Barriers and Facilitators Regarding Awareness, Selection, and Implementation of School-Based Interventions Addressing Physical Activity and Healthy Eating Behaviors: Perspectives of South Carolina Public School Administrators and Personnel

Purpose: This dissertation explores the perceptions and experiences of South Carolina (SC) public school administrators and personnel regarding barriers and facilitators to school-based interventions, with a focus on physical activity (PA) and healthy eating behaviors, to address childhood obesity. An integrative review was completed to identify challenges and supports to school-based weight management interventions.1-35 Findings from the integrative review provided the framework for the dissertation study, which used a concurrent multi-methodological design to investigate the barriers and facilitators regarding awareness, selection, and implementation of school-based interventions addressing PA and healthy eating behaviors in the SC education system and to examine how the coronavirus disease 2019 (COVID-19) pandemic affected these interventions. Problem: In SC, approximately 37% of children and adolescents are overweight or obese, and the state ranks 3rd in the nation for the number of youth ages 10-17 who are obese.36,37 Behaviors that lead to excess weight gain include inadequate participation in PA and consumption of high-calorie, low-nutrient foods.38 Substantial negative health outcomes are associated with obesity, including increased rates of chronic illnesses, diminished quality of life, and shorter life span.38-42 Childhood obesity is also linked to psychological and social problems, such as anxiety, depression, and stigmatization.38,43,44 School-based weight management interventions have successfully improved PA and eating behaviors; however, not all schools offer these types of interventions and some interventions are not implemented to their fullest extent.45-49 It is important to understand the factors that hinder and promote the delivery of school-based interventions. The following research question guided the study: What do public school administrators and personnel in South Carolina perceive and experience as barriers and facilitators regarding awareness, selection, and implementation of school-based interventions addressing physical activity and healthy eating behaviors? The specific aims of the dissertation were: • Aim 1: Describe actual and perceived barriers and facilitators public school administrators and personnel in South Carolina encounter regarding awareness, selection, and implementation of school-based physical activity and healthy eating interventions. ‒ Aim 1a. Identify actual and perceived concerns and experiences within school settings regarding the use of weight-related terminology and any stigma that may exist. ‒ Aim 1b. Assess ability to recruit and engage public school administrators and personnel in South Carolina to participate in an exploratory study on school-based interventions. • Aim 2: Identify greatest challenges and supports, priority focal areas, and school-based interventions that have been implemented along with their outcomes. Design: A concurrent multi-methodological study, informed by the Social Ecological Model (SEM)50-54 and the Steps in Quality Intervention Development (6SQuID) Model,55,56 was completed to form a comprehensive understanding of the phenomena.57,58 The qualitative descriptive component included one-time Key Informant Interviews (KIIs) with SC public school administrators. The quantitative descriptive component involved conducting a needs assessment survey of SC public school personnel. Findings: KII participants (N = 28) reported that negative beliefs, comments, and bullying behaviors were more prevalent toward students perceived as being overweight. School administrators also indicated that school-based interventions addressing PA and healthy eating behaviors were present in schools. Participants identified insufficient time as the main barrier and adequate support as the primary facilitator to school-based interventions. These factors inhibited or enhanced intervention implementation, based on the extent to which they were present. Survey respondents (N = 1311) reported the foremost barriers as insufficient time for PA (n = 514, 39.2%) and limited access to healthy foods for healthy eating behaviors (n = 271, 20.7%). The key facilitators were adequate support from school-level administrators for PA (n = 264, 20.1%) and adequate support from cafeteria staff for healthy eating behaviors (n = 234, 17.8%). Both interview and survey participants described the COVID-19 pandemic as causing changes in school-based interventions addressing PA and healthy eating behaviors and in academic delivery impacting PA and healthy eating behaviors. Responses revealed that schools’ abilities to address PA and healthy eating behaviors were negatively affected by COVID-19, and the pandemic was predicted to disrupt future school-based interventions related to PA and healthy eating behaviors. Conclusions: Information from this dissertation provides the foundation for future studies on mitigating barriers and maximizing facilitators to school-based interventions addressing PA and healthy eating behaviors, with the ultimate goal of decreasing rates of childhood obesity. Additionally, findings may help school systems to adapt school-based interventions to changes from the COVID-19 pandemic so that students can still receive and benefit from content on healthy lifestyle practices.59,60 A promising opportunity for interprofessional collaboration exists for health care and education professionals to work together on school-based interventions that address students’ health and academic needs

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

The London Game

The London Game is an interactive narrative developed by students and their instructor at Lindenwood University using the Twine tool. Players take the role of a time traveler who can experience any of three scenarios based on aspects of London history and culture of the seventeenth and eighteenth centuries: the Great Fire, the theatrical scene, and the struggles of poverty

The Dynamic Nature of Knowledge: Insights From a Dynamic Field Model of Children's Novel Noun Generalizations.

This paper examines the tie between knowledge and behavior in a noun generalization context. An experiment directly comparing noun generalizations of children at the same point in development in forced-choice and yes/no tasks reveals task-specific differences in the way children’s knowledge of nominal categories is brought to bear in a moment. To understand the cognitive system that produced these differences, the real-time decision processes in these tasks were instantiated in a dynamic field model. The model captures both qualitative and quantitative differences in performance across tasks and reveals constraints on the nature of children’s accumulated knowledge. Additional simulations of developmental change in the yes/no task between 2 and 4 years of age illustrate how changes in children’s representations translate into developmental changes in behavior. Together, the empirical data and model demonstrate the dynamic nature of knowledge and are consistent with the perspective that knowledge cannot be separated from the task-specific processes that create behavior in the moment