‘What is this about? Let’s play this out’: the experience of integrating primary health care registered nurses with school learning and support teams.

Changes in public health profiles and moves towards inclusive models of education have led to significant number of students in mainstream schools with special health needs. Addressing these needs requires collaboration between health professionals, educators and families. Integrated models of school-based health care can facilitate this collaboration; however, there is little evidence to guide their implementation. The School-Based Primary Health Care Service (SB-PHCS) is one such service that has been established in far west New South Wales. The School-Based Primary Health Care Service embeds health district-employed registered nurses with school learning support teams to increase service access, and improve health and education outcomes for students. We conducted focus groups with nurses and learning support teams to explore their experiences of implementing the School-Based Primary Health Care Service. Focus group transcripts were analysed using framework analysis. We found that defining the role and working across systems were challenges to program implementation, whereas a collaborative culture, relationship building and flexibility in work processes facilitated the integration of nurses into the school teams. We recommend others embarking on similar initiatives involve key stakeholders early in service development, understand each other's systems and processes, and provide clarity about the new role, but plan to adapt the role to fit the context. This study will be of interest to those involved in the implementation of integrated models of school-based health care.

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Children and adolescents in rural Australia experience poorer health and educational outcomes than those in urban areas. This paper presents findings from a qualitative study exploring the role of primary health care registered nurses (RNs) working in the School-Based Primary Health Care Service in Broken Hill, far west New South Wales. The Service integrates health district-employed RNs with school learning and support teams to increase service access and improve health and education outcomes for students. The findings show that RNs used care navigation to reduce barriers to care by addressing healthcare candidacy with students and families. The RNs also linked schools, families and health and social care services, and facilitated intersectoral collaboration to improve the support provided to students experiencing health and developmental issues. Integrating health district-employed RNs with existing student support services is a promising approach to improving the health and education of disadvantaged students. This study provides individual- and system-level explanations of the role of the school-based primary health care RN and can inform the development of similar services elsewhere.

Community Readiness to Prevent Opioid Overdose.

Effective community-based actions are urgently needed to combat the ongoing epidemic of opioid overdose. Community readiness (CR) has been linked to communities' support for collective action, which in turn has been associated with the success of community-wide prevention strategies and resulting behavior change. Our study, conducted in North Carolina, assessed the relationship between CR and two indices of opioid overdose. County-level data included a survey of health directors that assessed CR to address drug overdose prevention programs, surveillance measures of opioid overdose collected from death records and emergency departments, and two indicators of general health-related status. We found that counties' rates of CR were positively associated with their opioid-related mortality (but not morbidity) and that this relationship persisted when we controlled for health status. North Carolina counties with the highest opioid misuse problems appear to be the most prepared to respond to them.

A statewide evaluation of seven strategies to reduce opioid overdose in North Carolina.

BACKGROUND: In response to increasing opioid overdoses, US prevention efforts have focused on prescriber education and supply, demand and harm reduction strategies. Limited evidence informs which interventions are effective. We evaluated Project Lazarus, a centralised statewide intervention designed to prevent opioid overdose. METHODS: Observational intervention study of seven strategies. 74 of 100 North Carolina counties implemented the intervention. Dichotomous variables were constructed for each strategy by county-month. Exposure data were: process logs, surveys, addiction treatment interviews, prescription drug monitoring data. Outcomes were: unintentional and undetermined opioid overdose deaths, overdose-related emergency department (ED) visits. Interrupted time-series Poisson regression was used to estimate rates during preintervention (2009-2012) and intervention periods (2013-2014). Adjusted IRR controlled for prescriptions, county health status and time trends. Time-lagged regression models considered delayed impact (0-6 months). RESULTS: In adjusted immediate-impact models, provider education was associated with lower overdose mortality (IRR 0.91; 95% CI 0.81 to 1.02) but little change in overdose-related ED visits. Policies to limit ED opioid dispensing were associated with lower mortality (IRR 0.97; 95% CI 0.87 to 1.07), but higher ED visits (IRR 1.06; 95% CI 1.01 to 1.12). Expansions of medication-assisted treatment (MAT) were associated with increased mortality (IRR 1.22; 95% CI 1.08 to 1.37) but lower ED visits in time-lagged models. CONCLUSIONS: Provider education related to pain management and addiction treatment, and ED policies limiting opioid dispensing showed modest immediate reductions in mortality. MAT expansions showed beneficial effects in reducing ED-related overdose visits in time-lagged models, despite an unexpected adverse association with mortality.

