Conceptualizing adverse childhood experiences as a latent factor: Tests of measurement invariance across five racial and ethnic groups.

Adverse childhood experiences (ACEs) are conventionally measured using a cumulative-risk index without consideration of distinct measurement properties across racial and ethnic groups. Drawing from the 2018-2020 National Survey of Children's Health (N = 93,759; 48% female; average age: 9.52 years), we assess the measurement invariance of a latent-factor ACE model across five groups: Hispanic children (14%) and non-Hispanic White (73%), Black (7%), Asian/Pacific Islander (5%), and American Indian/Alaskan Native (1%) children. Results support configural and full metric invariance across groups. However, several ACE item thresholds differed across groups. Findings highlight the potential utility of a latent factor approach and underscore the need to assess differences across racial and ethnic groups in terms of the optimal conceptualization and measurement of ACEs.

Artificial Neural Network Analysis Examining Substance Use Problems Co-Occurring with Anxiety and Depressive Disorders Among Adults Receiving Mental Health Treatment.

Objective: The co-occurrence of anxiety disorders, depressive disorders, and substance use problems was examined. Methods: The Mental Health Client-Level Data dataset was used to conduct logistic regression models and an artificial neural network analysis. Logistic regression analyses were conducted among adults with anxiety (n = 547,473) or depressive disorders (n = 1,610,601) as their primary diagnosis who received treatment in a community mental health center. The artificial neural network analysis was conducted with the entire sample (N = 2,158,074). Results: Approximately 30% of the sample had co-occurring high-risk substance use or substance use disorder. Characteristics including region of treatment receipt, age, education, gender, race and ethnicity, and the presence of co-occurring anxiety and depressive disorders were associated with the co-occurring high-risk substance use or a substance use disorder. Conclusions: Findings from this study highlight the importance of mental health facilities to screen for and provide integrated treatment for co-occurring disorders.

STI Testing among Medicaid Enrollees Initiating PrEP for HIV Prevention in Six Southern States.

OBJECTIVES: The purpose of this study was to measure sexually transmitted infection (STI) testing among Medicaid enrollees initiating preexposure prophylaxis (PrEP) to prevent human immunodeficiency virus. Secondary data are in the form of Medicaid enrollment and claims data in six states in the US South. METHODS: Research partnerships in six states in the US South developed a distributed research network to accomplish study aims. Each state identified all first-time PrEP users in fiscal year 2017-2018 (combined N = 990) and measured the presence of STI testing for chlamydia, syphilis, and gonorrhea through 2019. Each state calculated the percentage of individuals with at least one STI test during 3-, 6-, and 12-month follow-up periods. RESULTS: The proportion of first-time PrEP users that received an STI test varied by state: 37% to 67% of all of the individuals in each state who initiated PrEP received a test within the first 6 months of PrEP treatment and 50% to 77% received a test within the first 12 months. CONCLUSIONS: Although the Centers for Disease Control and Prevention recommends STI testing at least every 6 months for PrEP users, our analysis of Medicaid data suggests that STI testing occurs less frequently than recommended in populations at elevated risk of syphilis, gonorrhea, and chlamydia.

Comparing Medicaid Expenditures for Standard and Enhanced Therapeutic Foster Care.

Therapeutic foster care (TFC) is a service for children with high behavioral health needs that has shown promise to prevent entry into more restrictive and expensive care settings. The purpose of this study was to compare Medicaid expenditures associated with TFC with Medicaid expenditures associated with an enhanced higher-rate service called Intensive Alternative Family Treatment (IAFT). We conducted a secondary analysis of Medicaid claims in North Carolina among children entering care in 2018-2019. Using propensity score analysis with difference-in-difference estimation, we compared monthly Medicaid expenditures before and after initiating TFC and IAFT (N = 5472 person-months). Youth entering IAFT had higher expenditures prior to treatment than those entering TFC. Both standard TFC and IAFT were associated with a downward trend in expenditures following treatment initiation. Both TFC and IAFT reverse a trend of increasing Medicaid costs prior to care among children with high behavioral health needs.

