Co-occurring risk and protective factors and regulatory behavior of infants living in low-income homes.

Early self-regulation is a foundation for lifelong wellness and can be shaped by the interplay among several vital exposures. In this study, we examined the emergence of reliable profiles based upon exposure to risk and protective factors in infancy, determined if sociodemographic resources predict profile membership, and determined if these profiles predict early regulatory behaviors in a sample of infants reared in low-income homes. Data were collected from a sample of primarily Black or White mother-infant dyads living in low-income homes in the Midwest (n = 222) during the infants' first year of life (mean maternal age at enrollment: 26.29 years; range 18-43 years). Exposures included mother-infant interactions; father support; maternal depression, stress, and self-efficacy; home environment; food security; and breastfeeding duration. Sociodemographic resources included poverty status; economic hardship; maternal education, employment, and age; parental marital status; and infant race and sex. Infant regulatory behaviors were measured with the Infant Behavior Questionnaire-Revised Very Short Form effortful control subscale (mean age 11 months; range 8.5-14.3 months). Latent profile analysis was used to profile infants by risk and protective exposures. Regression was used to differentiate profiles by sociodemographic resources and to predict infant regulatory behavior from profiles. Three profiles emerged: low father support, good maternal mental health, and poor maternal mental health. A married mother, less economic hardship, and working mothers predicted infant exposure to good maternal mental health. Infant regulatory behavior was best when the infant was exposed to the good maternal mental health profile. Implications for future research are discussed.

Community engagement to implement evidence-based practices in the HEALing communities study.

BACKGROUND: The implementation of evidence-based practices to reduce opioid overdose deaths within communities remains suboptimal. Community engagement can improve the uptake and sustainability of evidence-based practices. The HEALing Communities Study (HCS) aims to reduce opioid overdose deaths through the Communities That HEAL (CTH) intervention, a community-engaged, data-driven planning process that will be implemented in 67 communities across four states. METHODS: An iterative process was used in the development of the community engagement component of the CTH. The resulting community engagement process uses phased planning steeped in the principles of community based participatory research. Phases include: 0) Preparation, 1) Getting Started, 2) Getting Organized, 3) Community Profiles and Data Dashboards, 4) Community Action Planning, 5) Implementation and Monitoring, and 6) Sustainability Planning. DISCUSSION: The CTH protocol provides a common structure across the four states for the community-engaged intervention and allows for tailored approaches that meet the unique needs or sociocultural context of each community. Challenges inherent to community engagement work emerged early in the process are discussed. CONCLUSION: HCS will show how community engagement can support the implementation of evidence-based practices for addressing the opioid crisis in highly impacted communities. Findings from this study have the potential to provide communities across the country with an evidence-based approach to address their local opioid crisis; advance community engaged research; and contribute to the implementation, sustainability, and adoption of evidence-based practices. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04111939).

Hair sampling for cortisol analysis with mother-toddler dyads living in low-income homes.

BACKGROUND: A first step to advance stress science research in young children is understanding the relationship between chronic stress in a mother and chronic stress in her child. One non-invasive measure of chronic stress is hair cortisol. However, little is known about strategies for hair sampling in mother-toddler dyads living in low-income homes in the U.S. To address prior limitations, the purpose of this study was to understand the feasibility of sampling hair for cortisol analysis in mother-toddler dyads living in low-income homes in the U.S. We examined feasibility related to participation, eligibility, and gathering an adequate hair sample weight. METHODS: We approached 142 low-income, racially diverse, urban-dwelling mothers who were participating in an ongoing longitudinal birth cohort study for informed consent to cut approximately 150 hairs from the posterior vertex of their scalp and their toddlers' (20-24 months) scalp. We demonstrated the process of sampling hair with a hairstyling doll during home visits to the mother and toddler using rounded-end thinning shears. RESULTS: Overall, 94 of 142 mother-toddler dyads (66 %) participated in hair sampling. The most common reason for participation refusal was related to hairstyle. All but three hair samples were of adequate weight for cortisol extraction. DISCUSSION: The findings from this study can help researchers address sampling feasibility concerns in hair for cortisol analysis research in mother-toddler dyads living in low-income homes in the U.S.

Relations of Maternal Depression and Parenting Self-Efficacy to the Self-Regulation of Infants in Low-Income Homes.

