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Background Implementation strategies are strategies to improve uptake of evidence-based practices or interventions and are essential to implementation science. Developing or tailoring implementation strategies may benefit from integrating approaches from other disciplines; yet current guidance on how to effectively incorporate methods from other disciplines to develop and refine innovative implementation strategies is limited. We describe an approach that combines community-engaged methods, human-centered design (HCD) methods, and causal pathway diagramming (CPD)—an implementation science tool to map an implementation strategy as it is intended to work—to develop innovative implementation strategies. Methods We use a case example of developing a conversational agent or chatbot to address racial inequities in breast cancer screening via mammography. With an interdisciplinary team including community members and operational leaders, we conducted a rapid evidence review and elicited qualitative data through interviews and focus groups using HCD methods to identify and prioritize key determinants (facilitators and barriers) of the evidence-based intervention (breast cancer screening) and the implementation strategy (chatbot). We developed a CPD using key determinants and proposed strategy mechanisms and proximal outcomes based in conceptual frameworks. Results We identified key determinants for breast cancer screening and for the chatbot implementation strategy. Mistrust was a key barrier to both completing breast cancer screening and using the chatbot. We focused design for the initial chatbot interaction to engender trust and developed a CPD to guide chatbot development. We used the persuasive health message framework and conceptual frameworks about trust from marketing and artificial intelligence disciplines. We developed a CPD for the initial interaction with the chatbot with engagement as a mechanism to use and trust as a proximal outcome leading to further engagement with the chatbot. Conclusions The use of interdisciplinary methods is core to implementation science. HCD is a particularly synergistic discipline with multiple existing applications of HCD to implementation research. We present an extension of this work and an example of the potential value in an integrated community-engaged approach of HCD and implementation science researchers and methods to combine strengths of both disciplines and develop human-centered implementation strategies rooted in causal perspective and healthcare equity.

This study explores the perceptions and use of complementary and alternative medicine (CAM) by African American women who have been diagnosed with breast cancer when making treatment decisions. The study also addresses to what extent African American women breast cancer survivors perceive themselves as strong advocates for their own health and as leaders in promoting self- health advocacy for other African American women. Issues examined in this study are participants' knowledge, attitudes, and roles in relation to CAM as a treatment option for African American women living in greater metropolitan Seattle, Washington. Areas explored are (a) awareness and understanding of CAM modalities, (b) access/barriers to CAM providers, (c) access/barriers to good nutrition and exercise, (d) the benefits of integrating CAM into treatment plans, (e) how the attitudes of mainstream providers influence the choice of CAM, (f) how spiritual beliefs influence healthcare decisions, and (g) the leadership role of African American women in their own health advocacy. The study design is mixed methods, using two surveys and key informant interviews. It is non-causal, instead focusing on the participants' personal experiences and perspectives relevant to CAM. The sample for the surveys was African American breast cancer survivors. The two key informants were physicians who treat breast cancer patients. All data were triangulated to determine alignment. Keywords: better nutrition, breast cancer, complementary and alternative medicine, exercise, health advocacy, spirituality, western/conventional medicine.

