Research Approaches

Working Together to Improve Life Course Health

We are finishing up our deep dive into HRSA/MCHB’s strategic paradigm “Accelerate Upstream Together” by exploring how LCIRN researchers are working together to improve long-term health trajectories. Finding new ways to work together means exploring new approaches to working across disciplines, adopting new collaborative ways of working with family, community and youth as equal research partners, and ensuring that groups historically under-represented in research are now integral partners in collaborative research efforts. None of these new ways of working together happens automatically- each takes a real commitment from network members to be willing to set aside old ways of doing things, embrace and try new models, adjust to more equitable and productive power dynamics, and share credit for achievements across whole teams and networks of partners. Here we highlight four ways in which the LCIRN is pursuing more effective ways of working together towards our goals.

1. Transdisciplinary teams are of increasing importance for conducting life course intervention research. Individual researchers are unlikely to possess all of the knowledge, tools skills, and relationships, required for carrying out complex and multi-faceted research, but teams can be thoughtfully built and managed to include a variety of skills and perspectives. This type of teamwork is integral to effective translational research, though it is not a straightforward process. Transdisciplinary work requires humility and willingness to listen respectfully and to learn from others who bring a different perspective to the discussion. Researchers bring both their learned and lived experience to the research effort in ways that can challenge traditional categorizations. Each of our nine LCIRN Nodes is made up of researchers and stakeholders from multiple disciplines.

Example: In the School Node, clinicians and educators work together to improve children’s health through the school environment. Everyone brings their own understanding of the context, the stages of development, sensitive periods and potential points for intervention, how to design an intervention that is feasible and sustainable, and how to measure success.

2. Engaging families and youth stakeholders in all aspects and phases of life course intervention research, from design through to dissemination. Partnering with youth, families, and communities focuses interventions on outcomes that are meaningful to the recipiences and increases the potential for impact and equity over the life course. There is a spectrum of models of engagement, ranging from more traditional methods such as focus groups and consultations, to models like youth-led participatory action research, in which members of the target community are also part of the research team.

Example: As part of a process to envision what transformational change would look like for the youth justice system, Liz Barnert and Laura Abrams conducted focus groups with adolescents impacted by the system, as well as other stakeholders who work with and in the youth justice system.

Example: Family Voices is a key partner for the LCIRN’s engagement. Through our Family and Community Engagement Core, they have consistently provided a family perspective to help the LCIRN Scholars to plan and conduct their pilot projects. This has led to significant refinements and improvement to the study plans and approaches, and to the design and content of study informational materials

3. Partnering with community organizations and programs helps to ensure that interventions are relevant, feasible, and potentially scalable for impact at a population health level.

Example: As part of their LCIRN-funded pilot project, Priyanka Fernandes and Denise Nunez partnered with the Jewels of Youth Foundation to organize a forum for providers and families of children with special health care needs during the early months of the COVID-19 pandemic. The partnership allowed them to interact with and gather further information from underserved families within the region, and led to the development of a virtual emergency preparedness kit tailored to these families and available in Spanish and English

4.  Collaborating across MCHB Research Networks brings together expertise, leverages previous research and resources, and encourages researchers working on similar topics from different perspectives to collaborate in new ways

Example: Marianne Pugatch conducted an LCIRN-funded pilot study testing a virtual behavioral intervention to reduce substance use in teens with ADHD. Dr. Pugatch collaborated with mentors from the Developmental Behavioral Pediatrics Network (DPBNet) and the Adolescent and Young Adult Health Research Network (AYAH-RN) as well as the LCIRN to design, implement, and evaluate this study. More details about Dr. Pugatch’s pilot and how it benefited from cross-network collaboration available HERE

ADHD Adolescence

Intervention spotlight: INSPIRE

Applying a novel behavior change system to reduce alcohol use in teens with ADHD

Overview of the intervention:

INSPIRE is a digital game-based narrative environment developed at the University of California, San Francisco (UCSF) in collaboration with North Carolina State University (Ozer and colleagues) with funding from the National Science Foundation and the National Cancer Institute. Grounded in Social Cognitive Theory, the goal of the INSPIRE intervention is to increase self-efficacy skills and promote competence in adolescent decision-making to reduce alcohol use in a teenage social gathering scenario.

