Precision prevention: time to move beyond universal interventions

From error to insight: Removing non-systematic responding data in the delay discounting task may introduce systematic bias

Delay discounting (DD), which reflects a tendency to devalue rewards as the time to their receipt increases, is associated with health behaviors such as sleep disturbances, obesity, and externalizing behavior among adolescents. Response patterns characterized by inconsistent or unexpected reward valuation, called non-systematic responding (NSR), may also predict health outcomes. Many researchers flag and exclude NSR trials prior to analysis, which could lead to systematic bias if NSR (a) varies by demographic characteristics or (b) predicts health outcomes. Thus, in this study we characterized NSR and examined its potential beyond error by comparing it against DD with a secondary data analysis of the Adolescent Brain Cognitive Development (ABCD) Study-a population-based study that tracked youths (N = 11,948) annually from 8 to 11 years of age over 4 years. We assessed DD and NSR using the Adjusting Delay Discounting Task when youths were approximately 9.48 years old (SD = 0.51). We also examined three maladaptive health outcomes annually: sleep disturbances, obesity, and externalizing psychopathology. Our analysis revealed variations in NSR across races, ethnicities, and body mass index categories, with no significant differences observed by sex or gender. Notably, NSR was a stronger predictor of obesity and externalizing psychopathology than DD and inversely predicted the growth trajectory of obesity. These findings suggest that removing NSR patterns could systematically bias analyses given that NSR may capture unexplored response variability. This study demonstrates the significance of NSR and underscores the necessity for further research on how to manage NSR in future DD studies.

A positive psychology framework for understanding teenage driving behaviors: Examining the role of life purpose and mindfulness

OBJECTIVE

The overwhelming majority of teenage driving research in the US is framed around characteristics associated with risk, rather than factors that promote safety. In this study, we examine the role of purpose in life and mindfulness as two factors that may be associated with safer driving behaviors.

METHODS

Using survey responses from a nationally representative sample of teenagers (aged 16-19) we used structural equation modeling to construct three latent variables - sense of purpose, mindfulness, and risky driving-and evaluate the associations between these latent variables among teenage drivers. Risky driving was based on measures of self-reported distracted driving, drunk driving, driving under the influence of marijuana and other drugs, inconsistent seatbelt use, and riding with an impaired driver.

RESULTS

We found that sense of purpose and mindfulness were associated with fewer risky driving behaviors. We also identified mindfulness as a mediator between sense of purpose and risky driving.

CONCLUSIONS

Purpose in life and mindfulness are associated with fewer risky driving behaviors among US teenagers. Driver education and training could include components related to purpose and mindfulness, in order to promote safer driving behaviors in this population.

Accelerating a learning public health system: Opportunities, obstacles, and a call to action

Introduction

Public health systems worldwide face increasing challenges in addressing complex health issues and improving population health outcomes. This experience report introduces the concept of a Learning Public Health System (LPHS) as a potential solution to transform public health practice. Building upon the framework of a Learning Health System (LHS) in healthcare, the LPHS aims to create a dynamic, data-driven ecosystem that continuously improves public health interventions and policies. This report explores the definition, benefits, challenges, and implementation strategies of an LPHS, highlighting its potential to revolutionize public health practice.

Methods

This report employs a comparative analysis approach, examining the similarities and differences between an LPHS and an LHS. It also identifies and elaborates on the potential benefits, challenges, and barriers to implementing an LPHS. Additionally, the study investigates promising national initiatives that exemplify elements of an LPHS in action.

Results

An LPHS integrates data from diverse sources to inform knowledge generation, policy development, and operational improvements. Key benefits of implementing an LPHS include improved disease prevention, evidence-informed policy-making, and enhanced health outcomes. However, several challenges were identified, such as interoperability issues, governance concerns, funding limitations, and cultural factors that may impede the widespread adoption of an LPHS.

