Duration: 10/01/2024 to 09/30/2029

Administrative Advisor(s):

NIFA Reps:

Non-Technical Summary

Educating the public regarding diet/nutrition and mental health are important components of Cooperative Extension Educational Programs; however, there is currently no research or educational efforts that are focused on the intersection of mental health and diet/nutrition issues in the Western Region (WR). The present proposal aims to close that gap by bringing together communities, extension specialists, and academics from mental health and diet/nutrition disciplines to facilitate collaborative work to address the intersection of mental health and diet/nutrition. The proposed project will formalize the Western Region Mental Health Nutrition Network (WRMHNN). The network initially convened in October 2023 in Las Vegas, NV with 64 people from each state in the WR. Currently, the network is made up of a steering committee and four working groups. The proposed multi-state will further develop out the WRMHNN into a collaborative hub and spoke network based on the Project ECHO model. This will facilitate the connection and collaboration between nutrition and mental health experts across the WR and US. The present proposal aligns with the Agricultural and Food Research Initiative Food safety, Nutrition, and Health priority area, and within this priority, areas of Diet, Nutrition, and the Prevention of Chronic Diseases. The US agriculture and food systems depend on a healthy, both physically and mentally, agricultural workforce. The present project has the potential to unite nutrition and mental health related disciplines to mitigate the mental health crisis and improve healthy lifestyles for Western Region agricultural workers, and all residents in the Western Region.

Statement of Issues and Justification

The need as indicated by stakeholders:

In 2019, the Western Extension Directors Association (WEDA) identified Health and Nutrition as a regional priority. A need surfaced for more collaborative efforts among Cooperative Extension System (CES) professionals relative to food and nutrition best practices, programming, sharing of resources and finding additional resources to better address the nutrition and health needs of the region. To address this gap, WEDA initially commissioned a Design Team to develop a Western Region (WR) Nutrition and Health Team for greater collaboration regionally and for enhanced fund development efforts. The Design Team was charged with planning a process to develop the team and determine outcomes for their work. Members of the original Design Team included:

• Shannon Horrillo, Associate Director of Extension (NV)


• Roger Rennekamp, Extension Health Director, (CE/ECOP)


• Ivory Lyles, Director of Extension (NV)


• Barbara Petty, Director of Extension (ID)


• Ashley Stokes, Director of Extension (CO)


• Annie Lindsay, Extension Professional (NV)


• Marnie Spencer, Extension Professional (ID)


• Susan Baker, Extension Professional (CO)

Problem identification, planning, and implementation

Given the broad scope of health and nutrition, and the already established Western Region Family and Consumer Sciences Program Leaders Groups (which has representation from each state and shares best practices, programming, and resources in the area of food and nutrition), the Design Team worked to reduce duplication while identifying:

• What is currently happening in the WR related to mental health?


• Are there gaps that the WR Nutrition and Health Team can help bridge?

The Design Team accomplished these goals through:

• Secondary data analysis


• Interviews and surveys to assess gaps and assets around the Western Region

Secondary Data Analysis

The Design Team’s analysis of existing data in the area of health and nutrition clearly indicated a high need in the WR states (data is lacking from the territories) in relation to mental health. For example, the prevalence of depression among adolescents (ages 12-17y) and adults is higher in several Western Region states than nationally (2). More specifically:

• 9 WR states have a higher prevalence of adults with mental illness and substance use issues than nationally (1)


• 4 WR states (Wyoming, Washington, New Mexico, and Arizona) showed a decline in adult mental health ranking between 2021 and 2022 (1)


• 9 WR states (Oregon, New Mexico, Washington, Alaska, Nevada, Utah, Wyoming, Idaho, and Arizona) have the highest prevalence of youth major depressive episodes in the past year (1)


• 8 WR states (Oregon, Montana, Nevada, Colorado, New Mexico, Wyoming, Washington, and Arizona) have the highest prevalence of youth with substance use disorder in the past year (1)

The WR disproportionately exhibits higher mental health issues in both adults and youth. A lack of treatment availability (due to cultural perceptions of mental health, unmet need, lack of insurance, and overall financial barriers) is also higher in the WR (1).  Furthermore, COVID-19 has intensified the mental health crisis in the United States (2). In summary, the WR of the US reports higher prevalence of mental health issues that appear to be largely unaddressed.

