NINR - National Institute of Nursing Research Grants

NINR - National Institute of Nursing Research

TITLE: Identifying and Measuring the Palliative Needs of Children in Foster Care A major challenge in tailoring palliative care for children in foster care is a lack of appropriate measures and data identifying their needs. Among children with medical complexity, 27% utilize concurrent (hospice and end of life) care. This high percentage suggests that many CMC with more than 6 months of life expectancy could benefit from palliative care. The known health challenges among children in foster care and CMC suggests a strong likelihood of unmet palliative care needs for CMC in foster care, however, the scope and severity are unclear due to an absence of literature and limitations of data. Participatory action research methodologies with critically ill patients have led to positive outcomes between patient need and medical intervention. Research suggests collaborative co-design could help provide the context, insight and understanding to address unmet palliative needs for children in foster care. Therefore, this exploratory mixed methods study using a participatory co-design approach will determine what palliative care needs should be measured among CMC in foster care from the perspective of two partner groups: 1) Foster partners, including foster and biological parents, and adults formerly in foster care, and 2) health care team partners (including nurses, nurse practitioners, physicians, and social workers). Aim 1a: Qualitatively identify the lived experiences of foster partners caring for children in foster care with palliative needs, and quantitatively assess the clarity and relevance of an existing palliative screening tool in this population. Narrative interviews will be followed by a quantitative content validity index for a current parent-reported pediatric palliative care screening tool. Aim 1b: Qualitatively understand the lived experiences of health care partners caring for children in foster care with palliative needs, and quantitatively assess the clarity and relevance of an existing palliative screening tool for this population. Focus groups will be followed by a quantitative content validity index for a current health care team-reported pediatric palliative care screening tool. Aim 1c: Integrate qualitative and quantitative data into preliminary synthesized findings. Aim 2a: Conduct reflexive discussion and validation of the preliminary Aim 1c findings using a participatory co-design approach with representatives from the foster and health care team partner groups and Aim 2b: Collaboratively co-design screening priorities for palliative needs among foster children. This work will inform future research and clinical practice by anchoring inquiry within human-centered design research approaches to address palliative care needs in foster care.

NINR - National Institute of Nursing Research

Project Summary Advancements in cancer treatment are enabling breast cancer survivors to live longer, highlighting the need for more research on their ongoing needs after chemotherapy. By 2030, there are expected to be 4.9 million breast cancer survivors in the United States (US). Black women, in particular, face significant differences in breast cancer outcomes compared to other racial and ethnic groups. For example, Black women are frequently diagnosed at later stages, are twice as likely to develop aggressive cancers such as triple-negative breast cancer, which necessitates chemotherapy treatment, and have a 40% higher mortality rate compared to White women. Chemotherapy-induced peripheral neuropathy (CIPN), can be a debilitating side effect following treatment among breast cancer survivors. CIPN symptoms, including numbness, pain, and balance issues, can impede activities of daily living, substantially lower the quality of life, and lead to psychological distress and social isolation among patients. Limited research exists on CIPN presentations among Black breast cancer survivors. Understanding CIPN's impact on treatment decisions and quality of life for Black patients is important to ultimately reducing symptom burden and improving outcomes among survivors. Data on CIPN symptoms, severity, and treatment outcomes are needed to inform clinical interventions and improve patient care. To examine the impact of CIPN on Black breast cancer survivors, this proposed cross-sectional survey study aims to determine CIPN characteristics and severity among N=125 early-stage (stage I-III) Black breast cancer survivors following chemotherapy at a large urban academic medical center in the Southeastern US. Aim 1 will identify CIPN symptoms and severity using patient-reported outcome measures. Aim 2 will examine associations between CIPN severity and physiological, psychological, and social factors. Aim 3 will characterize the occurrence in treatment outcomes, such as chemotherapy dose reductions, dose delays, and treatment discontinuations. This study will illuminate CIPN's impact among Black breast cancer survivors, informing the design of future longitudinal research and interventions to reduce CIPN's impact and improve treatment outcomes. During the conduct of this fellowship, the applicant will pursue a rigorous training plan, under the supervision of an interdisciplinary team of mentors, to cultivate the skills needed to become and independent researcher. This study will provide the initial data to develop a longitudinal cohort of Black breast cancer survivors experiencing CIPN. The proposed fellowship aligns with the National Cancer Institute and the National Institute of Nursing Research’s strategic plans to train the next generation of cancer researchers and strengthen the cancer workforce while reducing symptom burden and optimizing care outcomes among breast cancer survivors.

NINR - National Institute of Nursing Research

Type 2 diabetes (T2D) has reached epidemic levels in the United States and, alarmingly, cases of early-onset T2D are steadily rising, with nearly 305,000 new cases diagnosed among 18 to 44 year-olds in the United States each year.1,2 Early-onset T2D (diagnosed before age 40) progresses more rapidly than older-onset T2D3 and is associated with increased risk of developing comorbid cardiovascular and kidney diseases and life-altering complications.2-5 Emerging adults (ages 18 to 29) with family histories of T2D have an especially high risk of developing early-onset T2D and associated complications.2,6 National Diabetes Prevention Programs (NDPPs) are the gold standard for T2D prevention,7 and emerging adults compared to older adults have lower participation and retention in NDPPs.8,9 The underlying reasons for emerging adults’ low NDPP participation, including this population’s T2D prevention-related health beliefs, have been ill-explored.8,9 High perceived threat and low perceived benefits related to the belief that T2D is inevitable paired with high perceived barriers and limited cues to action related to limited healthcare usage may have a powerful influence on emerging adults’ NDPP participation.10 Understanding the T2D prevention-related health beliefs of emerging adults with family histories of T2D can help identify opportunities to intervene to increase NDPP participation. The purpose of this study is to describe T2D prevention- and NDPP-related health beliefs of emerging adults with family histories of T2D, focusing on the perceived threat of developing T2D, perceived benefits and barriers of T2D prevention behaviors, and cues to action. A sample of 20 to 30 emerging adults will be recruited using three methods: recruitment from Indiana University Indianapolis and Bloomington and local community organizations, social media recruitment, and online recruitment from an Indiana-based research registry. Participants will be eligible if they are 18 to 29 years old, have at least one biological parent or sibling diagnosed with T2D, have a body mass index greater than or equal to 25, and have not participated in an NDPP. Data will be collected with a demographic survey and a semi-structured interview about T2D prevention- and NDPP-related health beliefs. Interviews will be transcribed and analyzed using qualitative descriptive methods as described by Sandelowski.11 Findings will elucidate how health beliefs influence T2D prevention behaviors of emerging adults with family histories of T2D including their NDPP participation and inform intervention development and NDPP adaptation to increase NDPP participation in this population to lower their risk of early-onset T2D. This grant will also support training of the principal investigator in conducting research with emerging adult populations, community-based participatory and intervention research, and postdoctoral fellowship preparation.