There is increasing recognition that young children's self-regulation provides a foundation for overall wellness later in life. Yet, infants reared in poverty may exhibit less-developed self-regulation compared to their more advantaged peers. Factors associated with poverty that may influence early self-regulation include maternal depression and parenting self-efficacy. However, few researchers have examined how both parenting self-efficacy and maternal depression may affect young children's self-regulation. The purpose of this study was to investigate the associations among maternal depression, parenting self-efficacy, and infant self-regulation for a racially diverse sample of 142 mother-infant dyads living in low-income households in the United States. Maternal depressive symptomatology was determined with the Edinburgh Postnatal Depressive Scale. Parenting self-efficacy was determined with a self-report measure, reflecting caregivers' mindset or feelings reflecting competency as a parent of an infant. Infant self-regulation was measured by parental report of the Infant Behavior Questionnaire Short Form Effortful Control subscale. While maternal depressive symptomatology and self-efficacy were directly and significantly correlated with infant self-regulation, results of a mediation model suggested that parenting self-efficacy mediated the relationship between maternal depressive symptomatology and infant self-regulation. Lower maternal depressive symptomatology predicted better parenting self-efficacy, in turn predicting better infant self-regulation. This study increases our understanding of how early factors shape the self-regulation of infants reared in low-income homes - highlighting the potential role of targeting parenting self-efficacy for parenting interventions for mothers experiencing depressive symptoms.

Conditions of Poverty, Parent-Child Interactions, and Toddlers' Early Language Skills in Low-Income Families.

Objectives The study examined the relations between parent-child interaction in the first year of life to toddlers' language skills at age 2 years for a sample of children reared in poverty; of specific interest was testing the Family Stress Model, which proposes that the conditions of poverty influence children's language skills through caregiver well-being (e.g., distress, depression) and interaction dysregulation. Methods Participants were from the Kids in Columbus Study, a birth-cohort study of children born to urban families experiencing material hardship. Caregiver questionnaires were collected when the child was 4-7 months to document poverty conditions (maternal hardship, institutional resources), caregiver well-being (depression, distress), and dysregulation in parent-child interactions. The Bayley-III assessed receptive and expressive language skills when the children were 2 years. Results On average, receptive language skills were nearly 1 SD below the normative mean. Path models showed a significant effect of caregiver-child dysregulated interactions on toddlers' language skills, and an indirect effect of maternal distress on parent-child interactions and, in turn, toddlers' language skills. Conclusions for Practice This study confirmed the theoretical Family Stress Model as a viable representation of the effects of poverty on the language skills of toddlers reared in homes experiencing socioeconomic disadvantage.

Leveraging health care reform to accelerate nurse practitioner full practice authority.

BACKGROUND AND PURPOSE: Since development of the nurse practitioner (NP) role, NPs have been advocating for policy allowing them to practice to the full extent of their training. The aim of this research was to determine whether passage of the Affordable Care Act (ACA) had an impact on expansion of NPs' scope of practice. METHODS: This was a retrospective descriptive study of NPs' scope of practice legislation from 1994 to 2016 using regulatory theory. Data sources included annual reports on NP legislation and state-level legislative and media coverage. CONCLUSIONS: Eight states adopted full practice authority (FPA) from 2011 to 2016, representing a two-fold increase compared with the previous 10 years. Seven states adopted Medicaid expansion. Nursing interest groups and politicians shaped their argument in favor of FPA around the increasingly insured population because of the ACA, provider shortages, and rural health care access issues. IMPLICATIONS FOR PRACTICE: Shaping the discourse of FPA beyond the benefits to the NP profession makes way for broader political interest and participation. Although the future of the ACA is unknown, as the 28 states without FPA continue to advocate for legislative change, they could benefit from the strategies of these newly adapted FPA states.

An Exploration of Contributing Factors to Patient Safety.

One in 3 patients is estimated to experience health care-related harm during hospitalization. This descriptive, cross-sectional study used the Safety Attitudes Questionnaire to measure interprofessional staff perceptions of safety and teamwork climate and a retrospective, modified Global Trigger Tool chart review methodology to measure unit-level patient outcomes. Safety climate and teamwork did not have a statistically significant relationship with the frequency of adverse events identified by the Global Trigger Tool. Researchers may consider the Global Trigger Tool for detecting unit-level adverse events.