Interviews and surveys to assess gaps and assets around the WR

In 2019-2020 the Design Team surveyed Family and Consumer Science Program Leaders to assess their perceptions of their state’s interest in mental health and their current engagement. Most Family and Consumer Science Program Leaders indicated their state was interested in addressing mental health needs. Additionally, 75% said their Extension system was currently engaged in mental health related programming, 50% said they were conducting research related to mental health, and 13% were unsure. This programming is primarily related to suicide awareness and prevention, mental health first aid, and the Farm and Ranch Stress Assistance Network. Additional extension efforts in opioid prevention, relationship stress management, stress management, financial management and mental health, physical activity, chronic disease management, nutrition and food resource management/food insecurity, food access, produce subscription programs and adverse childhood experiences were also noted. Overall, the Design Team’s survey indicates interest and active mental health related programming. However, Family and Consumer Science Program Leaders also highlighted that their current health and well-being, state health and nutrition professionals, and mental health specialists were not connected. So, despite interest and programming in mental health and existing nutrition programming little collaboration at the extension level exists.

      Finally, the Design Team assessed what resources were available through extension. Nearly all states had Nutritional Specialists and/or registered dietitians (RD) in extension positions, as well as other professionals extending research-based nutrition education in the communities. However, resources related to mental health were less robust. Only three states have Extension Mental Health Specialists (Montana, Nevada, and Idaho), while Utah has Extension faculty with expertise in mental health. Montana additionally provides the Rural Families Speak About Resilience multistate research and Extension project. Further, a primary focus of most WR mental health Extension is suicide prevention and stress management to promote well-being among farmers, ranchers, and other agricultural workers, such as the Western Regional Agricultural Stress Assistance Program (WRASAP). While these programs are critical, this indicates that large swaths of the population in the WR are not the focus of mental health efforts. Furthermore, the need for suicide prevention suggests that mental health issues are only being addressed when they reach a crisis level. Thus, the Design Team overall found robust nutrition programming in Western Region extension, but mental health resources appear more limited.

      Our secondary data analysis and the interviews highlight the importance of connecting nutrition and mental health to increase extension services through already established professionals. Additionally, Extension has several cross-campus partnerships that can be utilized to connect mental health and nutrition professionals, including: Center for Mental Health Research and Recovery (MT), Center for Research on Rural Education (MT), Youth Aware of Mental Health (MT), Rural Mental Health Preparation/Practice Pathway(MT), Center on Aging (WY, AZ, NV), School of Medicine (NV, WA, AZ), School of Nursing (WA), College of Social Work (UT), College of Public Health (OR, CO), Linus Pauling Institute (OR). Overall, across the WR professionals are interested in mental health outreach but limited extension programs exist. On the other hand, the nutrition extension network is robust. Given the close relationship between mental health and nutrition, the WR needs to connect mental health and nutrition extension efforts ideally through already existing channels. The present proposal will address this need.

The importance of the work:

Educating the public regarding diet/nutrition and mental health are important components of Cooperative Extension Educational Programs; however, currently no research or educational efforts that are focused on the intersection of mental health and diet/nutrition issues in the WR. The present proposal aims to close that gap by bringing together communities, extension specialists, and academics from mental health and diet/nutrition disciplines to facilitate collaborative work to address the intersection of mental health and diet/nutrition. The proposed Western Region Mental Health Nutrition Network (WRMHNN), comprised of representatives from land-grant institutions in the WR, will facilitate collaborative work addressing diet quality and food access to improve mental health outcomes across the lifespan. The present proposal is in line with the Agricultural and Food Research Initiative Food safety, Nutrition, and Health priority area, and within that priority area aligns with the Diet, Nutrition, and the Prevention of Chronic Diseases priorities. The US agriculture and food systems depend on healthy, both physically and mentally, agricultural workers. The present project has the potential to unite nutrition and mental health related disciplines to mitigate the mental health crisis and improve healthy lifestyles for WR agricultural workers, and all residents in the WR.

The consequences are if it is not done:

The WR, and in particular the Mountain West Region, historically has the highest suicide rates in the US dating back to the 1800s (3). Suicide is the culmination of poor mental health and substance use. Extensive meta-analyses show that major depressive disorder and substance use increase the likelihood of death by suicide (3). However, these issues are prevalent across the globe. The Western ethos of honor and self-sufficiency combined with contextual factors such as low population density, economic reliance on migratory natural resource extraction and harvest, and general exposure to suicide in the region indicates that these issues are long-standing and unlikely to change without concerted intervention efforts (3).