Design, Implementation, and Evolution of the Medicaid Outcomes Distributed Research Network (MODRN).

BACKGROUND: In the US, Medicaid covers over 80 million Americans. Comparing access, quality, and costs across Medicaid programs can provide policymakers with much-needed information. As each Medicaid agency collects its member data, multiple barriers prevent sharing Medicaid data between states. To address this gap, the Medicaid Outcomes Distributed Research Network (MODRN) developed a research network of states to conduct rapid multi-state analyses without sharing individual-level data across states. OBJECTIVE: To describe goals, design, implementation, and evolution of MODRN to inform other research networks. METHODS: MODRN implemented a distributed research network using a common data model, with each state analyzing its own data; developed standardized measure specifications and statistical software code to conduct analyses; and disseminated findings to state and federal Medicaid policymakers. Based on feedback on Medicaid agency priorities, MODRN first sought to inform Medicaid policy to improve opioid use disorder treatment, particularly medication treatment. RESULTS: Since its 2017 inception, MODRN created 21 opioid use disorder quality measures in 13 states. MODRN modified its common data model over time to include additional elements. Initial barriers included harmonizing utilization data from Medicaid billing codes across states and adapting statistical methods to combine state-level results. The network demonstrated its utility and addressed barriers to conducting multi-state analyses of Medicaid administrative data. CONCLUSIONS: MODRN created a new, scalable, successful model for conducting policy research while complying with federal and state regulations to protect beneficiary health information. Platforms like MODRN may prove useful for emerging health challenges to facilitate evidence-based policymaking in Medicaid programs.

Racial discrimination and other adverse childhood experiences as risk factors for internalizing mental health concerns among Black youth.

Adverse childhood experiences (ACEs) have been consistently linked to a reduction in healthy psychological adjustment among youth. Emergent evidence suggests that there are culturally specific ACEs, such as racial discrimination, that are particularly harmful to the mental health of Black youth. However, the psychological impact of racial discrimination on the mental health of Black youth relative to other ACEs remains underexplored. The present study aimed to address this gap by examining the extent to which racial discrimination was associated with other ACEs and elucidating the unique associations between children's experiences of racial discrimination and internalizing problems (i.e., depression, anxiety), after controlling for other ACEs. Data consisted of a subsample of Black children from the National Survey of Children's Health (N = 8,672; Mage  = 9.8 years; 51.1% male). Bivariate analyses illustrated that racial discrimination was positively associated with the co-occurrence of all other ACEs measured within the current study. Multivariable analyses using generalized linear mixed models revealed that racial discrimination was significantly associated with youth diagnoses of depression, adjusted odds ratio (aOR) = 1.35, 95% CI [1.23, 1.49], and anxiety, aOR = 1.39, 95% CI [1.31, 1.47], after controlling for other ACEs and sociodemographic covariates. The findings demonstrate that racial discrimination is comparably associated with youth internalizing problems relative to ACEs conventionally examined within the childhood trauma literature. The importance of these results, including how this knowledge can be leveraged to inform clinical practice and policy to promote the positive mental health of Black youth, are also discussed.

Health Care Access and Quality Among Children Exposed to Adversity: Implications for Universal Screening of Adverse Childhood Experiences.

