a reduction in CM mortality was significantly impacted by country (p = 0.03), history of CM (p = 0.007), payment mechanism (p < 0.001), confidence in response (p = 0.014), and appropriateness of the payment mechanism (p < 0.001). These findings suggest that estimating benefits from one culture may not be transferable to another, and that low- and middle-income countries, such as Ecuador, may be better served by developing their own benefits estimates for use in future benefit-cost analyses of interventions designed to prevent CM.

Economic analysis of a multi-site prevention program: assessment of program costs and characterizing site-level variability.

Programmatic cost analyses of preventive interventions commonly have a number of methodological difficulties. To determine the mean total costs and properly characterize variability, one often has to deal with small sample sizes, skewed distributions, and especially missing data. Standard approaches for dealing with missing data such as multiple imputation may suffer from a small sample size, a lack of appropriate covariates, or too few details around the method used to handle the missing data. In this study, we estimate total programmatic costs for a prevention trial evaluating the Strong African American Families-Teen program. This intervention focuses on the prevention of substance abuse and risky sexual behavior. To account for missing data in the assessment of programmatic costs we compare multiple imputation to probabilistic sensitivity analysis. The latter approach uses collected cost data to create a distribution around each input parameter. We found that with the multiple imputation approach, the mean (95 % confidence interval) incremental difference was $2,149 ($397, $3,901). With the probabilistic sensitivity analysis approach, the incremental difference was $2,583 ($778, $4,346). Although the true cost of the program is unknown, probabilistic sensitivity analysis may be a more viable alternative for capturing variability in estimates of programmatic costs when dealing with missing data, particularly with small sample sizes and the lack of strong predictor variables. Further, the larger standard errors produced by the probabilistic sensitivity analysis method may signal its ability to capture more of the variability in the data, thus better informing policymakers on the potentially true cost of the intervention.