The women's health needs study among women from countries with high prevalence of female genital mutilation living in the United States: Design, methods, and participant characteristics.

BACKGROUND: The Women's Health Needs Study (WHNS) collected information on the health characteristics, needs, and experiences, including female genital mutilation (FGM) experiences, attitudes, and beliefs, of women aged 18 to 49 years who were born, or whose mothers were born, in a country where FGM is prevalent living in the US. The purpose of this paper is to describe the WHNS design, methods, strengths and limitations, as well as select demographic and health-related characteristics of participants. METHODS: We conducted a cross-sectional survey from November 2020 -June 2021 in four US metropolitan areas, using a hybrid venue-based sampling (VBS) and respondent-driven sampling (RDS) approach to identify women for recruitment. RESULTS: Of 1,132 participants, 395 were recruited via VBS and 737 RDS. Most were born, or their mothers were born, in either a West African country (Burkina Faso, Guinea, Mali, Mauritania, Sierra Leone, The Gambia) (39.0%) or Ethiopia (30.7%). More than a third were aged 30-39 years (37.5%) with a majority who immigrated at ages ≥13 years (86.6%) and had lived in the United States for ≥5 years (68.9%). Medicaid was the top health insurer (52.5%), followed by private health insurance (30.5%); 17% of participants had no insurance. Nearly half of women reported 1-2 healthcare visits within the past 12 months (47.7%). One in seven did not get needed health care due to cost (14.8%). Over half have ever used contraception (52.1%) to delay or avoid pregnancy and 76.9% had their last pelvic and/or Papanicolaou (pap) exam within the past 3 years. More than half experienced FGM (55.0%). Nearly all women believed that FGM should be stopped (92.0%). CONCLUSION: The VBS/RDS approach enabled recruitment of a diverse study population. WHNS advances research related to the health characteristics, needs, and experiences of women living in the US from countries where FGM is prevalent.

Geographic Differences in Preconception Health Indicators Among Ohio Women Who Delivered Live Births, 2019-2021.

To determine whether geographic differences in preconception health indicators exist among Ohio women with live births, we analyzed 9 indicators from the 2019-2021 Ohio Pregnancy Assessment Survey (N = 14,377) by county type. Appalachian women reported lower rates of folic acid intake and higher rates of depression than women in other counties. Appalachian and rural non-Appalachian women most often reported cigarette use. Suburban women reported lower rates of diabetes, hypertension, and unwanted pregnancy than women in other counties. Preconception health differences by residence location suggest a need to customize prevention efforts by region to improve health outcomes, particularly in regions with persistent health disparities.

Timing of Postpartum Depressive Symptoms.

Introduction: Postpartum depression is a serious public health problem that can adversely impact mother-child interactions. Few studies have examined depressive symptoms in the later (9-10 months) postpartum period. Methods: We analyzed data from the 2019 Pregnancy Risk Assessment Monitoring System (PRAMS) linked with data from a telephone follow-up survey administered to PRAMS respondents 9 to 10 months postpartum in 7 states (N = 1,954). We estimated the prevalence of postpartum depressive symptoms (PDS) at 9 to 10 months overall and by sociodemographic characteristics, prior depression (before or during pregnancy), PDS at 2 to 6 months, and other mental health characteristics. We used unadjusted prevalence ratios (PRs) to examine associations between those characteristics and PDS at 9 to 10 months. We also examined prevalence and associations with PDS at both time periods. Results: Prevalence of PDS at 9 to 10 months was 7.2%. Of those with PDS at 9 to 10 months, 57.4% had not reported depressive symptoms at 2 to 6 months. Prevalence of PDS at 9 to 10 months was associated with having Medicaid insurance postpartum (PR = 2.34; P = .001), prior depression (PR = 4.03; P <.001), and current postpartum anxiety (PR = 3.58; P <.001). Prevalence of PDS at both time periods was 3.1%. Of those with PDS at both time periods, 68.5% had prior depression. Conclusion: Nearly 3 in 5 women with PDS at 9 to 10 months did not report PDS at 2 to 6 months. Screening for depression throughout the first postpartum year can identify women who are not symptomatic early in the postpartum period but later develop symptoms.

