Wise Program Research Articles

Landing wise program: feasibility study protocol for Parkinson's disease.

Regardless of the benefits of fall prevention programs, people with Parkinson's disease (PD) will still fall. Therefore, it is crucial to explore novel therapeutic approaches that are well-accepted and effective for addressing fall risk and the fear of falls among this population. The present study aims to assess the feasibility of the Landing Wise program as a therapeutic intervention for reducing the fear of falling in people with PD. A mixed-methods study will be conducted using convenience sampling to recruit 20 people with PD with a moderate concern of falling from a Parkinson's Patients Association. In addition to usual care, participants will attend 2 days per week, 90 min group sessions for 8 weeks. The intervention combines group cognitive behavioral intervention with the training of safe landing strategies. Feasibility will be assessed by six key domains (recruitment strategy and rates, enrollment, retention, acceptability, reasons for decline/withdrawal, and adverse events). Quantitative data will be analyzed using descriptive statistics to characterize the sample, followed by inferential statistics to evaluate differences in the Short Falls Efficacy Scale-International Scale, Movement Disorder Society Unified Parkinson's Disease Rating Scale, Timed Up Go, 6-Minutes Walking Distance, and fall frequency and severity scores between baseline and final assessment. Qualitative data will be analyzed using an inductive thematic analysis process. There is a growing interest in developing new effective therapeutic approaches for people with PD. If proven program feasibility, this study precedes a randomized controlled trial to establish the effectiveness of the Landing Wise program.

Girls Get WISE-A programming model for engaging girls+ in STEM.

The majority of STEM disciplines in Canada are male-dominated and there is a significant lack of programming available to girls. The Girls Get WISE program is a university-based program that is funded by the federal government, the university, and corporate sponsorship. This program is delivered in person by educational professionals, science students, and past participants. By engaging girls in hands-on interactive STEM activities in a safe and fun space, this program provides an opportunity for young women to showcase their talents and excitement for science-based topics. The features of this program and its evaluation over a 10 year period are described here.

S278 Assessing Adherence to Recommending 10-Year Intervals After Normal Screening Colonoscopy in Average-Risk Individuals Based on Specialty and Practice Status

Introduction: After a normal average-risk CRC screening colonoscopy, endoscopists should recommend repeat screening in 10 years. Target is 90% adherence per guidelines, and this has been a priority quality indicator for CMS Medical Incentive Payment System and the ACPs Choosing Wisely Program. Our 2017 quality improvement (QI) project showed poor adherence (less than 40%) among private gastroenterologists and academic surgeons. Prior to commencing a new QI initiative, this project assessed frequency of adherence in 2021 at a single site. Methods: Inclusion criteria: To minimize confounders, patients were limited to: (a) average-risk, 50-82 year old; (b) colonoscopy performed in 2021; (c) sole indication of CRC screening; (d) no biopsy, polypectomy, or reference to abnormal findings on procedure report. Study Setting: Hospital-based “open” endoscopy suite (i.e., utilized by academic/private gastroenterologists and academic surgeons) at an academic tertiary care center. Primary Outcome: Adherence to guideline intervals defined as repeat colonoscopy in 10 years, discontinuation of CRC screening due to patient’s age when bowel preparation is adequate or repeat colonoscopy within 1 year if bowel preparation is poor/inadequate. Adherence rates stratified by specialty and type of practice: academic gastroenterologist (n = 7), academic surgeon (n = 3), or private gastroenterologist (n = 6). Differences in adherence between groups assessed using chi-square analysis. Results: Among 465 eligible patients, mean age was 60.1 +/- 8.2 years, 38.5% male, and 76.8% African American. Adherence surpassed target of 90% adherence for academic gastroenterologists (total=96.0%) with (96.9%) or without GI fellows (88.9%) and was superior to adherence by private gastroenterologists or academic general surgeons (p < 0.001). The latter two groups were adherent in 32.4% and 42.3%, respectively (Figure). Adherence was significantly better with good/excellent bowel preps (71.8%) compared to other bowel prep categories (p< 0.001), and patients with poor, fair, or no documentation of prep were adherent in 42.1% (Table). Conclusion: In this project, adherence among academic gastroenterologist met guideline-specified target of 90% when a gastroenterology fellow participated in the procedure. In all other groups, adherence did not meet the recommended threshold. These data are similar to our 2017 QI project and identify an excellent opportunity for a quality intervention educational and monitoring project to improve performance.Figure 1.: Adherence to Guidelines per Endoscopic Specialty Table 1. - Adherence to Recommended Intervals stratified by Bowel Preparation Bowel Preparation Adherence to Recommended Intervals* P-value No Documentation 42.9% (9/21) < 0.001 Poor/Inadequate 62.2% (28/45) Fair 19.5% (8/41) Good/Excellent 71.8% (257/358) *Adherence to recommended intervals by guidelines defined as a 10-year repeat colonoscopy recommendation if colonoscopy was normal in an average-risk individual, < 1 year was recommended if the bowel preparation was inadequate, or repeat colonoscopy not recommended if patient was ≥66 years at time of normal colonoscopy.