Observed transition from opioid analgesic deaths toward heroin.

BACKGROUND: In the United States, overdose mortality from controlled substances has increased over the last two decades, largely involving prescription opioid analgesics. Recently, there has been speculation on a transition away from prescription opioid use toward heroin, however the impact on overdose deaths has not been evaluated. METHODS: Time series study of North Carolina residents, 2007 through 2013. Monthly ratio of prescription opioid-to-heroin overdose deaths. Non-parametric local regression models used to ascertain temporal shifts from overdoses involving prescription opioids to heroin. RESULTS: There were 4332 overdose deaths involving prescription opioids, and 455 involving heroin, including 44 where both were involved (total n = 4743). A gradual 6-year shift toward increasing heroin deaths was observed. In January, 2007, for one heroin death there were 16 opioid analgesic deaths; in December, 2013 there were 3 prescription opioid deaths for each heroin death. The transition to heroin appears to have started prior to the introduction of tamper-resistant opioid analgesics. The age of death among heroin decedents shifted toward younger adults. Most heroin and opioid analgesic deaths occurred in metropolitan areas, with little change between 2007 and 2013. CONCLUSIONS: The observed increases in heroin overdose deaths can no longer be considered speculation. Deaths among younger adults were noted to have increased in particular, suggesting new directions for targeting interventions. More research beyond vital statistics is needed to understand the root causes of the shift from prescription opioids to heroin.

Project Lazarus: community-based overdose prevention in rural North Carolina.

BACKGROUND: In response to some of the highest drug overdose death rates in the country, Project Lazarus developed a community-based overdose prevention program in Western North Carolina. The Wilkes County unintentional poisoning mortality rate was quadruple that of the state's in 2009 and due almost exclusively to prescription opioid pain relievers, including fentanyl, hydrocodone, methadone, and oxycodone. The program is ongoing. METHODS: The overdose prevention program involves five components: community activation and coalition building; monitoring and surveillance data; prevention of overdoses; use of rescue medication for reversing overdoses by community members; and evaluating project components. Principal efforts include education of primary care providers in managing chronic pain and safe opioid prescribing, largely through the creation of a tool kit and face-to-face meetings. RESULTS: Preliminary unadjusted data for Wilkes County revealed that the overdose death rate dropped from 46.6 per 100,000 in 2009 to 29.0 per 100,000 in 2010. There was a decrease in the number of victims who received prescriptions for the substance implicated in their fatal overdose from a Wilkes County physician; in 2008, 82% of overdose decedents received a prescription for an opioid analgesic from a Wilkes prescriber compared with 10% in 2010. CONCLUSIONS: While the results from this community-based program are preliminary, the number and nature of prescription opioid overdose deaths in Wilkes County changed during the intervention. Further evaluation is required to understand the localized effect of the intervention and its potential for replication in other areas.

Physical and sexual violence among North Carolina women: associations with physical health, mental health, and functional impairment.

OBJECTIVE: This study examines links between women's experiences of violence during adulthood (including physical and sexual violence) and women's physical health, mental health, and functional status. METHODS: Data were analyzed from a representative sample of 9,830 North Carolina women surveyed by the North Carolina Behavioral Risk Factor Surveillance System (BRFSS). RESULTS: One-quarter of the women experienced violence as adults, with current or ex-partners being the most common perpetrators. Logistic regression analyses that controlled for the sociodemographic characteristics of the women found that women who experienced violence were significantly more likely than other women to have poor physical health, poor mental health, and functional limitations. Moreover, these negative health outcomes were most prevalent among the women who experienced a combination of both physical and sexual violence. CONCLUSIONS: These findings underscore the need for trauma-informed women's health services and policies.