NINR - National Institute of Nursing Research

The standard of care for pediatric type 1 diabetes (T1D) is the use of continuous glucose monitoring (CGM) and automated insulin delivery (AID) systems to optimize glycemia. These diabetes technologies hold the potential to decrease the risk of acute and long-term complications. Yet, the rapid developments over the last decade have posed challenges for youth, caregivers, and healthcare professionals who must learn to use these devices. Use of these devices requires significant user interaction and remains labor-intensive, leading to variability in glycemic outcomes. Up to 75% of youth may have higher hemoglobin A1c levels despite device use, placing them at increased risk for complications over time. Schools offer a unique opportunity to support these populations. Youth with T1D spend nearly one third of their weekdays in school under the care of school nurses. School nurses have expressed a critical gap in their knowledge of T1D devices, which can negatively affect parent and student school experiences. To date, little to no research has explored interventions to support school nurses with T1D devices. Structured education may directly impact school nurse CGM and AID knowledge and confidence and student outcomes. e-Learning, defined as the delivery of education through digital resources, allows for flexible, asynchronous learning at a self-determined pace. App-based CGM and AID education stimulates active, problem-centered learning that improves the knowledge and confidence of endocrinology trainees. We propose to adapt an existing diabetes technology e-Learning tool to meet the needs of school nurses using the Discover-Design-Build-Test framework. In the Discover phase (Aim 1), focus groups of school nurses, parents of youth with T1D, teens with T1D, and diabetes clinicians will be used to understand CGM and AID use in the school setting, individual and organizational challenges for school nurses learning to use devices and perceptions of nurse understanding of these devices. The Design and Build phases (Aim 2) will engage school nurses to adapt an existing app-delivered diabetes device curriculum using user-centered design and educational theory. We will conduct usability testing, seeking quantitative and qualitative feedback, to guide app refinement before proceeding to a pilot in Aim 3. Pilot outcomes will focus on feasibility and acceptability (primary), school nurse knowledge and confidence (secondary) and health and academic outcomes for students with T1D cared for by participating school nurses (exploratory). The e-Learning tool developed will be tested in future studies with the goal of implementing a widely disseminatable tool that can lead to sustainable systems-level change to improve school health.

NINR - National Institute of Nursing Research

Project Abstract Over the past 10 years, the rates of multiple sclerosis (MS) have nearly doubled in the United States. This chronic, neuroinflammatory, and neurodegenerative disease is most often diagnosed between the ages of 20-40. In many countries, it is the main cause of nontraumatic disability in young adults. Cognitive impairment affects up to 70% of those with MS, in whom the incidence of early onset dementia is 7 times higher than it is in adults without MS. Cognitive- based rehabilitation, however, can improve memory and learning as well as symptoms of depression and anxiety, which may reinforce cognition. Traditional approaches to cognitive rehabilitation use restorative (drill and practice) and compensatory (management) strategies. Yet most cognitive interventions for persons with MS are predominantly visual or speech focused, which eliminates the possibility of stimulating multiple senses. Playing a musical instrument provides multisensory stimulation and feedback to enhance neuroplasticity in the learning process making it superior to traditional cognitive rehabilitation strategies. Music training is a multimodal activity that involves coordinating of sensory and motor sequences with planned actions that require higher cognitive resources. Music training has been associated with frontal lobe function and higher visuospatial, working memory and executive function performance across the life span. The purpose of this study is to determine the feasibility of Music-4-MS, a 12-week music-based, eHealth intervention. The specific aims are to 1) determine the feasibility and acceptability of delivering the Music-4-MS eHealth intervention among individuals with MS over 12 weeks; 2) evaluate the preliminary effect of Music-4-MS on cognitive (objective performance, subjective function), psychosocial (anxiety, depression, social function), and functional (physical function, fatigue, hand dexterity) well-being over time compared to an active control group; and 3) explore participants’ perceptions of the motivation, engagement, connection, and usefulness of Music-4-MS in their daily lives.

NINR - National Institute of Nursing Research

PROJECT SUMMARY Heart failure affects million adults in the U.S., is associated with high mortality, and is a leading cause for hospitalizations. The long-term objective of this project is to understand the impact of an existing, trauma- informed, community-based, nurse-led heart failure disease management program that provides care to heart failure patients with adverse social determinants of health and unmet social needs (poverty, unstable housing, substance use, mental illness). The Community Heart Failure Program (CHFP) is operated out of a safety-net hospital in the Pacific Northwest and delivers an innovative model of care, where staff provide clinical care in the location of the patient’s choosing, often a shelter, tent, apartment, or other non-clinic-based location. Point- of-care labs and ultrasound support clinical decision-making. Using trauma-informed care principles, including safety, trustworthiness, collaboration, empowerment, and choice, the CHFP and this research project were designed to engage patients with adverse social determinants of health and unmet social needs. This project advances health equity by removing barriers to high quality clinical care and clinical research participation. The short-term objective of this project is to establish feasibility of research study protocols that were designed to evaluate the impact of this innovative existing program. The proposed study is a prospective, longitudinal design (N=40). The specific aims of this project are to: 1) evaluate feasibility of research protocols, 2) compare healthcare utilization 6 months pre- and post-CHFP enrollment, and 3) compare guideline-directed medical therapy (GDMT), biomarkers, and patient-reported outcomes (PROs) at baseline and 3- and 6-months post-enrollment, and 4) examine associations between CHFP conceptual model key components (trust/relationship building, shared-decision making, care coordination, harm reduction) and outcomes (healthcare utilization, GDMT, biomarkers, and PROs). Descriptive statistics will be used for Aim 1. For Aim 2 and 3, paired t-tests (or Wilcoxon signed-rank test) will be used to compare outcomes pre- and post- enrollment, and effect sizes will be calculated to inform future intervention studies in this patient population. For aim 4, correlations (continuous variables) and chi-squared (categorical variables) will be used to examine the direction and strength of associations between key components of the conceptual model and model outcomes, in addition to multivariate regression to determine the independent effect of key components on outcomes. The goals of this project align with the strategic mission of the National Institute of Nursing Research to prioritize research that advances health equity by removing barriers to research participation, optimizes health for individuals and communities, and addresses pressing health challenges.