Childhood stress and birth timing among African American women: Cortisol as biological mediator.

Preterm birth (PTB) occurs among 1:11U.S. white women and 1:7.5 African American women and is a significant driver of racial disparities in infant mortality. Maternal stress is the most common clinical phenotype underlying spontaneous PTB. Specific patterns of stress and biological mediators driving PTB remain unclear. We examined the effect of childhood stress on birth timing among African American women and evaluated maternal cortisol elevation as a biological mediator. A prospective observational design was employed, with a single study visit at 28-32 weeks gestation and medical record review. The Stress and Adversity Inventory was administered, which provides a comprehensive estimate of childhood stress, stress in adulthood, and five core characteristic subscales (interpersonal loss, physical danger, humiliation, entrapment, role disruption). Venipuncture was performed between 11:00am and 4:00pm and plasma cortisol quantified by ELISA. Analyses controlled for stress in adulthood. Among a final sample of 89, cumulative childhood stress predicted birth timing (p=0.01). The association was driven by stress related to interpersonal loss and physical danger, with support for maternal cortisol as a biological mediator (ab=0.02, 95% CI [0.001, 0.045]; ab=0.02, 95% CI [0.001, 0.043], respectively). Results were similar, overall, in sub-group analyses among spontaneously laboring women (n=53); however, role disruption arose as an additional predictor, as mediated by cortisol elevations (ab=0.03, 95% CI [0.005, 0.074]). Of note, cortisol was no longer supported as a mediator linking physical danger to birth timing after adjusting for sleep quality and hours awake prior to venipuncture (ab=0.02, 95% CI [-0.0001, 0.046]). We provide preliminary evidence that, independent of stress in adulthood, childhood stress of specific core characteristics may shape birth timing, with cortisol elevation as a biological mediator. Further investigation is warranted and may bolster the development of biologically-informed screening tools for the prediction and targeted prevention of stress-related PTB.

Interleukin-1 Receptor Antagonist Polymorphism and Birth Timing: Pathway Analysis Among African American Women.

BACKGROUND: Timing of birth is a major determinant of newborn health. African American women are at increased risk for early birth, particularly via the inflammatory pathway. Variants of the IL1RN gene, which encode the interleukin-1 receptor antagonist (IL-1Ra) protein, are implicated in early birth. The biological pathways linking these variables remain unclear. Evidence also suggests that inflammatory pathways differ by race; however, studies among African American women are lacking. OBJECTIVES: We assessed whether an IL1RN variant was associated with timing of birth among African American women and whether this relationship was mediated by lower anti-inflammatory IL-1Ra production or related to a decrease in inhibition of proinflammatory IL-1ß production. METHODS: A candidate gene study using a prospective cohort design was used. We collected blood samples at 28-32 weeks of gestation among African American women experiencing an uncomplicated pregnancy (N = 89). IL1RN single-nucleotide polymorphism (SNP) rs2637988 was genotyped, and lipopolysaccharide-stimulated IL-1Ra and IL-1ß production was quantified. Medical record review determined timing of birth. RESULTS: Women with GG genotype gave birth earlier than women with AA/AG genotypes (b* = .21, p = .04). There was no indirect effect of IL1RN SNP rs2637988 allele status on timing of birth through IL-1Ra production, as evidenced by a nonsignificant product of coefficients in mediational analyses (ab = .006, 95% CI [-0.05, 0.13]). Women with GG genotype showed less inhibition of IL-1ß production for a unit positive difference in IL-1Ra production than women with AA/AG genotypes (b* = .93, p = .03). Greater IL-1ß production at 28-32 weeks of pregnancy was marginally associated with earlier birth (b* = .21, p = .05). DISCUSSION: Women with GG genotype may be at risk for earlier birth because of diminished IL-1ß inhibition, allowing for initiation of a robust inflammatory response upon even mild immune challenge. Study of inflammatory contributions to early birth among African American women may be key to identifying potential prognostic markers of risk and targeted preventive interventions.

Cross race comparisons between SES health gradients among African-American and white women at mid-life.

