Lisa M. Vaughn

Objective: To characterize factors influencing mental health following concussion from the perspectives of youth, their parents, and community stakeholders. Setting: Virtual sessions hosted by a tertiary care children's hospital. Participants: Youth aged 11–17 years with recent concussion, their parents, clinicians, trainers, coaches, and school personnel. Design: Qualitative study using focus groups (FGs) and group-level assessment (GLA) sessions. FGs used semistructured guides to elicit experiences. GLA followed a six-step process to generate, reflect on, and prioritize shared insights. Thematic analysis was applied to FG transcripts, while GLA themes were collaboratively developed. Themes from both methods were synthesized using card-sort methodology and iterative team review. Main Measures: Thematic synthesis of stakeholder perspectives on factors affecting postconcussion mental health. Results: FG sessions included 20 participants (15 youth, 5 parents); GLA sessions included 32 (10 youth, 9 parents, 13 stakeholders). Five convergent themes emerged: (1) concussion knowledge: education and informed care reassured, whereas limited knowledge, minimization of symptoms, and delays increased distress; (2) support systems: family, peer, school, and clinician support with timely accommodations protected mental health, whereas lack of support, bullying or peer pressure, and pressure to recover quickly hindered recovery; (3) preinjury mental health: previous anxiety or depression heightened risk and complicated recovery; (4) identity and sense of self: adapting expectations and embracing a “new normal” aided adjustment, whereas isolation and role change added strain; and (5) coping strategies: gradual return to activities, self-care, consistent routines, and celebrating progress supported recovery, whereas pressure to “push through” and rushed reintegration were detrimental. Conclusion: These qualitative insights revealed multifactorial influences on postconcussion mental health across individual, family, school, and care contexts. Implications include enhancing stakeholder education, promoting coordinated support across settings, integrating routine mental health assessments, addressing identity and role changes, and encouraging adaptive coping strategies to optimize recovery.

Background: Concept mapping (CM) is a widely used mixed method research approach for structuring and visualizing complex ideas across various fields, such as the health sciences. A critical bottleneck in the CM process is the idea synthesis phase, which remains labor-intensive, subjective, and consequently challenging to scale for large datasets. Objective: In this study, we propose IdeaDistiller, a semiautomated solution based on semantic clustering to optimize the idea synthesis step while maintaining methodological rigor through a human-in-the-loop approach. Methods: Using 9 health care–related datasets in English and Swedish, we systematically evaluated different embedding models, dimensionality reduction techniques, and clustering algorithms to identify robust and reproducible parameter settings for the proposed approach. IdeaDistiller clusters participant-generated ideas based on semantic similarity to identify similar ideas with different wording, suggests representative and unique ideas per cluster, and provides coherence scores and sorted outputs to aid manual validation. Results: Our findings suggest that IdeaDistiller may substantially reduce the manual effort involved in idea synthesis while preserving quality and transparency. However, human expertise remains indispensable for validating and refining cluster outputs. Conclusions: Integrating semiautomated methods into the CM workflow offers significant potential for improving the efficiency, scalability, and rigor of the CM process. Building on our work will enable the exploration of larger multilingual datasets and integration into future CM studies.

Rheumatic heart disease (RHD) requires long-term secondary antibiotic prophylaxis to prevent disease progression, yet sustained patient engagement remains challenging in many low- and middle-income countries. Within Uganda’s first integrated decentralized RHD control program, Accelerating Delivery of Rheumatic Heart Disease Preventive Services in Uganda (ADUNU), we applied a human-centered design (HCD) approach to co-develop strategies for improving engagement in care. Using two Group Level Assessment sessions (with n = 43 stakeholders) and three design focus group discussions (n = 23 stakeholders), participants identified and prioritized feasible implementation strategies. Strategies were synthesized into four domains: community integrated follow-up, structured patient health education and counselling, provider capacity and service delivery improvement, and strengthening stock planning for medicine availability. These co-developed strategies directly address barriers related to missed appointments, limited understanding of RHD, provider-patient interactions, and medicine stockouts within decentralized primary care settings. This participatory approach generated contextually grounded strategies, ready for prospective testing within decentralized RHD programs.