NINR - National Institute of Nursing Research

PROJECT SUMMARY Children living with chronic hepatitis B (CHB) must actively manage their disease throughout their lifetime due to the risk of progressive liver disease and hepatocellular carcinoma. Their transition to adult care complicates care management and typically occurs during adolescence and young adulthood, when health-related quality of life (HRQoL) can also diminish. The proposed mixed methods study seeks to provide insights into how family context and stigma influence care management and HRQoL among adolescents and young adults (AYAs) with CHB during their transition into adult care, with three specific aims: 1) To estimate the effects of family health risk factors on HRQoL trajectories among adolescents with CHB and to determine whether they are modified by family structure; 2) Explore care management experiences, including medical decision-making and adherence, for AYAs with CHB transitioning into adult care; and 3) Identify how key moments, such as disclosure, secrecy, and silence, from the family context form pivotal experiences that shape care management and HRQoL for AYAs with CHB. First, the quantitative phase utilizes the Hepatitis B Research Network Pediatric Cohort Study dataset, an investigation of HRQoL in youth with CHB in North America from 2010 to 2017, to examine how family context influences HRQoL trajectories among adolescents with CHB. Next, the qualitative and participatory phases involve primary data collection, leveraging the Johns Hopkins Viral Hepatitis Center. AYAs with CHB will be recruited (n=15) from the Center for in-depth interviews to explore transitioning into adult care, medical adherence, decision-making, and family communication and support. Second, all participants will be invited to participate in Collaborative Filmmaking. This participatory method involves filmmaking and discussions to identify how pivotal experiences within the family context have informed disease-related stigma and shaped care management and HRQoL. Data integration will include visual displays whereby data are visualized alongside each other. Participants will have the opportunity to incorporate their films into a composite film and share them publicly. This study is an in-depth exploration of AYA chronic disease management and HRQoL that involves public-facing work with the creation and dissemination of films. It is responsive to NICHD’s strategic plan theme to improve child and adolescent health and transitions to adulthood, including healthcare transitions for those with chronic health conditions. This research will provide foundational knowledge and actionable items for families, health providers, and public health professionals to support AYAs with CHB transitioning into adult care. The proposed research fulfills the dissertation and degree requirements for Ms. Block, PhD student at the Johns Hopkins Bloomberg School of Public Health. Training will be mentored by experts in viral hepatitis, AYA health, biostatistics, qualitative and participatory mixed methods, and translational science. With guidance from this robust mentorship team (Sponsor: Dr. Jill Owczarzak), research and training will support Ms. Block’s growth into an independent researcher dedicated to promoting the health and well-being of AYAs living with chronic disease.

NINR - National Institute of Nursing Research

PROJECT SUMMARY Sepsis is a major cause of hospitalization and death in the United States, and unplanned 30-day readmissions after sepsis are common, costly, and clinically consequential. Current approaches to readmission risk assessment rely primarily on clinical information recorded during hospitalization and often omit measurable non-medical barriers that may affect recovery and care transitions after discharge. These barriers include food insecurity, housing instability, transportation barriers, utility insecurity, and interpersonal safety. Each barrier can be measured using standardized screening items and, when documented in structured form, ICD-10-CM Z codes. In parallel, post-discharge risk may also vary with predefined, address-linked contextual exposures that can be measured at the neighborhood level (e.g., deprivation indices, rurality, proximity to essential services). GEO-SIRS will integrate electronic health record (EHR) data, patient-reported non-medical barrier screening, and geospatially derived contextual indicators to improve characterization of measurable post-discharge outcomes among sepsis survivors in a multi-site academic health system. The primary outcome is unplanned 30-day hospital readmission, defined using EHR encounter data; a secondary outcome is 30-day all-cause mortality, captured using EHR-linked mortality indicators. Analyses will rely on prespecified, clearly defined variables directly relevant to these outcomes, including clinical severity and demographic characteristics available in the EHR, to support valid inference and reproducible research. Aim 1: We will evaluate the quality and completeness of non-medical barrier information captured in electronic health records and standardize these data using ICD-10-CM Z codes to improve consistency, comparability, and future analytic reproducibility. Aim 2: We will use rigorous statistical and geospatial methods to identify geographic heterogeneity in sepsis readmission risk and compare patient-reported and geospatially derived measures of non-medical barriers and contextual exposures to determine where each source adds value and where important information may be missing. By emphasizing measurable exposures, prespecified clinically meaningful outcomes, and reproducible methods, GEO-SIRS will generate a stronger evidence base for future risk stratification and targeted care transition strategies after sepsis.

NINR - National Institute of Nursing Research

Variability in food processing across and within food groups classified as ultraprocessed foods (UPFs) makes quantifying processing levels challenging, and existing classification systems lack the needed granularity. Given the contribution of UPFs to dietary intake and the likely impact of respiratory health, understanding the precise inflammatory effects and pulmonary consequences of UPFs is critical. Our preliminary work demonstrates that Artificial Intelligence (AI) offers solutions for more precise quantification of UPF composition profiles and consumption, enabling the proposed study on the variable effects of UPF subgroups on pulmonary outcomes. Exacerbations of respiratory symptoms lead to significant medical expenditures, lost productivity, higher overall morbidity, and accelerated lung function decline. However, questions about the effects of food processing on pulmonary outcomes remain under-addressed, and dietary guidelines to date have focused on nutrients to limit, with little guidance on UPFs specifically. Diets high in UPFs have been linked to increased inflammatory markers, suggesting that inflammation may mediate the association between UPF consumption and adverse health outcomes. This relationship has not been rigorously explored in relation to pulmonary symptoms and may represent diet as a point of intervention. We hypothesize that UPF subgroups are variably associated with respiratory exacerbation frequency and severity, and that UPF impacts on the lung are mediated by chronic systemic inflammation. By combining novel AI methodologies to assess food processing with the deep clinical and molecular phenotypes of the COPDGene longitudinal cohort study, we are uniquely positioned to robustly investigate this hypothesis in the following specific aims: Aim 1. Quantify the association of AI-scored UPF consumption with respiratory exacerbations, lung function, and COPD in people at high risk of lung disease; Aim 2. Evaluate the mediating effect of inflammatory proteins in the associations between UPF consumption and respiratory exacerbations, lung function, and COPD. Through this research, we will elucidate the contributions of UPF consumption to systemic inflammation, COPD, and respiratory outcomes in a high-risk population, leveraging AI approaches to improve precision across UPF subgroups and generate insights into biomarkers for UPFs. Our long-term goal is to inform “food as medicine” interventions to reduce the severity and progression of chronic lung diseases, a high-priority area in need of precise methods and solutions.