OBJECTIVES:  Given recent advances toward universal screening for Adverse Childhood Experiences (ACEs), our objective was to investigate whether children with higher ACEs experience poorer quality of provider care and greater challenges accessing needed mental health treatment. METHODS: This study uses a nationally representative sample of US children aged 0-17 years drawn from the National Survey on Children's Health for 2016-2019. Caregivers and parents completed surveys between June 2016 and February 2020 (N = 131,774). Logistic regression models adjusting for identified covariates were used to test associations between a child's number of ACEs, their quality of provider care, and their access to mental health treatment. All analyses used appropriate survey weighting commands. RESULTS: High ACEs (4 or more) were associated with lower quality of provider care, including effective care coordination [OR 0.45, 95% CI (0.38, 0.52)], family-centered care [OR 0.49, 95% CI (0.41, 0.58)], shared decision making [OR 0.50, 95% CI (0.39, 0.85)], and referrals for care [OR 0.58, 95% CI (0.43, 0.80)]; children with high ACEs were also less likely to have a medical home [OR 0.66, 95% CI (0.57, 0.76)]. High ACEs were also significantly associated with greater difficulty accessing mental health treatment [OR 0.55, 95% CI (0.43, 0.70)]. Similar results were found for children in the moderate ACE (2-3) and low ACE (1) groups. CONCLUSIONS FOR PRACTICE: Findings indicate that greater ACEs were associated with poorer quality medical care and greater difficulty accessing needed mental health treatment. Because findings indicate that children with high ACEs may be the least likely to receive quality care or necessary mental health treatment to address this adversity, universal screening for ACEs should be considered with caution.

Use of Medications for Treatment of Opioid Use Disorder Among US Medicaid Enrollees in 11 States, 2014-2018.

Importance: There is limited information about trends in the treatment of opioid use disorder (OUD) among Medicaid enrollees. Objective: To examine the use of medications for OUD and potential indicators of quality of care in multiple states. Design, Setting, and Participants: Exploratory serial cross-sectional study of 1 024 301 Medicaid enrollees in 11 states aged 12 through 64 years (not eligible for Medicare) with International Classification of Diseases, Ninth Revision (ICD-9 or ICD-10) codes for OUD from 2014 through 2018. Each state used generalized estimating equations to estimate associations between enrollee characteristics and outcome measure prevalence, subsequently pooled to generate global estimates using random effects meta-analyses. Exposures: Calendar year, demographic characteristics, eligibility groups, and comorbidities. Main Outcomes and Measures: Use of medications for OUD (buprenorphine, methadone, or naltrexone); potential indicators of good quality (OUD medication continuity for 180 days, behavioral health counseling, urine drug tests); potential indicators of poor quality (prescribing of opioid analgesics and benzodiazepines). Results: In 2018, 41.7% of Medicaid enrollees with OUD were aged 21 through 34 years, 51.2% were female, 76.1% were non-Hispanic White, 50.7% were eligible through Medicaid expansion, and 50.6% had other substance use disorders. Prevalence of OUD increased in these 11 states from 3.3% (290 628 of 8 737 082) in 2014 to 5.0% (527 983 of 10 585 790) in 2018. The pooled prevalence of enrollees with OUD receiving medication treatment increased from 47.8% in 2014 (range across states, 35.3% to 74.5%) to 57.1% in 2018 (range, 45.7% to 71.7%). The overall prevalence of enrollees receiving 180 days of continuous medications for OUD did not significantly change from the 2014-2015 to 2017-2018 periods (-0.01 prevalence difference, 95% CI, -0.03 to 0.02) with state variability in trend (90% prediction interval, -0.08 to 0.06). Non-Hispanic Black enrollees had lower OUD medication use than White enrollees (prevalence ratio [PR], 0.72; 95% CI, 0.64 to 0.81; P < .001; 90% prediction interval, 0.52 to 1.00). Pregnant women had higher use of OUD medications (PR, 1.18; 95% CI, 1.11-1.25; P < .001; 90% prediction interval, 1.01-1.38) and medication continuity (PR, 1.14; 95% CI, 1.10-1.17, P < .001; 90% prediction interval, 1.06-1.22) than did other eligibility groups. Conclusions and Relevance: Among US Medicaid enrollees in 11 states, the prevalence of medication use for treatment of opioid use disorder increased from 2014 through 2018. The pattern in other states requires further research.

Exploring Clusters of Risk and Association With Child Maltreatment in North Carolina Counties.