The LCIRN-funded pilot study led by UCSF postdoctoral fellow Marianne Pugatch, PhD, LICSW examines the feasibility and acceptability of applying this innovative virtual behavior change system to the prevention of alcohol use in youth with attention deficit hyperactivity disorder (ADHD), a group known to be at risk for alcohol and substance misuse with major life course health consequences. As a first step, this pilot studied whether youth with ADHD could be engaged with the INSPIRE platform, and whether engagement promotes adolescent-initiated conversations with parents about alcohol use. Preliminary data show that adolescents with ADHD were engaged in the intervention. 

What makes this a life course intervention?

INSPIRE is designed to impact teen alcohol use at a sensitive period of 14-16 years and interrupt the risk trajectory of teen alcohol use. Further, it is designed to be vertically integrated into primary care settings and has been developed through a human-centered design process. As part of our evaluation of INSPIRE’s performance in this applied setting, we examined its potential impact on the parent-child ecosystem, including assessing the frequency of parent-teen communication regarding alcohol use in teens with ADHD. This intervention may be particularly well suited for youth with ADHD as it generates personalized interactive narratives addressing developmental characteristics of impulsivity and dysregulation through reinforcement learning, goal setting, and problem-solving.  

What are the benefits of collaborating across networks and institutions?

Applying this innovative behavior change system in a real-world setting was made possible through the collaboration of multiple individuals, disciplines, institutions and networks. The opportunity to leverage the current INSPIRE study to conduct this pilot project capitalized on prior federally funded research of the investigator team across institutions. It also enabled us to work collaboratively across three Maternal and Child Health research networks (Developmental -Behavioral Pediatrics Research Network; LCIRN; Adolescent and Young Adult Health Research Network), each bringing different resources and expertise. We collected data for the pilot through Developmental Pediatric Clinics. We worked with a senior investigator team that supported adding questions about ADHD to the survey and served as mentors on the project. We included an examination of parent-teen communication around alcohol use as a result of a discussion with the LCIRN team.

What are the next steps?

Future research will examine the effects of INSPIRE on self-efficacy, knowledge, and alcohol use among adolescents with ADHD.  We will potentially pursue additional funding to develop a parent component to INSPIRE. 


LCIRN Co-Hosts 2022 INRICH Workshop

The Life Course Intervention Research Network was recently honored to co-host with Cincinnati Children’s Hospital the 13th Annual Workshop of the International Network for Research into Inequalities in Child Health (INRICH).    Over three days in June we heard from international leaders in child health equity research on the workshop theme of Building Adaptive Interventions to Achieve Health Equity Across the Life Course. Neal Halfon, PI of the LCIRN, Director of the UCLA Center for Healthier Children, Families and Communities and Professor of Pediatrics, Public Health and Public Policy at UCLA, together with Rob Kahn, Professor and Associate Chair of Community Health, University of Cincinnati Department of Pediatrics, Executive Lead Population and Community Health and All Children Thrive (ACT) Cincinnati opened the workshop with an Introduction to the Life Course Health Development Approach to Interventions.  

The LCIRN has developed a framework showing how key characteristics of life course interventions can be incorporated across all stages of the research process to guide intervention development, testing and evaluation with the aim of finding ways to improve health trajectories. Characteristics included co-design of interventions with family and community engagement, strengths-based interventions focused on health optimization and interventions that were developmentally focused and strategically timed. Multi-level interventions, integrated across sectors that target upstream factors including social and structural determinants of health and that address emerging health development capabilities hold promise for health trajectory impacts.

Presentations on Day 1 addressed Working towards Shared Frameworks and Shared Metrics for Child Equity and on Day 2 Adaptive Multi-Level Approaches to Interventions to Improve Equity.  The concluding interactive session on Day 3 on Aligning Rhetoric and Research to Impact Global Child Health Equity drew together common themes from the conference presentations and began to consider practical next steps towards applying the most recent research findings to developing and implementing actionable interventions.  A full report from the conference will be released later this year, however some highlights included:

John Wright shows a wheel with the the various measures and data systems that feed into Connected BradfordJohn Wright, Director, Bradford Institute for Health Research, Bradford, UK presented on “A Little Less Association, A Little More Action” new approaches to implementing and evaluating early life interventions. John reported on their findings that many determinants of children’s health are socially patterned, and that poverty and inequalities are persistent and hard to change. Children’s lives are not being shaped by individual risk factors but by the streets they play on, the houses they live in, the quality of schools, food options- in other words by complex, interactive, systems factors.

