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INTRODUCTION: Rural communities often face chronic challenges of high rates of serious health conditions coupled with inadequate access to health care services-challenges exacerbated by the COVID-19 pandemic. One strategy with the potential to mitigate these problems is the increased use of telehealth technology. A feature of telehealth applications-collaboration between health care providers for consultation and other purposes-referred to herein as Rural Provider-to-Provider Telehealth (RPPT), introduces important expertise that may not exist locally in rural communities. Literature indicates that RPPT is operationalized through many methods with an array of purposes. While RPPT is a promising strategy that brings additional expertise to patient-centered rural care delivery, there is limited evidence addressing important considerations, including how patient access and outcomes, provider satisfaction and performance, and payment may be affected by its use. METHODS: Recognizing the significant potential of RPPT and the need for more information associated with its use, the National Institutes of Health convened a Pathways to Prevention (P2P) workshop to further understand RPPT's effectiveness and impact on improving health outcomes in rural settings. The P2P initiative, supported by several federal health agencies, engaged rural health stakeholders and experts to examine four key questions, identify related knowledge gaps, and provide recommendations to advance understanding of the use and impact of RPPT. RESULTS: Included in this report is a description of the process used to generate information about RPPT, the identification of key knowledge gaps, and specific recommendations to further build needed evidence. DISCUSSION: The emerging use of RPPT is an important tool for bridging gaps in access to care that impacts rural populations. However, to fully understand the value and effects of RPPT, new research is needed to fill the knowledge gaps identified in this report. Additionally, this report should help engage providers, payors, and policymakers interested in supporting evidence-informed RPPT practice, policy, and payment, with the ultimate aim of improving access to health care and health status of rural communities in the United States and worldwide.

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Introduction Little is known about childcare staff's and parents' uptake of and attitudes towards pertussis vaccine. Methods Questionnaires were distributed to St. Louis parents and childcare staff in fall, 2014. Parents versus staff and vaccinated versus unvaccinated individuals' beliefs regarding pertussis vaccine were compared using chi square tests. Multivariate logistic regressions were run to develop predictive models for staff's and parents' vaccine uptake. Results Overall, 351 parents and staff from 23 agencies participated (response rate = 32%). Parents were more likely than staff to have received pertussis vaccine (66.5 vs. 45.8%, X 2 = 12.5, p < .001). Predictors for staff vaccination included willingness to get vaccinated even if there was a cost (OR 6.6; CI 1.8-24.6; p < .01), awareness of vaccination recommendations (OR 5.2; CI 1.2-22.8; p < .05), and healthcare provider recommendation (OR 4.2; CI 1.2-15.1; p < .05). Parents' predictors of vaccination included perceived importance of vaccination (OR 9.9; CI 4.1-23.8; p < .001), healthcare provider recommendation (OR 4.6; CI 1.7-12.6; p < .01), believing vaccination is effective (OR 4.4; CI 1.1-18.0; p < .05), and knowing where to get vaccine (OR 3.5; CI 1.5-8.1; p < .01). Among unvaccinated staff (n = 52), 74.5% (n = 38) and 70.0% (n = 35) would receive pertussis vaccine if it were offered free of charge and onsite, respectively. Conclusions for Practice Childcare staff's and parents' pertussis vaccine uptake was higher than overall U.S. rates, though significantly lower than the Global Pertussis Initiative target. Implementing an education campaign and providing free vaccine on-site are likely to result in increased vaccine uptake.

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BACKGROUND: A 2011 nationwide school pandemic preparedness study found schools to be deficient. We examined the impact of a school nurse educational intervention aimed at improving K-12 school biological event preparedness. METHODS: Missouri Association of School Nurses (MASN) members were e-mailed a survey link in fall 2013 (ie, preintervention), links to online education modules (ie, intervention) in late fall, and a postintervention survey link in spring, 2014. School biological event readiness was measured using 35 indicators, for a possible score range of 0-35. A paired t-test compared pre- to postintervention preparedness scores. RESULTS: A total of 133 school nurses (33.6% response rate) completed a survey; 35.3% of those (N = 47) completed both pre- and postintervention survey that could be matched. Pre- and postintervention preparedness scores ranged from 5 to 28.5 (x‾ = 13.3) and 6.5 to 25 (x‾ = 14.8), respectively. Postintervention scores were significantly higher than preintervention scores for those who watched at least 1 module (t = -2.3, p < .05). CONCLUSION: The education intervention was effective at improving school preparedness, though the impact was small. The education intervention needs to be reassessed, especially in regard to providing a longer intervention period.