This study explored how multiple indicators of socioeconomic status (SES) inform understanding of race differences in the magnitude of health gains associated with higher SES. The study sample, 1268 African-American women and 2066 white women, was drawn from the National Longitudinal Surveys of Youth 1979. The outcome was the Physical Components Summary from the SF-12 assessed at age 40. Ordinary least squares regressions using education, income and net worth fully interacted with race were conducted. Single measure gradients tended to be steeper for whites than African-Americans, partly because "sheepskin" effects of high school and college graduation were higher for whites and low income and low net worth whites had worse health than comparable African-Americans. Conditioning on multiple measures of SES eliminated race disparities in health benefits of education and net worth, but not income. A discussion of current public policies that affect race disparities in levels of education, income and net wealth is provided.

Racial differences in the association between maternal prepregnancy obesity and children's behavior problems.

OBJECTIVE: Evidence for the adverse effects of prepregnancy obesity on offspring's neurodevelopmental outcomes has begun to emerge. The authors examined the association between prepregnancy obesity and children's behavioral problems and if the association would differ by race. METHODS: This observational study used a total of 3395 white (n = 2127) and African-American (n = 1268) children aged 96 to 119 months from the National Longitudinal Survey of Youth. Behavior Problem Index (BPI) total and subscale scores were used to measure children's behavioral problems. The association between maternal prepregnancy obesity and the BPI scores for each racial group was examined using multivariate linear and logistic regressions, controlling for prenatal, child, maternal, and family background factors. RESULTS: Maternal prepregnancy obesity was independently associated with an increase in the BPI total scores among the white sample only. Among the African-Americans, prepregnancy obesity was not associated with the BPI scores. Subsample analyses using externalizing and internalizing subscales also revealed similar trends. Among the white sample, children born to obese women were more socially disadvantaged than those born to nonobese women, whereas no such trend was observed in children of African-American obese and nonobese women. CONCLUSION: The impact of maternal prepregnancy obesity on children's behavioral problems differed by racial groups. Obesity-related metabolic dysregulations during the intrauterine period may not contribute to later children's behavioral problems. Social and psychological factors seem to play key roles in the association between prepregnancy obesity and childhood behavioral problems among whites.

Disparities in women's health across a generation: a mother-daughter comparison.

BACKGROUND: The U.S. Centers for Disease Control and Prevention has set national goals to eliminate health disparities by race, sex, and socioeconomic status. Progress in meeting these goals has been mixed. This paper provides a different view on the evolving health of U.S. women by examining a sample of daughters and their mothers. METHODS: The aim was to determine if the health risk profiles of daughters (born 1975-1992) were different from their mothers (born 1957-1964) measured when both were between the ages of 17 and 24 years. The U.S.-based National Longitudinal Survey of Youth 1979 and associated Children and Young Adult Surveys were used. The sample was 2411 non-Hispanic white and African American girls born to 1701 mothers. Outcomes were height, weight, body mass index (BMI), age of menarche, and self-reported health. RESULTS: In both races, daughters were taller but entered adulthood at greater risk for the development of chronic illness than their mothers. Racial differences were greater in the daughters' generation than in the mothers'. Whites in both generations experienced educational differences in health based upon the mother's educational level, with fewer years of maternal education associated with poorer health. African Americans of both generations experienced differences by maternal education in self-reported health. However, when African American daughters were compared with their mothers, daughters born to college educated women gained more weight and had higher BMI and earlier menarche than did daughters born to high school dropouts. CONCLUSION: Health deterioration across generations in both races suggests that much work is needed to meet Healthy People 2020 goals of health equity.

The effects of state-level scope-of-practice regulations on the number and growth of nurse practitioners.

BACKGROUND: It is widely recognized that there is significant state-level variation in scope-of-practice regulations (SSoPRs) for nurse practitioners (NPs). PURPOSE: This study was designed to examine whether SSoPRs influence labor markets for NPs. METHOD: Cross-sectional analysis examining how SSoPRs influence the number and growth in NPs; data from the Area Resource File and 2008 Pearson report were used. DISCUSSION: Restrictive SSoPRs reduced the number of NPs by about 10 per 100,000 and reduced the growth rate by 25%. No difference was found between states with the most restriction and those with some restrictions. CONCLUSIONS: These results imply that changes to practice regulations should not be incremental but should follow the current practices in the least restrictive states. Results also indicate that other factors (poverty, uninsurance rates, rurality) decreased the number of NPs, suggesting that solving the primary care provider shortage will require multiple strategies.