Teaching invasive species ethically: using comics to resist metaphors of moral wrongdoing & build literacy in environmental ethics

Invasive species outreach has long leaned on problematic and oversimplified messaging that narrowly frames the issue as binary: good-native vs. evil-invasive. Contemporary invasive species educational programming in the United States, as illustrated in this article, draw on this same approach that, while attention grabbing, both reinforces xenophobic rhetoric and fails to adequately educate on the complicated ethical decision-making processes that go into invasive species management. In response to this gap, I identify educational strategies using storytelling and narrative, specifically comics creation, as a productive way of deepening student engagement with invasive species management and building literacy in ethical environmental decision-making. Using comics without proper framing, however, might still reproduce good/evil binaries, as I exemplify using the Oregon Sea Grant WISE Program’s Aquatic Invasions! A Menace to the West invasive species comics curriculum. I suggest that improving comics-based invasive species curricula should include an emphasis on process-based learning and reflective practice to model the iterative nature of environmental management and provoke critical thinking about invasive species representation.

Association of a Geriatric Emergency Department Innovation Program With Cost Outcomes Among Medicare Beneficiaries

There has been a significant increase in the implementation and dissemination of geriatric emergency department (GED) programs. Understanding the costs associated with patient care would yield insight into the direct financial value for patients, hospitals, health systems, and payers. To evaluate the association of GED programs with Medicare costs per beneficiary. This cross-sectional study included data on Medicare fee-for-service beneficiaries at 2 hospitals implementing Geriatric Emergency Department Innovations in Care Through Workforce, Informatics, and Structural Enhancement (GEDI WISE) (Mount Sinai Medical Center [MSMC] and Northwestern Memorial Hospital [NMH]) from January 1, 2013, to November 30, 2016. Analyses were conducted and refined from August 28, 2018, to November 20, 2020, using entropy balance to account for observed differences between the treatment and comparison groups. Treatment included consultation with a transitional care nurse (TCN) or a social worker (SW) trained for the GEDI WISE program at a beneficiary's first ED visit (index ED visit). The comparison group included beneficiaries who were never seen by either a TCN or an SW during the study period. The main outcome evaluated was prorated total Medicare payer expenditures per beneficiary over 30 and 60 days after the index ED visit encounter. Of the total 24 839 unique Medicare beneficiaries, 4041 were seen across the 2 EDs; 1947 (17.4%) at MSMC and 2094 (15.4%) at the NMH received treatment from either a GED TCN and/or a GED SW. The mean (SD) age of beneficiaries at MSMC was 78.8 (8.5) years and at NMH was 76.4 (7.7) years. Most patients at both hospitals were female (6821 [60.8%] at MSMC and 8023 [58.9%] at NMH) and White (7729 [68.9%] at MSMC and 9984 [73.3%] at NMH). Treatment was associated with statistically significant mean savings per beneficiary of $2436 (95% CI, $1760-$3111; P < .001) at one ED and $2905 (95% CI, $2378-$3431; P < .001) at the other ED in the 30 days after the index ED visit. The association between treatment and mean cumulative savings at 60 days after the index ED visit per beneficiary was also significant: $1200 (95% CI, $231-$2169; P = .02) at one ED and $3202 (95% CI, $2452-$3951; P < .001) at the other ED. Among Medicare fee-for-service beneficiaries, receipt of ED-based geriatric treatment by a TCN and/or an SW was associated with lower Medicare expenditures. These estimated cost savings may be used when calculating or considering the bundled value and potential reimbursement per patient for GED care programs.

