Enhancing Methodological Approaches for Studying Health Effects of High-Concentration THC Products.

For public health protection, informed decision-making relies on having a robust foundation of evidence concerning risks and their prevention. Application of an evidence-based framework depends on the availability of pertinent, scientifically sound data generated by well-directed and valid research endeavors. In this essay, we address the current state of research in humans and the evidential base concerning high-concentration delta-9-tetrahydrocannabinol (delta-9-THC) products, which are readily available in the United States. Furthermore, we explore the intricate challenges faced in carrying out research on these products, which reflect the full range of study design issues: measurement of exposure and outcomes, confounding, selection bias, and the generalizability of findings. We offer recommendations to guide future research toward providing more informative evidence. By following these recommendations, researchers and funders on this emerging topic could move toward generating the valid and comprehensive evidence needed to effectively inform public health initiatives and guide policy decisions regarding high-concentration delta-9-THC products and their use. The urgency of generating such evidence cannot be overstated, given the widespread legalization and increasing availability and use of these products. (Am J Public Health. 2024;114(S8):S639-S644. https://doi.org/10.2105/AJPH.2024.307724).

US Hospital Service Availability and New 340B Program Participation.

Importance: The US 340B Drug Pricing Program enables eligible hospitals to receive substantial discounts on outpatient drugs to improve hospitals' financial sustainability and maintain access to care for patients who have low income and/or are uninsured. However, it is unclear whether hospitals use program savings to subsidize access as intended. Objective: To evaluate whether the 340B program is associated with improvements in access to hospital-based services and to test whether the association varies by hospital ownership. Design, Setting, and Participants: Difference-in-differences and cohort analysis from 2010 to 2019. Never and newly participating 340B general, acute, nonfederal hospitals in the US using data from the American Hospital Association's Annual Survey of Hospitals merged with hospital and market characteristics. Data were analyzed from January 1, 2023, to January 31, 2024. Exposures: New enrollment in 340B between 2012 and 2018. Main Outcomes and Measures: Total number of unprofitable service lines, ie, substance use, psychiatric (inpatient and outpatient), burn clinic, and obstetrics services; and profitable services, ie, cardiac surgery and orthopedic, oncologic, neurologic, and neonatal intensive services. Results: The study sample comprised a total of 2152 hospitals, 1074 newly participating and 1078 not participating in the 340B program. Participating hospitals were more likely than nonparticipating hospitals to be critical access and teaching hospitals, have higher Medicaid shares, and be located in rural areas and in Medicaid expansion states. At public hospitals, participation in the 340B program was associated with a significant increase in total unprofitable services (0.21; 95% CI, 0.04 to 0.38; P = .02) and marginal increases in substance use (5.4 percentage points [pp]; 95% CI, -0.8 pp to 11.6 pp; P = .09) and inpatient psychiatric (6.5 pp; 95% CI, -0.7 pp to 13.7 pp; P = .09) services. Among nonprofit hospitals, there was no significant association between 340B and service offerings (profitable and unprofitable) except for an increase in oncologic services (2.5 pp; 95% CI, 0.0 pp to 5.0 pp; P = .05). Conclusions and Relevance: The finding of the cohort study indicate that participation in the 340B program was associated with an increase in unprofitable services among newly participating public hospitals. Nonprofit hospitals were largely unaffected. These findings suggest that public hospitals responded to 340B savings by improving patient access, whereas nonprofits did not. This heterogeneous response should be considered when evaluating the eligibility criteria for the 340B program and how it affects social welfare.

Legislative Health Notes: Preliminary Learnings From Piloting a New Policy Analysis Tool.