The technical feasibility:

The WRMHNN is built on the Project ECHO model. The Project ECHO model was developed in the WR at the University of New Mexico. The use of the Project ECHO model is detailed below.  The model uses a “hub spoke” system to connect specialists via digital meetings (Zoom or Teams), shared resources through Google Drive, and shared information through the WRMHNN website (wrmhnn.org).  All land-grant universities in the WR have either Zoom or Microsoft Teams meeting software for their staff, students, and faculty. Further, even in the most rural states (Wyoming and Alaska), the universities have high speed internet access for these meetings. Furthermore, each land-grant university in turn has communication channels across their respective states through their Extension networks.

The advantages for doing the work as a multistate effort:

The WRMHNN is designed as a multistate effort. The low population density across the WR (an average of 45 people per square mile across the western US) requires collaboration across the region to meet the needs of the population. The mission of multistate programs is to facilitate research between State Agricultural Experiment Stations (SAES), Cooperative Extension Service (CES), and other research institutions/agencies on high priority topics that are beyond the scope of a single state. Supporting mental health through nutrition and food security and vice versa is a “high-priority topic” that requires “complex problem-solving activities which are beyond the scope of a single SAES, can be approached in a more efficient and comprehensive way.” Briefly here are some of the notable advantages of doing this work as a multistate effort:

1. Facilitates funding through SAES


2. Formalizes the network reporting through the National Information Management and Support System


3. Provides infrastructure for shared governance of the network


4. Increases visibility of the network for other interested researchers and extension specialists across the US


5. Increases likelihood of generating other federal and non-federal funding through the previously outlined advantages


6. Increase collaboration between nutrition and mental health researchers

What the likely impacts will be from successfully completing the work:

The goal of the Western Region Mental Health and Nutrition Network (WRMHNN) is to improve mental health outcomes across the lifespan through addressing diet quality and healthy food access^[1]. Within this overarching goal over this 5-year multistate project we expect the following impacts:

1. Use of the WRMHNN as a hub of both nutrition and mental health expertise for extension professionals and the general public (objective 3)


2. Increased access to professional development resources for extension staff on the intersection between mental health and nutrition (objective 1)


3. Establish intersectional programming and materials for extension on mental health and nutrition (objective 3)


4. Use of standard scales to evaluate intersectional programming in extension on mental health and nutrition (objective 2)

 

[1] Food access includes food insecurity, food swamps and deserts, rural communities, or other contextually define situations where access to affordable, healthy food is limited.

Objectives

Procedures and Activities

The following objectives will be met over the 5 multi-state period. The four working groups will work in concerted effort to meet the objectives.

Objective 1

Identify existing mental health and nutrition resources and gaps in existing resources related to the intersection of mental health and nutrition.

Protocol

Our needs assessment is based on the Center for Disease Control and Prevention’s best practices for conducting a needs assessment (19). This is a four-step process to plan, develop questions, select data collection method, and analyze the data collected.

1. Plan

• Define purpose and intended outcomes.


• Identify existing data through a literature review.
  
  
  
  • Resources found during the literature will be compiled into a resource repository hosted through Zotero (or similar) and linked to our website.
  
  
  • The WRMHNN members have extensive experience conducting and publishing literature reviews and review papers (20, 21).
  
  
  
  


• Identify stakeholders including primary beneficiaries, those involved with the primary beneficiaries, as well as policy makers.

2. Develop questions

• Decide what should be assessed with stakeholders/


• What format will be most useful (ex. questionnaire, focus group)

3. Collect data using developed questions

• We will recruit 100 Extension professionals from around the WR.
  
  
  
  • We will use snowball sampling and Extension listservs to recruit participants.
  
  
  • Our recruitment will also simultaneously advertise for the network to recruit potentially interested professionals.
  
  
  • We target Extension programs in the US Territories and Pacific Islands as well as 1994 Institutions as representation from these areas was low in our inaugural meeting.
  
  
  
  

4. Analyze and prioritize data

• Analyze the data for themes in responses (completed by Research and Data, Evaluation, and Common Measures working groups).
  
  
  
  • Aggregate data to explore differences by demographic and geographic features.
  
  
  • Summarize findings in an impact report for stakeholders.
  
  
  • Our findings will be published on our website.
  
  
  
  

Objective 2

Develop out the existing WRMHNN into an intersectional extension program on mental health and nutrition using the Project ECHO model.