Implementing the Med Wise Program in rural Alberta: A feasibility study to support seniors.

Implementing the Med Wise Program in rural Alberta: A feasibility study to support seniors.

Etiology and Outcomes of Acute Kidney Injury in Patients Admitted to a Single Tertiary Care Hospital: Balochistan Institute of Nephrology-Urology Quetta

Acute kidney injury (AKI) is a common clinical syndrome with broad spectrum of etiologies and an important cause of morbidity and mortality requiring hospitalization. Depending on the cause and nature of AKI it may complicate to be life threatening or even proceed to Chronic Kidney disease (CKD) compromising the quality of life.&#x0D; Methods: The current retrospective study determines the causes and outcomes of AKI in patients of different age groups, who required hospitalization at our tertiary care hospital from March 2018 to March 2020. Possible etiologic conditions for AKI were recorded during the study period and AKI was classified according to the causes, age and outcome.&#x0D; Results: records of total of 267 patients with diagnosis of AKI were obtained who were admitted during the study period. Obstetric related diagnosis was the commonest reason for AKI (n= 50 18.7%), another 42 (15.7%) had obstructive nephropathy, prerenal AKI in 35 patients (13.1%) and other causes such as glomerulonephritis, sepsis, pigment nephropathy and drug related interstitial nephritis among others.&#x0D; Majority of the patients needed dialytic support, n=190 (71.2%) and majority of patients n=181 patients (67.7%) recovered completely, and only 11 patients (4.2%) expired.&#x0D; Conclusion: Our study reveals that majority of patients with AKI presenting to BINUQ had reversible causes of AKI with complete recovery in significant number of patients. Community wise programs to early detect AKI with prompt treatment will decrease the likelihood of such patients adding to the CKD population.

12. Black Bear Conservation efforts in Ontario

Over the past 200 years, large carnivore range has been decreased due to an increase in human density and influence through agriculture and industrialization. The black bear (Ursusa americanus) is a severely impacted species which has experienced nearly a 50% range loss and has been extirpated from parts of North America. Much public controversy surrounds this species, due to issues associated with hunting, human-bear interactions, and species management strategies. Increasing public awareness of black bear ecology, a charismatic megafauna, will spark positive and pro-conservation efforts across North America. Therefore, area and knowledge-specific education is important in engaging affected communities in black bear ecology and the importance of conservation. The Ministry of Natural Resources has made an effort in these areas by establishing the Bear Wise Program, however there is room within this program for expansion and development of their initiatives. Such expansions include improvement of public education, community outreach and youth awareness of black bears in a holistic ecosystem, versus case specific, approach. Identification of high-impact areas in Ontario would support the allocation of provincial resources to address these issues by implementing changes in local infrastructure, educational development and region-specific management. This project builds off of already established black bear management to increase region and province-wide conservation. The knowledge provided through this project will allow for future efforts across a wide geographical area.

Implementation of ferritic steel as in vessel wall: Lessons learnt and follow up

ASDEX Upgrade (AUG) is the only tokamak in Europe to have low activation ferritic steel as the inner vessel wall facing component. Together with the massive tungsten tiles in the lower divertor, AUG is the tokamak with the closest DEMO wall. The project is a first step towards the extensive use of ferritic steel in future fusion reactors. For example, the test blanket module of ITER is planned to have a ferritic steel wall and thick tungsten tiles as a plasma facing component.The ‘ad hoc’ ferritic steel built with low activation capability is known as Eurofer. As the low activation property is not a requirement for AUG, the material selected for the project is the martensitic steel P92 which is the most similar material to Eurofer from a magnetic point of view. The purpose of the project is to improve understanding of the magnetic perturbation of the ferritic steel both on the plasma and magnetic probes, evaluating and controlling these effects. Additionally, the effect of the additional forces on the supporting structure has been addressed.Bearing this in mind, in 2013 a step wise program has been started and part of the W coated graphite tiles in the region of the inner column were replaced by steel tiles [1]. The first campaign did not suffer any particular issue related to the new material. According to the calculations, the plasma was almost unperturbed, thanks also to the toroidal symmetry of the tiles inside the vessel, and the magnetic probe measurements were properly corrected [2].Inspection of the machine pointed out some hardware problems. The graphite tiles adjacent to the steel tiles were damaged. The graphite tiles had broken edges in 5 from 64 positions and notches in many others. The coating of the graphite and steel tiles, made of tungsten and TiO respectively, was damaged. At first glance it was clear that the steel tiles were moving but it was definitely unexpected. In understanding the process, the location of the damage was the crucial hint. In fact all failures were located at the boundary between 2 vacuum vessel octants. To justify this failure mode inside the vessel, a hypothesis (about current flowing in the heat shield supporting structure) was made and FEM analyses were carried out in this direction. With extreme caution, in 2015 just one additional row of steel tiles was added together with diagnostics that confirmed the hypothesis. Now that a clear understanding of the problem has been reached, the project to add further rows of steel tiles can be continued. For the next campaign it is planned to replace all the tiles in the middle region of the heat shield together with stiffening and modification of the supporting structure.In this paper the learning process from the damage of the tiles and its causes, from the FEM analysis results to the data diagnostics will be reported. The future plans for steel tiles in AUG will be discussed.

