While unmet social needs are major drivers of health outcomes, most health systems are not fully integrated with the social care sector to address them. In this case study, we describe the development and implementation of a model utilizing student volunteer community resource navigators to help patients connect with community-based organizations (CBOs). We then detail initial implementation outcomes and practical considerations for future work.We used the Ten Essential Public Health Services Framework to guide program planning of a student “Help Desk” model for a community health center. Planning included a literature review, observation of exemplar programs, development of a CBO directory, and evaluation of the center’s patient population, clinical workflows, and data infrastructure. We piloted the model for two months. After pilot completion, we reviewed patient data to understand the feasibility of the student “Help Desk” model. We utilized planning and pilot execution materials, as well as pilot data, to develop and discuss practical considerations.Design and implementation complemented ongoing social needs screening and referral to CBOs by center case managers. Patients were asked if they would accept telephone follow-up by volunteers two and four weeks after the clinic visit. Of 61 patients screened, 29 patients were referred for follow-up. Ninety percent were reached at least once during the follow-up period, and 48% of patients referred reported connecting to at least one CBO. Only 27% of patients required escalation back to case managers, and no emergency escalation was needed for any patients. Students, faculty advisors, and community health center frontline staff and leadership supported the scale up and continuation of the “Help Desk” model at the community health center.Successful implementation required multi-sectoral collaboration, well-defined scope of practice, and data interoperability. Student volunteers are untapped resources to support integrated health and social care. Addressing the social determinants of health (SDOH) is a critical step in reducing health disparities. The World Health Organization defines the social determinants of health as “the conditions in which people are born, grow, live, work and age” . Specifi5678In addition to limitations on financing social care, the systems of health and social care remain siloed. Research of care models integrating medical and social care demonstrate improvements in patients’ access to social services, patient satisfaction, health behavior, and healthcare utilization 711121314.11121316171820212223257Health systems often do not have the capacity to both screen for and respond to unmet social needs through follow up and ongoing case management . One pot2830313233303233Volunteer models are typically adopted by larger health systems with resources to manage volunteer recruitment, training and oversight. However, safety-net community health centers, that serve uninsured and underserved individuals regardless of ability to pay, often lack resourced volunteer service programs yet are at the forefront of serving patients with unmet social needs and face greater resource constraints . In our Durham is a diverse mid-sized American city and county center. A nearly 20% increase in population over the past decade has contributed to financial development and investment . Howeverrd and 4th year respectively, one 4th-year undergraduate psychology student, and one 2nd-year graduate student in public policy. The academic institution has a university-wide initiative to support interdisciplinary research teams of undergraduate students, graduate students, faculty and community partners tackling complex societal challenges [The city is also home to Duke, a private university with a nationally prominent academic medical center. The initiators of this pilot study were four students at this academic institution, including two pre-medical undergraduate students in their 3allenges . As partThe university project team formed an academic-community partnership with Lincoln Community Health Center, Inc. a non-profit organization operating since 1971 in Durham. As a federally qualified health center, Lincoln receives designated funding from the United States Department of Health and Human Services to serve as a safety-net primary care center for medically vulnerable and underserved populations. Lincoln operates at nine locations in Durham County and in 2019 saw 36,361 unique patients . In 2019, 71% of Lincoln patients had incomes at or below 100% of the federal poverty level, approximately 57% of adults were uninsured, 89% were racial or ethnic minorities, and 51% said they were best served in a language other than English (mostly Spanish).Table 1).Student volunteer models for social needs screening, referral, and follow-up have been developed and implemented across the country, but evaluation is sparse and translation to federally qualified health centers—where patient need is greatest—is lacking. To inform the development of our model, we examined the literature for best practices on volunteer-based models, shadowed existing program sites, and conducted key informant telephone interviews with leaders of current programs. We closely studied the original “Help Desk” program that trained college volunteers to screen patients for unmet social needs, refer patients to community resources, and follow-up via phone to ensure that connections were made . This “H31Table 2) to systematically plan and implement the Help Desk at Lincoln [Before committing to a full launch of our Help Desk program, we first focused on a shorter pilot to assess the feasibility of integrating student volunteers into our community health center’s existing process for addressing patients’ unmet social needs. Our measures of feasibility included the percentage of patients who agreed to follow-up calls from a student volunteer after their visit with a case manager, the percentage of patients reached on the phone by volunteers, and percentage of patient follow-up that volunteers could independently manage without further escalation to case managers. We adapted the “Ten Essential Public Health Services” framework .Our thorough evaluation of existing practice revealed a significant opportunity for improvement: to support patients after their clinic appointment by encouraging follow-through with the CBO referral. The community health center did not have the capacity to consistently follow-up with patients and provide additional navigation support after initial screening and referral. This provided an opportunity for involvement of student volunteers. Our local model was developed with the intent to minimally disrupt existing practice while providing additional support to patients who were screened and referred . The directory included service descriptions, phone numbers, addresses, eligibility criteria, and languages served. The directory was designed to be used in real-time and updated continuously to incorporate feedback from patients, such as capacity of the organizations to serve more people.To support development of the student volunteer community resource navigator role, our team designed and implemented a comprehensive volunteer training protocol. Training included didactic lessons on social determinants of health, sessions on motivational interviewing, and a patient engagement curriculum including role play scenarios; orientation to the data collection platform; training on data quality adherence; volunteer onboarding at the community health center; shadowing and peer observation; and evaluation by academic faculty. In order to standardize volunteer practices, we created telephone follow-up scripts for volunteers incorporating principles of motivational interviewing . All volThe students and behavioral health team co-designed Help Desk workflows and program materials. Case managers completed PRAPARE screening and referrals on paper, and student volunteers collected these forms for weekly data input using the secure REDCap electronic data capture tool hosted at Duke University 48. Each During the six-week follow-up period of the pilot, volunteers participated in two shifts each week between one and two hours. Students called patients remotely from a private “Help Desk” office in an academic building. During their first shift in the pilot, students were supervised by their faculty advisor. In subsequent shifts, students conducted follow-up calls on their own. Students had weekly check-ins with their assigned case manager to clarify referrals and discuss the care plan for the patient. The student volunteers had weekly operational meetings and weekly case review meetings to review each patient served and to ensure data quality. Patient feedback data was used to curate the existing directory of community-based resources and inform practice changes (e.g. refining the script) through discussions at case reviews.Figure 2) [A logic model further directed implementation and evaluation of our volunteer program (igure 2) . In thisStudent program initiators received academic credit for participating in the Help Desk program for two semesters. The faculty advisor evaluated the student team through graded assignments scaffolded throughout the year: team charter; innovation analysis of similar Help Desk programs; action plan; program toolkit of protocols, forms, and templates; communication plan; and final report. Each semester, students also presented their progress publicly at university student research showcases. Students provided feedback on their experience to their faculty advisor and program funder through end-of-year surveys.Figure 3). Patients not referred (N = 32) constituted those without at least one community resource referral, those who refused to be contacted after the clinic visit, those with needs that student volunteers were not trained to manage , those who did not speak English or Spanish, or had missing contact information. Help Desk volunteers reached 26 patients (89%) by phone at least once within six weeks after their initial screening. Most (65%) of the patients reached were called on the first call attempt.We conducted a two-month pilot of our community health center Help Desk model. This included a two-week screening and referral period, followed by six weeks of follow-up calls in the pilot period. Of the 61 patients screened for unmet social needs by the behavioral health case managers, 29 patients were referred to four Help Desk student volunteers for follow-up , food insecurity, and financial assistance. Eighty-three percent of patients had referrals to community and social services for at least one of these top three referral areas. Fourteen patients (48%) reported accessing at least one of the recommended community resources. Barriers for patients unable to connect to the resources recommended included lack of time, lost contact information, need to clarify service application process, compromised physical health, major life events that took precedence, and failed contact with community-based organizations.Out of the 26 patients reached by volunteers, only seven patient cases were escalated for additional input or action from the behavioral health case manager. In the majority of these seven cases, the case manager was included primarily to encourage or reinforce the importance of the community resource referral. None of the patients presented with an emergency during follow-up that student community resource navigators needed to immediately escalate.Social needs and related health behaviors are major drivers of health outcomes . FederalWe found the following principles to be integral to successful implementation and program feasibility: 1) multi-sectoral collaboration; 2) well-defined scope of practice; 3) data systems to produce timely and actionable reports; and, 4) mechanisms for sustainability including training and onboarding, supervision, case conferences, and quality