The impact of prepregnancy obesity on children's cognitive test scores.

To examine the association between maternal prepregnancy obesity and cognitive test scores of children at early primary school age. A descriptive observational design was used. Study subjects consist of 3,412 US children aged 60-83 months from the National Longitudinal Survey of Youth 1979 Mother and Child Survey. Cognitive test scores using the Peabody Individual Achievement Test reading recognition and mathematics tests were used as the outcomes of interest. Association with maternal prepregnancy obesity was examined using the ordinary least square regression controlling for intrauterine, family background, maternal and child factors. Children of obese women had 3 points (0.23 SD units) lower peabody individual achievement test (PIAT) reading recognition score (p = 0.007), and 2 points (0.16 SD units) lower PIAT mathematics scores (p < 0.0001), holding all other factors constant. As expected, cognitive test score was associated with stimulating home environment (reading: ß = 0.15, p < 0.0001, and math: ß = 0.15, p < 0.0001), household income (reading: ß = 0.03, p = 0.02 and math: ß = 0.04, p = 0.004), maternal education (reading: ß = 0.42, p = 0.0005, and math: ß = 0.32, p = 0.008), and maternal cognitive skills (reading: ß = 0.11, p < 0.0001, and math: ß = 0.09, p < 0.0001). There was a significant association between maternal prepregnancy obesity and child cognitive test scores that could not be explained by other intrauterine, family background, maternal, and child factors. Children who live in disadvantaged postnatal environments may be most affected by the effects of maternal prepregnancy obesity. Replications of the current study using different cohorts are warranted to confirm the association between maternal prepregnancy obesity and child cognitive test scores.

Integrating risks for type 2 diabetes across childhood: a life course perspective.

Type 2 diabetes (T2DM) emerged among children, due in large measure to a strong physiological link between increased weight states and T2DM. In this article, cumulative risk factors for T2DM across childhood and its underlying mechanisms are reviewed. The points of intervention for T2DM should occur throughout childhood. The use of Halfon and Hochstein's framework enables practitioners and researchers in the nursing field to better understand a child's individual risk for T2DM. Only with this long view will prevention and interventions be successful in stemming the tide of the "twin epidemic" threatening children worldwide.

Racial differences in the health of childbearing-aged women.

UNLABELLED: The incidence of preterm birth in the United States varies by race/ethnicity and socioeconomic status. Given the unsatisfactory reduction in preterm birth with interventions directed at single risk factors, we examined the preconceptional health of childbearing-aged women of different racial/ethnic groups to understand the risk prior to pregnancy. PURPOSE: To evaluate the preconceptional health of childbearing-aged women by examining specific health factors implicated in preterm birth in light of racial/ethnic and socioeconomic factors. We tested the hypothesis that subgroups with historically high levels of preterm birth would have poorer preconceptional health compared to other groups and that the economic influence would be similar across groups. STUDY DESIGN AND METHODS: We performed a secondary analysis of cross-sectional population-based data from the National Health and Nutrition Examination Survey 2001-2002 and 2003-2004 data sets, including 1,497 of 2,108 eligible White, African American, and Mexican American women. We measured health using select indicators of cardiovascular and metabolic disorders, infectious disease, and sexual and substance-use behaviors associated with increased risk for preterm birth and conducted comparisons within and across racial groups. We used adjusted logistic regression by race. RESULTS: In addition to increased rates of preterm birth shown in the literature, childbearing-aged African American women have poorer overall preconceptional health than the other groups. Measures of socioeconomic status affect preconceptional health differently for each racial/ethnic group. CLINICAL IMPLICATIONS: Racial/ethnic subgroups with higher rates of preterm birth experience poorer health preconceptionally. Clinicians should address preconceptional health risks for preterm birth in all childbearing-aged women, paying attention to racial/ethnic-specific risks identified here.

African-American/white differences in the age of menarche: accounting for the difference.