Background: Children and adolescents presenting to emergency departments (EDs) with mental and behavioral health (MBH) concerns frequently exhibit agitation, which poses safety risks for patients and staff and strains ED resources. Validated tools for agitation risk stratification in pediatric MBH populations are lacking, and evidence-based, risk-informed management strategies remain underdeveloped. Addressing these gaps is critical to reducing the need for emergent interventions, enhancing safety, and optimizing care delivery. Objective: This study aims to (1) evaluate the predictive ability of a brief pediatric agitation risk prediction tool, a 5-item version of the Brief Rating of Aggression by Children and Adolescents (BRACHA-S), and (2) codevelop an associated risk-based management plan bundle. Methods: This is a single-center prospective mixed methods study. First, we conducted a prospective cohort study enrolling children and adolescents aged 5 to 18 years who presented to the ED with MBH concerns. At ED triage, nurses completed the BRACHA-S risk assessment tool. The primary outcome, agitation requiring intervention, was defined as the use of pharmacologic agents, physical restraints, or mechanical restraints for events of agitation or aggression, as extracted from the electronic health record and confirmed through chart review. Second, we will use qualitative participatory methodologies, including key informant interviews, group-level assessments, and participatory design workshops, to codevelop a multifaceted, tiered, risk-based management plan designed to mitigate agitation and aggression in pediatric ED patients. Insights will be gathered from diverse stakeholders, including patients, parents or guardians, and members of the care team. Results: Funding was secured in July 2024. Initial data collection commenced in October 2024 and is projected to conclude in 2026. For aim 1, enrollment was completed on November 1, 2025, achieving the targeted sample size of 472 participants. We hypothesize that the BRACHA-S will demonstrate strong predictive validity (area under the curve >0.70) for agitation requiring intervention. Data collection for aim 2 began in October 2025, with analysis and results anticipated by June 2026. As of April 2026, 10 patients and parents/guardians were enrolled for key informant interviews, 30 staff members were enrolled for group-level assessment sessions, and 9 participants were enrolled for participatory design workshops. For this aim, we will codevelop a stakeholder-informed, tiered, risk-based agitation management pathway aligned with BRACHA-S risk strata. Conclusions: This study outlines a pragmatic approach to early agitation risk identification and the management of agitation in pediatric ED settings. If BRACHA-S demonstrates predictive validity and is paired with a stakeholder-informed, tiered management pathway, this strategy could fill critical gaps in validated tools and structured workflows, ultimately enabling timely, least-restrictive interventions and improving patient and staff safety.

[This corrects the article DOI: 10.2196/85971.].

Background: Immigrants experience significant health disparities, which are exacerbated by a heavy stress burden, which in turn affects the epigenetic profiles of the immune system, leading to chronic diseases. Cumulative stress burden for immigrants ranges from immigration-related stressors to unique psychosocial, environmental, and everyday challenges, all of which contribute to negative psychological and biological impacts on their health over the life-course. Although social and environmental conditions have been established as key factors driving disparities in health outcomes, the effects of stress and epigenetic change among immigrants remain poorly understood, impeding the development of novel and robust intervention approaches aimed at reducing health disparities. Epigenetic changes can act as surrogate markers for the stress effect. However, very few studies have examined epigenetic marks associated with stress among African immigrants. Ethiopians form one of the largest groups of African immigrants in the United States; yet, this is the first study of this kind among Ethiopian American immigrants. Objective: This protocol aims to quantify cumulative stress burden and determine DNA methylation (DNAm) associated with stress among Ethiopian American immigrants. Methods: Working with community partners, a community advisory board, and 3 community research coordinators, we will conduct a community-engaged research study of Ethiopian American immigrants. Data collection occurs at public events, church gatherings, and festivals. We use a multistation model composed of five stations through which participants rotate: (1) eligibility screening and consent, (2) stress-related questionnaires, (3) clinical measures, (4) health status and demographic questionnaires, and (5) saliva collection and incentive receipt. The measures used are: Stress of Immigration Survey, Boen’s stress exposure measure, 10-item Perceived Stress Scale, Patient-Reported Outcomes Measurement Information System Global Health Scale (version 1.2), 8-item Patient Health Questionnaire, and 7-item Generalized Anxiety Disorder. Latent profile analysis, chi-square tests, and logistic regression will be used. Saliva samples will be tested using genome-wide DNAm. With a subset of the sample, we will also conduct and thematically analyze qualitative interviews to understand additional experiences of stress and buffers to stress among participants. Results: This study received National Institutes of Health R21 grant funding. Data collection began in October 2024 and will continue until November 2025 (currently at 89% completion). In November 2025, we will start data cleaning and analysis of questionnaires, clinical measures, and DNAm. We plan to complete data analyses and prepare scientific and community outputs by the Spring of 2026. Conclusions: The study will provide new insights to address health disparities among growing immigrant populations in the United States, informing novel and robust intervention approaches to reduce chronic illness and associated sequelae for vulnerable populations. Findings from this study may highlight the need for policy change, such as providing more support in the form of infrastructure and social service agencies for immigrants. International Registered Report Identifier (IRRID): DERR1-10.2196/85971