BACKGROUND: Decision makers face challenges in estimating local risk for child maltreatment and how best to prioritize which factors to intervene upon. METHODS: Using US Census and survey data for all US counties (N = 3141), we derived US county profiles characterized by the severity of child maltreatment risk factors observed at the county level, such as parental health, health care access, and economic distress. We estimated how five child maltreatment outcomes would vary across the profiles for North Carolina counties (n = 100): total maltreatment reports (including unsubstantiated and substantiated), substantiated neglect, substantiated abuse, whether services were received, and reported child's race/ethnicity. RESULTS: We derived three profiles of county-level child maltreatment risk: high, moderate, and low risk, denoting that predicted risk factors means within profiles were all high, moderate, or low levels compared to counties in other profiles. One risk factor did not follow this pattern: the drug overdose death rate. It was highest in the moderate-risk profile instead of the high-risk profile, as would have been consistent with other factor levels. Moderate-risk counties had the highest predicted rate of child maltreatment reports, with over 20 more reports per 10,000 residents compared to low-risk counties (95% CI, 1.38, 38.86). LIMITATIONS: We included only factors for which aggregate, county-level estimates were available, thus limiting inclusion of all relevant factors. CONCLUSIONS: Results suggest the need for increased family-based services and interventions that reduce risk factors such as economic distress and drug overdose deaths. We discuss the implications for tailoring county efforts to prevent child maltreatment.

Developing a Multi-Criteria Decision Analysis Tool to Support the Adoption of Evidence-Based Child Maltreatment Prevention Programs.

Decision-makers need to consider a range of factors when selecting evidence-based programs (EBPs) for implementation, which can be especially challenging when addressing complex issues such as child maltreatment prevention. Multi-criteria decision analysis (MCDA) frameworks and tools are useful for evaluating such complex decisions. We describe the development and testing of the first MCDA tool to compare EBPs for child neglect prevention. To develop the tool, we engaged stakeholders (n = 8) to define the problem and identify 13 criteria and associated weights. In a pilot study, we tested the MCDA tool with decision-makers (n = 11) who were asked to rank three evidence-based child neglect prevention interventions both with and without the tool. The MCDA's weighted sum intervention ranking differed from the ranking without the tool in the majority of the sample (55%). Decision-makers provided guidance on criteria that should be clarified or added, resulting in 16 criteria in an iterated tool. The most frequent criterion suggestions related to community acceptance of the intervention, health equity, implementation supports, and sustainability. Decision-maker feedback guided user interface refinements. The MCDA tool was generally well accepted by decision-makers due to their trust in the stakeholder engagement process. More research is needed to understand the acceptability of MCDA approaches in additional contexts and whether EBPs adopted with decision support have different population health impacts compared with EBPs adopted without support. MCDA tools could facilitate evidence-based responses to federal policy and funding opportunities such as the Families First Preventive Services Act.

Parental Involvement and Adolescents' Academic Achievement: Latent Profiles of Mother and Father Warmth as a Moderating Influence.

Parental involvement in their adolescents' education plays an important role in promoting their children's academic outcomes. Yet, more research is needed to examine the relationship between parenting practices and parental warmth as well as to consider the potential joint contribution of warmth from both fathers and mothers. Thus, the primary purpose of the current study is to examine the extent to which patterns of parental warmth across fathers and mothers moderate the association between parental involvement and adolescents' grade point average (GPA) and school engagement behaviors. Latent profile analysis was conducted to identify disparate profiles of fathers' and mothers' warmth within a nationally representative sample of 2,306 youths (51% male; mean age = 15.31 years, SD = 1.50; 77% non-Hispanic White) residing in opposite-sex, two-parent families from Wave I and II of the National Longitudinal Study of Adolescent to Adult Health. Latent-class enumeration processes support a five-profile solution characterized by differences in levels of parental warmth and congruency across parents: (a) Congruent High Warmth, (b) Congruent Moderate Warmth, (c) Congruent Low Warmth, (d) Incongruent High Mother/Low Father Warmth, and (e) Incongruent Low Father/Lower Mother Warmth. Subsequent multiple linear regression analyses reveal a moderating effect for Congruent Low Warmth on the relationship between parental involvement and adolescents' GPA. Ultimately, the results show that variation in parental warmth exists across fathers and mothers with differing impact on adolescents' outcomes. Excluding one parent without considering the joint effects of both parents will not produce an accurate and precise understanding of parenting in research or practice.