CONTEXT: In 2018, the Health Impact Project (the Project) developed and tested a new health in all policies (HiAP) tool called "legislative health notes" to provide state and local legislators with peer-reviewed evidence, public health data, and local data that illustrate potential positive and negative health and equity effects of proposed bills. OBJECTIVES: The Project sought to refine the health note methodology while piloting the tool in the Colorado and Indiana General Assemblies, and with the Council of the District of Columbia, and worked with affiliates to introduce them in North Carolina, Ohio, and California. DESIGN AND PARTICIPANTS: External partners solicited feedback on health notes via semistructured interviews and surveys from legislators, legislative staff, and expert reviewers who were familiar with health notes in each of these jurisdictions. RESULTS: Respondents shared that health notes were nonpartisan, were easy for nonexperts to understand, and would be more effective if delivered earlier in the legislative process. CONCLUSION: In response to informant feedback, practitioners can explore adding high-level summaries, increasing focus on health equity implications and the potential to work with legislators during the policy formulation phase. Data from this pilot suggest that legislative health notes are a promising nonpartisan and standardized tool to better understand the health and equity implications of proposed legislation.

Structural and relational factors for successful cross-sector collaboration in home visiting: a multiple case study.

BACKGROUND: Aligning delivery and financing systems across sectors to create broader systems of care can improve the health and well-being of families experiencing adversities. We aimed to identify structural and relational factors for best practices to achieve successful cross-sector collaboration among home visiting programs in the United States. MATERIALS AND METHODS: We used a multiple case study approach to identify best practices for successful cross-sector collaboration between home visitors and other community service providers. We selected five diverse exemplary cases with cross-sector collaboration with variation in implementing agency type and geographic location. Cases were selected using a positive deviance approach based on strong coordination and integration with different community service provider types identified from previous survey data. We conducted in-depth qualitative interviews with home visiting staff, community providers, and clients with a total of 76 interviews conducted from 2021 to 2022. We wrote memos to synthesize themes within each case through data triangulation using interview data, documents, and site visit observations. We compared themes across the five cases to create a cross-case synthesis of best practices for successful cross-sector collaboration. RESULTS: Across the five cases, relational factors including leadership from all levels, champions across sectors, and shared goals between community providers were key factors for successful collaboration. Interpersonal relationships, coupled with the desire and capacity to engage, facilitated effective coordination to address families' needs. At the structural level, shared data systems, written agreements, and co-location enabled care coordination activities. Community Advisory Boards provided a venue for developing partnerships, relationship-building, resource-sharing, and increasing awareness of home visiting. CONCLUSIONS: We identified key elements of successful cross-sector collaboration across five case studies where home visitors coordinate care frequently and/or are structurally integrated with a range of providers. These learnings will inform future interventions to improve home visiting collaboration with other community providers to create a system of care to enhance family well-being.

Changes in cross-sector collaboration between nurse home visitors and community providers in the United States: A panel survey analysis.

OBJECTIVE: Assess changes in cross-sector collaboration between Nurse-Family Partnership (NFP) nurse home visitors and community providers in the United States. DATA SOURCES AND STUDY SETTING: We collected primary data via internet-based surveys of all NFP nursing supervisors in the United States in 2018, 2020, and 2021. STUDY DESIGN: We conducted a panel survey to measure changes in cross-sector collaboration between NFP nurses and 10 provider types in healthcare and social services. We assessed relational coordination using the validated seven item Relational Coordination Scale and structural integration using four items adapted from the Interagency Collaboration Activities Scale. Responses over time were compared using one-way analysis of variances (ANOVAs) and pairwise t-tests. We used the Kruskal-Wallis rank test to assess differences in collaboration by implementing agency type. DATA COLLECTION: All nursing supervisors from NFP implementing agencies in the United States were eligible for the study. Survey implementation was conducted using Qualtrics and administered to all eligible participants (N = 370 [2018], 383 [2020], 414 [2021]). Email reminders were sent every 7-10 days, followed by a final telephone outreach. PRINCIPAL FINDINGS: The response rate was 71% in 2018, 83% in 2020, and 74% in 2021. Relational coordination scores were calculated as a mean of the seven items and ranged from 1 to 5 (not at all to completely); integration scores were calculated as a sum of the four items and ranged from 4 to 20, where higher scores indicated greater sharing of resources. Coordination with women's care increased from 2018 to 2020 (M = 3.39 vs. 3.57; p < 0.01); while coordination (M = 3.23 vs. 3.01; p < 0.05) and integration (M = 6.50 vs. 5.28 vs. 5.43; p < 0.01) with parenting programs decreased. CONCLUSIONS: Changes to cross-sector collaboration varied by provider type, likely due to the delivery of NFP and other services via telehealth during the COVID-19 pandemic. There is an opportunity to improve cross-sector collaboration in home visiting to better address family needs.