BACKGROUND Children and adolescents presenting to emergency departments (EDs) with mental and behavioral health (MBH) concerns frequently exhibit agitation, which poses safety risks for patients and staff and strains ED resources. Validated tools for agitation risk stratification in pediatric MBH populations are lacking, and evidence-based, risk-informed management strategies remain underdeveloped. Addressing these gaps is critical to reducing the need for emergent interventions, enhancing safety, and optimizing care delivery. OBJECTIVE This study aims to (1) evaluate the predictive ability of a brief pediatric agitation risk prediction tool, a 5-item version of the Brief Rating of Aggression by Children and Adolescents (BRACHA-S), and (2) co-develop an associated risk-based management plan bundle. METHODS This is a single-center prospective mixed-methods study. First, we conducted a prospective cohort study enrolling children and adolescents aged 5–18 years who presented to the emergency department (ED) with mental and behavioral health (MBH) concerns. At ED triage, nurses completed the BRACHA-S risk assessment tool. The primary outcome, agitation requiring intervention (ARI), was defined as the use of pharmacologic agents, physical restraints, or mechanical restraints for events of agitation or aggression, extracted from the electronic health record and confirmed through chart review. Second, we will employ qualitative participatory methodologies, including key informant interviews, group-level assessments (GLA), and participatory design workshops (PDW), to co-develop a multi-faceted, tiered, risk-based management plan designed to mitigate agitation and aggression in pediatric ED patients. Insights will be gathered from diverse stakeholders, including patients, parents or guardians, and members of the care team. RESULTS Funding was secured in July 2024. Initial data collection commenced in October 2024 and is projected to conclude in 2026. For Aim 1, enrollment was completed on November 1, 2025, achieving the targeted sample size of 472 participants. We hypothesize that the BRACHA-S will demonstrate strong predictive validity (AUC > 0.70) for agitation requiring intervention. Data collection for Aim 2 began in October 2025, with analysis and results anticipated by June 2026. For this aim, we will co-develop a stakeholder-informed, tiered, risk-based agitation management pathway aligned with BRACHA-S risk strata. CONCLUSIONS This study outlines a pragmatic approach to early agitation risk identification and management of agitation risk in pediatric ED settings. If BRACHA-S demonstrates predictive validity and is paired with a stakeholder-informed, tiered management pathway, this strategy could fill critical gaps in validated tools and structured workflows, ultimately enabling timely, least-restrictive interventions and improving patient and staff safety.

Introduction: Primary prevention of rheumatic heart disease (RHD) is aimed at timely diagnosis and treatment of superficial Group A Streptococcal infections, most commonly Strep sore throat. However, uptake and delivery of primary prevention for RHD-endemic regions has room for improvement. Community co-design is an important aspect of intervention development to increase sustainability and reach. Methods: Group-level assessment (GLA) sessions were used to understand the community’s priorities and insights around sore throat. Personas, or user archetypes, were then developed to capture the behaviours and characteristics of diverse future users of primary prevention in the district. Finally, these personas were used in community design workshops to identify barriers and facilitators to potential interventions, generate creative solutions to overcome identified barriers and prioritise implementation models based on impact and feasibility. The final list of implementation strategies was presented by workshop participants to the broader community for additional validation and feedback. Results: The GLA sessions identified five priority areas: (1) need for improved access to care, closer to home; (2) importance of mothers as caregivers; (3) strong influence of community leaders; (4) importance of community health workers and (5) role of traditional providers and practices. Five personas were created, including: hands-on caregiver, restricted caregiver, removed family decision-maker, helpful neighbour and influential leader. Design workshops identified the highest-rated interventions as: decentralisation of care delivery into the community (strategy 1), use of community health workers as key implementing partners (strategy 2) and streamlining sore throat services at public healthcare facilities (strategy 3). Participants proposed potential practical applications of these interventions. Conclusions: Community-based participatory research identified novel implementation strategies for an RHD primary prevention programme in Uganda. The value set and strategies developed in this study can now be used as guideposts to develop and test a package of implementation strategies for improving RHD primary prevention in Uganda.

BACKGROUND Concept mapping (CM) is a widely used mixed method research approach for structuring and visualising complex ideas across various fields, for example health sciences. A critical bottleneck in the CM process is the idea synthesis phase, which remains labor-intensive, subjective, and consequently challenging to scale for large datasets. OBJECTIVE In this study, we propose IdeaDistiller, a semi-automated solution based on topic modeling to optimise the idea synthesis step while maintaining methodological rigor through a human-in-the-loop approach. METHODS Using six healthcare-related datasets in English and Swedish, we systematically evaluated different embedding models, dimensionality reduction techniques, and clustering algorithms to identify robust and reproducible parameter settings for the proposed approach. IdeaDistiller clusters participant-generated ideas based on semantic similarity to identify similar ideas with different wording, suggests representative, unique ideas per cluster, and provides coherence scores and sorted outputs to aid manual validation. RESULTS Our findings suggest that IdeaDistiller may substantially reduce the manual effort involved in idea synthesis while preserving quality and transparency. However, human expertise remains indispensable for validating and refining cluster outputs. CONCLUSIONS Integrating semi-automated methods into the CM workflow offers significant potential for improving the efficiency, scalability, and rigour of the CM process. Building on our work will enable the exploration of larger multilingual datasets and integration in future concept mapping studies. The code for IdeaDistiller is publicly available.