NINR - National Institute of Nursing Research

PROJECT SUMMARY Despite improving survival rates due to recent medical advancements, pediatric B-cell acute lymphoblastic leukemia (B-ALL) patients continue to experience treatment-related toxicities, particularly those associated with high-dose Methotrexate (HD-MTX). Chemotherapy-induced oral mucositis (CIOM) is one such toxicity that can cause excoriated mouth sores and debilitating pain, thus decreasing quality of life and increasing healthcare costs. Children with B-ALL experience CIOM at higher rates than adults, yet mucositis clinical practice guidelines have primarily been developed using data from adult oncology patients. Food insecurity, which is observed more frequently in oncology populations and households with children, may contribute to these adverse CIOM outcomes by influencing diet quality and the oral microbiome (i.e., a collection of microbes within the oral cavity that serve as a protective mechanism when balanced and symbiotic). Food insecurity has been linked to poor diet quality in children and suboptimal health outcomes in adult cancer patients. In turn, poor diet quality has been associated with a dysbiotic oral microbiome and increased CIOM incidence and severity in adult cancer patients. Preliminary research has demonstrated a relationship between the oral microbiome and CIOM in pediatric oncology populations. However, the sociodemographic homogeneity of the participants, the omission of environmental and contextual covariates, and the exclusion of patient-reported outcomes limit the strength of the findings. Furthermore, research examining the influence of food insecurity and diet quality on CIOM is rarely conducted in pediatric oncology populations. The goal of this prospective observational study is to examine the interplay between food insecurity, diet quality, the oral microbiome, and patient-reported CIOM in 45 pediatric B-ALL patients before (T1) and two weeks after (T2) the first HD-MTX dose. The specific aims are: (1) to assess the association of food insecurity (area-, household-, and child- level) and diet quality with CIOM incidence and severity; (2) to investigate the association between the diversity and composition of the oral microbiome (16S rRNA sequencing of saliva) and CIOM incidence and severity; and (3) (exploratory aim) to explore whether food insecurity and diet quality alter the diversity and composition of the oral microbiome and subsequently impact CIOM incidence and severity. Participants will be recruited from Children’s Healthcare of Atlanta using a non-probability quota sampling method designed to reflect the sociodemographic distribution of pediatric leukemia cases as reported by the National Cancer Institute. Findings will help identify potential pathways that influence CIOM in the pediatric B-ALL population, supporting the development of future screening tools and interventional research that targets environmental, dietary, and biological factors to mitigate adverse outcomes. This project involves a team of expert researchers from Emory University and a comprehensive two-year training plan to prepare an independent researcher in pediatric oncology with expertise in environmental health, diet quality, microbiomics, and symptom science.

NINR - National Institute of Nursing Research

Health system resilience has emerged as a crucial objective for health systems globally, yet the critical role of the nursing workforce in achieving these targets remains insufficiently understood. Bridging this knowledge gap is essential to harness the full potential of nurses in strengthening health system resilience. The purpose of this F31 application is to prepare the applicant for a career as an independent investigator focused on expanding collective knowledge of key predictors and evidence- informed strategies for developing health system resilience. The proposed fellowship consists of two complementary components: 1) a training plan aimed at developing quantitative and qualitative methods proficiency, substantive disaster and health system resilience expertise, and role attainment of a nurse scientist; and 2) a research plan that will further understanding of the relationships between the nursing workforce, health system resilience, and disasters. A strong mentorship team that includes sponsors and collaborators from the University of Michigan Schools of Nursing, and Public Health will provide interdisciplinary expertise in the nursing workforce, global health, disasters, statistical analyses, and qualitative methodologies. Through formal coursework and mentorship, the training plan will allow the applicant to build upon early experience in qualitative methodologies, as well as substantially increase knowledge and experience in quantitative methodologies and data management. The applicant will be supported through intensive mentorship by an expert and personally committed team of mentors, advanced coursework, participation in the national and global scientific community, and progressively independent research. The proposed research project will utilize data from reputable open access sources including World Health Organization National Healthcare Workforce Statistics, country-level health data from the World Bank, country level disaster data from the Emergency Events Database (EM-DAT), and country-level health statistics from the World Health Organization. The specific aims are to 1) examine the relationship between the global nursing workforce, and population health outcomes during declared disasters, and 2) identify the facilitators, barriers, and key adaptations of the role of the nursing workforce in contributing to health system resilience during disasters. This study aligns with the National Institute of Nursing Research’s strategic plan by examining mechanisms to address health outcomes as well as population and community health by investigating approaches to mitigate negative outcomes at the macro level. Findings from this study are critical for shaping future policy and research agendas, and to better identify key predictors of health system resilience.

NINR - National Institute of Nursing Research

Adolescents with intellectual disabilities (ID) face significant health issues, particularly in managing chronic conditions such as cardiovascular (CV) health risks. These issues are exacerbated by limited physical activity (PA), health literacy challenges, and a lack of evidence-based health interventions. This project aims to address these gaps by engaging adolescents with ID and their stakeholders supporting ID as co-researchers to design, adapt, and pilot-test a virtual reality (VR)-based PA intervention tailored to their needs. The long-term goal is to dismantle factors to improve health outcomes for adolescents with ID through innovative, collaborative research that enhances health literacy, increases PA, and lowers CV health risks. With this goal in mind, the proposed K Mentored Research Scientist Development Award will direct Dr. Patricia West toward an established innovative independent research program. Guidance for her transition to independence will be provided in a strong institutional research environment at Michigan State University with dedicated interprofessional expert scientists and collaborative resources both internal and external to the University. The objectives of this application will address three specific aims: 1) adapt and validate research instruments by collaborating with adolescents with ID and their ID stakeholders to incorporate common language in measures for assessing health outcomes; 2) evaluate and select VR-based PA programs by engaging co-researchers in identifying effective VR exergame interventions for improving health outcomes through PA; and 3) pilot-test the VR PA intervention, which incorporates peer support. We will assess feasibility, acceptability, and preliminary efficacy of our 16-week VR exergame PA intervention using co-adapted measures and biologic CV risk measures. A quasi-experimental mixed-methods approach will be used, guided by our Logic Model. Preliminary evidence highlights the potential of interactive, technology-driven PA to address CV risks while fostering peer engagement and optimal self-efficacy to manage health. The expected outcomes are: 1) validated measures through greater health literacy, and 2) a co-designed intervention to reduce CV risks that helps adolescents with ID to take an active role in their health. By addressing critical gaps in health literacy, self-efficacy, and PA, this work advances healthcare practices and supports long-term improvements in public health.