La participación de los padres en la educación de sus hijos adolescentes desempeña un papel importante en el fomento de los resultados académicos de sus hijos. Sin embargo, se necesitan más investigaciones para analizar la relación entre las prácticas de crianza y la calidez de los padres y para tener en cuenta el posible aporte conjunto de calidez tanto de los padres como de las madres. Por lo tanto, el propósito principal del presente estudio es analizar el grado hasta el cual los patrones de calidez parental de los padres y las madres moderan la asociación entre la participación de los padres y el promedio de calificaciones de los adolescentes y las conductas de participación escolar. Se realizaron análisis de clases latentes para reconocer los diversos perfiles de calidez de los padres y las madres dentro de una muestra representativa a nivel nacional de 2306 jóvenes (51% masculina; edad promedio = 15.31 años, Desviación Típica= 1.50; 77% blanca no hispana) que vivían en familias formadas por dos padres del sexo opuesto de las fases I y II del Estudio Longitudinal Nacional de Salud del Adolescente al Adulto. Los procesos de enumeración de clases latentes respaldan una solución de cinco perfiles caracterizados por diferencias en los niveles de calidez parental y congruencia entre los padres: (a) calidez congruente alta, (b) calidez congruente moderada, (c) calidez congruente baja, (d) calidez incongruente, alta en la madre/baja en el padre, y (e) calidez incongruente, baja en el padre/más baja en la madre. Los análisis posteriores de regresión lineal múltiple revelan un efecto moderador para la calidez congruente baja en la relación entre la participación parental y el promedio de calificaciones de los adolescentes. Finalmente, los resultados demuestran que existe una variación en la calidez parental entre padres y madres con efectos muy distintos en los resultados de los adolescentes. Excluir a un padre sin tener en cuenta los efectos conjuntos de ambos padres no generará una comprensión certera y precisa de la crianza en la investigación o la práctica.

Adverse Childhood Experiences and Child Health Outcomes: Comparing Cumulative Risk and Latent Class Approaches.

Objectives This study seeks to further the work exploring adverse childhood experiences (ACEs) by proposing a novel approach to understanding the impact of ACEs through applying advanced analytical methods to examine whether combinations of ACEs differentially impact child health outcomes. Methods Using National Survey of Children's Health data, we use latent class analysis to estimate associations between classes of ACEs and child health outcomes. Results Class membership predicts child poor health, with differences found for specific ACE combinations. A subgroup of children exposed to poverty and parental mental illness are at higher risk for special healthcare needs than all other groups, including children exposed to 3 or more ACEs. Conclusions Different combinations of ACEs carry different risk for child health. Interventions tailored to specific ACEs and ACE combinations are likely to have a greater effect on improving child health. Our findings suggest children who experience specific ACE combinations (e.g., poverty and parental mental illness) are at particularly high risk for poor health outcomes. Therefore, clinicians should routinely assess for ACEs to identify children exposed to the most problematic ACE combinations; once identified, these children should be given priority for supportive interventions tailored to their specific ACE exposure and needs.

A Nationally Representative Study of Early Childhood Home Visiting Service Use in the United States.