Conclusions

Implementation of an LPHS has the potential to significantly transform public health practice. To realize this potential, a call to action is issued for stakeholders across the public health ecosystem. Recommendations include investing in informatics infrastructure, prioritizing workforce development, establishing robust data governance frameworks, and creating incentives to support the development and implementation of a LPHS. By addressing these key areas, public health systems can evolve to become more responsive, efficient, and effective in improving population health outcomes.

We need better ways to help students avoid the harms of stress: Results of a meta-analysis on the effectiveness of school-based stress management interventions

The level of psychological stress in children and adolescents has increased rapidly over the past decade. The aim of the present meta-analysis was to evaluate the effectiveness of school-based intervention programs targeting stress management and coping/resilience in school-aged children. The present study used more rigorous selection criteria than previous meta-analyses by only including randomized controlled trials to increase the validity of the meta-analysis. Fifty-five studies were selected for the analysis, including 66 comparisons in the case of stress and 47 comparisons in the case of coping/resilience outcomes. A meta-regression with robust variance estimation was used. Effects were calculated as the standardized mean difference (Hedges' g) between the intervention and control conditions at posttest. The results highlighted important methodological issues and the influence of outliers. Without outliers, the results indicated a small significant overall effect on stress (g = -0.15, p < .01) and coping/resilience (g = 0.14, p = .01). When outliers were included, the effect sizes markedly increased in both cases (gstress = -0.26, p = .022; gcoping/resilience = 0.30, p = .009). Stress management interventions were more effective if they were delivered by mental health professionals or researchers than by teachers. Coping/resilience interventions were more effective in older age groups, in selective samples, and if they included cognitive behavioral therapy. An explanation of the results and a detailed discussion of the limitations of the study and its implications for practice are considered.

ProjectDRIVE: study protocol for a randomized controlled trial to improve driving practices of high-risk teen drivers with a traffic violation

BACKGROUND

Teen drivers with a traffic violation are at increased risk for crashes and crash-related injuries; however, most parent-focused interventions target teen drivers with supervised learner's permits. Very few interventions are implemented at the probationary driver's license stage or target high-risk teen drivers, such as those with traffic violations. This paper describes the protocol of ProjectDRIVE, A Randomized Controlled Trial to Improve Driving Practices of High-Risk Teen Drivers with a Traffic Violation, which targets improving parent-teen communication about safe driving practices to reduce unsafe driving behaviors and traffic violation recidivism of teen drivers cited for traffic violation.

METHODS

Teen drivers (ages 16 or 17) cited for a moving violation and the parent/legal guardian most involved with the teen's driving are recruited from juvenile traffic courts following their required court hearing. After completing informed consent/assent, enrolled dyads are randomized into one of three groups using stratified block randomization: control, device feedback only, or device feedback plus parent communication training. Participating dyads are followed for 6 months with 3 months of active intervention. Using in-vehicle device and smartphone application technology, the study provides real-time and cumulative driving feedback to intervention teens and collects continually recorded, objectively measured driving outcome data throughout the teen's study participation. Primary outcomes include rates of risky driving events and unsafe driving behaviors per 1000 miles driven. Secondary outcomes include traffic violation recidivism up to 12 months following study completion and frequency and quality of parent-teen communication about safe driving practices.

DISCUSSION

Through partnership with the local juvenile traffic courts, this study integrates recruitment and randomization into existing court practices. Successfully completing this study will significantly impact juvenile traffic court's practices and policies by informing judges' decisions regarding the driving safety programs they refer to teens to prevent motor vehicle crashes and crash-related injuries and deaths. Trial registration The study was registered on ClinicalTrials.gov Registry (NCT04317664) on March 19, 2020, https://clinicaltrials.gov/study/NCT04317664 and updated on April 27, 2021. This protocol was developed per the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) Checklist.