Condom use among women of reproductive age (18-49 years) in Puerto Rico during the 2016 Zika virus outbreak: secondary analysis of data from a cross-sectional, population-based, cell-phone survey.

OBJECTIVES: Zika virus (ZIKV) can be sexually transmitted, and ZIKV infection during pregnancy can cause birth defects. Contraception is a medical countermeasure to reduce unintended pregnancy and ZIKV-associated birth defects. We estimated the prevalence of condom use and associated factors among women at risk for unintended pregnancy in Puerto Rico during the 2016 ZIKV outbreak. DESIGN: Secondary analysis of a cross-sectional, population-based, cell-phone survey. SETTING AND PARTICIPANTS: Women, 18-49 years, living in Puerto Rico during July-November 2016. We limited our analytical sample (n=1840) to women at risk for unintended pregnancy, defined as those who were sexually active with a man in the last 3 months and did not report menopause, hysterectomy, current pregnancy or desiring pregnancy. OUTCOME MEASURES: We estimated the weighted prevalence of any condom use among women at risk for unintended pregnancy. We calculated crude and adjusted prevalence ratios (aPRs) to examine the association between condom use and ZIKV-related factors, stratified by use of more effective versus less effective or no contraception. RESULTS: Overall, 32.7% (95% CI: 30.2% to 35.1%) of women reported any condom use in the last 3 months. Among women using more effective contraception, condom use was higher for women who received ZIKV counselling (aPR: 1.61, 95% CI: 1.15 to 2.25) and those worried about having a child with a ZIKV-associated birth defect (aPR: 1.47, 95% CI: 1.03 to 2.10). Among women using less effective or no contraception, condom use was associated with being worried (aPR: 1.20, 95% CI: 1.01 to 1.43) compared with those not worried about ZIKV infection or with a previous known infection. CONCLUSIONS: During the 2016 ZIKV outbreak, one in three women at risk for unintended pregnancy reported any condom use. Counselling to promote consistent and correct condom use may address concerns regarding ZIKV among women of reproductive age, which may differ by use of effective contraception.

Fertility and contraception among women of reproductive age following a disaster: a scoping review.

BACKGROUND: The prevalence and severity of disasters triggered by natural hazards has increased over the last 20 years. Women of reproductive age may encounter unique reproductive health challenges following a disaster. In this scoping review we identify gaps in literature to inform future research and search for potential associations between disasters by natural hazards and post-disaster fertility and contraception among women of reproductive age. METHODS: Medline (OVID), Embase (OVID), PsycInfo (OVID), CINAHL (Ebsco), Scopus, Environmental Science Collection (ProQuest Central), and Sociological Abstracts (ProQuest Central) were searched for articles published from 1980 through March 3, 2022 in English or Spanish language. Search terms were related to fertility, contraception, and disasters. We included original research that described a discrete natural hazard exposure, a population of women of reproductive age (15-49 years), and outcomes of fertility or contraception use or access, with pre- and post-disaster measures. RESULTS: Among 9788 citations, after initial exclusion 5121 remained for title and abstract review. One hundred and eighteen citations underwent full-text review and 26 articles met the inclusion criteria. Following critical appraisal, 20 articles were included in this review. Eighteen articles described outcomes related to fertility, five articles described contraception access, and three articles described contraception use. CONCLUSIONS: Clearly defined exposure measures, robust analyses, and methodical post-disaster assessment periods, may address the current gaps within disaster research on fertility and contraception among women of reproductive age. Consistent patterns in fertility following a disaster triggered by natural hazards were not identified between or within disaster types. Studies that assessed contraception found no change in use, while some studies found a decrease in contraceptive access overall.

Emergency Preparedness and Response: Highlights from the Division of Reproductive Health, 2011-2021.

This report provides historical context and rationale for coordinated, systematic, and evidence-based public health emergency preparedness and response (EPR) activities to address the needs of women of reproductive age. Needs of pregnant and postpartum women, and infants-before, during, and after public health emergencies-are highlighted. Four focus areas and related activities are described: (1) public health science; (2) clinical guidance; (3) partnerships, communication, and outreach; and (4) workforce development. Finally, the report summarizes major activities of the Division of Reproductive Health's EPR Team at the Centers for Disease Control and Prevention.