Coordination of family's care in an evidence-based nurse home visiting program.

Interprofessional care coordination within evidence-based prevention programs like Nurse-Family Partnership® (NFP) is necessary to meet family needs and maximize program impact. This study aimed to describe the coordination of families' care in the NFP home visiting context. We used an adapted grounded theory approach and purposively sampled seven NFP sites. We conducted telephone interviews with 95 participants: 51 NFP staff (54%), 39 healthcare providers (41%), and 5 social service providers (5%). All interviews were recorded, transcribed, validated, and analyzed in NVivo11. Many community providers in all sites described their knowledge of the characteristics of the NFP intervention, including the strength of its evidence to achieve outcomes. Care coordination was dynamic and changed over time based on client needs and staff willingness to work together. Effective care coordination in the NFP context from the provider perspective is driven by shared knowledge, integrated systems, mission alignment, and individual champions who value the program.

Health Effects of High-Concentration Cannabis Products: Scoping Review and Evidence Map.

Background. The concentration of pharmacologically active tetrahydrocannabinol (THC) in cannabis products has been increasing over the past decade. Concerns about potential harmful health effects of using these increasingly higher-concentration products have led some states to consider regulation of cannabis product THC concentration. We conducted a scoping review of health effects of high-concentration cannabis products to inform policy on whether the THC concentrations of cannabis product should be regulated or limited. Objectives. We conducted a scoping review to (1) identify and describe human studies that explore the relationship of high-concentration cannabis products with any health outcomes in the literature and (2) create an interactive evidence map of the included studies to facilitate further analyses. Search Methods. An experienced medical information specialist designed a comprehensive search strategy of 7 electronic databases. Selection Criteria. We included human studies of any epidemiological design with no restrictions by age, sex, health status, country, or outcome measured that reported THC concentration or included a known high-concentration cannabis product. Data Collection and Analysis. We imported search results into Distiller SR, and trained coders conducted artificial intelligence‒assisted screening. We developed, piloted, and revised data abstraction forms. One person performed data abstraction, and a senior reviewer verified a subset. We provide a tabular description of study characteristics, including exposures and outcomes measured, for each included study. We interrogated the evidence map published in Tableau to answer specific questions and provide the results as text and visual displays. Main Results. We included 452 studies in the scoping review and evidence map. There was incomplete reporting of exposure characteristics including THC concentration, duration and frequency of use, and products used. The evidence map shows considerable heterogeneity among studies in exposures, outcomes, and populations studied. A limited number of reports provided data that would facilitate further quantitative synthesis of the results across studies. Conclusions. This scoping review and evidence map support strong conclusions concerning the utility of the literature for characterizing risks and benefits of the current cannabis marketplace and the research approaches followed in the studies identified. Relevance of the studies to today's products is limited. Public Health Implications. High-quality evidence to address the policy question of whether the THC concentration of cannabis products should be regulated is scarce. The publicly available interactive evidence map is a timely resource for other entities concerned with burgeoning access to high-concentration cannabis. (Am J Public Health. 2023;113(12):1332-1342. https://doi.org/10.2105/AJPH.2023.307414).

Impact of Recreational Cannabis Legalization on Opioid Prescribing and Opioid-Related Hospital Visits in Colorado: an Observational Study.

