Search

Objectives: With funding from the Pregnancy Assistance Fund, the Maternal, Child, and Adolescent Health Division (MCAH) of California redesigned its existing Adolescent Family Life Program (AFLP) for expectant and parenting young women into a more intensive and structured intervention, AFLP with positive youth development (PYD). This paper presents key findings from a federally funded, rigorous implementation study of the two programs. Methods: This implementation study collected data from 13 agencies from January 2016 through December 2017, including interviews with 69 case managers and 18 supervisors; focus groups with 130 program participants; surveys of 66 case managers and 1330 young women; and observations of 42 visits with program participants. The study combined qualitative and quantitative analysis methods. Results: As designed, PYD was a much more structured and intensive program than AFLP. Case managers and supervisors saw value in the PYD model and new approach but needed more support and guidance than expected in order to deliver it with fidelity. MCAH provided additional trainings and technical assistance to address challenges. In practice, although staff noted differences in approach and content, the youth experience with the two programs was similar. Conclusions for Practice: Integrating the PYD framework into case management systems may foster youth self-sufficiency and resiliency. However, the rigid structure of the program was often challenging to implement in practice. Organizations interested in implementing prescribed case management approaches should consider allowing opportunities for flexibility in implementation and providing more detailed preservice training to prepare staff for real-world implementation. [ABSTRACT FROM AUTHOR]

Objective: Infants affected by prenatal alcohol and drug use are more likely to be removed from parental custody than those in the general population, although it is unclear whether their custody outcomes differ from infants investigated by child protection systems (CPS) for other reasons. This analysis seeks to compare trajectories of involvement and custody outcomes among infants investigated by CPS with and without documentation of prenatal substance exposure (PSE). Method: We used vital birth records linked to administrative CPS records to examine the timing of system involvement and 3-year custodial outcomes among investigated infants with and without identified PSE. We defined PSE according to documentation on the state's standardized hotline screening form, which CPS completes upon referral for alleged maltreatment. We estimated the likelihood a child was in nonparental custody at age 3 by specifying multivariable generalized linear models, adjusted for covariates available in the birth record. Results: In our sample of 22,855 infants investigated by CPS in 2017 in California, more than 26% had documentation of PSE. These infants experienced an accelerated timeline of system penetration and were 2.2 times as likely to be in nonparental placement at age 3. Discussion: PSE confers an independent risk of custody interruption among infants investigated by CPS. The younger age of these infants, complexity of parental substance use, and potential misalignment of administrative permanency timelines with parental recovery all suggest the need for increased research, policy, and programmatic interventions to serve this vulnerable population. Significance: Children with PSE face environmental risks in the early developmental period. Often in the United States, CPS is relied on to assess and mitigate these risks. Amid calls for a public health response to PSE, it is essential to understand how children with PSE interact with CPS. We describe the incidence and timing of custody interruptions in a large U.S. state, comparing infants with PSE to those investigated by CPS for other reasons. This study extends current understanding by demonstrating the independent risk of custody interruption conferred by PSE status. [ABSTRACT FROM AUTHOR]

Introduction: Smoking during pregnancy adversely affects perinatal outcomes for both women and infants. We conducted a retrospective cohort study of the state-funded Comprehensive Tobacco Treatment Program (CTTP) – the largest maternal tobacco cessation program in San Bernardino County, California – to determine the real-world program effectiveness and to identify variables that can potentially improve effectiveness. Methods: During 2012–2019, women who smoked during pregnancy were enrolled in CTTP's multicomponent behavioral smoking cessation program that implemented components of known efficacy (i.e., incentives, biomarker testing, feedback, and motivational interviewing). Results: We found that 40.1% achieved prolonged abstinence by achieving weekly, cotinine-verified, 7-day abstinence during 6 to 8 weeks of enrollment. Using intention-to-treat analyses, we computed that the self-reported point prevalence abstinence rate (PPA) at the six-month telephone follow-up was 36.7%. Cohort members achieving prolonged abstinence during the CTTP were five times more likely to achieve PPA six months after CTTP. Several non-Hispanic ethnicities (Black, Native American, White, or More than one ethnicity) in the cohort were two-fold less likely (relative to Hispanics) to achieve prolonged abstinence during CTTP or PPA at six months after CTTP. This disparity was further investigated in mediation analysis. Variables such as quitting during the first trimester and smoking fewer cigarettes at enrollment were also associated with achieving PPA at six months. Discussion: Racial/ethnic health disparities that have long been linked to a higher rate of maternal smoking persist even when the pregnant smoker enrolls in a smoking cessation program. Significance: What is already known on this subject? Causal factors that enable pregnant smokers to achieve abstinence during and after enrollment in maternal smoking cessation programs are not well understood. What does this study add? We found that US (United States) racial/ethnic disparities that have long been linked to higher national rates of maternal smoking for several non-Hispanic ethnicities (Black, Native American/Alaskan, White) also persisted in the form of lower abstinence rates in non-Hispanic ethnicities (Black, Native American, White, More than one ethnicity) who enrolled in the maternal smoking cessation program we evaluated. This racial/ethnic disparity in maternal smoking cessation program outcomes is a new addition to the literature and needs further study to identify the underlying causal factors. [ABSTRACT FROM AUTHOR]