Early childhood home visiting (HV) services are expanding broadly across the United States. Supported by federal policy, HV is now an integral part of maternal and child health services. However, no nationally representative estimate of HV use is available and no research has compared HV use across states. The 2011/12 National Survey on Children's Health was used to estimate the national and state prevalence of HV use for children 0-3 years. Generalized linear mixed modeling was used to predict HV use. An estimated 2,137,044 US children and families received HV during pregnancy and up to child age of 3 years. State HV prevalence range was 3.7-30.6 %. Nationally, 19.1 % of children below the federal poverty line received HV services. Although family poverty increased the odds of receiving HV services, higher rates of child poverty at the state level predicted less use of HV services. Important predictors of HV use include infant/child need factors (health risk, adverse experiences), predisposing factors (family size), and enabling factors (insurance type). This study provides the first estimates of national and state HV service use. Although findings indicate HV services are targeted to children at elevated risk for poor physical or developmental outcomes, our estimates show the vast majority of at-risk children did not receive HV services, including more than 80 % of low-income children, 76 % of preterm infants, and 57 % of very low birth weight infants. Increasing HV service availability could decrease negative health outcomes for young children.

Comparing primiparous and multiparous mothers in a nurse home visiting prevention program.

BACKGROUND: An important yet overlooked feature of prominent prevention programs serving expectant mothers is the exclusion of women with children. This study examines mothers (n = 3,260) participating in a program without parity exclusion criteria, and compares demographic characteristics, risk status, service use, and child maltreatment outcomes. METHODS: A longitudinal, prospective study comparing primiparous (n = 1,890) and multiparous (n = 1,370) mothers participating in a nurse home visiting program. Patient groups are compared using bivariate and multivariate methods. RESULTS: Comparison by parity shows multiparous mothers had higher cumulative risk scores and individual risk factors related to maternal and child health, behavioral health, and violence exposure. Multiparous mothers were more likely to seek out services themselves and to initiate services later in the postnatal period. A significant trend exists among more children and greater caregiver stress, maternal depression, and child maltreatment. Multivariate models indicate infants of multiparous mothers have a higher risk (hazard ratio = 1.49) for later reports of child maltreatment. CONCLUSIONS: As compared with primiparous mothers, multiparous mothers were at higher risk but had similar levels of service use. Programs limited to primiparous mothers are missing a critical opportunity for prevention. Programs serving multiparous mothers should incorporate strategies to directly address caregiver stress and postpartum depression.

Examining patterns of family resilience and neighborhood cohesion as moderators of the effects of adverse childhood experiences on the mental health of Black adolescents.

Adverse childhood experiences (ACEs) confer risk to the mental health of Black youth, but few studies have examined how youth gender, family, and neighborhood factors jointly influence the psychological impact of adversity. This study investigates if family resilience and neighborhood cohesion jointly moderate the link between latent ACE profiles and mental health among Black girls and boys. This study uses data from the National Survey of Children's Health, combined across the years 2016 through 2021, and includes a nationally representative sample of 5,493 Black youth (48% female) between the ages of 12 and 17. Two patterns of ACEs were identified using latent class analysis characterized by no-to-minimal ACE exposure and moderate-to-high ACE exposure. Membership in the high-ACEs class increased the risk for internalizing problems among Black boys (b = 0.56, p < .001) and girls (b = 0.42, p < .01). Only boys in the high-ACEs class who also reported low levels of family resilience and low neighborhood cohesion evidenced an increased risk for externalizing concerns (b = 0.70, p < .001). Conversely, only girls in the high-ACEs class who reported high levels of family resilience and low levels of neighborhood cohesion evidenced an increased risk for externalizing problems (b = 0.69, p < .01). Findings suggest that the impact of ACEs on mental health is not uniform across Black boys and girls, and that family and neighborhood-level factors may collectively shape the impact of ACEs on the mental health among Black youth in unique ways. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Associations between Work-Family Balance, Parenting Stress, and Marital Conflicts during COVID-19 Pandemic in Singapore.

