The Relationship Between Restrictive Regulation of Midwives, Practice Environment, and Professional Burnout: A 7-State Mixed-Methods Comparison of Autonomous and Restrictive State Regulation.

PURPOSE: The purpose of the study was to investigate the relationship between state regulation of the midwifery workforce, practice environment, and burnout. BACKGROUND: Burnout threatens the US midwifery workforce, with over 40% of certified nurse-midwives meeting criteria. Burnout can lead to poorer physical and mental health and withdrawal from the workforce. Burnout in midwives has been associated with lack of control and autonomy. In the United States, midwives' autonomy is restricted through state-level regulation that limits scope of practice and professional independence. METHODS: A mixed-methods study was conducted using an explanatory sequential approach. Quantitative and qualitative data were collected by online surveys and analyzed in a 2-stage process, followed by data integration. RESULTS: State regulation was not found to be independently associated with burnout (n = 248; P = .250); however, mediation analysis showed a significant association between state regulation, practice environment, and burnout. Qualitative analysis mirrored the importance of practice environment and expanded on its features. CONCLUSION: For midwives, unrestrictive practice regulation may not translate to burnout prevention without supportive practice environments. IMPLICATIONS FOR PRACTICE AND RESEARCH: Interventions should focus on promoting job flexibility, realistic demands, and professional values. While midwives' commitment to patients and the profession can help bolster the workforce, it can also amplify negative experiences of the practice environment.

COVID-19 vaccine hesitancy among rural Oklahomans.

INTRODUCTION: COVID-19 vaccination is widely recommended as a prevention strategy; however, vaccine uptake is disproportionately lower among rural Americans compared to their urban counterparts. Development of public health activities to address the rural-urban vaccine gap requires an understanding of determinants of vaccine hesitation. The present study explores perceptions of and barriers to COVID-19 vaccination among rural Oklahomans. METHODS: Between March and May 2021, 222 residents, unvaccinated for COVID-19, within rural Oklahoma counties completed a cross-sectional, online questionnaire to qualitatively assess perceptions, benefits, and concerns regarding getting vaccinated for COVID-19. RESULTS: Approximately two-fifths of rural respondents in the present study were hesitant to get vaccinated, even when a vaccine was made available to them. Major factors included limited knowledge and understanding about the vaccine, including potential side-effects and long-term complications, as well as skepticism surrounding COVID-19 vaccine development and efficacy. Among the potential perceived benefits of vaccination were protecting the health of vulnerable individuals and the ability to return to normal day-to-day activities. CONCLUSION: Increases in COVID-19 cases and deaths in rural areas are expected to continue as new variants are introduced within communities. The present findings highlight the need for the development of culturally tailored vaccine information, to be disseminated by local leaders within rural communities.

The impact of initial social distancing measures on individuals' anxiety and loneliness depending on living with their romantic/sexual partners.

In response to the COVID-19 pandemic, large swaths of the U.S. were under stay-at-home orders, thus preventing many individuals from leaving their homes. While previous studies have shown that such orders can be detrimental to mental health, specific mental health outcomes, such as loneliness and anxiety, have yet to be fully explored, particularly among various living situation contexts (e.g., living alone, with romantic/sexual partners, without romantic/sexual partners). The current study explores this using a mixed-methods approach. Data were collected via Amazon's M-Turk (N = 85). Kruskal-Wallis tests revealed significant differences between the three groups with respect to loneliness. Statistically significant greater levels of loneliness were found in individuals living alone compared to those living with romantic/sexual partners and those living with non-romantic/sexual partners. No significant differences in anxiety levels were detected. Qualitative analysis revealed similar themes among all groups regarding anxiety. When asked about loneliness, however, those living alone shared more about feeling isolated, unwanted feelings of solitude, and how technology only mitigates a portion of these feelings. Those living with others and sexual partners shared desires to see friends and co-workers, yet not to the severity described by individuals living alone. Romantic/sex life themes are also discussed.

Rural College Students' Amenability Toward Using At-Home Human Immunodeficiency Virus and Sexually Transmitted Infection Testing Kits.