Human Papillomavirus Vaccination Estimates Among Adolescents in the Mississippi Delta Region: National Immunization Survey­Teen, 2015-2017.

INTRODUCTION: The Delta Regional Authority (DRA) consists of 252 counties and parishes in 8 states in the US Mississippi Delta region. DRA areas have high rates of disease, including cancers related to the human papillomavirus (HPV). HPV vaccination coverage in the DRA region has not been documented. METHODS: We analyzed data for 63,299 adolescents aged 13 to 17 years in the National Immunization Survey-Teen, 2015-2017. We compared HPV vaccination initiation coverage estimates (≥1 dose) in the DRA region with coverage estimates in areas in the 8 Delta states outside the DRA region and non-Delta states. We examined correlates of HPV vaccination coverage initiation and reasons parents did not intend to vaccinate adolescents. RESULTS: Vaccination rates in the DRA region (n = 2,317; 54.3%) and in Delta areas outside the DRA region (n = 6,028; 56.2%) were similar, but these rates were significantly lower than rates in non-Delta states (n = 54,954; 61.4%). Inside the DRA region, reasons for parents' vaccine hesitancy or refusal were similar to those expressed by parents in the Delta areas outside the DRA region. Some parents believed that the vaccine was not necessary or had concerns about vaccine safety. CONCLUSION: HPV vaccination coverage in the DRA region is similar to coverage in other Delta counties and parishes, but it is significantly lower than in non-Delta states. Activities to address parental concerns and improve provider recommendations for the vaccine in the DRA region are needed to increase HPV vaccination rates.

Community-University Partnership Characteristics for Translation: Evidence From CDC's Prevention Research Centers.

Background: The Centers for Disease Control and Prevention's Prevention Research Centers (PRC) Program supports community engagement and partnerships to translate health evidence into practice. Translation is dependent on the quality of partnerships. However, questions remain about the necessary characteristics to develop and maintain translation partnerships. Aim: To identify the characteristics that influence community-university partnerships and examine alignment with the Knowledge to Action (K2A) Framework. Methods: Final Progress Reports (N = 37) from PRCs funded from September 2009 to September 2014 were reviewed in 2016-2017 to determine eligibility. Eligible PRCs included those that translated an innovation following the applied research phase (2009-2014) of the PRC award (n = 12). The PRCs and the adopters (i.e., community organizations) were recruited and participated in qualitative interviews in 2017. Results: Ten PRCs (83.3% response rate) and four adopters participated. Twelve codes (i.e., elements) were found that impacted partnerships along the translation continuum (e.g., adequate communication, technical assistance). Each element aligned with the K2A Framework at multiple steps within the translation phase. The intersection between the element and step in the translation phase is termed a "characteristic." Using interview data, fifty-two unique partnership characteristics for translation were found. Discussion and Conclusion: The results suggest multiple characteristics that impact translation partnerships. The inclusion of these partnership characteristics in policies and practices that seek to move practice-based or research-based evidence into widespread use may impact the receptivity by partners and evidence uptake by communities. Using the K2A Framework to assess translation partnerships was helpful and could be considered in process evaluations to inform translation partnership improvement.

The Economic Value of Informal Caregiving for Persons With Dementia: Results From 38 States, the District of Columbia, and Puerto Rico, 2015 and 2016 BRFSS.

OBJECTIVES: To estimate the economic value from a societal perspective of informal caregiving of persons with dementia in 38 states, the District of Columbia, and Puerto Rico. METHODS: Using a cost replacement method and data from the 2015 and 2016 Behavioral Risk Factor Surveillance System caregiver module, the US Bureau of Labor Statistics May 2016 Occupation Profiles, and the US Department of Labor, we estimated the number and economic direct cost of caregiving hours. RESULTS: An estimated 3.2 million dementia caregivers provided more than 4.1 billion hours of care, with an average of 1278 hours per caregiver. The median hourly value of dementia caregiving was $10.28. Overall, we valued these caregiving hours at $41.5 billion, with an average of $13 069 per caregiver. CONCLUSIONS: Caregivers of persons with dementia provide care that has important economic implications. Without these efforts, many people would either not receive needed care or have to pay for that support. Surveillance data can be used to estimate the contributions of informal caregivers and the economic value of the care they provide.