improvement.Multi-sectoral collaboration was integral to building this student volunteer Help Desk for the community health center. Research and design was led by a team of Duke University students and their faculty mentors through a university-sponsored program to encourage interdisciplinary research and program implementation. While other student models were completely designed by research and clinical staff 3234, the32The volunteer’s scope of practice was context specific and developed through multiple iterations of stakeholder feedback. Translation to other clinics will require local evaluation of workflow in order to achieve the similar success. Our project team designed a community resource navigator role that freed up behavioral health case managers to pursue other responsibilities and maximize volunteer impact. Compared to other Help Desk models in which volunteers conduct SDOH screening and referrals 333440, o333415One of the largest challenges in implementing this model was designing secure and actionable data systems. Risk compliance made it impossible for volunteers to work within the community health center’s electronic health record system resulting in double data entry of the data obtained using PRAPARE screenings. Generating reports to track progress and identify areas for improvement required access to the electronic health record to compare social needs information with health data not captured in PRAPARE . In the future, this could be improved by enabling electronic data capture of the initial social needs screen that automatically populates both the health record and the student volunteer’s data privacy compliant database.Building sustainability beyond the pilot primarily centered on the student workforce. Recruitment, onboarding and training had to commence during the pilot period in order for the volunteer program to be resourced appropriately for the summer months when students often leave the area. Strategies to address turnover beyond the academic year transitions included creating clear expectations for volunteer commitment and having at least one clinical champion and one volunteer coordinator to ensure continuous Help Desk operations through holidays and academic calendar breaks. The investment of university resources including faculty mentors, student project leads, space and resources for volunteers and their training were essential. A weekly seminar course to teach on topics of social determinants, health service delivery, evaluation, quality improvement, and health policy complemented the efforts and contributed to the students’ learning and engagement.Our pilot data also support the feasibility of integrating student volunteers as community resource navigators, according our feasibility measures of rate of patient refusal for follow-up, rates of patient contact via phone, and rate of escalation of patients to case managers. Only 21% of patients screened refused to be contacted by student volunteers after the clinic visit, and 89% of referred patients responded to student call attempts and voicemails on follow-up. Such data suggests that patients are open to follow-up calls from volunteers and can be consistently reached via phone. Further, the majority of patient interactions could be resolved by the student volunteers directly. Student volunteers reconnected 27% of patients with their case managers for additional support, and case managers reported this referral stream as acceptable and not burdensome. Of the patients reached by student volunteers, no emergency escalation was needed. This indicates that patients’ needs fell within the scope of practice of the navigators and limited the need for additional clinical resources due to escalation.After the pilot program, clinic leadership, case managers, the student team, and faculty advisors agreed the student Help Desk program was feasible and committed to sustain the program at the community health center. Case managers felt that the Help Desk program did not significantly burden their workload and allowed for follow-up that the clinic could not otherwise provide. Clinic leadership was motivated to collect more follow-up patient data to assess the effectiveness and cost-effectiveness of SDOH screening and referrals in order to better inform decisions related to long-term investments in the program and potential expansion to satellite clinics. Students and faculty advisors felt the experience would be a worthwhile experience for future students, and received funding from the university to continue to scale the program operations and conduct further evaluations.Between the pilot in spring 2019 and fall 2020, 19 additional student volunteers have been recruited and trained as community resource navigators. These students included medical students, nursing students, and undergraduate students from social science, public policy, pre-dental, and pre-health backgrounds. Since the pilot program, over 1900 patients have been screened for social needs and over 500 patients have been reached for follow-up by Help Desk volunteers. While our pilot study focused on feasibility, our team’s future analyses will focus on workforce development, implementation, and effectiveness.The Help Desk student volunteer model for community health centers is a valuable addition to the healthcare system and to society because it provides young adults interested in health careers with firsthand exposure to social determinants of health, collaborative evaluation, and problem solving. By design, our model included interdisciplinary and interprofessional engagement of students in different levels of learning (undergraduate and graduate) and fields of study related to healthcare. Our training protocol incorporated experiential, project-based learning and community engagement to expose students to the connection between unmet social needs and health. Our Help Desk model contributes to the growing body of research on educating students in social determinants, population health, and implementation science 5253.52Due to limited staff and resources, federally qualified health centers staff often feel challenged to respond to positive social needs screens, track outcomes of past referrals, and keep resource lists up to date . Previou1927In our case study, we describe in detail a structured process in which university students and their advisors were able to partner with a community health center to launch volunteer resource navigator programs. Specifically, we highlight key steps in our planning and implementation steps, such as studying similar models through literature review and observation, developing a resource directory, and evaluating the center’s patient population, clinical workflows, and data infrastructure. We also highlight four principles key to program feasibility. Our pilot data further reinforces the feasibility and sustainability of this model. We recommend that community health centers in areas with institutions of higher education consider these academic-community collaborations to increase capacity to serve patients’ needs and provide patient-centered care beyond individual clinic appointments. Trained student volunteers are an untapped resource that provide a low-cost and high-yield solution and can improve integrated care.


Environmental health literacy (EHL) is an emerging, multidisciplinary field that promotes understanding of how environmental exposures can affect human health. After discussing the regional relevance of environmental health knowledge and skills, this article describes three ongoing Appalachian projects that are focused on measuring and building EHL. America’s Health Rankings places Central Appalachia in particular near the bottom of all U.S. states in health outcomes, with Tennessee 42nd, West Virginia 44th, and Kentucky 45th among the 50 states.County Health Rankings places six of Virginia’s seven Central Appalachian counties in the state’s bottom quartile for health outcomes.5Well-documented health disparities in Appalachia include high incidence of diabetes, obesity, high blood pressure, and cancer.Many chronic health conditions disproportionately experienced across the region have been linked to environmental contaminants.13Deteriorating infrastructure,Environmental health literacy (EHL) is an emerging field that brings together content and methods from health, social, and environmental sciences to promote understanding of how environmental exposures can affect human health.Land-grant institutions are well positioned to help Appalachian organizations access and share information to improve regional EHL. The University of Kentucky (UK), for example, houses many initiatives that address regional environmental, health, and socioeconomic challenges. Spearheaded by faculty and staff from the Colleges of Public Health and Engineering, the Department of Dietetics and Human Nutrition, and the Kentucky Water Resources Research Institute, UK teams are conducting three NIH-funded, stakeholder-engaged studies that strive to measure and build regional EHL.Assessing EHL in Appalachia is a pilot study supported by the National Institute of Environmental Health Sciences (NIEHS) through the UK Center for Appalachian Research in the Environmental Sciences (UK-CARES) that addresses the intersection of EHL and water quality. Researchers are leveraging local knowledge from water utility operators and watershed volunteers to identify the knowledge and skills people need to protect their health in the event of water contamination. This study will produce one of the first validated EHL measurement instruments.Protect Your Body from Pollution with a Healthy Lifestyle , a project of the NIEHS-funded UK Superfund Research Program, seeks to increase EHL by educating people about food strategies that may reduce exposures and decrease harmful exposure-related health effects.Integrating Information Resources to Increase EHL in Appalachian Eastern Kentucky, funded by the National Library of Medicine, finds investigators working with Eastern Kentucky residents—including public health and healthcare stakeholders—to assess and improve existing environmental health-related risk maps and other information resources. The study answers calls to bridge knowledge and skills gaps by bringing together scientists, regulatory agencies, and community members to develop and disseminate accessible, understandable, and useful information.At its roots, EHL is context-specific. Communities face diverse health risks from assorted contaminants traveling varied pathways to expose different populations, and these risks must be addressed within unique social, economic, and political contexts. Community residents understand these contexts far better than anyone else. By taking a stakeholder-engaged approach to EHL, the projects described in this article are harnessing local knowledge to help ensure that people in the Appalachian region have the evidence-based, culturally competent guidance that they need to make decisions about both their health and their local environment.What is already known about this topic? Appalachia’s history of health disparities, along with potential linkages between some diseases and environmental contaminants, underscores the need for residents to have information, knowledge, and skills to protect themselves from potential environmental health threats. Local health departments and other community organizations play key roles in sharing information about these topics.What is added by this report? This report describes three ongoing projects designed to build environmental health literacy and improve available environmental health information resources in the region.What are the implications for public health practice, policy, and research?Stakeholder-engaged approaches can increase access to better information and help build environmental health literacy in Appalachia, ultimately leading to evidence-informed individual and community decisions.