BACKGROUND: College students residing in rural areas of the United States have limited access to human immunodeficiency virus (HIV) and sexually transmitted infection (STI) screening programs; yet, have increased rates of infection. METHODS: Students (N = 326), attending a state university located within a rural community, completed an online survey containing open-ended questions that gauged their perceptions and experiences with HIV/STI testing, amenability to at-home testing technology, and preferences for obtaining at-home testing kits. Inductive coding was used to create themes for each open-ended question. RESULTS: Students encounter a number of perceived barriers to accessing clinical HIV/STI testing venues including cost, utilization of parents' medical insurance, and stigma. Students desired screening paradigms that allow for a greater sense of privacy and the ability to be empowered through self-sampling methods. This includes the use of at-home testing kits, which could be accessed via mail, campus, or the local community. Although students were overwhelmingly amenable to using at-home testing, students discussed concerns with potential user error that could impact testing accuracy. CONCLUSIONS: Study findings suggest the importance of developing less clinically oriented systems of HIV/STI screening, which allow students to choose from an array of screening options. Removing perceived barriers, notably access and privacy concerns, to HIV/STI testing by leveraging at-home testing is one potential method to increase screening uptake among this at-risk population.

Perceived Confidentiality Risks of Mobile Technology-Based Ecologic Momentary Assessment to Assess High-Risk Behaviors Among Rural Men Who Have Sex with Men.

Although men who have sex with men (MSM) within rural communities are disproportionately impacted by HIV, limited HIV research and programmatic resources are directed to these communities within the U.S. There is a need for improved behavioral data collection methods to obtain more detailed information on the relationship between rural environments, sexual behavior, and substance use. Utilization of mobile health (mHealth) technologies, such as ecologic momentary assessment (EMA), has been advocated for; however, limited research has evaluated its utility among rural MSM. Forty MSM residing in rural Oklahoma were recruited to complete in-depth interviews related to participating online/mobile-based HIV prevention research. Men described a willingness to participate in HIV and substance use studies that use EMA methodologies for data collection; however, they raised various research-related concerns. In particular, participants indicated potential privacy and confidentiality concerns related to the use of the mobile technology-based EMA in public and the storage of data by researchers. Given the varying degree of sexual orientation and substance use disclosure by participants, rural MSM were largely concerned with being inadvertently "outed" within their communities. Men described the various strategies they could employ to protect private information and methods to minimize research risk. Study findings suggest that EMA is an acceptable research methodology for use among rural MSM in the context of HIV and sexual health information, when privacy and confidentiality concerns are adequately addressed. Input from community members and stakeholders is necessary to identify potential areas of concerns for participants prior to data collection.

The Effects of Individual and Dual ACE Domains on Binge Drinking: Comparisons by Gender.

BACKGROUND: Adverse Childhood Experiences (ACEs) show predictive utility concerning binge drinking. However, the literature is limited by 1. a focus on cumulative ACEs with little regard to specific domains, 2. a focus on those with the highest ACE scores, and 3. little consideration for gender differences. These approaches are problematic as ACE categories are fundamentally different, yet little distinction is given to specific ACE domains. The current study investigates which individual and dual ACE domain combinations are associated with binge drinking. METHODS: Data were obtained from the Behavioral Risk Factor Surveillance System (2011-2017; N = 80,391). A series of ANCOVAs were conducted to determine the association between single and dual combination ACE domains and binge drinking. RESULTS: Results show gendered effects of ACEs on binge drinking such that at 0, 1, and 2 ACEs, males reported statistically higher rates. For males with exactly two ACEs, combinations of either sexual abuse or family incarceration presented the highest levels of binge drinking- with the highest mean binge drinking score being the exact combination of the two. This contrasts with males with 1 ACE, where experiencing family incarceration or sexual abuse, as a single domain, did not represent significant risk above the average of having a single ACE. CONCLUSIONS: Results suggest that males may be resilient to either of these domains as singular events, yet when found in combination, may present a synergistic effect that increases the likelihood of binge drinking. Due to lower overall binge drinking rates, no significant patterns were found among females.

US trends in mask wearing during the COVID-19 pandemic depend on rurality.