NINR - National Institute of Nursing Research

Dating violence (DV) is common among U.S. high school age adolescents and has significant and lifelong negative health consequences, including suicide behaviors. Native American (NA) adolescents are at increased risk for violence victimization and/or perpetration in their dating violence, given their high rates of violence exposure in their homes and communities. Key challenges for dating violence prevention are the lack of services, fear of stigma and discrimination, and limited trust in and access to skilled professionals. The Fort Peck Reservation is home to the Assiniboine and Sioux Tribes in rural Montana. The reservation community reports high rates of violence and suicide behavior with underfunded and limited health and social service, especially for adolescents. The wide range of negative health and social outcomes associated with violence experienced by reservation-based NA adolescents underscores the call for innovative and targeted behavioral health interventions using appropriate technology. myPlan Teen, is an evidence-based healthy relationship and dating violence prevention intervention for adolescents and is delivered through a secure and confidential web based and mobile app. myPlan Teen provides adolescents with immediate access to information about healthy and unhealthy behaviors, safety strategies tailored to their situation with links to youth friendly resources, to reduce confusion, feelings of isolation and stigma associated with unhealthy relationships. In our CDC funded randomized control trial (RCT) with a national sample of 609 adolescents aged 15-17, we found adolescents randomized to myPlan Teen had a significant increase in use and helpfulness of safety behaviors compared to control group (adolescent health website). Further adolescents who used myPlan Teen reported a significant reduction in physical/sexual violence perpetration and suicide behaviors compared to control group. To advance the relevance and use of myPlan Teen with NA adolescents, our interdisciplinary team in partnership with Tribal Health leaders and Youth Advisory Board (YAB) will adapt myPlan Teen by integrating culturally relevant content, including tribal identity and communal mastery for NA adolescents to build healthy relationships, develop safety skills and access culturally relevant resources. Following the adaptation process, the team will evaluate the effectiveness of the culturally adapted myPlan Teen app on health and safety outcomes with 550 NA adolescents. In addition, we will examine the mechanisms by which myPlan Teen improves health and safety outcomes. The study will advance violence prevention interventions with NA adolescents and inform future processes to adapt and disseminate a digital intervention with adolescents nationally.

NINR - National Institute of Nursing Research

Advance care planning (ACP) supports patients in identifying and communicating their preferences for medical care and is a key component of individualized care. The Patient Self Determination Act of 1990 narrowly defined ACP as documentation of preferences for end-of-life procedures (e.g., resuscitation), resulting in a focus on advance directive completion. Since then, ACP has evolved to include a focus on preparing patients and caregivers for communication and decision-making across the illness trajectory, which is better conceptualized as “Care Planning” (CP) because the process includes both advance and in-the-moment decisions over the life course. While health systems have invested in CP as a requisite component of individualized care and it is reimbursed by the Centers for Medicare and Medicaid Services, wide heterogeneity of CP implementation and measurement remain, and the perspectives and needs of patients, caregivers, and interdisciplinary experts (e.g., nurses, attorneys, chaplains, etc.,) have not been considered. Unprecedented basic science (NIH Stage Model, Stage 0) is required to map the complexity of the entire CP process. Implementation science and human factors engineering offer a path towards clarity. This proposal advances the field of CP and implementation science by leveraging interdisciplinary expert, patient, and caregiver perspectives and human factors engineering methods to map implementation processes of CP and to identify clinically relevant CP outcomes across clinical and community settings and illness trajectories. We will apply the well-validated Consolidated Framework for Implementation Research (CFIR) model to illuminate CP’s complexity. CFIR domains include CP innovation characteristics (e.g., discussions) that operate in an inner setting (e.g., inpatient, outpatient, nursing home, hospice) and outer setting (e.g., policy) centered around subject matter experts (e.g., patients, caregivers, healthcare professionals, community leaders, legal/policy experts) involving a range of implementation components (e.g., initiating, facilitating, documenting, storing, accessing, updating CP wishes). This complexity is amplified by patients’ illness trajectories and setting. Our study aims are to: 1) Define processes of CP for varying settings (community, outpatient, acute care, long-term care, hospice), illness trajectories (healthy/chronic illness, serious illness, end-of-life) and healthcare access by creating CP Workflow Archetypes; and 2) Identify clinically relevant outcomes for each component of the CP Workflow Archetypes. Using CFIR and human factors engineering, we will map essential implementation factors of CP through focus groups and interviews and use Delphi methods to identify important implementation outcomes. Our long-term goal is to set the direction for future CP policy, research, and implementation.

NINR - National Institute of Nursing Research

Project Summary/Abstract Underrepresented groups are disproportionately impacted by nutrition-related chronic diseases. In Baltimore, a city with a majority minority population, disparities in healthy food access contribute to poor dietary intake. One third of Black residents and nearly 25% of older adults live in Healthy Food Priority Areas (HFPA), urban areas where unhealthy foods are more available than healthy foods. Common self-care tasks like food shopping, meal preparation, and cooking are also barriers to consuming a healthy diet among older adults. Poor dietary intake contributes to chronic disease risk and loss of muscle mass and strength, consequently limiting functional mobility. Ensuring that the next generation of researchers reflects the diversity of the larger population is essential to address all aspects of disparities, but there is a need to engage students at early education levels. UMB RAMP is a summer research training program that exposes high school (HS) students from historically excluded groups to translational research concepts and teaches basic lab techniques and clinical skills. Pilot data from our first cohort (86% Black) demonstrate a positive impact on HS students’ research career interest, but year-round paid experiences to engage and mentor these students in research labs are lacking for this age-group. In this phase 2 randomized controlled trial, we will determine if a 3-month virtual group nutrition education and virtual teaching kitchen cooking demonstrations paired with free produce tailored for older adults (>65 yrs) living in HFPA will improve diet and health-related outcomes compared to contact control. Our overarching hypothesis is that this intervention, personalized to include considerations of this older adult population’s barriers to consuming a healthy diet, will improve dietary quality and functional mobility while providing a paid, applied clinical research experience for HS students. Our research aims will determine the impact of the virtual intervention on diet and other health outcomes of older adults living in healthy food prior areas. The DEIA aims utilize a mixed methods approach to determine the impact of a year-long applied research opportunity on HS students from historically excluded groups' sense of belonging, confidence and motivation for pursuing undergraduate/career research experiences, and perceptions about both the aging field and the community impact of their research experience. We will also explore perceived impact from the older adult research participants related to working with young student researchers and how it may change their perceptions of research. Lack of effective interventions to improve diet quality among older urban adults represents a significant health problem. Simultaneously, workforce diversification is essential to meet growing US demands in research and biomedical science fields to address disparities in chronic disease outcomes. This project meets these demands by expanding research training opportunities for younger students to build confidence and self-efficacy that they belong in an academic research environment while providing a relatively low-cost intervention to disseminate to help narrow these gaps.