The federal government established a collective of agencies tasked with providing support and services to older adults and their caregivers known as the Aging Network. In order to effectively provide these services, the Aging Network must identify and disseminate current best practices. To this end, the Aging Network hosts three annual conferences: the National Association of Area Agencies on Aging (n4a), the Alliance of Information and Referral Systems (AIRS), and the National Association of States United for Aging and Disabilities (NASUAD). This content analysis of key themes emerging from Aging Network conference abstracts  from 2009 to 2019 expanded upon a similar study analyzing the preceding decade of conference materials . Reflexivity, analyst triangulation, and confirmability and dependability audits were used to enhance trustworthiness. The most common themes included planning and program development (n = 260), general policy (n = 166), and long-term services and supports system reform (n = 162). Although some themes, such as consumer-directed support (n = 122) and advocacy (n = 111) were consistent with the original article , others, such as managed care (n = 124) and financial exploitation (n = 50), demonstrated a societal shift in older adult supports and services. These results offer an additional effort towards disseminating current best practices and emerging issues to advance translation between research and practice. Researchers can use these results to better align their research agendas with the needs of the Aging Network for evidence-based interventions.


Elder abuse is a growing problem with significant public health implications. Because elder abuse shares root causes with other types of violence , awareness of elder abuse as a violence prevention priority is rising among public health professionals. Major limitations, however, affect delivery of effective population-level primary prevention for elder abuse, necessitating increased community partnerships. In Washington State, the Department of Health’s Injury and Violence Prevention Section and the Department of Social and Health Services Adult Protective Services Division are leveraging existing strategies to increase identification and reporting of potential elder abuse from falls and injury prevention partners . We describe: (1) challenges and opportunities in creating unique cross-program collaborations, (2) the combined education and outreach efforts of this partnership, and (3) strategies for sustained collaboration. Additionally, we share results of a scoping literature review on evidence-based violence prevention strategies applicable to elder abuse between 2015 – 2019. In the Pubmed and Academic Search Complete databases, the following terms were searched: elder abuse prevention, primary prevention, shared risk and protective factors. Only six articles were identified that addressed primary prevention efforts. Researchers note that primary prevention of elder abuse is poorly understood and challenges exist in applying methods from other types of violence. Education for key community members on identification of abuse is a promising intervention targeting shared risk and protective factors for public health to pursue. Cross-sector community partnerships and rigorous evaluation of primary prevention approaches are needed.


Crinum jagus was the most popular plant used against cough and approximately 32% of the plants have been reported as cough remedies for the first time. However, some of the documented plants have been reported for the treatment of cough and related respiratory diseases in several countries. In terms of the life-form, trees constituted the highest proportion of the medicinal plants (37%), while leaves (36%) were the predominant plant part prescribed for cough. Decoction was the main method of preparing the plants, which were all administered orally. Approximately 63% of the plants were exclusively sourced from the wild. The current study revealed the richness and widespread use of plant species for managing cough associated with respiratory diseases in the study area. The generated inventory contributes to the expanding database of valuable plant resources with medicinal potential in Nigeria and Africa.In many developing countries, community members depend on their local flora for treating diverse ailments including those affecting the respiratory system. This is often attributed to the high cost and limited access to health care facilities. This present study focused on the documentation of plant species used against cough associated with the respiratory diseases in Ede South Local Government Area of Osun State. The survey was conducted using semi-structured interviews among 100 participants. Information obtained was analyzed using different ethno-botanical indices including relative frequency of citation (RFC) and fidelity level (FL). A total of 87 plant species from 39 families, which was mostly represented by Fabaceae, were reported in the study area.  Respiratory diseases entail conditions such as chronic obstructive pulmonary disease (COPD), asthma, occupational lung diseases, and pulmonary hypertension . GloballAs a common symptom associated with respiratory diseases, cough may be categorized as either acute or chronic in nature . Acute cDespite the advances in pharmaceuticals and generally drug development, the importance of natural resources especially plants for healthcare and general well-being cannot be overemphasized ,17,18,192 on the latitude 7°42′ N and longitude 4°27′ E. Ede South Local Government Area comprises of 10 wards namely; Babanla Agate (Obada side), Kuye (Orita Oloki), Jagunjagun , Alajue 1 (Agip to sawmill and Cottage junction axis), Alajue 11 (village), Olodan (village), Baba Sanya (CAN Tower), Oloki Akoda , Sekona (town), Loogun .This survey was conducted at Ede South Local Government Area of Osun State, which is located in the south-western region of Nigeria . The heaThe population of the study area is estimated at 76,035 comprising of 39,385 males and 36,654 females . This inSemi-structured questionnaires were used to obtain the ethnobotanical information from the participants from April to August, 2017. The questionnaire was designed to capture the following information of plants used for the treatment of cough associated with respiratory diseases; local name, used plant part(s) and preparation method. Bio-data of the participants including their age, gender, residence, occupation, and educational background were also recorded. The participants were purposively selected comprising herb-sellers, traditional medical practitioners , farmers, and hunters in the area. They were informed of the concept of the study in order to seek their consent and willingness to participate in the survey. The participants were individually questioned on their knowledge of using plant species to treat cough associated with respiratory diseases. Ten native field assistants were engaged to administer and interpret the questions to the participants in their local language (Yoruba) in order to facilitate efficient communication.Sixty-five men and 35 women (to make-up the 100 participants) were interviewed on their knowledge about cough and its management in the study area. The majority of the participants were males (65%) and mostly herbalists (35%) in terms of their occupation .The plant species were initially identified using their local ‘Yoruba’ names and later matched with their respective scientific classifications through consultation of relevant literature , while tThe information  obtained through the ethnobotanical interviews were analyzed. In order to establish the importance of the documented plants used in treating cough associated with respiratory diseases, we analysed the data using the following ethnobotanical indices.Based on the methods described by Tardío and Pardo-de-Santayana , we evalIn an attempt to determine the preference of a particular plant species for the treatment of cough in the study area, the fidelity level (FL) was calculated as described by Friedman et al. . High FLThe study area is within the jurisdiction to the research study zones of Forestry Research Institute of Nigeria , a natioIn the current study, 87 locally used medicinal plant species from 39 families were recorded for the treatment and management of cough associated with respiratory diseases in the study area . The relThe family Fabaceae was the most represented for the 87 plant species documented as remedy against cough associated with respiratory diseases . The numCrinum jagus was the most popular plant used for cough among the participants. Member of the genus Crinum have been extensively utilised among diverse diseases in folk medicine globally and an increasing interest from pharmaceutical sector based on the therapeutic potential [Crinum jagus has long been regarded as a potent remedy for relieving asthma and related cough among the Yoruba of south-western part of Nigeria [Crinum are known to often be used for diverse ailments including respiratory diseases in Democratic Republic of the Congo [Crinum, are known to significantly contribute to their diverse medicinal attributes [Despite the relative high number of plants utilised for cough purpose, their ethnobotanical indices including FC (1–12), RFC (0.01–0.12) and FL (1–40%) were generally low . Furtherotential . Locally Nigeria ,31. Membhe Congo ,25, Ethihe Congo , Nigeriahe Congo , and Camhe Congo . The alktributes .Crinum jagus, Anacardium occidentale and Khaya grandifoliola  as well as seven plants  were the 10 most common plants used as cough remedy in the study area  while climbers were the lowest life-form for the plant species used for treating cough associated with respiratory problems . The domAs reported by the participants, diverse plant parts such as leaves, stem-bark, seeds, fruits, nuts, bulbs, and latex were utilised for managing cough in the study area . HoweverEven though the participants identified eight methods used for preparing the medicinal plants for managing cough in the study, the majority (approximately 40%) were prepared as decoction . In termAnanas comosus, Garcinia kola and Citrus aurantifolia) identified were used singly, few species were in multi-herbal combinations, while in some rare cases preparations were in herbal syrup  portion of the documented plant species for management of cough indicates the rich indigenous knowledge on plant resources in the study area. The study also revealed the high dependence (63%) on the wild populations for plant materials by the local community. Given the unsustainable nature of this practice, the incorporation of cultivation and other sustainable approaches  to mitigate decline and eventually loss of these plants is strongly recommended. Taken together, the current findings on the medicinal uses of plant species for cough provides baseline information for future biological efficacy testing and possible isolation of biological active compounds for managing/treating cough and associated respiratory conditions as well as expectorant.