Driving Skills at Licensure and Time to First Crash

BACKGROUND AND OBJECTIVES

Young drivers are overrepresented in crashes, and newly licensed drivers are at high risk, particularly in the months immediately post-licensure. Using a virtual driving assessment (VDA) implemented in the licensing workflow in Ohio, this study examined how driving skills measured at the time of licensure contribute to crash risk post-licensure in newly licensed young drivers.

METHODS

This study examined 16 914 young drivers (<25 years of age) in Ohio who completed the VDA at the time of licensure and their subsequent police-reported crash records. By using the outcome of time to first crash, a Cox proportional hazard model was used to estimate the risk of a crash during the follow-up period as a function of VDA Driving Class (and Skill Cluster) membership.

RESULTS

The best performing No Issues Driving Class had a crash risk 10% lower than average (95% confidence interval [CI] 13% to 6%), whereas the Major Issues with Dangerous Behavior Class had a crash risk 11% higher than average (95% CI 1% to 22%). These results withstood adjusting for covariates (age, sex, and tract-level socioeconomic status indicators). At the same time, drivers licensed at age 18 had a crash risk 16% higher than average (95% CI 6% to 27%).

CONCLUSIONS

This population-level study reveals that driving skills measured at the time of licensure are a predictor of crashes early in licensure, paving the way for better prediction models and targeted, personalized interventions. The authors of future studies should explore time- and exposure-varying risks.

Negative mood mind wandering and unsafe driving in young male drivers

OBJECTIVE

Road traffic crash fatalities disproportionately affect young male drivers. Driver distraction is a leading contributor to crashes. Mind wandering (MW) is a prevalent form of driver distraction that is linked to certain unsafe driving behaviours that are associated with increased crash risk (e.g., faster driving). Negative mood can lead to MW, and thus may represent a causal pathway to MW-related unsafe driving. This preliminary pre-post (T1, T2), randomized, controlled, single-blinded experiment tested whether negative mood, compared to neutral mood, increases MW while driving as well as unsafe driving and emotional arousal during MW. It also tested the moderating contribution of trait rumination and inhibitory control to this proposed causal pathway.

METHODS

Forty healthy male drivers aged 20 to 24 were randomly allocated to a negative or neutral mood manipulation involving deception. Individual differences in trait rumination and inhibitory control were measured at T1. At T1 and T2, participants drove in a driving simulator measuring driving speed, headway distance, steering behaviour, and overtaking. Heart rate and thought probes during simulation measured emotional arousal and MW, respectively.

RESULTS

Negative mood exposure led to more MW while driving (Odds Ratio = 1.79, p = .022). Trait rumination positively moderated the relationship between negative mood and MW (Odds Ratio = 2.11, p = .002). Negative versus neutral mood exposure led to increases in headway variability (Cohen's d = 1.46, p = .026) and steering reversals (Rate Ratio = 1.33, p = .032) during MW relative to focused driving. Between-group differences in emotional arousal were not significant.

CONCLUSION

Results support a causal pathway from negative mood to unsafe driving via MW, including the moderating contribution of trait rumination. If replicated, these preliminary findings may inform the development of interventions targeting this potential crash-risk pathway in vulnerable young driver subgroups.

Novel use of a virtual driving assessment to classify driver skill at the time of licensure

Motor vehicle crash rates are highest immediately after licensure, and driver error is one of the leading causes. Yet, few studies have quantified driving skills at the time of licensure, making it difficult to identify at-risk drivers before independent driving. Using data from a virtual driving assessment implemented into the licensing workflow in Ohio, this study presents the first population-level study classifying degree of skill at the time of licensure and validating these against a measure of on-road performance: license exam outcomes. Principal component and cluster analysis of 33,249 virtual driving assessments identified 20 Skill Clusters that were then grouped into 4 major summary "Driving Classes"; i) No Issues (i.e. careful and skilled drivers); ii) Minor Issues (i.e. an average new driver with minor vehicle control skill deficits); iii) Major Issues (i.e. drivers with more control issues and who take more risks); and iv) Major Issues with Aggression (i.e. drivers with even more control issues and more reckless and risk-taking behavior). Category labels were determined based on patterns of VDA skill deficits alone (i.e. agnostic of the license examination outcome). These Skill Clusters and Driving Classes had different distributions by sex and age, reflecting age-related licensing policies (i.e. those under 18 and subject to GDL and driver education and training), and were differentially associated with subsequent performance on the on-road licensing examination (showing criterion validity). The No Issues and Minor Issues classes had lower than average odds of failing, and the other two more problematic Driving Classes had higher odds of failing. Thus, this study showed that license applicants can be classified based on their driving skills at the time of licensure. Future studies will validate these Skill Cluster classes in relation to their prediction of post-licensure crash outcomes.