Understanding sustainable seafood consumption behavior: an examination of the Ocean Wise (OW) initiative in British Columbia

Dolmage, K. M., V. Macfarlane, and J. Alley. 2016. Understanding sustainable seafood consumption behavior: an examination of the Ocean Wise (OW) initiative in British Columbia. Ecology and Society 21(2):26.http://dx.doi.org/10.5751/ES-08491-210226

Med Wise: A theory-based program to improve older adults' communication with pharmacists about their medicines.

The health and economic toll of medication errors by older adults is well documented. Poor communication and medication coordination problems increase the likelihood of adverse drug events (ADEs). Older adults have difficulty communicating with health care professionals, including pharmacists. As such, the theory-based Med Wise program was designed. Building on the Self-efficacy Framework and the Chronic Care Model, this program was tested with community-dwelling older adults. This study and its resultant paper: (1) describe the theory-based design of the Med Wise program; (2) describe the collaboration of multiple community partners to develop a sustainable model for implementing Med Wise; and (3) present findings from the Med Wise course evaluation. Med Wise was designed to be a sustainable, skill-based educational and behavior change program consisting of two, 2-h interactive classes to enhance participants' medication communication skills and self-efficacy. To explore the potential to disseminate Med Wise throughout the state, a partnership was formed between the pharmacy team and the statewide Aging & Disability Resource Centers (ADRCs), as well as the Community-Academic Aging Research Network (CAARN). Over 30 lay volunteer leaders in 8 Wisconsin (U.S. State) counties were trained, and they delivered Med Wise through ADRC community centers. The CAARN staff evaluated the fidelity of the course delivery by leaders. To evaluate Med Wise, a quasi-experimental design using pre/post surveys assessed knowledge, worry and self-efficacy. A telephone follow-up three months later assessed self-efficacy and translation of medication management skills and behaviors. Med Wise programs were presented to 198 community-dwelling older adults while maintaining program fidelity. This evaluation found significant increases in older adults' knowledge about pharmacists' roles and responsibilities, likelihood of talking with a pharmacist about medication concerns, and self-efficacy for communicating with pharmacists. At the 3 month follow-up, participants reported increased interactions with pharmacists, with 29.2% of participants reported seeking medication reviews and 28.5% medication schedule reviews. The two-class Med Wise program showed sustained impact at 3 months on key outcomes. Further, the community partners successfully implemented the program with fidelity across 8 counties suggesting its ability to be disseminated and sustained. Future directions include expanding the program to examine wider adoption, and measuring program impact on regimen safety and health outcomes linked to increases in patient engagement.

Do Wise Choices Translate Into Cost Savings and Improved Outcomes?

Do Wise Choices Translate Into Cost Savings and Improved Outcomes?

Redesigned geriatric emergency care may have helped reduce admissions of older adults to intensive care units.