Introduction: Increasingly, community-based models of doula care are receiving attention as possible interventions to address racial inequities in maternal health care experiences and outcomes. In 2018, community-based organization SisterWeb launched to provide free culturally congruent community doula care to advance birth equity for Black and Pacific Islander pregnant people, with funding from the San Francisco Department of Public Health. We conducted a process evaluation of SisterWeb's first 1.5 years of existence to identify multilevel barriers and facilitators to implementation of their programs. Methods: Guided by the Equitable Evaluation Framework™, we conducted 46 in-depth interviews with individuals from 5 groups: SisterWeb leadership, doulas, doula mentors, and clients, and external stakeholders. Results: Barriers included having diverse clientele groups with unique needs, an ineffective payment model, and simultaneously building an organization and developing and implementing programs. Facilitators included the presence of established strategic partnerships, positive reception of services due to an unmet need for culturally and linguistically congruent pregnancy and birth support among SisterWeb's clients, a clear organizational vision and mission, and a unique doula cohort model. Discussion: Our findings suggest developing community doula programs pay close attention to the difference between launching a program versus an organization, including the required resources of each, the sustainability of payment models for community doulas, and the provision of culturally relevant, needed services within priority communities. Furthermore, strategic partnerships with maternal health stakeholders in birthing sites, particularly hospitals, are vital to the success of a community doula program. [ABSTRACT FROM AUTHOR]

Background: In 2011, California enacted its public safety realignment initiative (realignment) motivated by a U.S. Supreme Court ruling to reduce state prison overcrowding and in effort to reduce recidivism. Realignment transferred authority for lower-level felony offenders from the state to the counties, leading to a rapid reduction in state prison incarceration levels. Objective: This study drew on a unique dataset to assess the effects of California's efforts to downsize the prison system on maternal incarceration levels and to better understand the characteristics of incarcerated mothers and their children. Methods: Incarceration records concerning all women in California state prisons between 2010 and 2012 (N = 16,917) were linked to 7.5 million vital birth records dating to 1999 to identify incarcerated women who had given birth. Multinomial logistic regression models were specified to better understand offense type differences among incarcerated mothers versus nonmothers. Results: Findings indicate that realignment disproportionately affected women. The number of men entering prison decreased 67.8% between 2010 and 2012. In comparison, the number of women entering prison decreased 78.5%. Further, more than half of incarcerated women had given birth. Mothers were more likely than nonmothers to be convicted of nonviolent crimes. Discussion: This study underscores how prison downsizing can disproportionately reduce incarceration levels for women. Given that such large proportion of incarcerated women were mothers, this policy change may have potential spillover next-generation benefits. Finally, this work reinforces the potential to use linked administrative records to study incarcerated populations. [ABSTRACT FROM AUTHOR]

Background: Infant nutrition can influence development, eating behaviors and obesity risk. Nearly half of infants in the U.S. are in non-parental care where they consume much of their daily nutrition. Because little is known about the quality of infant nutrition in childcare, the study objective was to characterize the foods and beverages provided to infants in childcare in California. Methods: From a randomly selected sample of 2,400 licensed childcare in California, 736 responded to a 2016 survey; a subset of 297 cared for infants. Differences in 26 foods and 7 beverages provided between centers and homes, and by CACFP participation, were assessed using logistic regression models adjusted for CACFP participation and whether the site was a center or home, respectively. Results: Several differences between centers and homes were identified. One the day prior to the survey, more centers than homes ever provided cow's milk (25.1% vs 13.0%, p = 0.02) and whole grains (76.7% vs 62.9%, p = 0.03), and fewer centers than homes provided frozen treats (1.4% vs 10.3%, p = 0.003). When comparing difference by CACFP participation, fewer CACFP than non-CACFP sites usually provided breastmilk (32.6% vs 54.2%, p = 0.0004) and ever provided cow's milk (14.2% vs 37.1%, p < 0.0001). On the day prior to the survey, more CACFP than non-CACFP provided vegetables (91.0% vs 80.8%, p = 0.02), fruit (centers only) (97.2% vs 80.8%, p = 0.0003), and infant cereals (86.0% vs 61.2%, p < 0.0001). Fewer CACFP than non-CACFP provided sweetened yogurt (14.8% vs 36.7%, p < 0.0001). Conclusions for Practice: Childcare centers and CACFP participants tended to serve nutritious foods more than childcare homes and non-CACFP participants, respectively. Additional education and policies for childcare providers on appropriate foods and beverages for infants is recommended. [ABSTRACT FROM AUTHOR]