As part of the "Circuit-breaker" social distancing measure to address COVID-19, the government of Singapore closed schools and workplaces from April to May 2020. Although this helped reduce transmission rates, for working parents, this period had been a challenging experience of working from home while providing care for children full-time. Problems in the work-home interface can have a significant impact on parenting and marital harmony. We analyzed data from 201 married and employed parents in Singapore using online surveys. Latent profile analysis was used to identify profiles of parents' work-family balance (WFB) and spousal and employer support. Linear regression was used to examine links between profiles with parenting stress and marital conflicts. Results indicated three distinct profiles of WFB and social support levels: (a) Strong (43%), (b) Moderate (38%), and (c) Poor (19%). Mothers were more likely than fathers to be in the Moderate and Poor profiles. One key finding is that profiles characterized by poorer WFB were found to be linked with higher parenting stress and increased marital conflicts. There are important variations in parents' abilities to balance work and family and levels of social support received. Lock-downs can affect parenting and marital harmony especially for parents with poor WFB and weak social support. Any attention given to supporting working parents is vital and urgent to counter any problems in the work-family interface during a lockdown.

Examining Foster Care Outcomes for American Indian Children in the Context of the Indian Child Welfare Act.

The history of the child welfare system and related institutions with American Indian children and families has been marked by numerous atrocities, including unnecessary separations, assimilation, and trauma. The Indian Child Welfare Act (ICWA) was enacted in 1978 to promote the stability and security of American Indian tribes and families. For children involved in the child welfare system, ICWA prioritizes the placement of American Indian children with family or tribal members. This paper examines placement outcomes for American Indian children using recent national data over 3 years from the Adoption and Foster Care Analysis and Reporting System. Multivariate regression analyses showed that American Indian children were significantly less likely to be placed with same-race/ethnicity caretakers than their non-American Indian counterparts. In addition, American Indian children were not more likely to be placed with relatives or have trial home placement compared to non-American Indian children. These findings suggest that ICWA is not reaching its intended objectives regarding placement goals specified in the law regarding American Indian children. These policy shortcomings have significant implications for American Indian children, families, and tribes in terms of well-being, family connection, and cultural loss.

Generation of the Chemical and Social Stressors Integration Technique (CASS-IT) to identify areas of holistic public health concern: An application to North Carolina.

Due to structural racism and income inequality, exposure to environmental chemicals is tightly linked to socioeconomic factors. In addition, exposure to psychosocial stressors, such as racial discrimination, as well as having limited resources, can increase susceptibility to environmentally induced disease. Yet, studies are often conducted separately in fields of social science and environmental science, reducing the potential for holistic risk estimates. To tackle this gap, we developed the Chemical and Social Stressors Integration Technique (CASS-IT) to integrate environmental chemical and social stressor datasets. The CASS-IT provides a framework to identify distinct geographic areas based on combinations of environmental chemical exposure, social vulnerability, and access to resources. It incorporates two data dimension reduction tools: k-means clustering and latent profile analysis. Here, the CASS-IT was applied to North Carolina (NC) as a case study. Environmental chemical data included toxic metals - arsenic, manganese, and lead - in private drinking well water. Social stressor data were captured by the CDC's social vulnerability index's four domains: socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. Data on resources were derived from Federal Emergency Management Agency (FEMA's) Resilience and Analysis Planning Tool, which generated measures of health resources, social resources, and information resources. The results highlighted 31 NC counties where exposure to both toxic metals and social stressors are elevated, and health resources are minimal; these are counties in which environmental justice is of utmost concern. A census-tract level analysis was also conducted to demonstrate the utility of CASS-IT at different geographical scales. The tract-level analysis highlighted specific tracts within counties of concern that are particularly high priority. In future research, the CASS-IT can be used to analyze United States-wide environmental datasets providing guidance for targeted public health interventions and reducing environmental disparities.

Duration of medication for opioid use disorder during pregnancy and postpartum by race/ethnicity: Results from 6 state Medicaid programs.