NINR - National Institute of Nursing Research

BLOOM Project Summary Birth is the leading reason for hospital admission in the United States. There are three possible birth outcomes: spontaneous vaginal birth (SVB), which is a birth without forceps or vacuum, operative vaginal birth which is a birth with forceps or vacuum, and cesarean. SVB is the best birth outcome for most women and babies' short- and long-term health, the least expensive birth outcome, and the birth outcome most women want. This makes it an excellent example of high-value healthcare. SVB rates vary significantly across hospitals and this variation is not explained by hospital structural characteristics. There are high-performing hospitals where women have appropriately excellent SVB rates and these hospitals exist across all structural characteristics (bed size, teaching status, technology status, rurality, and state). Nurses provide most direct patient care to women in labor and this care is critical for supporting SVB. Preliminary research suggests that a hospital's nursing organizational resources, including the work environment and staffing, differentiate high-performers from low-performers. In this research we look to optimize the health of our current and future generations by learning from our high- performing hospitals for birth outcomes to inform practice and policy. The purpose of this study is to examine high-performing hospitals with excellent SVB outcomes overall and for women from racial/ethnic minorities, who typically experience lower SVB rates, compared with low-performers regarding the organizational resources that differentiate them and to understand what the high- performers do, especially regarding those differentiating organizational resources, that sets them apart. Accordingly, we propose to conduct an explanatory sequential mixed methods study. In Aim 1, we will examine the relationship between hospital nursing organizational resources and SVB, for women overall and from racial and ethnic minority groups in high-performing hospitals (compared to low), by leveraging a novel benchmarking/ranking approach42 that uses propensity score weighting and machine learning methods. Sub-Aim 1: We will explore the relationship of varying state midwifery and staffing legislation with the presence of high- and low-performers. In Aim 2, we will explore the pathways by which high- and low-performing hospital's nursing organizational factors prevent or contribute to SVB outcomes and disparities, as well as high-performer's actions, interventions or culture to realize these organizational factors, their recommendations for improvement and implementation. We will do this via a semi- structured qualitative interview with hospital maternity leaders. In Aim 3, we will develop a joint display map, integrating the aspects of the hospital organizational resources identified in Aim 1 with the pathways and recommendations from Aim 2 to understand the relationship between the organizational resources and performance status to illumine actions for improvement.

NINR - National Institute of Nursing Research

Abstract National health authorities point to collecting sexual orientation and gender identity (SOGI) data as essential to systematically addressing the health and healthcare needs of sexual- and gender-diverse (SGD) people across all domains of life. The State of New Mexico answered this call by directing all its government agencies, including those overseeing or financing health and human service delivery, to collect voluntary self-reported SOGI data. These vital (a) illuminate the nature and extent of disparities and adverse health outcomes for a minoritized population, (b) encourage patient-centered care, and (c) develop equity-focused evidence-based interventions (EFEBIs) to eliminate long-standing disparities. New Mexico is a bellwether for other states wanting to routinize processes for robust demographic analyses of SGD people, enhance coordination of health services, guide policy and funding decisions, advance EFEBIs for their varied citizenries and monitor progress toward health equity for SGD people. New Mexico's health department (NMHealth) operates 53 public health offices (PHOs)— ideal settings for analyzing the uptake and sustainment of SOGI data collection. Staffed in large part by nurses, PHOs are a critical safety net for racially, ethnically, and geographically diverse communities in New Mexico, offering a wide range of health services, from immunizations, family planning, nutritional programming, substance use harm reduction, testing and treatment for sexually transmitted infections, cancer prevention and control, and other medical care across the lifespan. This multilevel, mixed-method R01 study will test the acceptability, appropriateness, and feasibility of implementation strategies in PHOs to enable SOGI data collection with different populations and in urban, rural, and frontier contexts. Guided by the Interactive Systems Framework, our interdisciplinary team will (1) assess gaps in implementation readiness to engage in accurate, reliable, and usable SOGI measurement in PHOs; and apply implementation mapping to systematically select and tailor implementation strategies to address barriers; (2) deploy and evaluate identified implementation strategies to enable SOGI data collection in PHOs in a sequential multiple assignment randomized trial (SMART); and (3) use the Discover, Design, Build, and Test framework to develop an online toolkit integrating manualized implementation strategy resources to disseminate SOGI data collection in service delivery settings. Our team of researchers, healthcare providers, and patient advocates are poised to foster use of implementation strategies for inclusive SOGI data collection, so the state and nation are prepared to identify, analyze, and advance EFEBIs to intervene in the alarming disparities negatively shaping SGD health and well-being. Through the innovative use of models and methods from dissemination and implementation science, our team's overall goal is to tackle a long-running, perplexing problem—the rampant deficiencies in state-sponsored data collection systems that abet the invisibility of SGD people in public health, medical, and human service records, thwart the development of EFEBIs, and buttress poor health outcomes.

NINR - National Institute of Nursing Research

This study evaluates multi-level interventions—ranging from state-level policy action to healthcare organizational strategy and frontline care delivery innovations—to effectively prevent nurse burnout and mitigate the severity of burnout among the roughly half of hospital-based nurses already burned-out. Study objectives will be accomplished by leveraging unique data from thousands of nurses in approximately 535 hospitals in multiple states (CA, FL, NJ, PA) across 4 time-points spanning 20 years. We will generate repeated samples of these hospitals at multiple time-points (already collected: 2006, 2016, 2024, to be collected 2026). Using a repeated cross-sectional design with changing organizational and policy influences overtime, we are uniquely positioned to evaluate potentially causal relationships of modifiable organizational factors and state-level policy interventions on nurse burnout. Each time-period of data includes repeated measures of nurse outcomes (e.g., burnout, job dissatisfaction, intent to leave employment), and hospital factors and models of care (e.g., staffing levels, work environment, Magnet). These cross-sections of data will be linked with contemporaneous American Hospital Association data for considering structural features of hospitals (e.g. teaching status). In combination, we will have 4 cross-sections of data from 535 hospitals (with fluctuating nurse populations), with changing organizational, policy, and other intervening influences (e.g. CA staffing policy relative to non-policy states, 2008 Great Recession, 2020 Covid-19 pandemic). Our quantitative analytic approach uses hierarchical models with time-varying covariates to capture the multilevel structure of the data, as well as difference-in-difference models with propensity score weighting for rigorous causal inferences of changes in organizational factors on changes in outcomes. Using data collected in 2026, we will empirically identify typologies of hospitals with respect to their proportions of nurses with high burnout and average tenure and conduct in-depth interviews with key nurse leaders (hospital nurse executives, nurse managers) in hospitals representative of each of the typologies to elucidate the facilitators and barriers to reducing hospital nurse burnout and turnover. This multi-modal study has novel potential for sustained impact since it will (1) evaluate the impact of modifiable organizational and policy changes on hospital nursing and models of care on nurse burnout; (2) leverage 20 years of repeated cross-sections of data to evaluate potentially causal mechanisms between modifiable hospital factors and external policy interventions on nurse burnout; (3) evaluate currently employed nurses and those who recently left employment to understand whether the reasons nurses say they would leave hospital employment are the same as the reasons they actually leave; (4) integrate quantitative findings with qualitative frontline hospital leadership perspectives to move from evidence to action. The cumulative evidence will inform targeted recommendations for policy and hospital interventions for reducing the unprecedented high rates of nurse burnout and low retention.