Changing drinking pattern does not influence health perception: a longitudinal study of the atherosclerosis risk in communities study.

OBJECTIVE: To investigate if dynamic changes in the pattern of alcoholic beverages consumption are associated with modifications in health perception. DESIGN, SETTING, AND PARTICIPANTS: This study investigated 12 332 middle aged men and women from the atherosclerosis risk in communities study who reported drinking status and perceived health triennially from 1987 to 1995. Crude and adjusted risks for change in health perception between visits two and three by change in drinking status between visits one and two were computed. In the multivariate analysis the sample was restricted to participants with stable drinking status between visit two and three and stable health perception between visits one and two, to assure that exposure and outcome were not temporary. Covariates included age, sex, race, income, smoking status, educational level, and obesity. RESULTS: Health for persons who stopped or started drinking, or continued to abstain was more likely to decline than was health for persons who continued to drink even after adjustment and restrictions (drinking cessation: OR = 1.6, 95% CI = 1.1, 2.3; started drinking; OR = 1.4, 95% CI = 0.9, 2.2; continued abstaining from alcohol: OR = 1.5, 95% CI = 1.3, 1.9). Among participants with poor perceived health, starting, stopping, or continuing to abstain from alcohol did not improve health in relation to participants that continued to drink. CONCLUSION: Increasing and decreasing drinking patterns and continuous abstinence were associated with declining health perception in comparison with continuous drinking, while starting or stopping drinking did not improve health perception of persons with poor perceived health. These findings suggest that change in health perception was not biologically related to alcohol consumption.

Anger temperament is modestly associated with the risk of type 2 diabetes mellitus: the Atheroslcerosis Risk in Communities Study.

OBJECTIVE: Trait anger has been shown to predict coronary heart disease; however, there are no prior studies evaluating anger as a risk factor for type 2 diabetes. The objective of this study was to determine if anger proneness predicted type 2 diabetes using prospective analyses. METHODS: We analyzed data on trait anger, assessed by questionnaire, in a longitudinal, bi-racial cohort study of 11,615 initially non-diabetic adults aged 48-67, who were subsequently followed for 6 years for the development of type 2 diabetes. RESULTS: There was no relation between overall trait anger and the subsequent risk of diabetes; however, individuals in the highest tertile of trait anger temperament scores had a 34% increased risk of developing diabetes compared to those in the lowest tertile (Relative hazard [RH] = 1.34; 95% confidence interval: 1.10, 1.62), following adjustment for age, race, gender, and education. The relation between anger temperament and diabetes remained significant following adjustment for behavioral factors (smoking, physical activity, and caloric intake) (RH = 1.31; 95% CI: 1.08, 1.60) but was non-significant after additional adjustment for waist-to-hip ratio and body-mass index (RH = 1.18; 95% CI: 0.97, 1.44). CONCLUSIONS: While we found no relation between overall trait anger and incident diabetes, persons who had higher anger temperament subscale scores had a slightly increased risk of type 2 diabetes, which was largely explained by adiposity. Anger temperament may deserve further attention as a potential risk factor for type 2 diabetes.

Lifetime prevalence of migraine and other headaches lasting 4 or more hours: the Atherosclerosis Risk in Communities (ARIC) study.

OBJECTIVES: To evaluate the lifetime prevalence of migraine and other headaches lasting 4 or more hours in a population-based study of older adults. BACKGROUND: Migraine and other headaches not fulfilling migraine criteria are common afflictions. Yet the health and social effects of these conditions have not been fully appreciated, particularly among older adults. METHODS: The study included 12 750 participants in the Atherosclerosis Risk in Communities (ARIC) Study from 4 US communities. Prevalence estimates of a lifetime history of migraine and other headaches lasting 4 or more hours were obtained for race and gender groups. A cross-sectional analysis was done to assess the relationship between headache type, by aura status, and various sociodemographic and health-related indices. RESULTS: Compared to education beyond high school, having completed less than 12 years of education was significantly associated with an increased occurrence of migraine with aura (prevalence odds ratio [POR], 1.47; 95% confidence interval [CI], 1.08 to 2.01). Family income less than $16 000, compared to family income of $75 000 or greater, was significantly associated with migraine with aura (POR, 1.68; 95% CI, 1.07 to 2.64), migraine without aura (POR, 1.56; 95% CI, 1.14 to 2.14), and other headaches with aura (POR, 1.89; 95% CI, 1.14 to 3.13). The prevalence odds ratio was higher in each headache category, particularly for those with an aura, for those with hypertension versus normotension and for those who perceived their general health as poor compared to those whose perception was excellent. CONCLUSIONS: A lifetime history of migraine with aura and other headaches with aura was more common among whites, women, and younger participants. Further investigation of headaches lasting 4 or more hours, particularly by aura status, is warranted.