Introduction Hispanics/Latinos are disproportionately affected by obesity in the U.S. Multiple factors place Hispanic/Latino children at risk for overweight, warranting guidance of a socio-ecologic approach to examine causes of obesity. The purpose of this study was to increase understanding of the factors that influence Hispanic/Latino childhood obesity through an intergenerational lens including children, parents/caregivers, and grandparents. Methods Eight focus groups were conducted with Hispanics/Latinos (N = 68 adults, N = 22 youth), using a semi-structured moderator's guide. Audio-recordings were transcribed, and thematically analyzed. Findings were categorized within the PRECEDE–PROCEED planning model. Results Adult participants were middle-aged (M = 37.8 ± 9.8 years) and youth were between the ages of 10–17 (M = 14.0 ± 1.8 years). Six themes emerged: eating habits, cultural perceptions of weight, acculturation, childhood obesity perceptions, economic issues, and generational differences. The major parental influence was lack of time to provide healthy meals due to socio-economic factors: long work hours and availability of nearby fast food options. Youth shared that childhood obesity is due to sedentary behaviors, permissive parenting and lack of parental modeling (the latter two factors often exacerbated by extended work schedules). Discussion Discordant perceptions about unhealthy eating habits emerged. Adults expressed a lack of nutritional knowledge and skills to prepare healthy meals; while adolescents emphasized permissive parenting styles and lack of discipline lead to unhealthy lifestyles in Hispanic families. Findings emphasize involving parents/caregivers and youth to understand discordant perceptions that can inform the development of prevention programs. [ABSTRACT FROM AUTHOR]

Objectives Despite significant investments in Maternal and Child Health (MCH), the United States still lags behind other countries in key MCH indicators. A well-trained workforce is needed to improve MCH. The Division of MCH Workforce Development of HRSA’s Maternal and Child Health Bureau provides funding to schools of Public Health to support Centers of Excellence in MCH, which is focused on preparing the next generation of MCH leaders through specialized training and mentorship. One such center, the Tulane Center of Excellence in MCH (CEMCH), is housed at the Tulane University School of Public Health and Tropical Medicine. This study evaluated the perceived effectiveness and acceptability of the CEMCH leadership training program. Methods A mixed-methods approach was used, consisting of semi-structured interviews and quantitative surveys which were analyzed through inductive methods based in grounded theory and non-parametric methods respectively. Results Results indicated an overall high level of program satisfaction by all stakeholders. Mentorship and personal attention emerged as an important benefit for both former and current Scholars. The opportunity to gain real-world understanding of MCH work through program activities was an added benefit, although these activities also presented the most challenges. Community stakeholders generally did not view the program as providing immediate organizational benefit, but recognized the distal benefit of contributing to a well-trained MCH workforce. Conclusions for Practice These results will be used to inform other MCH training programs and strengthen Tulane’s CEMCH. A well-trained MCH workforce is essential to improving MCH, and high-quality training its foundation. [ABSTRACT FROM AUTHOR]

Objectives Household stressors, such as food insecurity, contribute to the home emotional environment and negatively affect child development. Little research on this topic has been conducted among very young children. This study aimed to examine the relationship between food insecurity and the home emotional environment, as well the extent to which the relationship may be mediated by maternal symptoms of depression. Frequency of praise, affection, and discipline of young children by mothers were examined as markers of the home emotional environment. Methods Data were collected in a cross-sectional study of mothers of children under the age of five (N = 4231). Logistic regression was used to assess the relationship between level of food security and frequency of praise and discipline of children. Mediation analysis using the KHB method was conducted to test whether maternal mental health mediated the relationship between food insecurity and each outcome. Results Low and very low food security were significantly associated with higher odds of disciplining children with high frequency. Controlling for all covariates, frequency of praise was not significantly associated with level of household food insecurity. Differences in praise and discipline frequency were found by language of interview, maternal education, and employment. Conclusions for Practice Parent-child interactions, specifically related to discipline, are related to food insecurity. Further research should consider cultural patterns and mechanisms behind the relationship between food insecurity and the home environment. Household stressors begin affecting children at young ages, and early intervention is essential to prevent further negative sequelae as children grow older. [ABSTRACT FROM AUTHOR]