BACKGROUND: Cannabis may be a substitute for opioids but previous studies have found conflicting results when using data from more recent years. Most studies have examined the relationship using state-level data, missing important sub-state variation in cannabis access. OBJECTIVE: To examine cannabis legalization on opioid use at the county level, using Colorado as a case study. Colorado allowed recreational cannabis stores in January 2014. Local communities could decide whether to allow dispensaries, creating variation in the level of exposure to cannabis outlets. DESIGN: Observational, quasi-experimental design exploiting county-level variation in allowance of recreational dispensaries. SUBJECTS: Colorado residents MEASURES: We use licensing information from the Colorado Department of Revenue to measure county-level exposure to cannabis outlets. We use the state's Prescription Drug Monitoring Program (2013-2018) to construct opioid-prescribing measures of number of 30-day fills and total morphine equivalents, both per county resident per quarter. We construct outcomes of opioid-related inpatient visits (2011-2018) and emergency department visits (2013-2018) with Colorado Hospital Association data. We use linear models in a differences-in-differences framework that accounts for the varying exposure to medical and recreational cannabis over time. There are 2048 county-quarter observations used in the analysis. RESULTS: We find mixed evidence of cannabis exposure on opioid-related outcomes at the county level. We find increasing exposure to recreational cannabis is associated with a statistically significant decrease in number of 30-day fills (coefficient: -117.6, p-value<0.01) and inpatient visits (coefficient: -0.8, p-value: 0.03), but not total MME nor ED visits. Counties with no medical exposure prior to recreational legalization experience greater reductions in the number of 30-day fills and MME than counties with prior medical exposure (p=0.02 for both). CONCLUSIONS: Our mixed findings suggest that further increases in cannabis beyond medical access may not always reduce opioid prescribing or opioid-related hospital visits at a population level.

Cross-sector Collaboration Between Public Health, Healthcare and Social Services Improves Retention: Findings from a Nurse Home Visiting Program.

The study aimed to examine the association between cross-sector collaboration in Nurse-Family Partnership (NFP), a model home visiting program, and participant retention. We used the 2018 NFP Collaboration Survey that measured agency-level collaboration, operationalized as relational coordination and structural integration, among nine community provider types (including obstetrics care, substance use treatment, child welfare). This dataset was linked to 2014-2018 NFP program implementation data (n = 36,900). We used random-intercept models with nurse-level random effects to examine the associations between provider-specific collaborations and participant retention adjusting for client, nurse, and agency characteristics. The adjusted models suggest that stronger relational coordination between nurses and substance use treatment providers (OR:1.177, 95% CI: 1.09-1.26) and greater structural integration with child welfare (OR: 1.062, CI: 1.04-1.09) were positively associated with participant retention at birth. Stronger structural integration between other home visiting programs and supplemental nutrition for women, infants, and children was negatively associated with participant retention at birth (OR: 0.985, CI: 0.97-0.99). Structural integration with child welfare remained significantly associated with participant retention at 12-month postpartum (OR: 1.032, CI: 1.01-1.05). In terms of client-level characteristics, clients who were unmarried, African-American, or visited by nurses who ceased NFP employment prior to their infant's birth were more likely to drop out of the NFP program. Older clients and high school graduates were more likely to remain in NFP. Visits by a nurse with a master's degree, agency rurality, and healthcare systems that implement the program were associated with participant retention. Cross-sector collaboration in a home visiting setting that bridges healthcare and addresses social determinants of health has potential to improve participant retention. This study sets the groundwork for future research to explore the implications of collaborative activities between preventive services and community providers.

Impact of cannabis legalization on healthcare utilization for psychosis and schizophrenia in Colorado.