NINR - National Institute of Nursing Research

What Interventions to Reduce Hospital Nurse Burnout Are Most Effective? Nurse burnout is a threat to healthcare safety, and to nurse and patient outcomes. Burnout among nurses has been a long-standing concern only accelerated by the COVID-19 pandemic. Burnout is a syndrome caused by chronic workplace stress and characterized by feelings of emotional exhaustion, cynicism towards one’s work, and decreased professional efficacy. Pre-pandemic, about 30% of nurses were burned out. Today, nearly half of 4.7 million nurses are experiencing burnout. This unsustainable high level of burnout has dire consequences for nurses and patients alike. Nurse burnout is associated with higher odds of patient mortality, failure to rescue, and prolonged length of stay, as well as nurse job dissatisfaction and turnover. We propose to integrate two approaches to addressing burnout: investigation of organizational characteristics as determinants of burnout, notably conducted by the proposed research team in recent decades, and health system administrators’ current implementation of interventions to reduce nurse burnout. Our preliminary studies reveal that organizational and individual interventions are being implemented nationwide and that nurses prefer organizational ones. It is unknown how preferred and implemented interventions relate to hospitals’ performance on nurse burnout, individual nurse burnout, and reducing burnout over time. Crucially, whether these interventions’ effectiveness depends on the work environment is unknown. Integration of these two approaches will yield a representation of reality across a large, geographically diverse hospital sample to inform whether certain intervention combinations are most effective and in what organizational contexts. The proposed aims address the Notice of Special Interest NOT-NR-23-012, “Addressing Organizational Factors to Prevent or Mitigate Nurse Burnout,” which invites “research studies to develop and evaluate novel organizational interventions to prevent and mitigate nurse burnout,” by identifying the currently preferred and implemented interventions, their work environment contexts, and their relation to nurse burnout, dissatisfaction, and intent to leave and hospital performance on nurse burnout. We propose to conduct a cross-sectional and longitudinal observational study utilizing 2024 and 2026 hospital nurse survey data from 31,942 nurses in 1,278 hospitals (in 2024) in 10 U.S. states to determine how preferred and implemented interventions relate to hospitals’ performance on nurse burnout, individual nurse burnout, and reducing burnout over time. The potential impact of the proposed study would be high because it would provide actionable results to optimize burnout intervention choices and contexts to mitigate pervasive nurse burnout.

NINR - National Institute of Nursing Research

Chronic obstructive pulmonary disease (COPD) is a leading cause of death in the U.S. (3rd worldwide) and disproportionately affects individuals living in rural areas. Poor COPD outcomes are influenced by exposures common in rural settings, such as wood smoke, dust, and agricultural byproducts known to adversely affect respiratory health. There is a critical need for accessible COPD interventions that can be delivered in rural communities. Respiratory muscle strength training (RMST) is an empirically validated therapy that can improve ventilation and airway defenses and reduce dyspnea symptoms in patients with COPD. Few studies have evaluated the effects of RMST on respiratory function, respiratory quality of life (R-QOL), dyspnea, and dyspnea-related kinesiophobia in patients with COPD in rural areas. Our multicomponent, mHealth-delivered COPD intervention, Respiratory Muscle Strength Training and Fitness Program (RESP-FIT) is feasible and acceptable. RESP-FIT incorporates home-based RSMT using a portable training device, mHealth, and behavior theory. Integration of remote spirometry and ecological momentary assessment (EMA) allows measurement of lung function and symptoms (including dyspnea) in real-time in a remote setting. This integrated design (RMST + mHealth + EMA) addresses three key areas: 1) COPD-related physical deconditioning and associated symptoms; 2) health behaviors, including dyspnea-related kinesiophobia; and 3) accessibility (i.e., a portable respiratory intervention enhanced by mHealth/remote technology) for intervention delivery in rural areas. In Aim 1, we will conduct a RCT to evaluate efficacy of RESP-FIT on dyspnea, dyspnea-related kinesiophobia, and R-QOL in adults with COPD. Participants will be randomized to the RESP-FIT intervention or enhanced usual care (control) study arms. In Aim 2, we will identify barriers, facilitators, and contextual factors (e.g., environmental exposures, age, distance from healthcare provider, social support, access to care, income) that may moderate intervention engagement, adherence, and outcomes. RESP-FIT has high potential for scalability. Successful completion of these aims will lay the groundwork for subsequent implementation initiatives that support positive health outcomes and respiratory health for patients with COPD.

NINR - National Institute of Nursing Research

PROJECT SUMMARY More than 20 million children in the US lack sufficient access to essential healthcare. School-based health centers (SBHCs) have been broadly implemented to address this unmet need, particularly for low-income and minoritized children, by providing primary healthcare at school. Despite proven feasibility with over 3000 SBHCs now in operation in the US, the effectiveness of SBHCs to improve health outcomes has yet to be established. It is critical to determine the effectiveness of SBHCs to inform future investment and policy focused on SBHC expansion or modification, as well as best practices. Our multidisciplinary team propose asthma as an ideal pediatric disease to examine SBHC effectiveness. Asthma is the most common chronic disease in childhood, affecting more than 6 million children in the US. It has detrimental consequences, particularly for low-income, Black and Latinx children who experience more missed schooldays, poor school performance, parental lost workdays, and urgent visits than their higher income and white counterparts from asthma. This disproportionate morbidity borne by marginalized children is largely due to poor access to guideline-based asthma care and adverse social determinants of health (SDOH). Many low-income, Black and Latinx children with asthma now receive care in SBHCs and have the potential to receive guideline-based asthma care at school. While prior cross-sectional and small cohort studies suggest that SBHCs improve pediatric asthma outcomes, there has yet to be a large-scale examination of the effectiveness of SBHCs to improve asthma care and outcomes for marginalized children. With traditional community health centers (CHCs) as a comparator condition, we propose to conduct an unprecedented, multi-state and longitudinal study examining the effectiveness of SBHCs to advance health equity in asthma care. We will examine electronic health record (EHR) data from 2015-2025 in the OCHIN, inc. data network, the largest data network of SBHCs and CHCs in the US serving >6 million low-income and vulnerable patients nationwide, including 395 SBHCs and 1280 CHCs in 16 states. Our data network includes longitudinal measures of asthma care and outcomes with novel linkages to geographically coded SDOH data on community-level economic, environmental, and structural factors. In Aim 1 we will determine whether SBHCs are more (or less) effective than CHCs at providing high quality asthma care and reducing asthma exacerbations among low-income children; and evaluate the potential synergy of these two settings for optimal asthma care. In Aim 2 we will examine whether SBHCs are more (or less) effective than CHCs at improving asthma outcomes given specific adverse SDOH. In Aim 3 we will conduct qualitative work with multi-level SBHC partners, including children/caregivers, SBHC staff and policymakers to explain quantitative findings in Aims 1 and 2. Leveraging this unique network of SBHCs, this study provides a landmark opportunity to examine the effectiveness of SBHCs to improve pediatric asthma care for marginalized children and will inform national SBHC policy.

