There are substantial uncertainties in the risk assessment of odorants, the greatest being how likely it is that the individual odorants monitored actually are the main contributors to the overall odor sensed. Missing the key odorants invalidates the study. OPM can help identify key odorants that have been compiled into odor wheels . The exposure measurements tend to have less uncertainty than the thresholds against which they are evaluated. ODTC50 values typically range over several orders of magnitude, and the health hazard thresholds incorporate one-to-three orders of magnitude of uncertainty factors in their extrapolation from animal data. Even under controlled conditions using test odorants, panelist threshold testing by dilutions resulted in interlaboratory variation in results up to 4-fold . Accordingly, most risk characterizations are crude, screening-level evaluations that require further refinement if thresholds are approached by exposure estimates. For the experimental and epidemiology studies, all suffer from the problem of self-reporting and the inherent variability in human response, which clearly varies by sex, age, pre-existing health conditions and prior experiences. Epidemiological studies of odor and health have notably weak exposure assessments, and experimental studies suffer the lack of standardized exposure methods and difficulty carrying out blinded studies . So far, no toxicological study has been able to separate the health effects of odors from those of the co-pollutants in the mixture . The health effects reported by residents living near odor sources may be due to odorless co-pollutants with odor serving as a marker of exposure . Few epidemiology studies, however,drying cannabis look at this possibility. Proximity to an odor source would be a determinant; however, residence distance to the source was often a poor predictor of odor induced health complaints.
The sole experimental study of odor , which was discussed in Section 4.3, could not separate the effects of odors from those of co-pollutants in the mixture.Risk perception plays a large role in how exposures to odors can lead to annoyance and outrage. Risk perception has been defined as how the exposed judge the severity of the risk and involves personal and cultural values and attitudes. Different perceptions of risk are applied to involuntary, imposed exposures, man-made sources and the unfamiliar. Odors often encompass all three of these factors. Key worries from odor exposures include long-term health ailments such as asthma or lung cancer , ability to socialize at one’s own property that is odor impacted, and potential decrease in property value . These perceived risks likely are experienced disproportionately by disadvantaged communities. The air monitoring of the community north of Denver was funded by USEPA as an environmental justice study , and a community well-being study followed shortly thereafter . Participants took an online survey four times over a year. The results at the community level showed that odor-impacted communities had no difference in well-being than the control communities. Individual results, however, showed that respondents who reported that the air was “very fresh” or “odor is highly acceptable” had higher levels of well-being. This finding supports other studies that indicate that unpleasant odors lead to annoyance, general psychological stress, and reduced quality of life. Researchers in Australia studied environmental justice and odors around Melbourne . They used a novel cluster approach to represent communities affected by odor and concluded that self-reported odor exposure correlated with indicators of socioeconomic disadvantage in the community clusters affected by odor.Large gaps exist in the dataset used to evaluate the health risks posed by odors. Chief among these is the lack of dose-response studies for total odor exposure rather than just for individual odorants.
Only a single experimental study of odor mixture exposure and health effects has been conducted . Clearly, more studies are needed, especially measuring physiological and psychological responses simultaneously so correlations can be determined. Longitudinal “before-and-after” epidemiology studies are needed to determine the magnitude of impact of installing an odor-emitting facility near a neighborhood. For example, the large health-effects study in California after the natural gas leak in Aliso Canyon would benefit from pre-leak community health data. To aid exposure assessment, analytical techniques and sampling require improvement. For one set of odorants – additives to natural gas to impart odor – broad availability of laboratories with the capability to measure sulfur compounds at sufficiently low detection limits is both a health and a safety need .In the United States, approximately 20% of adolescents and young adults have a mental health or substance misuse disorder, and these disorders account for a significant portion of the burden of disability for individuals in this age group. These behavioral disorders are associated with other areas of risk including higher rates of suicide, injury, risky sexual activity and unwanted pregnancy and low educational or work achievement. Despite the recognition of the significant short- and long-term impacts of behavioral health disorders on development and the availability of effective treatments, only about one-third of adolescents with a diagnosable behavioral disorder receive appropriate care. Rates of mental health treatment decrease further as adolescents transition into young adulthood. Of particular concern, only half of adolescents who meet criteria for “severe” impairment from a mental health disorder report having received care and only 40% of 18e25 year olds with a serious mental illness that impairs functioning report receiving treatment. On average, 10 years pass from the initial onset of a mental health disorder and seeking treatment, with younger age at onset associated with longer delays in treatment.