Background and Objectives Pediatricians face numerous challenges in providing care for children with special health care needs (CSHCN). Few studies have described health care resources available to support pediatricians to care for CSHCN. This study investigated available resources to care for CSHCN and factors associated with having a greater proportion of CSHCN in practice. Methods We conducted a statewide survey of active members of the American Academy of Pediatrics in California to study pediatric subspecialty care access, community and office resources and practice barriers. We performed a logistic regression model on having an “above average proportion” of CSHCN in practice, adjusting for demographics, practice type (rural vs. suburban/urban) and medical resources, care satisfaction, and ease of subspecialty access. Results Our response rate was 50.2% (n = 1290); 75% of respondents reported providing some primary care services, with many primary care pediatricians caring for a high proportion of CSHCN. Pediatricians reported an average of 28% CSHCN in their practices. Rural pediatricians lacked subspecialty access (10-59% reporting no access to the various subspecialties). Factors relating to higher CSHCN in practice included being in academic medical centers and satisfaction in caring for CSHCN. Conclusions Pediatricians report lack of access to mental health services, care coordination and case management. Academic medical centers and higher physician satisfaction in care delivery for CSHCN are associated with more CSHCN in practice. Promoting ways to support pediatricians, such as practice collaboration with behavioral specialists, may be necessary to encourage primary care pediatricians to provide medical homes for CSHCN. [ABSTRACT FROM AUTHOR]

Objective To determine the association of age at index birth with postpartum contraceptive use and optimal interpregnancy interval (IPI, defined as delivery to next pregnancy >18 months), controlling for provider type and client demographics among adolescent mothers who have repeat pregnancies. Methods California's 2008 birth records were linked to California's Medi-Cal and Family PACT claims data to identify 26,393 women with repeat births between 2002 and 2008, whose index birth occurred as an adolescent, and who received publicly-funded services within 18 months after the index birth. Multivariable regression analyses were conducted to examine the relationship between timing of contraception provision and interpregnancy intervals, adjusting for socio-demographic factors. Results Seventy-eight percent of adolescent women did not receive contraception at their first postpartum visit, and twenty-eight percent of adolescent women never received contraception from a Family PACT or Medi-Cal provider. Adolescents who were older at their index birth had lower rates of optimal IPIs. Native American, Asian-Pacific Islander and Latina women had lower rates of optimal IPIs compared to white women. Compared to those using only barrier methods, adolescent women receiving highly effective contraceptive methods had a 4.25 times higher odds of having an optimal IPI than those receiving hormonal methods (OR 2.10), or using no method (OR 0.70). Conclusion Effective postpartum contraceptive use and being a Family PACT provider were associated with optimal birth spacing among adolescent mothers, yet racial and ethnic disparities persisted. A missed opportunity was the provision of contraception at the first postpartum visit. Providers should aim to remove barriers to initiation of contraception at this visit. [ABSTRACT FROM AUTHOR]

Objective To provide preliminary descriptive data on caregiver and child weight status, parenting styles, feeding styles, and feeding practices of a small American Indian sample. Methods Participants included a subsample of American Indian caregivers ( n = 23) identified from a larger study that was conducted in five states. Using previously validated instruments, means, standard deviations, and ranges for general parenting styles, feeding styles, and feeding practices were explored. Results In general, most caregivers reported healthy feeding practices. Most caregivers scored higher on responsive compared to restrictive or permissive in general parenting. Of the sample, 12 caregivers (52.2 %) were classified in the indulgent feeding style category, 5 caregivers (21.7 %) were classified as authoritative, 5 (21.7 %) uninvolved, and 1 (4.3 %) authoritarian. Conclusions More investigations are needed to explore questions raised by this study about using common tools that measure childhood obesity with American Indian families. [ABSTRACT FROM AUTHOR]