Text mining of Reddit posts: Using latent Dirichlet allocation to identify common parenting issues

Parenting interventions offer an evidence-based method for the prevention and early intervention of child mental health problems, but to-date their population-level effectiveness has been limited by poor reach and engagement, particularly for fathers, working mothers, and disadvantaged families. Tailoring intervention content to parents' context offers the potential to enhance parent engagement and learning by increasing relevance of content to parents' daily experiences. However, this approach requires a detailed understanding of the common parenting situations and issues that parents face day-to-day, which is currently lacking. We sought to identify the most common parenting situations discussed by parents on parenting-specific forums of the free online discussion forum, Reddit. We aimed to understand perspectives from both mothers and fathers, and thus retrieved publicly available data from r/Daddit and r/Mommit. We used latent Dirichlet allocation to identify the 10 most common topics discussed in the Reddit posts, and completed a manual text analysis to summarize the parenting situations (defined as involving a parent and their child aged 0-18 years, and describing a potential/actual issue). We retrieved 340 (r/Daddit) and 578 (r/Mommit) original posts. A model with 31 latent Dirichlet allocation topics was best fitting, and 24 topics included posts that met our inclusion criteria for manual review. We identified 45 unique but broadly defined parenting situations. The majority of parenting situations were focused on basic childcare situations relating to eating, sleeping, routines, sickness, and toilet training; or related to how to respond to child negative emotions or difficult behavior. Most situations were discussed in relation to infant or toddler aged children, and there was high consistency in the themes raised in r/Daddit and r/Mommit. Our results offer potential to tailor parenting interventions in a meaningful way, creating opportunities to develop content and resources that are directly relevant to parents' lived experiences.

Rethinking Cell Phone Use While Driving: Isolated Risk Behavior or a Pattern of Risk-Taking Associated with Impulsivity in Young Drivers?

This study examines whether cell phone use stands apart from a general pattern of risky driving practices associated with crashes and impulsivity-related personality traits in young drivers. A retrospective online survey study recruited 384 young drivers from across the United States using Amazon’s Mechanical Turk to complete a survey measuring risky driving practices (including cell phone use), history of crashes, and impulsivity-related personality traits. Almost half (44.5%) of the drivers reported being involved in at least one crash, and the majority engaged in cell phone use while driving (up to 73%). Factor analysis and structural equation modeling found that cell phone use loaded highly on a latent factor with other risky driving practices that were associated with prior crashes (b = 0.15, [95% CI: 0.01, 0.29]). There was also an indirect relationship between one form of impulsivity and crashes through risky driving (b = 0.127, [95% CI: 0.01, 0.30]). Additional analyses did not find an independent contribution to crashes for frequent cell phone use. These results suggest a pattern of risky driving practices associated with impulsivity in young drivers, indicating the benefit of exploring a more comprehensive safe driving strategy that includes the avoidance of cell phone use as well as other risky practices, particularly for young drivers with greater impulsive tendencies.