BACKGROUND: Emergency department (ED) visits involving psychosis and schizophrenia have increased at a rate exceeding population growth in the United States over the past decade. Research shows a strong dose-response relationship between chronic use of high-potency cannabis and odds of developing symptoms of psychosis. The aim of this study was to evaluate the impact of cannabis legalization on psychosis and schizophrenia-related ED visits in Colorado. METHODS: Using administrative data from Colorado Hospital Association (CHA) on county-level quarterly ED visits between January 1, 2013, and December 31, 2018, we applied a difference-in-difference analysis to examine how new exposure to recreational cannabis dispensaries after 2014 differentially influenced the rate of ED visits for psychosis and schizophrenia, comparing counties with no prior medical cannabis dispensary exposure to counties with low or high medical dispensary exposure. RESULTS: As recreational dispensaries per 10,000 residents increased, there was no significant association with the rate of schizophrenia ED visits per capita (incidence rate ratio or IRR: 0.95, 95% CI [0.69, 1.30]) while the rate of psychosis visits increased 24% (IRR: 1.24, 95% CI [1.02, 1.49]). Counties with no previous medical dispensaries experienced larger increases in schizophrenia ED visits than counties already exposed to a low level of medical dispensaries, but this effect was not significant. Counties with low baseline medical exposure had lower increases in rates of psychosis visits than counties with high baseline medical exposure (IRR 0.83, 95% CI [0.69, 0.99]). CONCLUSIONS: There was a positive association between the number of cannabis dispensaries and rates of psychosis ED visits across all counties in Colorado. Although it is unclear whether it is access to products, or the types of products that may be driving this association, our findings suggest there is a potential impact on the mental health of the local population that is observed after cannabis legalization.

Cannabis legalization and cannabis-involved pregnancy hospitalizations in Colorado.

The primary objective of this study was to evaluate the association between presence of recreational cannabis dispensaries and prevalence of cannabis-involved pregnancy hospitalizations in Colorado. This was a retrospective cohort study of pregnancy-related hospitalizations co-coded with cannabis diagnosis codes in the Colorado Hospital Association from January 1, 2011, through December 31, 2018 (recreational cannabis began January 1, 2014). Our primary outcome was cannabis-involved pregnancy hospitalizations per 10 k live births per county. The primary exposure measure was county variation in the number of recreational dispensaries. We controlled for counties' baseline exposure to medical cannabis dispensaries and used Poisson regression to evaluate the association between exposure to recreational cannabis and hospitalizations. During the study period, cannabis-involved pregnancy hospitalizations increased from 429 to 1210. Mean hospitalizations per county (1.7 to 4.7) and per 10 k live births (13.2 to 55.7) increased. Overall, increasing recreational dispensaries were associated with increases in hospitalizations (1.02, CI: 1.00,1.04). When comparing counties with different densities of baseline medical cannabis market, low and high exposure counties had fewer hospitalizations than those counties with no exposure (low: IRR 0.97, CI: 0.96-0.99; high: 0.98, CI: 0.96-0.99). In Colorado, there was more than a two-fold increase in cannabis-involved pregnancy hospitalizations between 2011 and 2018. Counties with no baseline exposure to medical cannabis had a greater increase than other counties, suggesting the recreational market may influence cannabis use among pregnant individuals.

Comparison of hospital claims and poison center data to evaluate health impact of opioids, cannabis and synthetic cannabinoids.

INTRODUCTION: Over the past 10 years, opioids and cannabis have garnered significant attention due to misuse and legalization trends. Different datasets and surveillance mechanisms can lead to different conclusions the due to a variety of factors. The primary objective of this study was to compare and describe trends of opioid, cannabis, and synthetic cannabinoid-related healthcare encounters and poison center (PC) cases in Colorado, a state that has legalized cannabis. METHODS: This was a retrospective study comparing hospital claims data (Colorado Hospital Association (CHA)) and poison center cases to describe opioid, cannabis and synthetic cannabinoid-related healthcare encounters and exposures in Colorado from 2013 to 2017 using related genetic codes and International Statistical Classification of Disease codes. RESULTS: Both datasets observed increases in cannabis related encounters and exposures after recreational cannabis legalization in 2014. CHA reported an increase for cannabis-related ER visits from 14,109 in 2013 to 18,118 in 2017 while PC noted a 74.4% increase in cannabis-related cases (125 to 218). CHA inpatient visits associated with cannabis also increased (8311 in 2013 to 14,659 in 2017). On the other hand, Opioid-related exposures to the PC fell (1092 in 2013 to 971 in 2017) while both Opioid-related ER visits (8580 in 2013 to 12,928 in 2017) and inpatient visits in CHA increased (9084 in 2013 to 13,205). CONCLUSIONS: This study demonstrates the differences in surveillance methodology for concurrent drug abuse epidemics using hospital claims and PC data. Both systems provide incomplete reports, but in combination can provide a more complete picture.