Bradford City Collaboratory aims to have a cumulative effect by implementing public health interventions in one place where they are most needed. Key tenets include co-production with communities; harnessing and connecting routine data; and translating evidence into policy.

Front cover of the Child of the North reportKate Pickett, Professor of Epidemiology, University of York, UK & David Taylor-Robinson, Professor of Public Health and Policy, Institute of Population Health, University of Liverpool, UK presented on Deep causes of inequality, and why are multi-level, comprehensive interventions necessary

David presented data from their recent Child of the North Report explaining that the north/south divide in child health in the UK explains the north/south divide in adult health. To ensure an adequate quality of life for all families with children requires action and putting children at the heart of intervention development and government policy. Children’s voices need to be at the center of this conversation.

Systems work practices ensure that primary actors are at the heart of the process by fostering connection, embracing context, and reconfiguring powerCynthia Rayner, Adjunct Lecturer & Senior Researcher, Bertha Centre for Social Innovation, University of Cape Town Graduate School of Business, South Africa gave a presentation entitled Systems Work: Harnessing Connection, Context & Power to Create Equitable Systems for All. Based on her book The Systems Work of Social Change co-authored with Francois Bonnici, Cynthia’s presentation explored how the ideas in the book might be applied to child health equity.

  • We are the systems we seek to change. By participating in them, we maintain and extend them.
  • How can we explore the day-to-day practices, beliefs and behaviors, values and assumptions about how systems work in order to change them?
  • Adopting a systems approach means not just analyzing the system in “industrial” terms but also acquiring an in-depth understanding of the human relationships between the people within the systems.
  • This approach reconfigures power towards those with lived experience of an issue, and who are part of the communities who are seeking change.

Two prizes were awarded for poster presentations:

Saltanat Childress, University of Texas Arlington School of Social Work and LCIRN Scholar

Poster: Family wellbeing in global cultures: Establishing foundations for adaptive interventions for children’s health equity in Kyrgyzstan

Shuang Zhou, Erasmus Medical Center, Rotterdam, The Netherlands, School of Public Health, Peking University, Beijing, China

Poster: Neighborhood socioeconomic status mobility and childhood growth trajectory: The Generation R study

The full workshop program can be found on the INRICH website and you can watch all of the speakers and poster presentations on YouTube. LCIRN members are invited to consider joining INRICH. Next year’s workshop will be held in Paris, France.


Upstream Interventions

accelerate upstream togetherWe’re continuing our deeper dive into HRSA/MCHB’s strategic paradigm “Accelerate Upstream Together”. This newsletter we’re exploring how the LCIRN is moving interventions “upstream” to either prevent the development of health challenges, or address and reverse them as soon as they occur. Upstream interventions are more likely to be successful than interventions that are applied only after conditions are well established.

Yet these interventions are also more challenging to design and implement because there are so many factors that contribute to the development of health challenges over long periods of time. The Life Course Health Development (LCHD) framework indicates that in order to develop effective upstream interventions we must understand those “pivot points” or key factors in a child’s developmental ecosystem that are most important in the genesis of health challenges, and how and when to intervene to act on them. Upstream interventions may address:

  1. Events and experiences early in life, including the sensitive pre-and peri-conception periods. Evidence suggests that certain aspects of this life stage are particularly important in setting the foundation for future health, including secure early relationships, capacity for emotional regulation and establishing healthy behaviors.
  2. Aspects of the child’s family and community environment that are not traditionally targeted by health interventions, including social and structural determinants of health – factors in the child’s family and community environments that can impact their sense of well-being and their life-long health.

In order to design and implement effective interventions to improve health, we need to understand when and how these factors exert their influence, and how to either prevent events or experiences that pose health threats from occurring, or to mitigate any potentially harmful effects once they occur.


Intergenerational Migrant Health Interventions

Migrants experience significant changes in their social and cultural environments, some of which pose challenges to their health trajectories. The immigration experience is part of the history of America. In the past, as now, this experience occurred in a variety of contexts- for many it was a much welcomed, awaited and desired change with new hope for the future.  For others it was an unexpected response to a traumatic event, such as war or persecution, and for some the move was enforced and even at times against a person’s will. We are now starting to understand that the nature and consequences of the immigrant experience can have profound effects on a person’s health and well-being and can even impact the health of future generations.