Youth with autism spectrum disorder (ASD) represent a growing population with significant service needs. Prominent among these needs are high rates of co-occurring psychiatric conditions that contribute to increased functional impairments and often necessitate mental health services. Executive functioning deficits are associated with ASD as well as common co-occurring conditions  and an evidence-based intervention has been developed and tested to address executive functioning within the school context. There is an urgent need to implement indicated evidence-based interventions for youth with ASD receiving care in community mental health settings. Interventions that optimally “fit” the mental health services context as well as the complex and co-occurring mental health needs of these youth have the potential to improve key clinical outcomes for this high priority population.); and (3) conduct a feasibility pilot test of EFFECT for ASD in community mental health settings.This mixed-methods developmental study will apply the Exploration, Preparation, Implementation, Sustainment implementation framework and a community-academic partnership approach to systematically adapt and test an evidence-based executive functioning intervention for youth with ASD for delivery in community mental health settings. Specific aims are to (1) conduct a need and context assessment to inform the systematic adaptation an executive functioning evidence-based intervention; (2) systematically adapt the clinical intervention and develop a corresponding implementation plan, together entitled “Executive Functioning for Enhancing Community-based Treatment for ASD,” (EFFECT for ASDTailoring evidence-based interventions for delivery in community-based mental health services for youth with ASD has the potential to increase quality of care and improve child outcomes. Results from the current study will serve as the foundation for large-scale hybrid implementation and effectiveness trials and a generalizable approach for different service systems of care and clinical populations.NCT04295512.Clinicaltrials.gov,  Autism spectrum disorder (ASD) is characterized by impairments in socialization, communication, and restricted interests and repetitive behaviors . CurrentThe public mental health service system plays a key role in serving school-age youth with ASD , 12. MenDespite significant efforts to develop and test EBIs targeting core ASD symptoms as well symptoms associated with co-occurring psychiatric conditions, community implementation deficits persist –18. ManyUntil recently, most of the ASD intervention research was primarily aimed at examining the efficacy of interventions conducted in research settings or the effectiveness of delivery in non-mental health settings Identified as a key National Institute of Mental Health Research Domain Criteria subconstruct , executiUOT [UOT targets impairments in flexibility, goal setting and planning, and problem solving [UOT is effective in improving flexibility, organization, and problem solving for youth with ASD as well as youth with attention-deficit/hyperactivity disorder when delivered in school settings [UOT as an EBI with good quality evidence [UOT in community settings [UOT revealed no important moderators of effect in a very diverse sample  [The role of executive functioning in the etiology of mental health conditions has spurred increased focus on this key construct in intervention development efforts –57. A coUOT ), was de solving , 48, 59.settings , 60, supevidence . Teachersettings , 62, 63.ome, IQ) .UOT trials suggest that EBIs addressing mechanisms such as executive functioning have the potential to effectively address symptoms related to ASD as well as the range of co-occurring mental health symptoms and conditions. Additionally, findings demonstrate sustained improvements in problem solving a year after completion of UOT, irrespective of youth race or ethnicity and income [UOT in mental health service settings. Through its high rates of feasibility and acceptability, UOT could help meet mental health provider training needs related to effective, targeted interventions for ASD [UOT was designed and tested in school settings to be delivered by school staff, the intervention target and associated training model is potentially transferrable to mental health settings. UOT was designed as lesson plans specifically to be implemented in school settings and delivered in group settings by school staff. Thus, adaptation or augmentation to maximize its fit with client clinical and provider training needs and thus implementation within mental health services is needed. However, there have been no studies testing the effectiveness and utility of an executive functioning EBI in mental health settings for youth with ASD and co-occurring mental health conditions, especially one specifically developed for this service setting and high priority population.Results from d income . Togethe for ASD . AlthougUOT to improve key clinical and implementation outcomes for youth with ASD when systematically adapted for delivery in public mental health services. The Exploration, Preparation, Implementation, Sustainment [UOT and develop a corresponding implementation plan to maximize its adoption and effectiveness in community mental health service settings. Specifically developed for public service sectors, EPIS specifies the implementation process, divided into four phases , and implementation factors  associated with two contextual levels (inner and outer contexts). The outer context details external factors such as service environment and client population characteristics whereas the inner context refers to intra-organizational factors organizational and provider characteristics. Innovation factors detail those context-specific elements key to fit between an EBI and the context in which it is implemented. Bridging factors refers to those that span and link the inner and outer contexts. For example, system level policies, funding, partnership and collaboration, and advocacy can serve to link inner and outer contexts. Given its alignment with the focus and aims of the current project, the EPIS framework will be applied to all study activities [UOT for implementation in youth mental health services.Aim 1. Conduct a need and context assessment to inform the systematic adaptation of UOT and develop a corresponding implementation plan entitled EFFECT for ASDAim 2. Systematically adapt Aim 3. Conduct a feasibility pilot test of EFFECT for ASD in community mental health settings.Executive Functioning for Enhancing Community-based Treatment for ASD (EFFECT for ASD) aims to examine the utility of tainment  (EPIS) itivities , 66. As tivities , a commuEFFECT for ASD will target two implementation change mechanisms affecting both implementation and clinical outcomes in mental health: 1) provider attitudes and perceptions of intervention fit and (2) provider’s intention to use , defined as a partnership involving community members and academic researchers targeting a cause relevant to the community of interest , will beUOT and creation of a corresponding implementation plan for use in the mental health services context.A sequential mixed-method approach, with secondary quantitative methods preceding primary qualitative methods will be used to identify factors key to the adaptation of N = 100) will initially be recruited for the quantitative survey, with a subset of these participants (N = 40) also recruited to participate in subsequent qualitative focus groups. CAP members and leaders from partnered community-based mental health agencies will be asked to facilitate identification and recruitment of participants. Recruitment will occur through several methods, including in-person appearances at staff meetings, flyers posted in patient areas, and targeted email contact. Survey participants who agree to be contacted regarding future study activities will be recruited to participate in qualitative focus groups. Participants will include mental health leaders , mental health providers , and caregivers of youth with ASD either currently or previously receiving mental health services, namely psychotherapy services.Participants  agency leader (approximately one group), (2) mental health provider (approximately two groups), and (3) caregivers of youth (approximately two groups). Estimated time commitment and compensation for participation include 90 and 20 min and $40 and $20 for focus groups and