Cost Analysis of Prevention Research Centers: Instrument Development.

The 2014-2019 Prevention Research Centers (PRC) Program Funding Opportunity Announcement stated that "all applicants will be expected to collaborate with CDC to collect data to be able to perform cost analysis." For the first time in the 30-year history of the PRC Program, a cost indicator was included in the PRC Program Evaluation and a cost analysis (CA) instrument developed. The PRC-CA instrument systematically collects data on the cost of the PRC core research project to eventually answer the CDC PRC Program Evaluation question: "To what extent do investments in PRCs support the scalability, sustainability, and effectiveness of the outcomes resulting from community-engaged efforts to improve public health?" The objective of this article is to briefly describe the development of the PRC-CA instrument. Data obtained from the PRC-CA instrument can be used to generate cost summaries to inform decision making within the PRC Program and each individual PRC.

Measuring Audience Engagement for Public Health Twitter Chats: Insights From #LiveFitNOLA.

BACKGROUND: Little empirical evidence exists on the effectiveness of using Twitter as a two-way communication tool for public health practice, such as Twitter chats. OBJECTIVE: We analyzed whether Twitter chats facilitate engagement in two-way communications between public health entities and their audience. We also describe how to measure two-way communications, incoming and outgoing mentions, between users in a protocol using free and publicly available tools (Symplur, OpenRefine, and Gephi). METHODS: We used a mixed-methods approach, social network analysis, and content analysis. The study population comprised individuals and organizations participating or who were mentioned in the first #LiveFitNOLA chat, during a 75-min period on March 5, 2015, from 12:00 PM to 1:15 PM Central Time. We assessed audience engagement in two-way communications with two metrics: engagement ratio and return on engagement (ROE). RESULTS: The #LiveFitNOLA chat had 744 tweets and 66 participants with an average of 11 tweets per participant. The resulting network had 134 network members and 474 engagements. The engagement ratios and ROEs for the #LiveFitNOLA organizers were 1:1, 40% (13/32) (@TulanePRC) and 2:1, -40% (-25/63) (@FitNOLA). Content analysis showed information sharing (63.9%, 314/491) and health information (27.9%, 137/491) as the most salient theme and sub-theme, respectively. CONCLUSIONS: Our findings suggest Twitter chats facilitate audience engagement in two-way communications between public health entities and their audience. The #LiveFitNOLA organizers' engagement ratios and ROEs indicated a moderate level of engagement with their audience. The practical significance of the engagement ratio and ROE depends on the audience, context, scope, scale, and goal of a Twitter chat or other organized hashtag-based communications on Twitter.

Economic Evaluation Enhances Public Health Decision Making.

Contemporary public health professionals must address the health needs of a diverse population with constrained budgets and shrinking funds. Economic evaluation contributes to evidence-based decision making by helping the public health community identify, measure, and compare activities with the necessary impact, scalability, and sustainability to optimize population health. Asking "how do investments in public health strategies influence or offset the need for downstream spending on medical care and/or social services?" is important when making decisions about resource allocation and scaling of interventions.

A Cost Analysis of the 1-2-3 Pap Intervention.

BACKGROUND: Cervical cancer places a substantial economic burden on our healthcare system. The three-dose human papillomavirus (HPV) vaccine series is a cost-effective intervention to prevent HPV infection and resultant cervical cancer. Despite its efficacy, completion rates are low in young women aged 18 through 26 years. 1-2-3 Pap is a video intervention tested and proven to increase HPV vaccination completion rates. PURPOSE: To provide the full scope of available evidence for 1-2-3 Pap, this study adds economic evidence to the intervention's efficacy. This study tested the economies of scale hypothesis that the cost of 1-2-3 Pap intervention per number of completed HPV vaccine series would decrease when offered to more women in the target population. METHODS: Using cost and efficacy data from the Rural Cancer Prevention Center, a cost analysis was done through a hypothetical adaptation scenario in rural Kentucky. RESULTS: Assuming the same success rate as in the efficacy study, the 1-2-3 Pap adaptation scenario would cover 1000 additional women aged 18 through 26 years (344 in efficacy study; 1346 in adaptation scenario), and almost three times as many completed series (130 in efficacy study; 412 in adaptation scenario) as in the original 1-2-3 Pap efficacy study. IMPLICATIONS: Determination of the costs of implementing 1-2-3 Pap is vital for program expansion. This study provides practitioners and decision makers with objective measures for scalability.