Traditional Chinese medicine (TCM) has been practiced for thousands of years, but only within the last few decades has its use become more widespread outside of Asia. Concerns continue to be raised about the efficacy, legality, and safety of many popular complementary alternative medicines, including TCMs. Ingredients of some TCMs are known to include derivatives of endangered, trade-restricted species of plants and animals, and therefore contravene the Convention on International Trade in Endangered Species (CITES) legislation. Chromatographic studies have detected the presence of heavy metals and plant toxins within some TCMs, and there are numerous cases of adverse reactions. It is in the interests of both biodiversity conservation and public safety that techniques are developed to screen medicinals like TCMs. Targeting both the p-loop region of the plastid trnL gene and the mitochondrial 16S ribosomal RNA gene, over 49,000 amplicon sequence reads were generated from 15 TCM samples presented in the form of powders, tablets, capsules, bile flakes, and herbal teas. Here we show that second-generation, high-throughput sequencing (HTS) of DNA represents an effective means to genetically audit organic ingredients within complex TCMs. Comparison of DNA sequence data to reference databases revealed the presence of 68 different plant families and included genera, such as Ephedra and Asarum, that are potentially toxic. Similarly, animal families were identified that include genera that are classified as vulnerable, endangered, or critically endangered, including Asiatic black bear (Ursus thibetanus) and Saiga antelope (Saiga tatarica). Bovidae, Cervidae, and Bufonidae DNA were also detected in many of the TCM samples and were rarely declared on the product packaging. This study demonstrates that deep sequencing via HTS is an efficient and cost-effective way to audit highly processed TCM products and will assist in monitoring their legality and safety especially when plant reference databases become better established.

Non-disclosure of concussion complicates concussion management, but almost nothing is known about non-disclosure in military settings. This study describes concussion disclosure-related knowledge, attitudes, perceived social norms, perceived control, and intention. Additionally, the study identifies determinants of high intention to disclose concussion symptoms. Cross sectional survey. First-year service academy cadets completed a cross-sectional survey to assess perceptions of concussion disclosure. Independent variables included: gender, race, ethnicity, high school athlete status, NCAA athlete status, previous concussion history, previous concussion education, socioeconomic proxy, concussion-related knowledge, attitudes about concussion, perceived social norms (perceived peer/organizational support and actions), and perceived control over disclosure. Log-binomial regression was used to identify determinants of high intention to disclose concussion symptoms. A total of 972 first-year military service academy cadets completed the survey [85% response; age=18.4±0.9y]. In the simple models, previous concussion history was associated with lower intention to disclose concussion symptoms. High perceived control over disclosure, higher concussion knowledge, more favorable attitudes and social norms about concussion were associated with high intention to disclose. In the multivariable model, a 10% shift towards more favorable perceived social norms (PR=1.28; p<0.001) and attitudes (PR=1.07; p=0.05) about concussion were associated with high intention to disclose concussion symptoms. High perceived control over disclosure was associated with high intention to disclose concussion symptoms (PR=1.39; p=0.08). Concussion-related perceived social norms, attitudes, and perceived control are associated with intention to disclose. Organizationally appropriate intervention strategies can be developed from these data.

BackgroundCessation counseling and pharmacotherapy are recommended for hospitalized smokers, but better coordination between cessation counselors and providers might improve utilization of pharmacotherapy and enhance smoking cessation.ObjectiveTo compare smoking cessation counseling combined with care coordination post-hospitalization to counseling alone on uptake of pharmacotherapy and smoking cessation.DesignUnblinded, randomized clinical trialParticipantsHospitalized smokers referred from primarily rural hospitalsInterventionsCounseling only (C) consisted of telephone counseling provided during the hospitalization and post-discharge. Counseling with care coordination (CCC) provided similar counseling supplemented by feedback to the smoker’s health care team and help for the smoker in obtaining pharmacotherapy. At 6 months post-hospitalization, persistent smokers were re-engaged with either CCC or C.Main MeasuresUtilization of pharmacotherapy and smoking cessation at 3, 6, and 12 months post-discharge.Key ResultsAmong 606 smokers randomized, 429 (70.8%) completed the 12-month assessment and 580 (95.7%) were included in the primary analysis. Use of any cessation pharmacotherapy between 0 and 6 months (55.2%) and between 6 and 12 months (47.1%) post-discharge was similar across treatment arms though use of prescription-only pharmacotherapy between months 6–12 was significantly higher in the CCC group (30.1%) compared with the C group (18.6%) (RR, 1.61 (95% CI, 1.08, 2.41)). Self-reported abstinence rates of 26.2%, 20.3%, and 23.4% at months 3, 6, and 12, respectively, were comparable across the two treatment arms. Of those smoking at month 6, 12.5% reported abstinence at month 12. Validated smoking cessation at 12 months was 19.3% versus 16.9% in the CCC and C groups, respectively (RR, 1.13 (95% CI, 0.80, 1.61)).ConclusionSupplemental care coordination, provided by counselors outside of the health care team, failed to improve smoking cessation beyond that achieved by cessation counseling alone. Re-engagement of smokers 6 months post-discharge can lead to new quitters, at which time care coordination might facilitate use of prescription medications.Trial RegistrationNCT01063972