The LCIRN is funding two pilot projects aimed at understanding and improving intergenerational migrant health:

  • Saltanat Childress, LCIRN Scholar and Assistant Professor of Social Work at the University of Texas-Arlington is studying ways to prevent Adverse Childhood Experiences (ACEs) and promote family well-being among immigrants from Central Asia and the former Soviet Union. Her pilot study “Family Wellbeing in Global Cultures: Establishing Foundations for Adaptive Interventions Across the Lifespan” aims to identify key socio-cultural and psychological risk and protective factors that can affect the family life of immigrants and refugees. She plans to explore how these factors are related to caregiver and child/adolescent outcomes, and what strategies are used to navigate family processes.
  • Kevin Roy, Professor of Social Work at the University of Maryland and Jerica Berge, Professor and Vice-Chair for Research, Dept Family Medicine and Community Health, University of Minnesota Medical School are conducting an LCIRN pilot study into the relationship between “Immigrant Father Involvement and Child Health/Well-Being over the Lifespan.” The role of immigrant fathers is an understudied aspect of life course health research. This mixed-methods study aims to explore how men and their families cope with the challenges of acculturation, economic setbacks, legal issues and constrained educational opportunities, and which factors promote or constrain their own and their family’s health and well-being.

By understanding more about these upstream factors and the way they impact life-long health and well-being, we can start to work alongside immigrant populations to co-create new types of interventions that will best address challenges and have a positive impact on health development trajectories.


Intervention Spotlight: Family Foundations + Financial Coaching

We asked PI Mark Feinberg to give us an update on his new study which aims to combine the Family Foundations preventive co-parenting intervention with a financial coaching intervention.

Overview of the intervention:

We have begun a line of work that seeks to mitigate disparities between low-income and wealthier parents and children by providing education and skills-based coaching to expectant, low-income parents in financial management and co-managing household and child-related financial matters. We are developing a new prevention approach by adapting and integrating two evidence-based models: (1) a model of financial education and coaching for low-income individuals deployed by Capital Good Fund, a Rhode Island-based non-profit working in six states; and (2) a preventive intervention developed at PSU that helps first-time parents build supportive coparenting relationships (Family Foundations; FF).

Why was this adaptation needed? How will it help to accelerate progress?

There is great potential synergy in integrating the two areas: Finances are a major source of conflict among couples, particularly low-income couples who already have a high level of financial instability. Financial strain and interparental conflict contribute to key factors that undermine children’s development and well-being: parental stress and depression, father disengagement, and harsh parenting. This innovative project will not only integrate financial education and coaching with support for positive, cooperative coparenting, but also develop new material that supports low-income parents in extending coparenting skills (communication, problem-solving, joint family management) to cooperation and coordination around financial responsibilities. 

What makes this a life course intervention?

This approach is based in a life course health framework as financial strain and interparental conflict are linked risk factors for young children’s development, affecting basic physiological and psychological self-regulatory capacities with implications for health throughout the lifespan.conceptual model of family foundations co-parenting intervention shows connections between environment, parent relationships, and child well-being

What are the next steps?

To create the integrated program, we are first conducting qualitative interviews with racially/ethnically diverse, low-income parents to understand their experiences and concerns in the pregnancy and early childhood periods. We will then develop the adapted program, gain feedback on the new material from low-income parents, and finally conduct a pilot test to assess feasibility and generate data to support an NIH RO1 application for a randomized trial.


Accelerating Upstream Together

accelerate upstream together

In our Year 3 in Review, we reflected on HRSA/MCHB’s strategic paradigm “Accelerate Upstream Together”. Let’s take a deeper dive into what we’re doing at the LCIRN around each of these topics, starting with “accelerate”.

Accelerate means to work faster to improve MCH outcomes and eliminate disparities. At the LCIRN we are approaching this in three ways.

  1. Making the switch from describing to intervening.

As researchers, we want to understand as much as possible about the processes that lead to healthy development and the ways that they can get off track. While observational epidemiological studies are invaluable, multiple studies that describe, essentially, the same associations are of limited use, and at a certain point we have to stop describing and start intervening. Process studies are still a part of our research portfolio – but only with a view to developing an intervention that can bring about an improvement in health status at individual and population levels. Making this switch is not easy.  Observational studies are quicker and frankly easier to perform. Planning, developing, designing, piloting and fielding a new intervention can take years, and can appear daunting to a new researcher whose research output is being closely monitored. Fortunately, we have senior investigators in the network who have experienced this path and are willing to provide mentorship to our scholars and junior researchers, as well as advocating for greater recognition of the work of intervention development in the faculty review process.