Racial/ethnic differences in the prevalence of gestational diabetes mellitus and maternal overweight and obesity, by nativity, Florida, 2004-2007.

OBJECTIVE: We examined the risk of gestational diabetes mellitus (GDM) among foreign-born and U.S.-born mothers by race/ethnicity and BMI category. DESIGN AND METHOD: We used 2004-2007 linked birth certificate and maternal hospital discharge data of live, singleton deliveries in Florida to compare GDM risk among foreign-born and U.S.-born mothers by race/ethnicity and BMI category. We examined maternal BMI and controlled for maternal age, parity, and height. RESULTS: Overall, 22.4% of the women in our study were foreign born. The relative risk (RR) of GDM among women who were overweight or obese (BMI ≥ 25.0 kg m(-2)) was higher than among women with normal BMI (18.5-24.9 kg m(-2)) regardless of nativity, ranging from 1.3 (95% confidence interval (CI) = 1.0, 1.9) to 3.8 (95% CI = 2.1, 7.2).Foreign-born women also had a higher GDM risk than U.S.-born women, with RR ranging from 1.1 (95% CI = 1.1, 1.2) to 2.1 (95% CI = 1.4, 3.1). This finding was independent of BMI, age, parity, and height for all racial/ethnicity groups. CONCLUSIONS: Although we found differences in age, parity, and height by nativity, these differences did not substantially reduce the increased risk of GDM among foreign-born mothers. Health practitioners should be aware of and have a better understanding of how race/ethnicity and nativity can affect women with a high risk of GDM. Although BMI is a major risk factor for GDM, it does not appear to be associated with race/ethnicity or nativity.

Preconception health among women with frequent mental distress: a population-based study.

PURPOSE: We examined the extent to which mental distress may be associated with a woman's preconception health. METHODS: We analyzed population-based, self-reported data from the 2005, 2007, and 2009 Behavioral Risk Factor Surveillance System (BRFSS) and limited analyses to 213,137 women aged 18-44 years. Women whose mental health was not good for ≥14 days during the past month were categorized as having frequent mental distress. For 15 preconception health indicators, we used chi-square tests to measure differences in prevalence by mental distress and the average marginal predictions approach to logistic regression to assess associations between mental distress and each preconception health indicator in separate models, adjusted for demographic characteristics. We conducted analyses using SUDAAN software to account for the complex sampling design and used weights to produce unbiased estimates. RESULTS: The prevalence of good preconception health for each indicator was higher for women reporting infrequent mental distress (chi-square p value<0.001 for all). The greatest disparities in preconception health between women with infrequent and frequent mental distress, respectively, were adequate social and emotional support (adjusted prevalence ratio [aPR]=1.4, prevalence=83.7% and 54.8%), not smoking (aPR=1.2, 82.3% and 62.4%), adequate fruit and vegetable consumption (aPR=1.2, 26.1% and 21.5%), normal weight (aPR=1.2, 50.4% and 39.0%), and good general health (aPR=1.2, 91.7% and 71.5%). CONCLUSIONS: Interventions tailored for women with poor mental health may be needed to target specific preconception health indicators, such as social support, smoking, weight, and nutrition.

WIC participation and breastfeeding among White and Black mothers: data from Mississippi.

Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been associated with lower rates of breastfeeding; studies have suggested this relationship may be modified by race. The purpose of this study is to examine the association between WIC participation and breastfeeding behaviors among white and black women in Mississippi. Using data from the 2004-2008 Mississippi Pregnancy Risk Assessment Monitoring System, we calculated multivariable prevalence and hazard ratios to assess the relationships among WIC participation during pregnancy and breastfeeding initiation and duration through 10 weeks postpartum. Stratified analyses were performed for white and black women. 52.2 % of white and 82.1 % of black women participated in WIC. 60.4 % of white and 39.7 % of black women initiated breastfeeding, and 26.5 % and 21.9 %, respectively, were breastfeeding at 10 weeks postpartum. WIC participation was negatively associated with breastfeeding initiation among whites (APR: 0.87; 95 % CI 0.77-0.99), but not blacks (APR: 0.99; 95 % CI 0.28-1.21). WIC participation was not associated with breastfeeding duration for women of either race (white: AHR: 1.05, 95 % CI 0.80-1.38; black: AHR: 0.91, 95 % CI 0.65-1.26). The results among white women suggest that Mississippi WIC might benefit from an in depth evaluation of the program's breastfeeding promotional activities to determine if aspects of the program are undermining breastfeeding initiation. High rates of participation in the WIC program among black women, and the overall low rates of breastfeeding in this population point to the potential the program has to increase breastfeeding rates among blacks.

Preconception health of reproductive aged women of the Mississippi River delta.

Optimal preconception health (PCH) may improve maternal and infant outcomes, priority issues in Mississippi (MS). Our study objective was to compare the PCH of women in the MS Delta to other regions. We analyzed Behavioral Risk Factor Surveillance System data from 2005, 2007, and 2009, and limited analyses to 171,612 non-pregnant black and white women 18-44 years of age. Region was defined as 14 MS Delta counties (MS Delta), remainder of MS (MS non-Delta), Delta states (LA, AR, TN), and non-Delta US states. We calculated adjusted prevalence ratios (aPR) to assess associations between region and 16 indicators of optimal PCH, controlling for demographic characteristics. Healthy PCH factors such as consuming ≥5 fruits and vegetables daily and normal body mass index (18.5 kg/m(2) to <25 kg/m(2)), respectively, were more prevalent in the MS non-Delta (aPR = 1.3; 95 % CI: 1.0,1.7 and aPR = 1.2; 95 % CI: 1.0,1.4), non-MS Delta (aPR = 1.5; 95 % CI: 1.2,2.0 and aPR = 1.3; 95 % CI: 1.1,1.5) and non-Delta states (aPR = 1.7; 95 % CI: 1.3,2.2 and aPR = 1.4; 95 % CI: 1.2,1.6) compared to the MS Delta. Physical activity levels were higher among non-Delta US states compared to the MS Delta (aPR = 1.3; 95 % CI: 1.1,1.4). Household income and race confounded the associations between region and PCH. Reproductive aged women in the MS Delta had poorer PCH, particularly for physical activity and nutrition, than women in other regions. MS Delta service providers and public health practitioners should consider implementing or enhancing lifestyle, nutrition, and physical activity interventions, with a special focus on reducing income-based and racial disparities.

Racial/ethnic differences in the percentage of gestational diabetes mellitus cases attributable to overweight and obesity, Florida, 2004-2007.

INTRODUCTION: Gestational diabetes mellitus (GDM) affects 3% to 7% of pregnant women in the United States, and Asian, black, American Indian, and Hispanic women are at increased risk. Florida, the fourth most populous US state, has a high level of racial/ethnic diversity, providing the opportunity to examine variations in the contribution of maternal body mass index (BMI) status to GDM risk. The objective of this study was to estimate the race/ethnicity-specific percentage of GDM attributable to overweight and obesity in Florida. METHODS: We analyzed linked birth certificate and maternal hospital discharge data for live, singleton deliveries in Florida from 2004 through 2007. We used logistic regression to assess the independent contributions of women's prepregnancy BMI status to their GDM risk, by race/ethnicity, while controlling for maternal age and parity. We then calculated the adjusted population-attributable fraction of GDM cases attributable to overweight and obesity. RESULTS: The estimated GDM prevalence was 4.7% overall and ranged from 4.0% among non-Hispanic black women to 9.9% among Asian/Pacific Islander women. The probability of GDM increased with increasing BMI for all racial/ethnic groups. The fraction of GDM cases attributable to overweight and obesity was 41.1% overall, 15.1% among Asians/Pacific Islanders, 39.1% among Hispanics, 41.2% among non-Hispanic whites, 50.4% among non-Hispanic blacks, and 52.8% among American Indians. CONCLUSION: Although non-Hispanic black and American Indian women may benefit the most from prepregnancy reduction in obesity, interventions other than obesity prevention may be needed for women from other racial/ethnic groups.