APCDs can Provide Important Insights for Surveilling the Opioid Epidemic, With Caveats.

State-level all-payer claims databases (APCDs) are a possible new public health surveillance tool, but their reliability is unclear. We compared Colorado's APCD with other state-level databases for use in monitoring the opioid epidemic (Colorado Hospital Association and Colorado's Prescription Drug Monitoring Program database for 2010-2017), using descriptive analyses comparing quarterly counts/rates of opioid-involved inpatient and emergency department visits and counts/rates of 30-day opioid fills between databases. Utilization is lower in the Colorado APCD than the other databases for all outcomes but trends are parallel and consistent between databases. State APCDs hold promise for researchers, but they may be better suited to individual-level analyses or comparisons of providers than for surveillance of public health trends related to addiction.

A case study of care co-ordination between primary care providers and nurse home visitors to serve young families experiencing adversity in the Northwestern United States.

Nurse home visitors in Nurse-Family Partnership® (NFP) work with mothers experiencing social and economic adversities to improve their and their children's health. Collaboration between nurse home visitors and primary care providers (PCPs: healthcare providers and social workers embedded within obstetrics, paediatrics and family medicine practices) can improve service delivery for families experiencing the greatest adversities. However, little is known about how and to what extent PCPs collaborate with home visiting nurses. We conducted a single exploratory case study between April 2019 and February 2020 to better understand how PCPs collaborate with home visiting nurses to meet family needs in one NFP site, purposefully selected for strong collaboration. We conducted in-depth qualitative interviews with 22 PCPs, including 5 nurses, 7 physicians, 7 social workers and 3 non-direct care professionals, including patient navigator and hospital executives. Interviews were recorded, transcribed, validated and coded inductively. Codes were grouped into broader categories and thematic memos across provider role were written to triangulate perspectives. Healthcare providers interacted with home visiting nurses mainly during the referral process, while social workers provided more specific examples of service co-ordination. In this case study, we saw mutual awareness, co-operation and collaboration to serve families with high needs. Even in this case, purposefully selected to represent strong collaboration, there were opportunities to enhance co-ordination to improve the health and social needs of young families experiencing adversity.

A qualitative study of effective collaboration among nurse home visitors, healthcare providers and community support services in the United States.

Collaboration across sectors is needed to improve community health, but little is known about collaborative activities among public health prevention programs. Using the Nurse-Family Partnership® (NFP) home visiting program as context, this qualitative study aimed to describe effective collaboration among nurse home visitors, healthcare providers and community support services to serve families experiencing social and economic adversities. We used grounded theory to characterise collaboration with six purposively sampled NFP sites in the United States through in-depth interviews. We interviewed 73 participants between 2017 and 2019: 50 NFP staff, 18 healthcare providers and 5 other service providers. Interviews were recorded, transcribed, validated and analysed in NVivo 11. Validation steps included inter-coder consistency checks and expert review. Thematic memos were synthesised across sites. Most participants perceived collaboration to be important when serving families with complex needs, but substantial variation existed in the degree to which NFP nurses collaborate with providers dependent on provider type and community context. Factors that contributed to effective collaboration were relational in nature, including leadership commitment and provider champions, shared perceptions of trust, respect and value, and referral partnerships and outreach; organisational in terms of mission congruence between providers; and structural such as policy and system integration that facilitated data sharing and communication channels. These findings provide greater insights into effective cross-sector collaboration and care coordination for families experiencing adversities. Collaboration across sectors to promote health among families experiencing adversities requires intentional efforts by all inter-professional providers and continued commitment among all levels of leadership to coordinate services.

Changes in Emergency Department Encounters for Vomiting After Cannabis Legalization in Colorado.