surveys, respectively.UOT and development of corresponding implementation protocol. Provider and caregiver specific versions will be utilized for quantitative and qualitative measures. Table UOT . Items assessing implementation outcomes  will be developed or adapted to assess specific UOT intervention content and format. Semi-structured focus group guides with pre-selected interview questions that correspond to the quantitative surveys will be used to facilitate participant discussion of perspectives regarding: (1) the role and impact of executive functioning in mental health services, (2) executive functioning experience and training needs, and (3) key areas for adaptation of UOT for mental health services, including adaptations to the content, context, and training of UOT and associated provider training.Quantitative and qualitative measures will be designed and administered to elicit information regarding inner context  targets emphasized in EPIS framework and key to the adaptation of Informed by the systematic mixed-methods needs assessment of mental health services for youth with ASD in AIM HI , a sequeUOT intervention and create a corresponding implementation plan to maximize feasibility and fit in mental health settings.Informed by aim 1 mixed-method findings, an iterative, collaborative approach will be used to adapt and enhance the existing UOT developers.Participants include CAP members, the principal investigator, and key mentors and consultants, including original UOT and corresponding implementation plan development and providing feedback on drafted materials. UOT adaptation will include a particular focus on implementation feasibility and external validity of EFFECT for ASD models while also retaining core UOT principles and core components, or those key to UOT effectiveness. Using an iterative approach, meetings will focus on reviewing and refining drafted materials, with particular emphasis on modifications that support implementation feasibility and utility in mental health settings. The principles behind UOT and corresponding intervention components will be outlined, and CAP members will discuss how these might best fit into the mental health service context. Aim 1 results will be presented for validation and used for reference on key modifications. Incorporating this feedback, the principal investigator will develop the initial version of EFFECT for ASD. In subsequent meetings, CAP members will provide feedback for further revisions. This process will be used for the development and revision of all materials and UOT developers and mentors (Drs. Kenworthy and Anthony) will review the protocol throughout this process to assess suggested adaptations and ensure fidelity with the principles and UOT core elements.Meetings will focus on providing feedback regarding aim 1 findings as well as discussion and incorporation of findings to guide adaptation of UOT components, including modules with multiple EF-focused lessons  and structured lesson plans and materials . Possible adaptations include (1) modification of language and activities appropriately for the mental health setting ; (2) adaptation of materials and components key to mental health service context, including those targeting managing challenging behavior [UOT components and proposed adaptation areas informed by the Chambers and Norton’s adaptome platform [This process will likely preserve the behavior , parent behavior , home gevities);  adaptatiplatform , which splatform , 101, biUOT and corresponding implementation plan. Measures will be informed by the existing adaptation framework developed by Stirman and colleagues [Quantitative measures and qualitative approaches will be utilized to characterize and document the adaptations made to lleagues  and exislleagues , 103. SpThe primary goal of this aim is to conduct a pilot test examining the feasibility of EFFECT for ASD in mental health settings. Pilot study will evaluate (1) feasibility, utility, and perceived fit of EFFECT for ASD in publicly funded mental health service settings; (2) EFFECT use and adherence; and 3) preliminary youth clinical outcomes, including changes in executive functioning and challenging behaviors  will be recruited from partnered community-based mental health clinics. Sample size was informed by prior feasibility pilot studies focused on community-based service interventions for youth and recommendations regarding appropriate statistical analyses [Provider-youth dyads . Providers in the treatment condition will receive training according to the protocol developed in aim 2 whereas providers in the waitlist condition will receive training approximately 6 months after those in the treatment condition. Participants will be asked to complete measures pre (baseline) and six-months post implementation of EFFECT for ASD or at the beginning and end of 6 months for the control condition. Across conditions, provider participants will submit video recordings of intervention sessions with enrolled families and a corresponding provider-report fidelity measure to assess intervention fidelity. As with aim 1 findings, CAP will aid with interpretation of findings.Quantitative measures and qualitative approaches will be administered to provide a comprehensive understanding of the primary implementation and secondary clinical outcomes of EFFECT for ASD, including feasibility, acceptability, uptake, fidelity, and effectiveness of EFFECT for ASD. Quantitative youth outcome measures will be administered pre and post, whereas implementation outcomes will be collected at post  allows for dropout rates similar to that of prior pilot studies in the same setting while also meeting the threshold for sufficiently precise parameter estimates [UOT. As such, we anticipate an effect size that approximates the medium effect observed in the UOT randomized-clinical trial [d = .55). Qualitative and mixed-method analyses of structured interviews will utilize the same procedures as in aim 1.Descriptive analyses and examination of qualitative themes related to perceptions of the feasibility, acceptability, and appropriateness of EFFECT for ASD will be used to evaluate key implementation outcomes. For quantitative measures, criteria for determining sufficient feasibility, acceptability, and appropriateness will be applied, including examination of mean-level ratings on relevant measures . This hybrid effectiveness-implementation design  builds aUOT for youth. Finally, the current project is focused specifically on adapting and testing an executive functioning intervention for youth with ASD and co-occurring mental health conditions. However, it is an entry point for generalizable application of EFFECT for ASD to other clinical populations and service settings where executive functioning significantly impacts community-based care for youth. This will help provide community mental health providers with the training they require to address the growing service demands of youth with complex clinical presentations such as youth with ASD and co-occurring mental health conditions.Once developed and pilot tested, findings will inform the development of a larger-scale effectiveness-implementation hybrid type 2 trial of EFFECT for ASD with simultaneous examining EFFECT for ASD clinical effectiveness and implementation plan or strategies. Our primary feasibility and acceptability outcomes will support assessment of readiness for a large-scale trial. Additionally, we are leveraging the focus on scaling out an EBI with good effectiveness and implementation outcomes as well as the use of established approaches known to facilitate the successful development of an effective and feasible intervention in children’s mental health settings to support these next steps. Further large-scale studies will allow for evaluation within the context of broader, more varied mental health organizations or systems providing mental health care to youth with ASD, including evaluation of further multilevel  factors on EFFECT for ASD adoption and use. Additionally, future studies will also permit examination of methods to optimize EFFECT for ASD, including identification of the smallest effective dose and/or active ingredients of The current project has received Institutional Review Boards approval from San Diego State University as well as partnered health care organizations and broader County Department of Behavioral Health Services. At time of submission, aim 1 quantitative survey data collection has begun.