Protocol

Project Extension for Community Healthcare Outcomes (ECHO) is based out of the University of New Mexico. The Project ECHO model has four components (22):

1. Videoconferences/Webinars to leverage resources and expertise


2. Outcome focused disease management


3. Collaborative management between local professionals, their peers, and subject matter experts


4. Systematic methods to monitor outcomes

The Project ECHO model has been successfully used in other Cooperative Extension arenas (23–26). Currently, no ECHO Hub exists specifically to integrate mental health and nutrition experts. The present project will sign up to join the ECHO network through their “Becoming a Partner” pathway. We will use the process described by Ghosh and colleagues to evaluate the WRMHNN project ECHO implementation (22). Briefly, over the course of a year we will complete an environment scan, online survey, focus group discussions, objective review of sessions, and review programmatic data (22).

Objective 3

Initiate a research portfolio across the WR investigating the intersectionality of nutrition and mental health.

Protocol

Based on our needs assessment outcomes, we will initiate small pilot research projects focused on secondary data analysis and tool evaluation. This objective builds off our data, evaluation, and common measures and research working groups described above. We expect that these pilot projects will 1) investigate scales that can be used to evaluate the effectiveness of nutrition, mental health, and intersecting programming, and 2) evaluate common elements between suicide risk factors and nutritional issues using publicly available large datasets such as the Youth Risk Behavior Surveillance System and the Adolescent Brain Cognition and Development dataset. Both the data, evaluation, and common measures and research working groups output will be used to develop and conduct a survey across the WR assessing suicide risk by nutrition status markers. 

Milestones:

Year 1: Planning and environment assessment

• Conduct a needs assessment to understand the current landscape of mental health and nutrition in the WR. (Objective 1)


• Increase recruitment with a focus on members from the US Pacific Territories and 1994 Institutions. (Objective 1)


• Initialize resource repository for relevant literature, tool kits, and educational materials. (Objective 1, 3)


• Develop Project ECHO model (Objective 2)


• Develop satellite meetings at related professional society meetings (Objective 3)

Year 2: Capacity building and resource development

• Establish partnerships with academic institutions, healthcare providers, and community organizations to leverage expertise and resources. (Objective 1)


• Based on needs assessment from Year 1 and repository of relevant resources, develop training workshops and webinars on nutrition and mental health research, evidence interventions, and best practices in community engagement. (Objective 1)


• Develop and or adapt evaluation measures for the workshops and webinars. (Objective 1)


• Collaborate with professional societies to host the WRMHNN meeting through USDA conference grant funding (Objective 3)

Year 3: ECHO model deployment and research initiation

• Conduct training workshops and webinars developed in Year 2. (Objective 2)


• Initiate monitoring and evaluation data collection on ECHO model. (Objective 2)


• Develop pilot research projects based on the needs assessment from Year 1 with new partnerships established in Year 2. (Objective 3)


• Present research conducted within the WRMHNN at professional society meetings (Objective 3)

Year 4: Evaluation

• Scale up workshops and webinars in collaboration with local partners and stakeholders.


• Collect and analyze data from pilot research projects. (Objective 2)


• Analyze data on ECHO model efficacy and performance. (Objective 2)


• Share findings through publications, presentations, and media outreach to raise awareness and advocate for policy change.


• Develop symposia related to mental health and nutrition at professional society meetings (Objective 3)


• Develop federal grant proposals based on collaborative work (Objective 3)

Year 5: Sustainability and expansion

• Develop a sustainability plan to ensure the continuity of the network. (Objective 2)


• Celebrate achievements and milestones with network members and stakeholders.


• Develop Federal and private grants based on ECHO model evaluation and pilot research projects. (Objective 2, 3)


• Evaluate the network’s overall impact and identify lessons and priorities for the next 5 years.


• Continue to develop federal grant proposals and ideally begin work on funded grant proposals from year 4 (Objective 3)

Expected Outcomes and Impacts

Projected Participation

View Appendix E: Participation

Educational Plan

The WRMHNN website (wrmhnn.org) will be maintained to provide access to the network itself, upcoming Project ECHO sessions, a link to the resource repository, a link to publications and de-identified datasets/dashboards (where appropriate), and to Extension impact reports and fact sheets.

 

The ECHO model facilitates outreach as it welcomes the public and specialists to learn more about mental health and nutrition. We will advertise the WRMHNN ECHO sessions on extension listservs, professional society list servs, and local chapters of professional organizations (for example the Academy for Nutrition and Dietetics has local chapters within each state).