Join Us: Please consider advocating at your own institution for increased recognition of faculty effort in intervention development, especially interventions that are to be delivered in community settings and have a focus on health equity.

  1. Funding Pilot Studies

The LCIRN has made a commitment to devote a portion of our funding to supporting pilot studies that hold real promise for the development of new approaches to interventions. These pilot studies are being conducted by our LCIRN node members, who are mid-level or senior researchers testing an intervention in preparation for applying for funding for a larger study; and by our LCIRN Scholars, a group of early-career intervention researchers. Scholar Dr. Keisha Wint, for example, is piloting an intervention designed to help preschool teachers support children when they grieve. 

  1. Stacking and Bundling Effective Interventions

This approach takes interventions that already have a strong evidence base and links them together through an integrated delivery system to a targeted population such that the overall impact is greater than that of any one intervention alone. Drs. Michael Msall and Susan Hintz are developing the “Success After Prematurity” node around this concept – identifying and scaffolding existing interventions, then filling in the gaps, to ensure that low-income families of preemies have access to the resources and interventions they need to give their children the best opportunities for development.

Bundled interventions may be particularly effective when they address social determinants of health – e.g., Dr. Adam Schickedanz, leader of the LCIRN Adversity, Adaptation and Resilience Node has been studying the impact of medical-financial partnerships as a way to improve child and family health. Mark Feinberg, leader of the Family Health Development Node is studying new ways to couple his evidence-based co-parenting intervention, Family Foundations, with financial coaching.

Cross-Cutting Issues Resources

Family Matters

Graphic showing four families

by Shari Barkin and Sophia De Oliveira

Families matter. In fact, family health is the most proximal social determinant of health we have. While many measurement tools exist for individuals, it is just as critical to measure family functioning to capture context.  The Family Measurement Node, nested in the Life Course Intervention Research Network, conducted a scoping literature review to identify existing family functioning tools and innovative opportunities for further development. We created a matrix to identify these tools and, when available, a link to access them easily. The ultimate goal of the family measurement node is to consistently implement family measurement to pinpoint areas for intervention and inform policy.

We identified 40 tested family functioning tools and created a family measurement tool matrix. These tools assess different aspects of family functioning such as organizational processes, belief systems, and communication processes.  We encourage you to try it out and let us know how this helps you further your life course research intervention development and implementation, keeping family front and center.


Complex Systems

Book Review: The Ecology of Childhood: How our Changing World Threatens Children’s Rights

The Ecology of Childhood:  How our Changing World Threatens Children’s Rights

By Barbara Bennett Woodhouse 2020 New York University Press

Review by Shirley Russ

In her book The Ecology of Childhood, Barbara Bennett Woodhouse tells the compelling story of how she initially set out to conduct an ethnographic study comparing children’s well-being in the Cedar Key area of Florida, where there appear to be few social safety nets, and the village of Scanno in the Abruzzo Region of Italy, with its much more generous child welfare policies. However, the Great Recession in 2008 had major impacts on the lives of children in both regions, transforming her study from a comparison of policies to one which instead revealed the power of global forces to threaten the well-being of all children. The author lays out how the direct and indirect effects of the recession and subsequent reactions, including economic stimulus packages in the US, and strict austerity measures in Italy, had an immediate and lasting impact on children and their families, and brought home how closely the fortunes of different countries are tied together. In short, policies developed and enacted in the US affect children in the US, but also affect children in Italy.  Globalization is real and tangible and, Woodhouse argues, a force that must be addressed for children to thrive.

Woodhouse documents a detailed study of the microsystems – e.g. family and peer groups where children’s daily lives unfold; the mesosystems where the microsystems overlap and intersect – e.g. in faith-based schools in local communities; and the exosystems that encircle children’s worlds even though children do not enter them – e.g. parents work place, housing markets, demonstrating how forces in each of these systems impact children’s sense of identity and well-being. What she has to say is not encouraging, with a disturbing number of trends placing ever increasing pressures on the family unit and on children, including climate change, mass migration, job losses and the technological revolution to name but a few. 