Background: Globally, 1.7 million people were newly infected with HIV in 2018. Condoms are inexpensive, cost-effective, reduce HIV/STI incidence, morbidity, mortality, and unintended pregnancies, and result in health care cost savings. Given the rapid increase in at-risk adolescent and young adult (AYA) populations in countries with high HIV/STI prevalence as well as the reductions in donor support, promoting consistent condom use remains crucial. We synthesized all peer-reviewed literature on condom promotion programs with a focus on promotion in low and lower middle income (LMIC) countries and with AYA users. Methods: We systematically reviewed the published literature. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methods, we identified 99 articles published between 2000–2019. Results: Condom promotion programs were generally effective in changing attitudes, social norms, and beliefs in favor of condom use, and 85% demonstrated positive effects on multiple condom use measures. Programs targeting AYA were at least equally as effective as those targeting others and often showed greater use of best practices, such as mass media (66%) and audience segmentation (31%). We also saw differences between programs in the intervention strategies they used and found greater effects of marketing strategies on AYA compared to the overall sample. Conclusion: Condoms remain essential to prevention, and donor support must be maintained to combat the HIV/STI epidemic. Despite gains made in the prevention of HIV and the scaling up of treatment programs, incidence is still alarmingly high in some settings. The recent Evidence for Contraceptive Options and HIV Outcomes (ECHO) study, for example, found an incidence rate of 3.8% among young women in select study sites . GloballCondoms are inexpensive and cost-effective. They reduce HIV and STI incidence, morbidity, mortality, and unintended pregnancies and result in cost savings for healthcare and social sectors. Condoms are highly effective in preventing sexual transmission of HIV. Consistent and correct use of the male condom significantly reduces HIV transmission during vaginal sex 80%)  and anal0%  and aCondoms are also a familiar and convenient prevention method to most people and are, for many, still the only viable option to prevent HIV, STIs, and unintended pregnancies. Condoms are a user-initiated method, are easy to use and store, do not require medical prescriptions or direct provision by health-care personnel or in facilities, and can be used by anyone who is sexually active—including youth. Condom programming is one of five core UNAIDS Prevention Pillars  and shouThe current study has two overarching aims: (1) to analyze the literature in order to demonstrate which condom promotion programs have been shown to be effective and their characteristics; (2) to provide an overall description of published condom programs worldwide. We address these aims in the context of the current environment for condom demand creation and donor-sponsored programs.Strong condom programming requires investment at the systems level in program stewardship, which will support improvements in demand and supply, leading to improved program outcomes. Mann Global Health, in close collaboration with the United Nations Family Planning Agency (UNFPA), UNAIDS, and the Bill and Melinda Gates Foundation (BMGF), has developed a theory of change for this systems level approach, as shown in Program stewardship is a critical function for every nationally-owned condom program to develop and implement strategies to increase use sustainably. The components of program stewardship—leadership and coordination that stretch across all sectors engaged in condom programming , and commercial); production and dissemination of program analytics to inform intervention design and monitor progress; financing to support needed interventions; and a supportive policy and regulatory environment—are all prerequisites for success. In particular, investments in strengthening leadership and coordination and program analytics are urgently needed in many countries. These investments at the systems level will improve quantification of need and understanding of existing use and create a strong evidence base to understand supply and demand dynamics that influence uptake and use . NationaGiven the landscape of current condom programming, there is a need to understand the state of evidence for condoms as an HIV/STI prevention strategy and an effective contraceptive method, especially for young people, as well as gaps in the knowledge base and the potential for future programs and research to move the field forward. In particular, the use of a total market approach (TMA)  is critical to the future of condom marketing ,14.The need for effective application of TMA is even greater given the rapid growth in the population of adolescents and young adults (AYA) in regions most affected by HIV/STI, including sub-Saharan Africa (SSA). AYA populations in SSA are estimated to increase to some 250 million under age 25 by 2030, and, given their potential sexual risk taking behavior, the HIV/STI epidemic remains a public health priority calling for comprehensive and innovative solutions .Thus, there is a need to document and systematically review the state of evidence on condom programs with a specific focus on effectiveness of interventions to promote condom use through communication and social marketing, which have been the primary demand creation strategies used to date. The current research provides evidence and a framework for future programing to support TMA programs.Overall goals of this study are to systematically review all published literature on outcomes of condom distribution programs worldwide. One important part of this project is to understand the demand generation strategies in low and lower middle income (LMIC) countries and to understand the AYA generation of condom users in order to develop effective demand promotion strategies. We hypothesize (H1) that demand generation efforts have been effective in increasing determinants of condom use, and (H2) that demand generation has been effective in increasing sales and distribution of condoms. We also ask the research question (RQ1) of whether these efforts have been more effective among specific population groups, in specific geographic locations or settings, and based on specific media channels and strategies.In particular, we ask whether these efforts have been more effective among AYA ages 15–34 during the period in the which the project/study was conducted. Given the rapid growth of the AYA population in regions such as SSA, understanding how best to promote condoms to this priority population is critical to future prevention efforts.We conducted a systematic search of the published, peer-reviewed literature using all relevant major online research literature databases (specified below) and following widely accepted methods for systematic review  . We noteWe identified as relevant any manuscripts published in the English language in health, social science, and business literature that used at least one of the four Ps of marketing, had a behavioral objective targeting promotion of condom sales, use, and related behaviors, and had a health objective targeting HIV/STI or related disease prevention. We based the review methodology in part on methodologies from a previous review of branded social marketing campaigns conducted by the lead author . SpecifiWe selected search terms based on the authors’ experiences in the field and conducting previous reviews and in consultation with a medical research librarian. We applied the following criteria to conduct the search: (1) limited to only include articles published from 2000 onward; (2) search terms included condoms + marketing, brands, branding, health promotion, free distribution, commercial, subsidized; (3) went beyond other recent reviews  to include distribution programs for commercial brands (to extent any published results) ; coding For completeness, we also searched literature known to the authors, including publications on condom promotion, social marketing, and related intervention studies in low and middle income countries. In particular, the bibliographies of two recent meta-analyses on social marketing and mass media intervention were reviewed, and potential citations were screened following the methods described ,19,20.We searched all sources listed above in the date range of January 2000 to December 2019. Based on this process, we created a database of all 4240 unduplicated articles on social marketing interventions regarding condoms. Based on abstract review, we immediately excluded 3988 articles that did not relate to condom promotion or marketing, were clearly not original research, or were only focused on other family planning methods, leaving 252.Next, we obtained and reviewed the 252 full-text articles based on our specific criteria for inclusion in study. Namely, we screened them for reports on interventions that: (1) were original research ; (2) utilized some form of social marketing principles ; (3) targeted behavior relating to condom use; and (4) targeted HIV/STI prevention and/or related reproductive health outcomes as a health objective. We also screened to ensure the articles included specific reports of evaluation or implementation of social marketing activities, defined as coordinated efforts to promote, distribute, or use pricing strategies to encourage adoption of various products aimed primarily at HIV/STI prevention. Based on this in-depth screening process, we excluded 153 articles and identified 99 articles for inclusion in the study. Note that, due to the diverse nature of the literature on demand creation and marketing interventions in this area and the varying methods of reporting outcomes, we chose not to attempt a meta-analysis of effects of reviewed interventions on behavior. Rather, the purpose of this paper is to describe the nature of the interventions and literature, hopefully promoting more uniform reporting of condom promotion outcomes in the future.Once the review sample of articles was identified, the first two authors individually read each of the articles in-depth and coded them for specific content reported in the results section. The