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BACKGROUND: Little is known about childcare agency staff vaccination requirements, parents' perceptions of these requirements, or vaccine uptake in these populations. METHODS: A questionnaire was administered to St Louis parents and childcare agency staff in fall of 2014. The χ(2) tests compared staff's versus parents' uptake of hepatitis A, pertussis, and seasonal influenza vaccines. Multivariate logistic regression was used to examine individuals being fully immunized (ie, having received influenza, hepatitis A, and pertussis vaccines). RESULTS: Overall, 351 parents and staff from 23 agencies participated (response rate, 32%). One-third of staff (34.4%, n = 33) and parents (37.6%, n = 96) were fully immunized. Parents and staff were equally likely to have received the influenza vaccine (48.8% and 47.3%, respectively), but more staff received the hepatitis A vaccine (85.3% vs 67.5%, χ(2)=11.0, P < .001), and more parents received the pertussis vaccine (66.5% vs 45.8%, χ(2)=12.5, P < .001). Determinants of being fully immunized included having previously received the influenza vaccine, being offered the vaccines, belief that vaccination is important, having immunization recommendation awareness, and not having vaccine misperceptions. CONCLUSIONS: Childcare agency staff vaccination can protect employees and children from disease, but their uptake of vaccines needs improvement. Future interventions should be aimed at increasing uptake to lower disease transmission in childcare settings.

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BACKGROUND: Vaccine-preventable diseases pose a significant risk to children in childcare. However, few regulations exist regarding childcare staff vaccination. This study aimed to assess support for a childcare agency staff mandatory vaccination policy. METHODS: Surveys were distributed to staff and parents at 23 St Louis, Mo, childcare agencies during fall 2014. Staff and parents' support for a mandatory vaccination and/or agency certification program were compared using χ(2) tests. Multivariate logistic regression was conducted using a 2-level nested design and controlling for gender, race, age, and income to determine predictive models for support for a mandatory staff vaccination policy and/or agency certification program. RESULTS: Overall, 354 parents and staff participated (response rate, 32%). Most supported a mandatory staff vaccination policy (80.0%; n = 280) or agency certification program (81.2%; n = 285), and there were no differences between parents versus staff. Determinants of support for a mandatory policy included willingness to receive influenza vaccine annually, belief that vaccines are safe and effective, and support for the policy only if there were no costs. CONCLUSIONS: There is strong support for some type of childcare agency staff vaccination policy. Implementing such a policy/program should be a collaborative endeavor that addresses vaccine cost and access.

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BACKGROUND: School preparedness for bioevents, such as emerging infectious diseases, bioterrorism, and pandemics, is imperative, but historically has been low. METHODS: The Missouri Association of School Nurses members were sent an online survey during the 2013-2014 school year to assess current bioevent readiness. There were 15 and 35 indicators of school disaster and bioevent preparedness, respectively. Multivariate linear regressions were conducted to delineate factors associated with higher school disaster and bioevent preparedness scores. RESULTS: In total, 133 school nurses participated, with a 33.6% response rate. On average, schools had fewer than half of the disaster or bioevent indicators. Disaster and bioevent preparedness scores ranged from 1-12.5 (mean, 6.0) and 5-25 (mean, 13.8), respectively. The least frequently reported plan components included bioterrorism-specific psychological needs addressed (1.5%, n = 2), having a foodservice biosecurity plan (8.3%, n = 11), and having a liberal sick leave policy for bioevents (22.6%, n = 30). Determinants of better bioevent preparedness include perception that the school is well prepared for a pandemic (P = .001) or natural disaster (P < .05), nurse being on the disaster planning committee (P = .001), and school being a closed point of dispensing (P < .05). CONCLUSION: Schools are underprepared for biological events and are not on track to meet state and national biological preparedness goals.

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Communities will rely on open points of dispensing (PODs) for mass dispensing of medical countermeasures following a bioterrorism attack or a pandemic. US Cities Readiness Initiative (CRI) open POD preparedness is assessed using the Technical Assistance Review (TAR) but focuses on oral prophylaxis dispensing; mass vaccination readiness is not well measured. Non-CRI preparedness had not been studied. In 2013 an online questionnaire was sent to all 456 CRIs and a random sample of 500 non-CRIs to measure open POD preparedness and exercise participation. Hierarchical linear regression was used to describe factors associated with higher POD preparedness and exercise participation scores. In total, 257 subjects participated, for a 41% response rate. Almost all open PODs have existing written plans and/or a layout for each site (93.4%, n=240, and 87.0%, n=220). Only half (46.7%, n=120) have an alternative dispensing modality in place, and even fewer (42.6%, n=104) report having adequate staffing. Determinants of open POD preparedness were perceived preparedness, participation in more POD exercises, and more closed POD coverage. Most jurisdictions conducted a full-scale exercise and a staff notification drill (83.7%, n=215 for both). Fewer than half (40.5%, n=104) have conducted a vaccination clinic exercise. Determinants of increased POD exercises were perceived preparedness, years of work experience, community type (nontribal), and larger population. Because successful open POD deployment is critical, jurisdictions need to plan for mass vaccination, use of alternative dispensing modalities, and recruitment strategies to increase POD staffing.