Limited data exist concerning differences in concussion-education exposure and how education exposures relate to care seeking and symptom disclosure, specifically by National Collegiate Athletic Association Division I student-athletes. To investigate demographic characteristics associated with concussion-education exposure and examine whether overall education exposure (yes versus no) and education-source exposure number (multiple sources versus a single source) affect concussion care-seeking and disclosure factors in Division I student-athletes. Cross-sectional study. Classroom or online survey. Division I student-athletes (n = 341). Frequencies and proportions were computed for sex, race, school year, sport, and concussion history across concussion-education groups. Prevalence ratios (PRs) and 95% CIs were calculated to quantify the associations between student-athlete characteristics and (1) overall concussion-education exposure and (2) source-exposure number. Separate multivariable linear regression models estimated adjusted mean differences (MDs) and 95% CIs, which allowed us to assess differences in concussion knowledge, attitudes, and perceived social norms relative to concussion-education exposure and exposure to multiple sources. Separate multivariable binomial regression models were performed to estimate adjusted PRs and 95% CIs in order to evaluate associations of intention, perceived control, and care-seeking or disclosure behaviors and overall concussion-education exposure and exposure to multiple sources. All models controlled for sex, sport, and concussion history. Overall, 276 (80.9%) participants reported previous concussion education, with 179 (64.9%) being exposed to multiple sources. Student-athletes who participated in a contact sport (adjusted PR = 1.24; 95% CI = 1.06, 1.44) and those who had a concussion history (adjusted PR = 1.19; 95% CI = 1.09, 1.31) had higher prevalences of concussion-education exposure. Females had a lower prevalence of reporting multiple sources (adjusted PR = 0.82; 95% CI = 0.68, 0.99). Overall concussion-education exposure was significantly associated with more favorable perceived social norms surrounding concussion care seeking (adjusted MD = 1.37; 95% CI = 0.13, 2.61). These findings highlighted the potential differences in overall concussion-education exposure and provide clinicians with information on groups who may benefit from additional targeted education.

There are limited data connecting personality and behavioral tendencies and traits related to concussion care-seeking/disclosure behaviors and minimal research exists surrounding the relationship between risky behaviors, sensation-seeking, and concussion-related outcomes. This study examined the association between sensation-seeking and a student-athlete’s concussion-related knowledge, attitudes, perceived social norms, and concussion care-seeking/disclosure behaviors (intention to disclose concussion symptoms, perceived control over symptom disclosure, self-removal from play due to concussion symptoms, continued play with concussion symptoms, and disclosure of all concussions at the time of injury). The current study utilized a retrospective cohort of collegiate student-athletes at a single National Collegiate Athletic Association Division I institution. Separate multivariable linear regression models estimating mean differences (MD) and 95% Confidence Intervals (CI) estimated the association between sensation-seeking and concussion knowledge, concussion attitudes, and perceived social norms. Separate multivariable binomial regression models estimating adjusted prevalence ratios (PR) and 95%CI estimated the association between sensation-seeking and intention to disclose concussion symptoms, perceived control over symptom disclosure, self-removal from play due to concussion symptoms, continued play with concussion symptoms, and disclosure of all concussions at the time of injury. All models were adjusted for sex, sport participation, and concussion history. Higher sensation-seeking was significantly associated with less favorable concussion attitudes (adjusted MD = -1.93; 95%CI = -3.04,-0.83), less favorable perceived social norms surrounding concussion (adjusted MD = -1.39; 95%CI = -2.06,-0.72), and continuing to play while experiencing concussion symptoms (adjusted PR = 1.50; 95%CI = 1.10, 2.06). Student-athletes with increased sensation-seeking could be at risk for failing to disclose a concussion, decreasing athlete safety and resulting in less optimal care post-injury. Results will inform future theory-based concussion education programs which consider behavioral tendencies and traits as well as sport culture to promote concussion care-seeking/disclosure and individualized interventions based on risky behavior engagement.