One approach to reducing delay in treatment and improving treatment delivery is the development of models aimed at improving recognition and treatment for behavioral health disorders in primary care settings through the integration of behavioral health services into medical settings. In the United States,ebb flow it is estimated that 84% of adolescents have an outpatient visit and 66% have a well checkup annually and 70% of young adults report having a source of primary care. Among adolescents who are seen in primary care settings, 14%e 38% have been found to meet criteria for a mental health disorder. Several studies have also shown high rates of mental health comorbidity among individuals with chronic medical illnesses commonly seen in primary care, which when present is associated with higher levels of medical symptom burden, health care costs, and worse medical outcomes. A recent meta-analysis of integrated behavioral health trials across pediatric age groups found that they had a small-to-moderate effect improving the outcomes of mental health and substance use disorders. Thus, the integration of care has the potential to improve outcomes for both behavioral and physical health. In this article, we aim to specifically review research regarding models of integrated behavioral health in primary care settings among adolescent and young adult populations with the aim of describing needed areas of research.To be included, studies had to be focused on older adolescents and/or young adults , examine patient outcomes, have a comparison group, offer an integrated or health care provider-led intervention for a behavioral health condition in primary care, be published in English, and be conducted in 2004 or later. Studies of adult populations that did not specifically examine young adults separate from the older adult population were not included. For the purposes of this review, we considered school based health clinics and college health clinics to be primary care settings. We excluded studies that recruited from the primary care setting but did not have evidence of collaboration or care delivered in that setting, as well as those conducted in the broader school setting such as classroom or campus-wide interventions. We only included those focused on treatment or secondary prevention in at-risk individuals. As the intent was to look at alcohol and illicit drug misuse, tobacco use interventions were not included. In total, when duplicates were excluded, the systematic searches identified 1,086 potential articles of which 1,032 did not meet inclusion criteria based on review of the title or abstract . We conducted full-text article reviews for the remaining 54 articles plus an additional 3 articles identified via bibliographies of identified literature for a total of 57. Of these 57, 36 articles were excluded. The reasons for exclusion included the following: pilot or feasibility trial with no comparison group , repeat use of a study sample without the presentation of new patient outcomes , intervention not in a primary care setting , not intervention trial , and no behavioral outcomes provided.
Based on full-text review, 21 trials were identified for inclusion. As detailed in Table 1, studies meeting inclusion criteria were conducted in multiple countries including the United States , Australia , New Zealand , South Africa , and multiple countries . All included studies were reviewed for quality by two independent reviewers using the US Preventive Services Task Force Quality Rating Criteria for Randomized Controlled Trials and Cohort Study Criteria . Differences in scores were subsequently reconciled via discussion between reviewers. To promote accurate comparison, studies identified in our review were organized into three groups with increasing levels of integration. Groups were determined a priori based on the framework outlined in the 2010 report on Evolving Models of Behavioral Health Integration in Primary Care: “coordinated care,” “co-located care,” and “integrated care”. In “coordinated care models,” primary care providers work with community-based behavioral health specialists to provide care. The behavioral health specialist may serve as an advisor to the primary care provider without seeing the patient or can provide direct care with a coordinated exchange of information. Educational interventions that aim to enhance primary care provider skills with support and oversight by mental health providers also fit into this category. In “co-located care models,” primary care and behavioral health providers are located in the same setting to simplify the referral process, enhance communication between providers, and remove patient barriers to care. “Integrated care” refers to models of care with a shared treatment plan between providers with both behavioral and health elements. These models often involve a multidisciplinary team working together using a predefined protocol and a “population-based approach” to tracking outcomes in order to assure improvement for the entire patient panel. Our review identified a total of 21 randomized controlled trials with behavioral health outcome measurement among adolescents and young adults: 17 in the category of “coordinated care,” 0 in the category of “co-located care,” and 4 in the category of “integrated care.” Results are discussed by category below, and details of specific studies within each category are provided in Table 1.Our review identified 17 studies meeting the criteria for “coordinated care.” Eight studies described interventions in which enhanced behavioral health care was provided by the primary care provider. One study examined provider communication skills training aimed at increasing patient and family engagement in behavioral health care and found improvements in parent-reported child functioning for minority, but not white, youth. Five studies examined the effectiveness of provider training in screening, brief motivational interviewing, and referral for substance misuse among adolescent and young adult populations and found the use of these methods to be effective in reducing alcohol or other substance misuse, increasing patient’s readiness to change substance misuse behaviors, and/or decreasing consequences of substance misuse. One additional study found that training providers to implement a behavioral health contract paired with consultation among college students reduced the frequency of drinking and driving but not overall substance misuse. A final study found that screening coupled with access to a telephone-based parenting intervention was associated with reductions in child aggressive and delinquent behaviors and attention problems. Seven studies examined technological approaches to providing behavioral health care in the primary care setting. Four examined computer-facilitated brief intervention for substance misuse for adolescent and young adults either with or without brief advice from the primary care provider and found such strategies to be effective in reducing substance misuse. In one of these studies, even a single dose of computer-facilitated motivational interviewing showed sustained effects for a year. The remaining three studies used technological interventions to improve outcomes for depression. One study examined the use of mobile health symptom-tracking technology for adolescent and young adult depression and found significant improvements in provider reported skills and patient-reported emotional self-awareness but not in mental health outcomes or treatment engagement.