The situation appears so acute, and so much at risk of entering a bigger downward spiral, that the author argues a global movement is urgently needed to safeguard children’s well-being. She views the most sensible place to start as the universal adoption of the UN Convention on the Rights of the Child, a Children’s Right treaty that has not currently been adopted by the US. Those who are hesitant about the UN Rights approach frequently cite concerns about the potential erosion of the role of the family as protector, provider and nurturer of children; while supporters of the approach emphasize the profound nature of the global changes occurring in society, and the potential threats to children that families alone would have little power to counteract. In this book, despite making a strong case, I do not think the author will quite succeed in either allaying the fears of the first group, or providing the second with a strong enough argument to win the day. For example, Italy has already adopted the UN Convention on Children’s Rights, but it is unclear what impact that might have had on their response to the great recession. However, she does provide excellent examples of the power of youth and children’s voices, and the need to have them heard and considered by decision-makers at all levels. 

The rights agenda is not all that Woodhouse has to offer. In her previous writings she has developed the idea of “ecogenerism,” a child-centered and environmentally-informed perspective on events. Its guiding philospophy regards a commitment to the welfare of future generations as the mark of a just and sustainable society. This leads on to proposals for a child-centered value system as a measure of how well a society is truly functioning.  Here, the author is on solid and familiar ground. In Chapter 5, she explores two current crises largely attributable to exosystemic factors: the sharp decline in birth rates in developed countries, and the migration of young people from rural to urban areas. Her arguments are well developed, balanced and compelling. Do we really want a future where young people are afraid to have children for fear of not being able to support them, or one where younger generations must leave behind older in search of ever-moving jobs and affordable housing, severing family and social ties in the process? These are real and immediate issues affecting almost all families worldwide, and the author’s sincerity in making the case for the need to address them urgently makes for particularly strong writing.  

Woodhouse’s ecogenerism idea resonates strongly with life course approaches to health development. Both are “future-leaning” in their orientation, arguing that investments early on pay dividends later in ways that are good not just for some but for the whole of society. As stewards of the environment, we must look to the future, considering not just the immediate impact of our actions, but the likely impact 10, 50 even 100 years from now. Children benefit from spending time in nature in ways that we are only beginning to fully understand, and one of the most powerful incentives for finding the best ways to interact with our environment is to leave behind a world where children can thrive. This “intergenerational perspective” has yet to permeate the political arena in a meaningful way, and this book goes a long way towards making the argument for an “ecogenerative” or “life course” lens to be applied to all contemporary decision-making.  

In the final chapter, Woodhouse returns to a “small is beautiful” approach, urging grassroots actions that incorporate the principles of children’s rights, advancing child-friendly communities, and building a world fit for children. This book has much to offer anyone interested in children’s rights, and an ecological approach to the study of children’s well-being. It is an excellent and informative resource for anyone studying – or teaching – on child development, and will be sure to spark much classroom debate.


Charting the Life Course: an interdisciplinary blueprint

Charting the life course: an interdisciplinary blueprint visualizes the pathways forward: integrate data sets across the life span, improve data science, model high-dimensional data in new ways, systems and network modeling, standardized measures

The NCATS Life Course Research Visual Toolkit, Charting the Life Course: An Interdisciplinary Blueprint, which officially launched on April 14th, serves to increase knowledge about innovative life course research methods by providing content that is widely available and accessible to researchers across multiple disciplines through both longer and shorter visual formats presented by national and international experts in life course research.

In addition to the six recorded webinars, there are shorter 5 – 15 minute videos to allow a personalized educational approach for anyone interested in learning more about life course research methods and applications. The video archive, available in the CLIC Education Clearinghouse and Life Course Visual Toolkit YouTube Channel, includes both broad overviews of the subject matter and ‘How To’ videos that describe best practices for applying data science and complex methodological techniques to life course research questions.

This toolkit was made possible through the generous contributions of the planning committee and speakers’ time, with support from the Vanderbilt (VUMC 5UL1TR002243-04) and Utah (ULTTR002538) CTSAs and partial funding from the Life Course Intervention Research Network (Health Resources and Services Administration, UA6MC32492). Drs. Heidi Hanson and Shari Barkin led the working group to develop and create the toolkit.