Importance: Cannabis hyperemesis syndrome is an emerging clinical issue associated with cannabis use. Legalization of cannabis has led to an increase in vomiting-related illnesses in health care settings. Objective: To examine whether legalization of cannabis in Colorado has been associated with increases in vomiting-related emergency department (ED) visits. Design, Setting, and Participants: A cross-sectional design was used to assess the increase in ED claims for vomiting reported to the Colorado Hospital Association between January 1, 2013, and December 31, 2018, in counties that had no prior cannabis dispensaries before legalization compared with those that did. A total of 820 778 patients seeking care through Colorado EDs were included in the analysis. Exposures: The number of medical and recreational cannabis dispensaries per county per quarter. Main Outcomes and Measures: County per capita rate of vomiting-related ED claims per quarter. Results: Vomiting-related ED health care encounters increased from 119 312 in 2013 to 153 699 in 2018 (29% increase). Over this period, 203 861 patients (25%) were aged 0 to 18 years; 114 201 (14%) were aged 19 to 25 years, and 502 771 (61%) were aged 26 years or older; 510 584 patients (62%) were female. Additional recreational dispensaries were associated with increased vomiting-related ED visits (incidence rate ratio, 1.03; 95% CI, 1.01-1.05), but counties with high baseline medical dispensary exposure experienced smaller increases in vomiting-related ED visits than counties with no baseline medical dispensary exposure (incidence rate ratio, 0.97; 95% CI, 0.95-0.99). Counties with a high number of medical marijuana dispensaries had increases at a 5.8% slower rate than counties with none. Conclusions and Relevance: The findings of this study suggest that cannabis legalization in Colorado is associated with an increase in annual vomiting-related health care encounters with regard to exposure to these markets. It may be useful for health care clinicians to be aware of cannabis hyperemesis syndrome and inquire about cannabis use when appropriate.

A Qualitative Study of Mothers' Perspectives on Enrolling and Engaging in an Evidence-Based Nurse Home Visiting Program.

Prevention programs like Nurse-Family Partnership® (NFP) must enroll and retain clients of the intended population to maximize program impact. NFP is an evidence-based nurse home visitation program shown in randomized trials to improve maternal and child health and life course outcomes for first-time parents experiencing economic adversity, particularly for mothers with limited psychological resources. The purpose of this study was to understand enrollment and engagement experiences of mothers with previous live births referred to NFP in a formative study of the program for this population, but did not enroll or dropped out before program graduation. We used a grounded theory approach and purposively selected three NFP sites with variation in enrollment rates. We conducted telephone interviews with 23 mothers who were either referred to NFP and declined enrollment or former clients who dropped out before graduation. All interviews were conducted in English, recorded, transcribed, and validated. We developed an iterative codebook with multiple coders to analyze our data in NVivo11 and wrote thematic memos to synthesize data across study sites. Mothers described experiencing overlapping risk factors including physical and behavioral health conditions, child welfare involvement, and housing insecurity. Mothers from all sites discussed how they were referred to the NFP program, their experience of the enrollment process, reasons for enrolling or not enrolling, and reasons for dropping out after initial enrollment. Key themes that influenced mothers' decision-making were: perceptions of program value, not needing the program, their living situation or being too busy as a deterrence, and past experiences including a distrust of health care. Reasons for attrition were related to no longer needing the service, being assigned a new nurse, being too tired postpartum, and moving out of the service area. One way to support home visiting nurses in family enrollment and engagement is to build their professional capacity to implement trauma-informed strategies given mothers' life experiences.

National survey of nurse home visitor collaboration with health care and social services.