Charged with transforming geriatric emergency care by applying palliative care principles, a process improvement team at New York City's Mount Sinai Medical Center developed the GEDI WISE (Geriatric Emergency Department Innovations in Care through Workforce, Informatics, and Structural Enhancements) model. The model introduced workforce enhancements for emergency department (ED) and adjunct staff, including role redefinition, retraining, and education in palliative care principles. Existing ED triage nurses screened patients ages sixty-five and older to identify those at high risk of ED revisit and hospital readmission. Once fully trained, these nurses screened all but 6percent of ED visitors meeting the screening criteria. Newly hired ED nurse practitioners identified high-risk patients suitable for and desiring palliative and hospice care, then expedited referrals. Between January2011 and May2013 the percentage of geriatric ED admissions to the intensive care unit fell significantly, from 2.3percent to 0.9percent, generating an estimated savings of more than $3million to Medicare. The decline in these admissions cannot be confidently attributed to the GEDI WISE program because other geriatric care innovations were implemented during the study period. GEDI WISE programs are now running at Mount Sinai and two partner sites, and their potential to affect the quality and value of geriatric emergency care continues to be examined.

Rates of reflux before and after laparoscopic sleeve gastrectomy for severe obesity.

A current management dilemma in laparoscopic sleeve gastrectomy (LSG) patients is the development of significant gastroesophageal reflux symptoms after surgery. Treatment is typically directed towards reducing acid reflux despite the surgical removal of parietal cell mass. In contrast, laparoscopic Roux-en-Y gastric bypass (LRYGB) has been known to reduce or resolve preoperative reflux symptoms. The objective of this study was to determine the incidence of preoperative and postoperative reflux of LSG and LRYGB patients, and review reflux treatment type and response. A retrospective chart review was performed for patients undergoing either LSG or LRYGB between January 2010 and December 2012 as part of the Weight Wise program, Royal Alexandra Hospital, Edmonton, Canada. A total of 387 cases were included in our review. We observed a significant reduction in BMI postoperatively for both LSG and LRYGB groups (p < 0.001). Between surgical groups, preoperative proton-pump inhibitor (PPI) use was not significantly different; however, at 1 month (p < 0.05) to 1-2 years (p < 0.001), there was significantly increased PPI use in patients after LSG in comparison to LRYGB. Of the LSG patients that continued their PPI treatment after surgery, 58% increased, 42% continued the same, and 0% decreased their dose 1 year after surgery. Reflux symptoms are significantly increased after LSG in comparison to LRYGB patients. In addition, LSG patients more frequently require initiation of reflux treatment after surgery than that of LRYGB patients. Patients reported postoperative reflux symptom relief with acid-suppressant therapies.

Weight Loss and Outcomes in Wait-listed, Medically Managed, and Surgically Treated Patients Enrolled in a Population-based Bariatric Program

Multidisciplinary bariatric care is increasingly being delivered in Canada within publicly funded regional programs. Demand is high, wait lists are long, and clinical effectiveness is unknown. To examine the "real-world" outcomes associated with a publicly funded, population-based regional bariatric (medical and surgical) program. Prospective observational cohort. Five hundred consecutive patients (150 wait-listed, 200 medically treated, 150 surgically treated) from the Edmonton Weight Wise program were enrolled. The primary outcome was weight change (kg). Between-group changes were analyzed using multivariable regression adjusted for age, sex, and baseline weight and "last-observation-carried-forward" was used for missing data. Subjects transitioning between groups (wait-list to medical or medical to surgery) were censored when crossing over. At baseline, mean age was 43.7 ± 9.6 years, mean body mass index was 47.9 ± 8.1 kg/m, and 88% were female. A total of 412 subjects (82%) completed 2-year follow-up and 143 (29%) subjects crossed over to the next treatment phase. Absolute and relative (% of baseline) mean weight reductions were 1.5 ± 8.5 kg (0.9 ± 6.1%) for wait-listed, 4.1 ± 11.6 kg (2.8 ± 8.1%) for medically treated, and 22.0 ± 19.7 kg (16.3 ± 13.5%) for surgically treated (P<0.001) subjects. For surgery, weight reductions were 7.0 ± 9.7 kg (5.8 ± 7.9%) with banding, 21.4 ± 16.0 kg (16.4 ± 11.6%) with sleeve gastrectomy, and 36.6 ± 19.5 kg (26.1 ± 12.2%) with gastric bypass (P<0.001). Rates of hypertension, diabetes, and dyslipidemia decreased to a significantly greater degree with surgery than medical management (P<0.001) and stayed the same or increased in wait-listed subjects. Population-based bariatric care, particularly bariatric surgery, was clinically effective. Weight and cardiometabolic risk was relatively stable wait-listed patients receiving "usual care."