Context: There are limited data concerning differences in concussion education exposure and how education exposures relates to care-seeking and symptom disclosure, specifically in Division I student-athletes. Objective: Investigate demographic characteristics associated with concussion education exposure and examine whether overall education exposure (yes vs. no) and education source exposure number (multiple sources vs. single source) affects concussion care-seeking and disclosure factors in Division I student-athletes. Design: Cross-sectional survey. Setting: Classroom or online. Participants: NCAA Division I student-athletes (n=341). Main Outcome Measure(s): Frequencies and proportions were computed for sex, race, school year, sport, and concussion history across concussion education groups. Prevalence ratios (PR) and 95% confidence intervals (CI) quantified the association between student-athlete characteristics and 1) overall concussion education exposure and 2) source exposure number. Separate multivariable linear regression models estimated adjusted mean differences (MD) and 95%CI to assess differences in concussion knowledge, attitudes, and perceived social norms relative to concussion education exposure and exposure to multiple sources. Separate multivariable binomial regression models estimated adjusted PRs and 95%CI to assess associations of intention, perceived control, and care-seeking/disclosure behaviors and overall concussion education exposure and exposure to multiple sources. All models controlled for sex, sport, and concussion history. Results: Overall, n=276 (80.9%) reported previous concussion education, with 179 (64.9%) exposed to multiple sources. Student-athletes that participated in a contact sport (adjusted PR=1.24, 95%CI=1.06,1.44) and those who had a concussion history (adjusted PR=1.19, 95%CI=1.09,1.31) had higher prevalence of previous concussion education exposure. Females had a lower prevalence of reporting multiple sources (adjusted PR=0.82, 95%CI=0.68, 0.99). Overall concussion education exposure was significantly associated with more favorable perceived social norms surrounding concussion care-seeking (adjusted MD=1.37, 95%CI=0.13,2.61). Conclusions: Findings highlight potential differences in overall concussion education exposure and provide clinicians with information on groups who may benefit from targeted additional education.

Background: The skin serves as the first line of defence for an organism against the external environment. Despite the global significance of salmon in aquaculture, a critical component of this first line of defence, mesenchymal stromal cells, remains unexplored. These pluripotent cells can differentiate into various tissues, including bone, cartilage, tendon, ligament, adipocytes, dermis, muscle and connective tissue within the skin. These cells are pivotal for preserving the integrity of skin tissue throughout an organism lifespan and actively participate in wound healing processes. Results: In this study, we characterise mesenchymal stromal cells in detail for the first time in healthy Atlantic salmon tissue and during the wound healing process. Single-nucleus sequencing and spatial transcriptomics revealed the transcriptional dynamics of these cells, elucidating the differentiation pathways leading to osteogenic and fibroblast lineages in the skin of Atlantic salmon. We charted their activity during an in vivo wound healing time course, showing clear evidence of their active role during this process, as they become transcriptionally more active during the remodelling stage of wound healing. Conclusions: For the first time, we chart the activity of sub-clusters of differentiating stromal cells during the process of wound healing, revealing different spatial niches of the various MSC subclusters, and setting the stage for investigations into the manipulation of MSCs to improve fish health.Competing Interest StatementRoss D. Houston and Carolina Penaloza are an employees of Benchmark Genetics, a commercial salmon breeding company. The other authors declare no competing interests.