Objectives: Racial and ethnic groups in the US exhibit major differences in low birthweight (LBW) rates. While previous studies have shown that community level social indicators associated with LBW vary by race and ethnicity, it is not known whether these differences exist among racial or ethnic groups who live in the same neighborhood or community. To address this question, we examined the association of community level features with LBW among African American, White and Hispanic women who live in similar geographic areas. Methods: The analysis is based on geocoded birth certificates for all singleton live births in the year 2000 to women residing in 805 California ZIP codes. Community level social and demographic data were obtained from U.S. Census data files for the year 2000 and surrogate indices of population level alcohol and drug abuse and dependence were derived from hospital discharge data (HDD). Tobit and bootstrap analyses were used to test associations with birth outcomes, maternal characteristics, and community level social and demographic features within and across the three groups of women living in similar geographic areas. Results: The results demonstrate major racial and ethnic differences in community level correlates of LBW. Rates of LBW among African Americans were lower if they lived in areas that were more densely populated, had greater income disparities, were more racially segregated, and had low rates of alcohol abuse or dependence. These associations were different or absent for Hispanic and White women. Conclusions for Practice: The results suggest that despite living in the same areas, major differences in neighborhood features and social processes are linked to birth outcomes of African American women compared to Hispanic and White women. Further research, especially using multilevel approaches, is needed to precisely identify these differences to help reduce racial and ethnic disparities in LBW. [ABSTRACT FROM AUTHOR]

The objective of this study was to create a psychometrically sound measure of family-centered care, the Family-Centered Care Assessment (FCCA), developed through a process led by families in collaboration with maternal and child health leaders. The items for the FCCA scale were initially developed by families of children and youth with special needs in partnership with pediatric providers and researchers. Using an Institutional Review Board-approved research protocol, the questions were revised based on input from focus groups of diverse parents in three states. Parental responses (N = 790) to the revised 59-item survey were collected online from families in 49 states. Item distributions uniformly showed excellent spread. A principal axes factor analysis confirmed the existence of a single factor. Rasch modeling item analyses identified a reduced subset of 24 items that demonstrated excellent psychometric properties. All items met the criteria for a linear Rasch scale. Empirical evidence in support of the construct validity of the 24-item measure was derived: all items had a positive and substantial item-total correlation; person alpha scale reliability was >0.80 and the item reliability was >0.90; both separation indices were >2.0; infit and outfit statistics were within 0.5-1.5; and item difficulties ranged between −2 and +2 logits. Strong rank-ordered associations and large effect sizes were observed for six indicators of quality of care. This study's family-led process produced a tool, the FCCA, to measure families' experience of care with excellent psychometric properties. [ABSTRACT FROM AUTHOR]

To determine Latino parents' beliefs on the health effects of beverages on infants and toddlers, their sources of information on beverages and perceived barriers to following guidelines for healthy beverage consumption by children. We conducted 29 interviews with parents of Latino children ages 6-36 months. Parents were recruited in three community health centers in Northern California. The interviews were recorded, transcribed and analyzed using standard qualitative methods. The following dominant themes emerged. Parents believed that water and milk were healthy beverages for children and that sugar-sweetened beverages (SSBs) were unhealthy. Views on 100 % fruit juice were mixed. Parents distinguished between homemade beverages such as 'agua fresca' which they considered healthy, despite containing added sugar, and beverages from stores which were viewed as unhealthy. Participants' main source of information on beverages was the federal nutrition program for Women, Infants, and Children (WIC). Parents were confused, however, as to why WIC provides juice yet counseled parents to avoid giving their children juice. Parents preferred to receive information on beverages from experts. Differing practices among family members regarding which beverages they provide to children was the most important barrier to following beverage guidelines. Our study suggests that Latino parents are receptive to counseling on beverages from expert sources. Such counseling should address both store-bought and homemade beverages. The WIC program is a key source of information on beverages for Latino parents; thus counseling offered by WIC should be evidence-based and avoid mixed messages. [ABSTRACT FROM AUTHOR]

Combination antiretroviral therapy for persons living with HIV/AIDS (PLHA) has extended life expectancy, and enabled PLHA to live productive lives that can include having children. Despite calls to address childbearing for PLHA there has been limited attention to developing safe conception programs. This research sought to assess the childbearing desires of PLHA and the experiences of health care providers serving this population. Research entailed a brief cross-sectional client survey given to HIV-infected men and women over age 18 at two Los Angeles County clinics administered over an 8-week period. Focus group discussions were conducted with providers at each clinic site. Although 39 % of the 93 clients surveyed reported a desire to have children, two-thirds of clients had not discussed their desires, or methods of safe conception, with providers. Providers reported challenges in providing safe conception services in resource poor settings where clients cannot afford assisted fertility services and in the absence of national, state, or county guidelines for safe conception. They noted complex and varied client circumstances and a critical need for provider training in safe conception. Guidelines that focus on safe conception and harm reduction strategies as well as the legal ramifications of counseling on these practices are needed. HIV providers need training and patients need educational tools and workshops informing them of the risks, challenges, and options available to them and their partners to safely conceive and bear an HIV-negative child. [ABSTRACT FROM AUTHOR]