A Promising Approach to Narrowing the School-to-Prison Pipeline

Recent dramatic increases in the number of youth arrested for nonserious behavior in schools have led some jurisdictions to search for solutions to the “school-to-prison pipeline.” In this article, we evaluate the WISE arrest diversion program in Utica, New York. We use a mixed-methods evaluation design including: (1) a pre–post program comparison of school conduct by participants, (2) a pre–post program comparison of school-based arrests at Upstate High School, (3) a multivariate analysis that estimates the influence of the WISE program on school-based arrests while controlling for citywide juvenile arrests and the passage of time, and (4) interviews conducted with students, program staff, and stakeholders. Although the program appeared more successful in reducing Upstate High School’s reliance on arrest than in improving school conduct among participants, results suggest that the WISE arrest diversion program contains promising elements and lessons for narrowing the school-to-prison pipeline.

Erratum to: Can Local Voluntary Environmental Programs ‘‘Work’’? An Examination of Fort Collins’ (Colorado) Climate Wise Program

Erratum to: Can Local Voluntary Environmental Programs ‘‘Work’’? An Examination of Fort Collins’ (Colorado) Climate Wise Program

Can Local Voluntary Environmental Programs “Work”? An Examination of Fort Collins’ (Colorado) Climate Wise Program

Previous research on voluntary environmental programs (VEPs) frequently assesses the effectiveness of federal, state, and third party programs and why organizations seek to join such programs. Yet, research has yet to evaluate the effectiveness or firm motivation relative to local VEPs. Recognizing this gap, our paper examines the structure and organization of Fort Collins' Climate Wise program, a local VEP. Using a variety of sources, we find that the program has successfully met both short- and long-term goals by persistently self-evaluating and seeking outside financial support. Findings from this analysis can aid in understanding and developing local VEPs elsewhere. Specifically, this initial research suggests that local VEPs need to consider local context and available resources when implementing such programs. Furthermore, it is possible for local VEPs to attract a diverse variety of participating firms by avoiding one-size-fits-all participation levels and by establishing a sense of ownership among partners.

Innovation under the Climate Wise program

This paper examines the impact of participation in the Climate Wise program, one of the largest voluntary programs enacted in the US, on innovative activity by firms. In operation from 1993 to 2000, the Climate Wise program was designed to reduce greenhouse gas emissions by promoting innovation in energy efficiency and energy related activities. We begin by examining what types of firms were most likely to participate in this voluntary initiative. We find that the Climate Wise program was attractive to large firms, more R&D intensive firms, and firms with more financial resources. To consider the impact of Climate Wise participation on the innovative behavior of firms, we investigate whether participants and non-participants differed in the number of successful environmental and non-environmental patent applications between 1993 and 2003. We find some evidence that participation in the Climate Wise leads to a change in environmental patenting but only among less R&D intensive firms.

Reducing Rural Youth Substance Abuse by Educating Parents Through Nontraditional Technology-Based Methods: A Focus On Parental Acceptance of the Online Parenting Wisely Program

Purpose To examine acceptance of technology-based substance abuse prevention programming involving use of the Internet in a rural parent population. Methods Rural parents from a southern state in the east central part of the United States were recruited through local advertisements to participate in two study-related tasks: a brief survey and an online parenting skills educational program entitled Parenting Wisely . Findings Recruitment efforts yielded a total of 39 initial contacts. Of these potential subjects, 25 completed surveys and five requested online program access. Findings demonstrated parents were more likely to indicate a plan to participate in the online program if they cited a primary reason of perceived benefit, whereas parents were more likely to not participate if they selected a lack of time for task commitment as their emphasized motive. Of the five participants who requested online program access, only two of them actually attempted any modules. Neither of them successfully finished any module. Conclusions While rural parents indicated some degree of acceptance to an online parenting educational program through survey responses, those indications did not translate to actual completion of the Parenting Wisely program. Recruitment methods seemed to be most effective with flyer distribution and word-of-mouth social networking strategies, while the cost of newspaper advertisements seemed to greatly outweigh any perceived benefit. Also, the window for potential subject recruitment was most optimal in a four to six week timeline. More research with a larger sample size is needed in order to help identify and validate demographic characteristics leading to increased likelihood of online program participation. In addition, expanded follow-up research is needed to determine as to why parents do or do not complete such programming. Key Words: Adolescent, Access to Care, Parents, Substance Abuse Prevention, Technology, Rural