Psychological Constructs Related to Seat Belt Use: A Nationally Representative Survey Study

Seat belt use can significantly reduce fatalities in motor vehicle crashes (Kahane, 2000). Nevertheless, the current U.S. seat belt use rate of 89.6% (Enriquez & Pickrell, 2019) indicates that a relatively small but pervasive portion of the population does not wear seat belts on a full-time basis. Whereas much is known about the demographic predictors of seat belt use, far less is understood about psychological factors that predict individual proclivities toward using or not using a seat belt. In this study, we examined some of these potential psychological predictors. A probability-based web survey was conducted with 6,038 U.S. residents aged 16 or older who reported having driven or ridden in a car in the past year. We measured self-reported seat belt use and 18 psychological constructs and found that delay of gratification, life satisfaction, risk aversion, risk perception, and resistance to peer influence were positively associated with belt use. Impulsivity and social resistance orientation were negatively associated with belt use. Prior research has shown that psychological factors like delay of gratification, risk aversion/perception, and impulsivity predict other health behaviors (e.g., cigarette smoking, sunscreen use); our results extend this literature to seat belts and can aid the development of traffic safety programs targeted at non-users who-due to such factors-may be resistant to more traditional countermeasures such as legislation and enforcement.

Age-specific incidence of injury-related hospital contact after release from prison: a prospective data-linkage study

BACKGROUND

In population studies, the risk of injury declines after early adulthood. It is unclear if a similar age difference in the risk of injury exists among people released from prison.

METHODS

Prerelease survey data collected between 1 August 2008 and 31 July 2010, from a representative cohort of sentenced adults (≥18 years) in Queensland, Australia, were linked prospectively and retrospectively to person-level emergency department, inpatient hospital and correctional records. To ascertain predictors of injury-related hospital contact, we fit a multivariate Andersen-Gill model and tested the interactions between age group (<25 years, ≥25 years) and each variable.

RESULTS

In 1307 adults released from prison, there were 3804 person-years of follow-up. The crude injury rate was 385 (95% CI 364 to 407) per 1000 person-years and did not differ according to age group. Factors associated with increased injury-related hospital contact included a history of mental illness, preincarceration injury, a history of incarceration, release from a short prison sentence (<90 days), being reincarcerated during follow-up and identifying as Indigenous. The effect of mental illness, risky alcohol use, prior incarceration and intellectual disability differed across age group and predicted increased risk of injury among people aged ≥25 years compared with their counterparts without these characteristics.

CONCLUSIONS

Unlike in the general population where the risk of injury declines with age, older adults released from prison are at similar risk compared with their younger peers. Adults released from prison with mental illness, a history of injury-related hospital contact and who identify as Indigenous are particularly indicated groups for injury prevention.

Driver licensing and motor vehicle crash rates among young adults with amblyopia and unilateral vision impairment

This retrospective cohort study investigated whether unilateral vision impairment (UVI) or amblyopia are associated with driver licensing and crash risk among young adults. Electronic health records for New Jersey residents who were patients with the Children's Hospital of Philadelphia's healthcare network were linked to statewide driver licensing and crash data. We compared young adults with a diagnosis of UVI and/or amblyopia to peers without such a diagnosis. Young adults with UVI or amblyopia were less likely to acquire a driver's license than those without these conditions. However, among licensed drivers, the risk of a police-reported crash was similar in all three groups.

Leading Causes of Fatal and Nonfatal Unintentional Injury for Children and Teens and the Role of Lifestyle Clinicians: A Commentary

Unintentional injury and death as a public health concern has not been established in the pediatric population. This is a commentary on a review of epidemiological data of unintentional deaths and injuries with a focus on age, sex, and racial differences in this population. The review takes in-depth look at children aged 0-19 years in the US, followed by a discussion of strategies suggested to address mechanisms of these injuries/deaths. Lifestyle clinicians have a significant role in educating this population and their parent/guardians. Therefore providing insight into the interpretation of the data can support practical education and prevention interventions.