results of all reviews were compiled and discussed by the reviewers. Potential sources of differences in assumptions and approaches in coding articles were identified and discussed. A consensus was reached about coding, and common procedures were adopted where discrepancies were identified.Fifty-five percent (55%) of studies were published before 2010. The majority of studies were conducted in low and middle income countries, mostly in South Asia and Sub Saharan Africa (54), with some reported in wealthy countries, mainly the USA (27). Finally, the largest single age range targeted was AYA age 15–34 (35%), followed by women (31%). Eleven percent of studies specifically targeted LGBTQ populations.For each characteristic listed in the left-hand column, A higher percentage of articles in the 2000s reported targeting the AYA population (57%) compared to the overall population (45%), and the reverse was true in the 2010s . Thirty-eight percent of efforts in Sub-Saharan African targeted the overall sample compared to 29% that targeted AYAs. However, 40% of efforts in the US/Canada targeted AYAs compared to 27% for this region in the overall sample.As shown in There were some differences observed between AYA-targeted marketing and overall. Sixty-six percent of AYA marketing used mass media compared to 52% of the overall sample. The largest difference in mass media channel reported was 26% for AYA point of sale/location marketing efforts compared to 16% in the overall sample for that category. Among other marketing techniques reported, 31% of AYA efforts used audience segmentation (considered widely to be best marketing practice ) compareHigher percentages of efforts targeting AYA used theory, with 63% reporting some kind of theoretical framework, driven mainly by greater use of psychological theory . Fifty-one percent of AYA efforts reported formative research in the marketing effort compared to 33% in the overall sample, with higher percentages reported for the AYA efforts in each category of formative research methods.Examination of the studies in terms of the use of the four Ps of marketing  revealed that 45% used all four marketing techniques . PromotiThere were only small differences in the observed reporting of sample characteristics, research design type, and statistics between the overall and the AYA targeted efforts. However, higher percentages of AYA targeted efforts reported pre-behavioral and behavioral objectives  compared to the overall sample (56% and 57% respectively). Thirteen percent of the overall sample reported targeting sales/distribution objectives compared to only 3% of AYA efforts. Similarly, higher percentages of AYA efforts reported achieving condom use behavior outcomes  compared to the overall sample , and again more of the overall sample targeted sales distribution (24%) than AYA efforts (14%).Next, we analyzed the significant effects data by publications that reported capturing each outcome data category. Analyzed as a ratio, we continued to see higher significant effects on awareness and reactions to promotions among the overall sample (71%) compared to AYA efforts (50%). However, we saw only small differences in effects for pre-behavioral outcomes and sales/distribution but a higher percentage of the overall sample demonstrating condom use outcomes (85%) compared to the AYA efforts (76%). Despite these differences, it should be noted that, with the exception of awareness/reactions effects among AYA efforts (50%), all the findings for significant effects among studies that measured specific outcomes were generally high (greater than 70% and most above 85%), indicating that, when condom use marketing targets these outcomes of interest, the efforts are mostly effective.In terms of intervention characteristics, there were relatively few differences in terms of the intermediate outcomes. One notable difference was that 90% of interventions using mass media  reported significant effects on attitudes, beliefs, and intentions to use condoms, and the same percentage was displayed among programs for AYA .In terms of behavioral outcomes, we saw a similar pattern of consistent effects between intervention categories, but the effects on AYA condom use were somewhat lower (72% compared to 86% for other populations) for those using mass media.Awareness outcomes were consistently lower overall and lower among AYA compared to the general sample and the other populations. These results were consistent across all intervention characteristics.Finally, the effects of condom promotion programs on sales were generally higher among AYA compared to the overall sample and other populations across most intervention characteristics. Across the marketing Ps, all AYA focused programs showed significant effects and were consistently higher than the overall sample and other populations, suggesting that marketing strategies were especially effective in encouraging condom purchases among AYA.In a Sustained demand generation that results in repeat, intensive exposure to behavior change messages tailored to diverse user needs remains a critical need in many countries. Decreasing funding for condom programming across many countries has weakened efforts to develop and deliver behavior change interventions of the scale and the intensity necessary to overcome barriers to condom use . SignifiCondom programs must ensure that there are adequate condom supplies and distribution systems to meet current and future user demand. Though some countries have made progress in securing sufficient funding for condom procurement and for increasing condom distribution through the public sector, under-served areas remain. Condom stock-outs at the facility level and condom wastage remain challenges. Procurement of condoms in excess of reasonable projections for growth in demand also contributes to condom wastage in some countries . EffortsThis study demonstrates that condoms continue to be widely promoted worldwide and, given the epidemiology of HIV/STIs, they remain a crucial technology for preventing transmission. In 2017, UNAIDS estimated that 36.9 million people were living with the HIV virus with 1.8 million new infections, the majority through unprotected sexual intercourse . In addiThe importance of condom promotion is suggested in part by the significant body of research in the field, some 99 published studies using the restrictive inclusion criteria in this study, and the pace of studies increased in the decade from 2010–2019 (54 of 99 reviewed) despite recent reductions in condom donor spending. However, it is worth noting that the percentage of studies showing a significant effect on condom use dropped from 87% in 2000–2009 to 78% in 2010–2019. The latter may reflect an increase in interest in evaluation data to support continued expenditures on campaigns and justify specific approaches and population focus; however, at the same time, the effects of other prevention and treatment efforts, such as PrEP, influence consistent condom use .This review confirmed our original H1 that condom promotion studies are effective in promoting determinants and condom use. Condom promotion studies demonstrated a high degree of effectiveness in promoting condom use and related behavioral outcomes, with 85% demonstrating positive effects in these areas. It is worth noting that a smaller percentage of studies demonstrated message awareness in specific promotions (71%), indicating perhaps a need for better dosage/exposure measurement as well as sustained delivery of promotions.Condom promotion studies that examined sales and distribution overwhelmingly reported an increase in sales or distribution , confirming H2. Large scale condom promotion efforts reached widespread populations, including those most in need in low and middle income countries that face a disproportionate burden of HIV/STI infections and unmet contraceptive needs. This was true even in the most recent years (since 2010), when donor funding for condom distribution and promotion has declined.Best practice marketing techniques were widely used in condom promotion, with the majority of studies employing multiple marketing channels and Ps from marketing theory. Additionally, a wide mix of marketing channels were used, and these were generally targeted to the media platforms most widely used in the country/region. In particular, there was widespread use of community outreach, radio, and outdoor advertising promotion. It is worth noting that relatively few studies used social media or other digital media to promote condoms, likely because they were often conducted in LMIC. However, this represents an opportunity to expand the reach and the recognition of condom promotion efforts.In terms of RQ1 and whether condom promotion efforts have targeted or have been more effective among population groups such as AYA or in specific geographic locations and other settings, we made several findings. First, a disproportionate number (35 of 99) of condom promotion effort targeted AYA populations compared to other age sub-groups. Given that AYA are at greater risk, this is promising. However, it is worth noting that the majority of these AYA targeted efforts were in the US and Canada, and a disproportionately smaller number were in Sub-Saharan Africa, where condom promotion will be greatly needed in the coming decade and beyond.We also observed greater use of mass media channels and greater use of behavior change theory in AYA condom promotion efforts compared to the overall sample. Thus, these efforts have potential to reach wider AYA audiences and are guided by solid conceptual foundations. We observed significant effects of AYA targeted efforts but overall not greater effects than on the overall sample. We did observe lower levels of effects on product awareness and positive reactions to promotions, but this may also reflect differences in media preferences and use. Given that we found very few efforts that utilized digital and social media, especially in the decade from 2010–2019, when such strategies become widespread in public health, this may reflect a need and an opportunity to shift condom promotion campaigns to the channels most used by AYA.Overall, condom promotion efforts with AYA when specific outcomes of increasing positive attitudes, social norms, and beliefs as well as condom use behavior and sales/distribution were targeted were effective. This is promising, given that AYA are often hard to reach and at risk. This review suggests that condom promotion efforts are at least equally effective with AYA as with the overall sample of marketing promotions, and thus, considering the massive need for programs given rising AYA populations, such efforts deserve greater emphasis and attention.There is a need for more research that sheds light on how best to build healthy markets  for condoms ,29. MoreDespite its many strengths and new information yielded by this systematic review, the study has some limitations. First, promotion terminology is known to be difficult to identify in some cases due to inconsistent use of language in communication and marketing literature ,31. SecoDespite advances in HIV treatments, including pre-exposure prophylaxis (PrEP), condoms remain an essential prevention method, especially in light of the tremendous demographic shifts in sub-Saharan Africa over the coming decade . New pri