NINR - National Institute of Nursing Research

PROJECT SUMMARY The carework sector is both a fundamental part of our economy and the backbone of our health and social safety net. Whether working in healthcare, education, or social services, 20% of U.S. workers provide essential care for the ill, the elderly, individuals with disabilities, and children. The U.S. care workforce is predominately women, with women from minoritized racial and ethnic groups disproportionately concentrated in the lowest-paying positions and sectors. Despite our dependence on this workforce for our nation’s well-being, we know comparatively little about how care work impacts the health of those who perform it. Research on this question is critical not only for designing interventions to support the health and retention of these workers, but also for elucidating broader mechanisms through which work functions as a social determinant of health (SDOH) for women and minoritized populations. We propose a mixed-methods investigation, combining quantitative analyses of the Panel Study of Income Dynamics (PSID) and National Health Interview Survey (NHIS) with qualitative interviews of care workers. Our approach will test whether care work is associated with a care work health penalty, conceptualize and measure how pathways such as devaluation and workplace conditions drive this penalty, and consider whether these pathways disproportionately impact minoritized groups. To help guide our research and dissemination to reach a wide audience, we will establish a community-based advisory board (CAB) and a policy advisory board (PAB). In Aim 1, we will use the NHIS and PSID to describe the health status of care workers and test whether there is a health penalty for being employed in care work relative to comparable non-care occupations over the life course. This analysis will assess a range of physical and mental health outcomes, including self-rated health and indicators of stress and burnout. Aim 2 will examine the pathways through which care work may lead to negative health outcomes, focusing on our four hypothesized mechanisms described above: intersectional devaluation, risk of injury and illness, a racialized and gendered “ethic of care,” and resource-constrained work environments. Qualitative interviews with 125 low-wage workers and higher- wage health care workers will be used to refine our conceptual model, identifying how these mechanisms manifest in the lived experiences of workers. Insights from these interviews will inform the refinement of quantitative measures in the NHIS and PSID datasets. Quantitative analyses will then test the relative contribution of each mechanism to the health penalty and investigate interactions with race-ethnicity. Finally, in Aim 3, we will measure the relationship between employment in low-wage carework occupations and health over the life course. We will also test interactions between low-wage carework, race-ethnicity, and mental and physical health outcomes. Qualitative interviews will explore how care workers experience these intersectional vulnerabilities in their workplaces, with particular attention to the compounded impacts of racism, sexism, and economic precarity.

NINR - National Institute of Nursing Research

Project Summary Emergency Department (ED) decision-making is inherently complex, influenced by uncertainty, time pressure, and high-stakes consequences. ED crowding exacerbates these challenges by increasing distractions and cognitive load, often leading to suboptimal decisions and adverse outcomes. Triage nurses are typically the first point of contact for medical needs assessment. For example, their role in prioritizing patients is one of the most consequential decisions, yet current triage accuracy is only about 60% compared to expert benchmarks. This performance gap stems from the complexity of ED scenarios, which often exceed human cognitive limits. Artificial Intelligence (AI), including Large Language Models (LLMs), offer the potential to support triage nurses and all members of the ED team by improving decision-making on many ED tasks, especially during crowding. Advantages of such tools include rapid processing of large volumes of data, operating without fatigue, and being deployable on demand – all while rivaling human decision-making on a wide variety of tasks. With recent advances in AI, there is a timely opportunity to investigate its utility in supporting ED decision-making. While AI/LLMs could be vital support for ED decision-making, there is no gold standard (expert annotated labeled data) by which to evaluate the quality or accuracy ED decisions, and no standardized tasks or metrics. We propose to develop a set of gold-standard ED decisions derived by expert annotation on patient cases for a set of decision-making tasks, and establish a set of metrics for assessing decision-making performance. In addition, we will fine-tune and validate fine-tuned LLMs, with the best-performing model termed “AI-Triage+”. We will then test the performance of AI-Triage+ on ED decision-making-tasks vs. status quo (human decisions) and existing pre-trained (generalist) AI models. AIM 1: Compare the performance of AI models to a gold standard on five ED decision-making tasks: ESI (Emergency Severity Index) level recommendation, Patient-facing diagnostic question generation, Acceptable safe wait time values for each patient, Recommend diagnostic tests and ED procedures for the patient, and Recommend ED resource level based on the patient's needs (aka patient disposition). We will assess overall model performance and performance on specific subsets of cases, e.g., by diagnoses, age group, ED workload (overcrowding score). AIM 2: Estimate the impact of AI models' decisions on clinical outcomes. Using existing risk equations, we will estimate how different ED decisions by AI models will impact ICU admissions or death in ED, hospital admissions, and length of hospital stay. We will also explore the potential of AI-Triage+ to improve ED efficiency at a system level. This work directly supports the NINR focus on systems and models of care, offering foundational tools and insights to guide AI integration into ED practice.

NINR - National Institute of Nursing Research

Project Summary In the United States, women are twice as likely to report depression and anxiety than men, and face stressors related to interlocking systems of oppression such as racism, sexism, and xenophobia. Interlocking systems of oppression can exacerbate inequalities in mental health by manifesting an unequal distribution of women’s resources and result in symptoms of depression and anxiety like exhaustion, hopelessness, and loss of interest. Despite the growing recognition of the mental health impacts of systems of oppression, several studies have analyzed this relationship at the individual-level, and not the structural or policy-level. Political intersectionality focuses on how policies and laws enact unfair practices against intersectional groups and subdue their rights. Policies related to structural gendered racism may shape the inequitable allocation of women’s social, economic, and political resources across racial, ethnic, and nativity groups, which may put racially and ethnically minoritized women at risk for depression and anxiety. The objective of this R01 grant proposal is to use novel theoretical frameworks and methodologies to examine how structural gendered racism-related policies impact depression and anxiety through intersectional social-structural factors among US- and foreign-born Black, Latina, and white women. This proposal will also aim to identify the best strategies to enhance adoption of supportive policies, and de-implement harmful policies that perpetuate systemic inequities. Informed by Intersectionality, Constrained Choice theory, and a policy implementation science, we propose a sequential explanatory mixed methods study with US- and foreign-born Black, Latina, and white women, and policy stakeholders. Aim 1 examines the direct and indirect relationships between structural gendered racism-related policies, intersectional social-structural factors, depression and anxiety among US- and foreign-born Black, Latina, and white women. Population-based data of adult women’s depression and anxiety from the National Health Interview Survey will be linked to state structural gendered racism-related policies, and an existing structural sexism and racism index of state social, economic, and political data from publicly available administrative sources. Aim 2 includes conducting focus groups with US- and foreign-born Black, Latina, and white women to explicate quantitative findings and identifying unanticipated themes. Aim 3 includes integrating findings from Aims 1 and 2 to systematically develop policy implementation strategies using a three-round Delphi method approach with US- and foreign-born Black, Latina, and white women, and policy stakeholders. This proposal responds to RFA-NR-25-004 by analyzing “relevant policies that reinforce intersectional social-structural factors and identify social-structural interventions to improve mental health.”