The Teen Driver

For many teenagers, obtaining a driver's license is a rite of passage, conferring the ability to independently travel to school, work, or social events. However, immaturity, inexperience, and risky behavior put newly licensed teen drivers at risk. Motor vehicle crashes are the most common cause of mortality and injury for adolescents and young adults in developed countries. Teen drivers (15-19 years of age) have the highest rate of motor vehicle crashes among all age groups in the United States and contribute disproportionately to traffic fatalities. In addition to the deaths of teen drivers, more than half of 8- to 17-year-old children who die in car crashes are killed as passengers of drivers younger than 20 years of age. This policy statement, in which we update the previous 2006 iteration of this policy statement, is used to reflect new research on the risks faced by teen drivers and offer advice for pediatricians counseling teen drivers and their families.

Precision Prevention and Early Detection of Cancer: Fundamental Principles

Prevention and early detection is critical for reducing the population cancer burden. Two approaches have been used: Population approaches change social norms (e.g., smoking bans) or impose incentives (e.g., cigarette taxes); high-risk strategies intervene upon individuals with elevated cancer risk (e.g., smoking cessation). Knowledge about carcinogenesis mechanisms, extreme exposures, and inherited susceptibility provides opportunities to develop precision prevention and early-detection (PPED) strategies. PPED aims to understand the basis of risk, identify groups that optimally benefit from interventions, characterize heterogeneity in intervention responses, optimize intervention timing, and minimize toxicities. We propose a framework around which PPED strategies can be developed. Currently available cancer prevention and early-detection approaches have the potential to reduce a large proportion of the cancer burden in the population. However, even if fully implemented, existing methods cannot fully eliminate the cancer burden. New PPED approaches that exploit the growing knowledge of molecular and biological cancer mechanisms should be developed and implemented. Cancer Discov; 8(7); 803-11. ©2018 AACR.

Developmental Aspects of Unintentional Injury Prevention Among Youth: Implications for Practice

Unintentional injuries, the leading cause of morbidity and mortality among youth in the United States, are burdensome and costly to society. Continued prevention efforts to reduce rates of unintentional injury remain imperative. We emphasized the role of practitioner influence across a linear concept of injury prevention comprising delivery, practice, and application/generalization and within the context of child developmental factors. Specific strategies for injury prevention tailored to the cognitive development stage of the patient are provided. This information may be useful to health care practitioners, who have significant interaction with youth and their families.

Precisely Where Are We Going? Charting the New Terrain of Precision Prevention

In addition to genetic data, precision medicine research gathers information about three factors that modulate gene expression: lifestyles, environments, and communities. The relevant research tools-epidemiology, environmental assessment, and socioeconomic analysis-are those of public health sciences rather than molecular biology. Because these methods are designed to support inferences and interventions addressing population health, the aspirations of this research are expanding from individualized treatment toward precision prevention in public health. The purpose of this review is to explore the emerging goals and challenges of such a shift to help ensure that the genomics community and public policy makers understand the ethical issues at stake in embracing and pursuing precision prevention. Two emerging goals bear special attention in this regard: (a) public health risk reduction strategies, such as screening, and (b) the application of genomic variation studies to understand and reduce health disparities among population groups.

The Role of Sleep in the Relationship Between Victimization and Externalizing Problems in Adolescents

Victimization is linked to externalizing outcomes in adolescents and recent theorizing suggests that sleep plays a role in this relationship; however, there is little evidence examining sleep as a mediator. This study examines associations between victimization experiences and changes in aggression, delinquency, and drug use. Data were obtained from three waves of a school-based study with middle-school youth (n = 785; 55 % female; 20 % African American; M = 12.32, SD = .51 years at T1), and path analyses were used to test the key hypotheses. Analyses controlling for major life events, demographic factors, and school site revealed that victimization indirectly affected delinquency and drug use, but not aggression, through its relationship with sleep problems. Further, the effects of sleep problems on drug use were specific to females. These data suggest that intervening to address sleep problems resulting from victimization may serve to reduce some forms of externalizing behavior.