OBJECTIVE: To assess the degree to which nurses in a national public health home visiting program collaborate with interprofessional providers to serve families experiencing adversity. DESIGN: A descriptive, cross-sectional survey measured collaborative practices between nurse home visitors, health care, and social service providers. A census of 263 nursing supervisors completed a web-based survey. MEASUREMENTS: The survey included the validated 7-item Relational Coordination Scale, adapted items from the Interagency Collaboration Activities Scale on shared resources, and items related to collaboration attitudes and beliefs. Data were analyzed with descriptive statistics. RESULTS: Relational coordination scores, which are relative measures, ranged from 1 to 5; highest with supplemental nutrition for Women, Infants & Children (M = 3.77) and early intervention (M = 3.44); and lowest with housing (M = 2.55). The greatest sharing of resources was with supplemental nutrition (sum = 12.95) and mental health providers (sum = 11.81), and least with housing (sum = 7.26); with a range of 1-30 where higher scores indicated greater resource-sharing. CONCLUSION: Home visiting nurses collaborate with interprofessional providers with variation in the degree of collaboration between agencies and by provider type within an agency. Collaboration was a function of two interrelated domains: interpersonal relationships supported by organizational and contextual factors at the systems-level.

Kids, Cops, and Community: A Qualitative Assessment of Police, Youth, and Parent Perceptions of Each Other.

CONTEXT: Police and communities alike have experienced many traumatic incidents over the last 4 years, prompting police departments across the country to rethink their approach to community programs. PROGRAM: Aurora's Gang Reduction Impact Program (A-GRIP) launched "Kids, Cops, and Community" (KC&C) in Aurora, Colorado, as a community-based quality improvement project designed to improve community relations by better understanding Aurora police and community members' perceptions of each other and current A-GRIP and Aurora for Youth programs by assessing police, youth, and parents' perceptions of each other. IMPLEMENTATION: After a review of current scientific literature on police-community relations, a KC&C advisory group oversaw the creation of key informant interview and focus group guides. A-GRIP recruited participants for 37 interviews (20 police, 8 youth, and 9 parents) and 3 youth focus groups. The community advisory group assisted in the development of salient themes and practical recommendations. The final report outlined 5 major themes (pros/cons of types of police interactions, respectful communication, false uniqueness effect, parenting and police as parents, and youth-police programming awareness) and 2 specific recommendations (sustain/increase opportunities for police-youth interactions and increase community awareness of youth programming). EVALUATION: A-GRIP members had a rich discussion of the implications of these findings in which there was broad support for identifying a strategy to use these results to improve police-community relations. The coalition was challenged by identifying clear next steps because of turnover in administration and coalition leadership, but they have made progress in increasing information and resource sharing. DISCUSSION: This project provides the first model we are aware of that incorporates a systematic assessment of police, youth, and parent perspectives from the same community. Other communities may find value in adapting the KC&C process to identify promising approaches and refine programming elements of police-community engagement activities.

Risk assessment practices among home visiting nurses and child protection caseworkers in Colorado, United States: A qualitative investigation.

Nurses and caseworkers engage in assessments with the families they serve. Nurse home visitors from Nurse-Family Partnership (NFP) improve maternal-child health outcomes with first-time low-income mothers through care, education and support. In the United States, Child Protective Services (CPS) are state-level governmental agencies that protect children, including responding to reports of child maltreatment. This paper aimed to characterise similarities and differences in risk assessment practices between NFP nurses and CPS caseworkers in Colorado, United States. Using a grounded theory approach, we conducted in-depth qualitative interviews with 112 NFP and CPS workers from seven Colorado NFP sites from 2013 to 2015. Study sites were purposefully selected based on size, structure, geography and degree of collaboration with CPS. We conducted interviews first with NFP sites and used snowball sampling to recruit CPS workers. Interviews were recorded, transcribed, validated and then coded in NVivo 10. Memo writing was conducted to organise and link concepts within the theme of risk assessment. NFP and CPS workers emphasised the importance of risk assessment in their respective practices. Although there were similarities in the types of risks assessed, we found variations in work processes, operational definitions and methods of risk assessment between the two organisations that impacted inter-organisational collaboration to serve high-risk mothers and their children. NFP and CPS workers may have different roles and responsibilities but their underlying goals are the same - to keep children and their families safe and healthy. By understanding these similarities and differences in practice, there lies potential to improve collaboration between home visiting programmes and child welfare to provide integrated service delivery of high-risk families and prevention of future child maltreatment.