Eating disorders are widespread illnesses with significant impact. There is growing concern about how young people overuse online resources leading to mental health sequelae.We gathered data from 639 individuals from a population cohort. Participants were all young adults at the point of contact and were grouped as having probable eating disorder with excessive exercise (n=37) or controls (n=602). We measured obsessionality, compulsivity, impulsivity, and problematic internet use. Group differences in these domains were evaluated; and structural equation modelling (SEM) was used to assess structural relationships between variables.Cases had higher scores of obsessional thoughts of threat , intolerance towards uncertainty , thoughts of importance and control , compulsivity , negative urgency , and higher problematic usage of the internet . Our SEM showed significant partial mediation of problematic internet use on both the effect of obsessionality latent factor on cases , as well as of sensation seeking latent factor on cases .Youth with eating disorder and heightened exercise levels have increased obsessive thoughts of threat, compulsivity traits and sensation seeking impulsivity. The association between obsessive thoughts and eating disorders, as well as sensation seeking and eating disorder symptoms were partially mediated by problematic internet use. Excessive use of online resources may be playing a role in the development or maintenance of eating disorder symptoms in the background of obsessional thoughts and sensation seeking impulsive traits. Eating disorders (EDs) have the highest morbidity and mortality of all mental illnesses  and affeOver the last decade, there has been growing concern over the impact of online media on eating disorders , 2017. PExcessive exercise is a particularly challenging eating disorder behavior that can lead to catastrophic consequences e.g. precipitous weight loss, coupled with exercise through injury, heart abnormalities (e.g. life threatening bradycardia), rhabdomyolysis, among other complications . AN cohoObsessional ideas about own body image are core symptoms of AN  and haveLinked to obsessional traits, ‘intolerance of uncertainty’ (IU) is the tendency for a negative emotional, cognitive and behavioral reaction to uncertain situations and events. Compulsive eating disorder behaviors have been linked to IU . IU has Compulsivity has been defined as a trait in which actions are persistently repeated despite adverse consequences . BehavioImpulsivity is a multi-faceted construct referring to acting without forethought or reflection or consideration of the consequences. PUI has been linked with increased levels of trait impulsivity and compulsivity  and sensThis current study had two aims: first we aimed to compare the behavioral characteristics of eating disorder traits with heightened levels of exercise in respect to their levels of (1) impulsivity, (2) compulsivity, (3) obsessionality, (4) sensation seeking, (5) intolerance to uncertainty and (6) problematic usage of the internet against controls. By doing so, we aim to quantify differences on group level in our dataset, as they have been demonstrated in previous research, and establish that our cohort does share the behavioral characteristics in line with current literature. Therefore, we hypothesized that participants with eating disorders and heightened exercise will present with increased levels of trait impulsivity, compulsivity, obsessionality, as well as heightened levels of intolerance for uncertainty and sensation seeking when compared to controls. Our second aim would be to statistically explore the structural relationship between the variables in our model and consecutively the potential mediating effect that problematic internet use may have on these neurobiological dimensions on their effect on eating disorders. To date there is no study exploring those mediating effects of PUI in eating disorders.Participants were recruited from the Neuroscience in Psychiatry Network (NSPN) UK youth cohort:, which is a longitudinal cohort, exploring brain development trajectories and mental health outcomes . The samThe procedures of this study were carried out in accordance with the Declaration of Helsinki and the study was approved by the Cambridge East Research Ethics Committee . All subjects gave informed consent online.Participants were classified as cases according to whether or not they displayed high probability of having an eating disorder diagnosis and excessive exercise. For the assessment of their eating disorder diagnosis we used the SCOFF Eating Disorder Questionnaire . This isProblematic usage of the internet was quantified using the Internet Addiction Test short-12 item version (IAT-12) ((IAT-12) . The IATCambridge–Chicago Compulsivity Trait Scale (CHI-T) ( (CHI-T) . This is (CHI-T) .The Barratt Impulsiveness Scale short version (BIS-8) to quantify impulsive personality , Perseverance (lack of), Sensation Seeking, Positive Urgency, Impulsive Behavior Scale (S-UPPS) is a measurement of impulsivity as a multi-faceted and multi-dimensional construct, comprising five impulsive personality traits  is a measure of sensation seeking as a psychobiological trait of need for novelty, complexity and intensity  for every model and compared each model with the previous one using chi-square comparisons. We finalized our SEM when reached non-significant improvement in our model via path change .Our final sample comprised 37 cases , and 602 controls. Group comparison results are shown in Cases had higher scores of obsessional thoughts of threat , obsessional intolerance towards uncertainty (OBQ) , obsessional thoughts of importance and control , transdiagnostic compulsivity traits , negative urgency , intolerance of uncertainty (IUS) , and higher problematic usage of the internet . All other results were non-significant or became non-significant after the application of Bonferroni correction for multiple comparisons. We used standardized mean difference (Cohen’s d) under the assumption of normality and homogeneity of variances.Problematic internet use was associated with obsessionality  and sensation seeking ; eating disorder case was associated with obsessionality , sensation seeking  and PUI . The chosen model with the lowest RMSEA was model 8 see  which haThis is the first study to examine the problematic online behaviors, coupled with behavioral characteristics of a putative eating disorders cohort with heightened excessive exercise behaviors. In our study, we identified, through group comparisons, that cases, as compared to controls, had heightened degree of obsessive thoughts of threat, obsessional intolerance towards uncertainty, obsessional thoughts of importance and control, high cross-diagnostic traits of compulsivity, negative urgency impulsivity and higher levels of problematic internet use. Those results are in line with previous research, that obsessional preoccupation with food and food predominance, as well as and intolerance to uncertainty manifesting with deficits in social decision making, planning and action, as well as fear of unduly evaluation from others . IncreasFurthermore, our study is the first to explore the mediation effect of problematic internet behaviors on the impact of obsessionality and sensation seeking, to eating disorder symptoms, via SEM. Our analysis showed partial mediation, for both effects of obsessionality (0.24 to 0.21) and sensation seeking (0.11 to 0.09) suggestive that obsessional thoughts and sensation seeking impulsivity traits, when present in in young populations, may be impacting on the development or perseverance of eating disorders, partially via the problematic usage of online resources. While a SEM analysis does not provide evidence for causal directional link, it highlights the importance for future studies that can potentially examine this interaction further. Previous longitudinal research has shown that the use of social media (Facebook) maintained weight and shape concerns as well as state anxiety  as compaWe have several limitations to consider in this study deriving from our data collection process and instruments used. Given that this is an online survey, it has less quality control and less accuracy for measuring psychopathology constructs as compared to face-to-face clinical assessments. For example, we used the SCOFF questionnaire to ascertain putative AN or BN diagnosis. While the SCOFF is an efficient screening tool for AN and BN, and its specificity and positive predictive value are reasonable   for a scWe have shown that our case group of putative eating disorders with heightened levels of activity have increased levels of obsessionality, cross-diagnostic compulsivity, negative urgency impulsivity, intolerance of uncertainty and higher levels of problematic usage of the internet. We have demonstrated that obsessionality latent factor and sensation seeking latent factor predict cases, and that problematic usage internet resources mediates that relationship. This mediation provides us novel insight into the potential role of problematic use of online resources for the development and perseverance of eating disorder psychopathology with heightened exercise levels.