Lifetime health disparity between African-American and white females begins with lower birthweight and higher rates of childhood overweight. In adolescence, African-American girls experience earlier menarche. Understanding the origins of these health disparities is a national priority. There is growing literature suggesting that the life course health development model is a useful framework for studying disparities. The purpose of this study was to quantify the influence of explanatory factors from key developmental stages on the age of menarche and to determine how much of the overall race difference in age of menarche they could explain. The factors were maternal age of menarche, birthweight, poverty during early childhood (age 0 through 5 years), and child BMI z-scores at 6 years. The sample, drawn from the US National Longitudinal Surveys of Youth Child-Mother file, consisted of 2337 girls born between 1978 and 1998. Mean age of menarche in months was 144 for African-American girls and 150 for whites. An instrumental variable approach was used to estimate a causal effect of child BMI z-score on age of menarche. The instrumental variables were pre-pregnancy BMI, high gestational weight gain and smoking during pregnancy. We found strong effects of maternal age of menarche, birthweight, and child BMI z-score (-5.23, 95% CI [-7.35,-3.12]) for both African-Americans and whites. Age of menarche declined with increases in exposure to poverty during early childhood for whites. There was no effect of poverty for African-Americans. We used Oaxaca decomposition techniques to determine how much of the overall race difference in age of menarche was attributable to race differences in observable factors and how much was due to race dependent responses. The African-American/white difference in childhood BMI explained about 18% of the overall difference in age of menarche and birthweight differences explained another 11%.

Does a satisfactory relationship with her mother influence when a 16-year-old begins to have sex?

PURPOSE: To examine aspects of the mother-daughter relationship as perceived by the 16-year-old (cohesion, flexibility, communication, monitoring, and satisfaction with time spent together) as they relate to when the daughter began having sex. METHODS: A secondary analysis using data from the National Longitudinal Survey of Youth Child (1992-2000) and Young Adult (1996-2004) surveys were analyzed (N = 1,592). Logistic regression models estimated reports of cohesion, flexibility, communication, monitoring, and satisfaction with time spent together with sexual initiation by age 16. All models controlled for the mother's sociodemographic characteristics, lack of independence due to sisters in the sample, and extended time away from mother. RESULTS: Girls who reported being satisfied with the amount of time spent with their mother were less likely to report early sexual initiation. In addition, these girls were three times more likely to report good communication and four times more likely to report high levels of cohesion with their mothers. Individually, in addition to satisfaction with time spent together, high levels of cohesion and good communication were also associated with lower reports of sexual initiation by age 16. CLINICAL IMPLICATIONS: The feeling of being satisfied with the time spent together appears to be a global measure of the individual dimensions of cohesion and communication. Efforts in delaying sexual initiation in adolescents need to be directed at the mother-daughter relationship. Interventions to develop these dimensions within the relationship during early adolescence, as compared to interventions when sexual activity may have already occurred, are warranted.

Risk factors for smoking in rural women.

BACKGROUND: This study examined the association between social, demographic, and psychologic factors and smoking status among Appalachian Ohio women. A secondary aim examined whether specific factors could be identified and segmented for future tailored treatment of tobacco dependence. METHODS: A cross-sectional survey (n=570) obtained information about social, demographic, and psychologic factors and smoking. Logistic regression described associations between these characteristics and smoking status. Chi-square automatic interaction detection (CHAID) analyses identified subgroups at risk for smoking. RESULTS: Fifty-two percent never smoked, with 20.5% and 27.5% categorized as former and current smokers, respectively. Women with low adult socioeconomic position (SEP) were more likely to smoke (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.74-5.34) compared to high SEP women. Other factors associated with current smoking included age 31-50 (OR 2.30, 95% CI 1.22-4.33), age 18-30 (OR 3.29, 95% CI 1.72-5.34), Center for Epidemiologic Studies Depression scale (CES-D) score≥16 (OR 1.99, 95% CI 1.31-3.05), and first pregnancy at age<20 (OR 1.74, 95% CI 1.14-2.66). The prevalence of smoking was 50% among those with four or more risk factors compared to 10% for those reporting no risk factors. CHAID analyses identified low adult SEP and depressive symptoms as the combination of risk factors most strongly associated with smoking; 49.3% of women in this subgroup currently smoked. CONCLUSIONS: Low SEP in adulthood, maternal circumstances, and depressive symptoms are associated with current smoking. Tailored cessation interventions that address these risk factors should be developed and further evaluated in an attempt to reduce disparities in smoking prevalence among this vulnerable group of women.