Depressive symptoms and the risk of type 2 diabetes: the Atherosclerosis Risk in Communities study.

OBJECTIVE: The goal of this study was to determine whether depressive symptoms predict type 2 diabetes. RESEARCH DESIGN AND METHODS: We analyzed data on depressive symptoms (including recent fatigue, sleep disturbance, feelings of hopelessness, loss of libido, and increased irritability) in a longitudinal, biracial cohort study of 11,615 initially nondiabetic adults aged 48-67 years, who were subsequently followed for 6 years for the development of type 2 diabetes. RESULTS: At baseline, depressive symptoms were positively associated with BMI, fasting insulin, systolic blood pressure, caloric intake, physical inactivity, and current smoking (all P < 0.05). In prospective analyses, after adjusting for age, race, sex, and education, individuals in the highest quartile of depressive symptoms had a 63% increased risk of developing diabetes compared with those in the lowest quartile (relative hazard [RH] 1.63, 95% CI 1.31-2.02). This relation persisted after adjustment for stress-associated lifestyle factors (smoking, physical activity, caloric intake, and adiposity) (1.28, 1.02-1.60) and metabolic covariates (fasting insulin and glucose, lipids, blood pressure, and adiposity) (1.38, 1.10-1.73). CONCLUSIONS: In this cohort, depressive symptoms predicted incident type 2 diabetes. This relation is only partially explained by demographic, metabolic, and lifestyle factors. Possible neuroendocrine mediators of the stress-obesity-diabetes relationship require further evaluation in prospective cohort studies that use an established tool to assess depression and incorporate neurohormonal measurements.

The association between trait anger and incident stroke risk: the Atherosclerosis Risk in Communities (ARIC) Study.

BACKGROUND AND PURPOSE: This study examined the relation between trait anger and incident stroke risk among participants without a history of stroke at the first follow-up examination of the Atherosclerosis Risk in Communities (ARIC) study. METHODS: The study sample included 13 851 black and white men and women, aged 48 to 67 years, who completed the Spielberger Trait Anger Scale. Median follow-up time was 77.3 months. RESULTS: In the full cohort, Cox proportional hazards regression analyses showed a modest increase in the risk for stroke among individuals with high trait anger, though the association did not remain statistically significant after multivariate adjustment. Participants < or =60 years of age who reported having high trait anger had a 2.82 (95% CI, 1.65 to 4.80) times greater risk for hemorrhagic and ischemic strokes combined (any) and a 2.93 (95% CI, 1.64 to 5.22) times greater risk for ischemic strokes alone than their counterparts who reported having low trait anger (hazard rate ratios adjusted for sex and race/ethnicity). Similarly, among participants with HDL cholesterol levels >47, the risk for any stroke was 2.86 (95% CI, 1.56 to 5.25) times greater for those who reported having high trait anger, whereas the risk for ischemic strokes alone was 2.98 (95% CI, 1.58 to 5.61) times greater (hazard rate ratios adjusted for age, sex, and race/ethnicity). These associations remained strong and statistically significant after further adjustment for several established biological and sociodemographic risk factors for stroke and were absent among older participants and those with lower HDL cholesterol values. CONCLUSIONS: Trait anger was associated with an increased risk for incident stroke in the ARIC study among younger participants and those with higher HDL cholesterol levels.