Organization/Governance

All members of this multi-state HATCH project are eligible for office.

 

We will use a hub and spoke model to maintain the network. A steering committee comprised of a chair vice-chair (incoming chair), secretary, outreach coordinator, heads of each working group, and interested stakeholders will be the central hub. The central hub will plan the yearly meeting, assess progress on the objectives outline above (quarterly) and setting interim objectives and checkpoints as needed. Finally, the steering committee will be responsible for integrating working group outputs into reports (example: REEPort updates).

 

Roles within the steering committee

The chair is responsible for scheduling meetings, making sure the working groups are meeting regularly, and evaluating progress towards yearly goals.

The vice-chair will support the chair, especially in checking in with the working groups and evaluating the progress towards yearly goals. At the end of the year the chair and vice chair will work together to set interim goals for the upcoming year (as needed) with the steering committee.

The secretary will develop steering committee meeting agendas, keep meeting minutes, and maintain a meeting roster.

The outreach coordinator will be lead the project ECHO development and initialization. The outreach coordinator will lead the ECHO specialist team. 

 

We will also have four working groups based on the working groups developed in at the inaugural meeting:

• Professional development, training, and resources


• Data, evaluation, and common measures


• Research


• Program development

Each working group will have a head and secretary. Within working groups, the head is responsible for organizing the working group meetings and reporting back to the steering committee. The secretary within each working group is responsible for meeting agendas and minutes. The secretary will succeed the president after one year. The working groups will work together to complete the objectives. The working groups will meet monthly.

 

The steering committee will be elected by the whole network at the yearly meeting. The individual elected as the vice-president will serve as the incoming president to help main continuity between years. Each position is a 1-year term.

Literature Cited

1. Reinert, D. Fritze, T. Nguyen, “The State of Mental Health in America 2022” (Mental Health America, Alexandria, VA, 2021).


2. “Teen mental health” (National 4-H Council, 2020); https://4-h.org/wp-content/uploads/2020/06/4-H-Mental-Health-Report-6.1.20-FINAL.pdf.


3. C. M. Pepper, R. E. Dumas, L. E. Glenn, K. M. Perry, G. M. Zeller, L. N. Collins, A cultural script for suicide among White men in the Mountain West Region of the United States. American Psychologist, doi: 10.1037/amp0001311 (2024).


4. R. C. Kessler, M. Angermeyer, J. C. Anthony, R. DE Graaf, K. Demyttenaere, I. Gasquet, G. DE Girolamo, S. Gluzman, O. Gureje, J. M. Haro, N. Kawakami, A. Karam, D. Levinson, M. E. Medina Mora, M. A. Oakley Browne, J. Posada-Villa, D. J. Stein, C. H. Adley Tsang, S. Aguilar-Gaxiola, J. Alonso, S. Lee, S. Heeringa, B.-E. Pennell, P. Berglund, M. J. Gruber, M. Petukhova, S. Chatterji, T. B. Ustün, Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry 6, 168–176 (2007).


5. Ranking the States, Mental Health America. https://www.mhanational.org/issues/ranking-states.


6. F. J. Charlson, S. Diminic, H. A. Whiteford, The Rising Tide of Mental Disorders in the Pacific Region: Forecasts of Disease Burden and Service Requirements from 2010 to 2050. Asia & the Pacific Policy Studies 2, 280–292 (2015).


7. Suicide Rates by State | Suicide | CDC (2022). https://www.cdc.gov/suicide/suicide-rates-by-state.html.


8. C. A. Myers, Food Insecurity and Psychological Distress: a Review of the Recent Literature. Curr Nutr Rep 9, 107–118 (2020).


9. M. Maynard, L. Andrade, S. Packull-McCormick, C. Perlman, C. Leos-Toro, S. Kirkpatrick, Food Insecurity and Mental Health among Females in High-Income Countries. IJERPH 15, 1424 (2018).


10. D. J. Arenas, A. Thomas, J. Wang, H. M. DeLisser, A Systematic Review and Meta-analysis of Depression, Anxiety, and Sleep Disorders in US Adults with Food Insecurity. J GEN INTERN MED 34, 2874–2882 (2019).


11. M. M. Lane, E. Gamage, N. Travica, T. Dissanayaka, D. N. Ashtree, S. Gauci, M. Lotfaliany, A. O’Neil, F. N. Jacka, W. Marx, Ultra-Processed Food Consumption and Mental Health: A Systematic Review and Meta-Analysis of Observational Studies. Nutrients 14, 2568 (2022).