BACKGROUND: Medication for opioid use disorder (MOUD) is evidence-based treatment during pregnancy and postpartum. Prior studies show racial/ethnic differences in receipt of MOUD during pregnancy. Fewer studies have examined racial/ethnic differences in MOUD receipt and duration during the first year postpartum and in the type of MOUD received during pregnancy and postpartum. METHODS: We used Medicaid administrative data from 6 states to compare the percentage of women with any MOUD and the average proportion of days covered (PDC) with MOUD, overall and by type of MOUD, during pregnancy and four postpartum periods (1-90 days, 91-180 days, 181-270 days, and 271-360 days postpartum) among White non-Hispanic, Black non-Hispanic, and Hispanic women diagnosed with OUD. RESULTS: White non-Hispanic women were more likely to receive any MOUD during pregnancy and all postpartum periods compared to Hispanic and Black non-Hispanic women. For all MOUD types combined and for buprenorphine, White non-Hispanic women had the highest average PDC during pregnancy and each postpartum period, followed by Hispanic women and Black non-Hispanic women (e.g., for all MOUD types, 0.49 vs. 0.41 vs. 0.23 PDC, respectively, during days 1-90 postpartum). For methadone, White non-Hispanic and Hispanic women had similar average PDC during pregnancy and postpartum, and Black non-Hispanic women had substantially lower PDC. CONCLUSIONS: There are stark racial/ethnic differences in MOUD during pregnancy and the first year postpartum. Reducing these inequities is critical to improving health outcomes among pregnant and postpartum women with OUD.

Trends in Use of Medication to Treat Opioid Use Disorder During the COVID-19 Pandemic in 10 State Medicaid Programs.

Importance: Federal and state agencies granted temporary regulatory waivers to prevent disruptions in access to medication for opioid use disorder (MOUD) during the COVID-19 pandemic, including expanding access to telehealth for MOUD. Little is known about changes in MOUD receipt and initiation among Medicaid enrollees during the pandemic. Objectives: To examine changes in receipt of any MOUD, initiation of MOUD (in-person vs telehealth), and the proportion of days covered (PDC) with MOUD after initiation from before to after declaration of the COVID-19 public health emergency (PHE). Design, Setting, and Participants: This serial cross-sectional study included Medicaid enrollees aged 18 to 64 years in 10 states from May 2019 through December 2020. Analyses were conducted from January through March 2022. Exposures: Ten months before the COVID-19 PHE (May 2019 through February 2020) vs 10 months after the PHE was declared (March through December 2020). Main Outcomes and Measures: Primary outcomes included receipt of any MOUD and outpatient initiation of MOUD via prescriptions and office- or facility-based administrations. Secondary outcomes included in-person vs telehealth MOUD initiation and PDC with MOUD after initiation. Results: Among a total of 8 167 497 Medicaid enrollees before the PHE and 8 181 144 after the PHE, 58.6% were female in both periods and most enrollees were aged 21 to 34 years (40.1% before the PHE; 40.7% after the PHE). Monthly rates of MOUD initiation, representing 7% to 10% of all MOUD receipt, decreased immediately after the PHE primarily due to reductions in in-person initiations (from 231.3 per 100 000 enrollees in March 2020 to 171.8 per 100 000 enrollees in April 2020) that were partially offset by increases in telehealth initiations (from 5.6 per 100 000 enrollees in March 2020 to 21.1 per 100 000 enrollees in April 2020). Mean monthly PDC with MOUD in the 90 days after initiation decreased after the PHE (from 64.5% in March 2020 to 59.5% in September 2020). In adjusted analyses, there was no immediate change (odds ratio [OR], 1.01; 95% CI, 1.00-1.01) or change in the trend (OR, 1.00; 95% CI, 1.00-1.01) in the likelihood of receipt of any MOUD after the PHE compared with before the PHE. There was an immediate decrease in the likelihood of outpatient MOUD initiation (OR, 0.90; 95% CI, 0.85-0.96) and no change in the trend in the likelihood of outpatient MOUD initiation (OR, 0.99; 95% CI, 0.98-1.00) after the PHE compared with before the PHE. Conclusions and Relevance: In this cross-sectional study of Medicaid enrollees, the likelihood of receipt of any MOUD was stable from May 2019 through December 2020 despite concerns about potential COVID-19 pandemic-related disruptions in care. However, immediately after the PHE was declared, there was a reduction in overall MOUD initiations, including a reduction in in-person MOUD initiations that was only partially offset by increased use of telehealth.