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Disaster planners' attitudes toward pre-event anthrax and smallpox vaccine for first responders and point-of-dispensing (POD) workers have not been examined. An online questionnaire was sent to US Cities Readiness Initiative (CRI) and non-CRI public health disaster planners in 2013. Multivariate logistic regressions were used to assess determinants of belief that first responders and POD workers should be offered the anthrax and/or smallpox vaccine before an event. A total of 301 disaster planners participated. Only half (50.6%, n=126) were aware of the ACIP recommendation that first responders could be offered pre-event anthrax vaccine. Many (66.0%, n=164) believed that pre-event anthrax vaccine should be offered to first responders. The oldest respondents were least likely to believe anthrax vaccine should be given (OR: 0.27, 0.12, 0.63, p<.001). Fewer disaster planners believed that pre-event anthrax vaccine should be offered to POD workers compared to first responders (55.0% vs 66.0%, X(2)=151, p<.001). Almost 20% (18.3%, n=47) reported having already received pre-event smallpox vaccine. Among the unvaccinated (n=210), half (52.0%, n=105) were willing to receive pre-event smallpox vaccine if it was offered free of charge. Half (53.4%, n=133) believed that POD workers should be offered smallpox vaccine before an event. Many disaster planners support pre-event anthrax vaccination for first responders and POD workers, and about half support pre-event smallpox vaccine for POD workers. Jurisdictions should consider partnering with first responder agencies to implement a pre-event anthrax vaccination program.

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BACKGROUND: Points of dispensing (PODs) are deployed for medical countermeasure mass dispensing. However, infection prevention and vaccine administration pre-event training offered and just-in-time (JIT) education planned for POD workers have not been assessed. METHODS: Disaster planners were sent an online questionnaire in 2013. McNemar tests compared training offered to staff versus volunteers and pre-event training versus JIT training. RESULTS: In total, 301 disaster planners participated. The most frequent pre-event training included hand hygiene (59.1% and 28.0%) and personal protective equipment (PPE) selection (52.1% and 24.1%) for staff and volunteers, respectively. Few provided pre-event training on the cold chain technique (14.8% and 5.1%) or smallpox vaccine administration (4.7% and 2.3%) for staff or volunteers. For all topics except smallpox vaccine administration, more staff than volunteers received pre-event training (P < .01). The most frequent planned JIT training includes hand hygiene (79.8% and 73.5%) and PPE selection (79.4% and 70.0%) to staff and volunteers. For all topics, more JIT education is planned for staff than volunteers (P < .001). More JIT training is planned than has been given pre-event for all topics (P < .001). CONCLUSION: More pre-event training is needed on infection prevention and vaccine administration to ensure safe and successful POD deployment.

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INTRODUCTION: Thoracic outlet syndrome (TOS) refers to a group of conditions resulting from compression of the neurovascular structures of the thoracic outlet. The parameters for physical therapy include myofascial release (MFR), neuromuscular therapy (NMT), muscle strengthening, and stretching. This case study examined the effects of neuromuscular therapy, massage, and other manual therapies on a 56-year-old female presenting with bilateral numbness over the forearms and hands on waking. Numbness occurred most days, progressing to "dead rubbery" forearms and hands once or twice a month. METHODS: The treatment plan was implemented over eight weeks and consisted of six, 50-minute bodywork sessions. Several nonbodywork strategies were also employed to address potential contributing factors to the TOS symptomology experienced by the client. Objective measurements included posture analysis (PA), range of movement (ROM), and Roos and Adson's tests. The Measure Your Own Medical Outcome Profile (MYMOP2), a client-generated measure of clinical outcome, was used to measure clinical change. RESULTS: MYMOP2 overall profile score results demonstrated an improvement of 2.25 from pretreatment to post-treatment measurement. Clinically meaningful change was measured by the individual and was indicative of substantial symptom improvement where a score change of over one was considered as meaningful. CONCLUSIONS: A course of massage was effective for numbness symptoms in an individual with TOS, and results lasted over a year without additional treatments. Further research is needed to fully understand the effects of massage for TOS symptoms.

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Dr. Mary Wakefield is the administrator of the Health Resources and Services Administration. She came from the University of North Dakota, where she directed the Center for Rural Health. She has served as director of the Center for Health Policy, Research and Ethics at George Mason University and has worked with the World Health Organization's Global Programme on AIDS in Geneva, Switzerland. She is a fellow in the American Academy of Nursing and was elected to the Institute of Medicine of the National Academies. A native of North Dakota, Wakefield holds a doctoral degree in nursing from the University of Texas.

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In an eyetracking study, we examined whether readers use psychological essentialist reasoning and perspective taking online. Stories were presented in which an animal or an artifact was transformed into another animal (e.g., a donkey into a zebra) or artifact (e.g., a plate into a clock). According to psychological essentialism, the essence of the animal did not change in these stories, while the transformed artifact would be thought to have changed categories. We found evidence that readers use this kind of reasoning online: When reference was made to the transformed animal, the nontransformed term ("donkey") was preferred, but the opposite held for the transformed artifact ("clock" was read faster than "plate"). The immediacy of the effect suggests that this kind of reasoning is employed automatically. Perspective taking was examined within the same stories by the introduction of a novel story character. This character, who was naïve about the transformation, commented on the transformed animal or artifact. If the reader were to take this character's perspective immediately and exclusively for reference solving, then only the transformed term ("zebra" or "clock") would be felicitous. However, the results suggested that while this character's perspective could be taken into account, it seems difficult to completely discard one's own perspective at the same time.

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