12. D. Guzek, D. Gła¸bska, B. Groele, K. Gutkowska, Fruit and Vegetable Dietary Patterns and Mental Health in Women: A Systematic Review. Nutr Rev 80, 1357–1370 (2021).


13. M. Gholizadeh, L. Setayesh, H. Yarizadeh, A. Mirzababaei, C. C. T. Clark, K. Mirzaei, Relationship between the double burden of malnutrition and mental health in overweight and obese adult women. J Nutr Sci 11, e12 (2022).


14. T. Burrows, S. Teasdale, T. Rocks, M. Whatnall, J. Schindlmayr, J. Plain, G. Latimer, M. Roberton, D. Harris, A. Forsyth, Effectiveness of dietary interventions in mental health treatment: A rapid review of reviews. Nutrition & Dietetics 79, 279–290 (2022).


15. R. S. Opie, C. Itsiopoulos, N. Parletta, A. Sanchez-Villegas, T. N. Akbaraly, A. Ruusunen, F. N. Jacka, Dietary recommendations for the prevention of depression. Nutr Neurosci 20, 161–171 (2017).


16. J. Godos, W. Currenti, D. Angelino, P. Mena, S. Castellano, F. Caraci, F. Galvano, D. Del Rio, R. Ferri, G. Grosso, Diet and Mental Health: Review of the Recent Updates on Molecular Mechanisms. Antioxidants (Basel) 9, E346 (2020).


17. M. P. Burke, L. H. Martini, E. Çayır, H. L. Hartline-Grafton, R. L. Meade, Severity of Household Food Insecurity Is Positively Associated with Mental Disorders among Children and Adolescents in the United States. The Journal of Nutrition 146, 2019–2026 (2016).


18. E. Serhal, A. Arena, S. Sockalingam, L. Mohri, A. Crawford, Adapting the Consolidated Framework for Implementation Research to Create Organizational Readiness and Implementation Tools for Project ECHO. Journal of Continuing Education in the Health Professions 38, 145 (2018).


19. Phase 1: Assessment | Training Cadre | Professional Development & Training | Healthy Schools | CDC (2019). https://www.cdc.gov/healthyschools/tths/trainingcadre/phase1.htm.


20. C. J. Nikolaus, R. An, B. Ellison, S. M. Nickols-Richardson, Food insecurity among college students in the United States: A scoping review. Advances in Nutrition 11, 327–348 (2020).


21. C. J. Nikolaus, S. Johnson, T. Benally, T. Maudrie, A. Henderson, K. Nelson, T. Lane, V. Segrest, G. L. Ferguson, D. Buchwald, Food insecurity among American Indian and Alaska Native people: a scoping review to inform future research and policy needs. Advances in Nutrition 13, 1566–1583 (2022).


22. S. Ghosh, B. M. Roth, I. Massawe, E. Mtete, J. Lusekelo, E. Pinsker, S. Seweryn, P. K. Moonan, B. B. Struminger, A Protocol for a Comprehensive Monitoring and Evaluation Framework With a Compendium of Tools to Assess Quality of Project ECHO (Extension for Community Healthcare Outcomes) Implementation Using Mixed Methods, Developmental Evaluation Design. Front. Public Health 9, 714081 (2021).


23. NH Opioid Prevention Project [infographic], Extension (2021). https://extension.unh.edu/resource/nh-opioid-prevention-project-infographic.


24. Project ECHO Health Literacy. https://www.floridaruralhealth.org/health-literacy-echo.


25. O. Ogundele, R. Mutrux, K. Hoffman, M. Becevic, Improving Access to Care for Vulnerable Missourians: The Hotspot Project. Mo Med 120, 318–323 (2023).


26. K. Sohl, L. Levinstein, A. James, S. Greer, K. Boles, A. B. Curran, M. Mahurin, M. O. Mazurek, V. Nanclares, ECHO (Extension for Community Healthcare Outcomes) Autism STAT: A Diagnostic Accuracy Study of Community-Based Primary Care Diagnosis of Autism Spectrum Disorder. J Dev Behav Pediatr 44, e177–e184 (2023).

Attachments

Land Grant Participating States/Institutions

AZ, MT, NV, WY

Non Land Grant Participating States/Institutions

University of Alaska Fairbanks, University of Nevada