INTRODUCTION: Face masks are widely recommended as a COVID-19 prevention strategy. State mask mandates have generally reduced the spread of the disease, but decisions to wear a mask depend on many factors. Recent increases in case rates in rural areas following initial outbreaks in more densely populated areas highlight the need to focus on prevention and education. Messaging about disease risk has faced challenges in rural areas in the past. While surges in cases within some communities are likely an impetus for behavior change, rising case rates likely explain only part of mask-wearing decisions. The current study examined the relationship between county-level indicators of rurality and mask wearing in the USA. METHODS: National data from the New York Times' COVID-19 cross-sectional mask survey was used to identify the percentage of a county's residents who reported always/frequently wearing a mask (2-14 July 2020). The New York Times' COVID-19 data repository was used to calculate county-level daily case rates for the 2 weeks preceding the mask survey (15 June - 1 July 2020), and defined county rurality using the Index of Relative Rurality (n=3103 counties). Multivariate linear regression was used to predict mask wearing across levels of rurality. The model was adjusted for daily case rates and other relevant county-level confounders, including county-level indicators of age, race/ethnicity, gender, political partisanship, income inequality, and whether each county was subject to a statewide mask mandate. RESULTS: Large clusters of counties with high rurality and low mask wearing were observed in the Midwest, upper Midwest, and mountainous West. Holding daily case rates and other county characteristics constant, the predicted probability of wearing a mask decreased significantly as counties became more rural (β=-0.560; p<0.0001). CONCLUSION: Upticks in COVID-19 cases and deaths in rural areas are expected to continue, and localized outbreaks will likely occur indefinitely. The present findings highlight the need to better understand the mechanisms underlying perceptions of COVID-19 risk in rural areas. Dissemination of scientifically correct and consistent information is critical during national emergencies.

The frequencies and disparities of adverse childhood experiences in the U.S.

BACKGROUND: Adversity experienced during childhood manifests deleteriously across the lifespan. This study provides updated frequency estimates of ACEs using the most comprehensive and geographically diverse sample to date. METHODS: ACEs data were collected via BRFSS (Behavioral Risk Factor Surveillance System). Data from a total of 211,376 adults across 34 states were analyzed. The ACEs survey is comprised of 8 domains: physical/emotional/sexual abuse, household mental illness, household substance use, household domestic violence, incarcerated household member, and parental separation/divorce. Frequencies were calculated for each domain and summed to derive mean ACE scores. Findings were weighted and stratified by demographic variables. Group differences were assessed by post-estimation F-tests. RESULTS: Most individuals experienced at least one ACE (57.8%) with 21.5% experiencing 3+ ACEs. F-tests showed females had significantly higher ACEs than males (1.64 to 1.46). Multiracial individuals had a significantly higher ACEs (2.39) than all other races/ethnicities, while White individuals had significantly lower mean ACE scores (1.53) than Black (1.66) or Hispanic (1.63) individuals. The 25-to-34 age group had a significantly higher mean ACE score than any other group (1.98). Generally, those with higher income/educational attainment had lower mean ACE scores than those with lower income/educational attainment. Sexual minority individuals had higher ACEs than straight individuals, with significantly higher ACEs in bisexual individuals (3.01). CONCLUSION: Findings highlight that childhood adversity is common across sociodemographic, yet higher in certain categories. Identifying at-risk populations for higher ACEs is essential to improving the health outcomes and attainment across the lifespan.

Immigration-related arrest, parental documentation status, and depressive symptoms among early adolescent Latinos.

OBJECTIVES: Experiencing an immigration-related arrest of a family member adversely impacts youth well-being, yet the role of parental documentation status for exacerbating adverse mental health outcomes following these arrests has not been investigated. METHOD: Using a general population sample of Latino 7th-grade students in an urban public school district in the south-central United States (N = 611), we examined the relationship between an immigration-related arrest of a family member and depressive symptoms as well as the moderating associations of perceived parental documentation status. RESULTS: Using ordinary least squares regression, findings indicate that experiencing or witnessing an immigration-related arrest of a family member is significantly associated with higher rates of depressive symptoms. Moreover, parental citizenship status has a moderating effect; depressive symptoms are magnified among youth who report that both of their parents have undocumented legal status. CONCLUSIONS: The study findings suggest that there are significant consequences for youth well-being when a family member is arrested for immigration-related violations. Further, among youth whose parents are both undocumented, there appears to be a compounding effect on mental health. Immigration policies, programs, and schools need to consider the emotional needs of youth who have undocumented parents, particularly in the context of elevated immigration enforcement. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Forty Years of Research on Predictors of Homelessness.

Homelessness is a chronic public health issue in the U.S. This paper reviews the endurance and evolution of individual, youth, and family homelessness over the past 40-plus years. Thematic findings detail research on predictors of homelessness among adolescents, runaway youth, veterans, older adults, sheltered families, and female-headed families. Results provide a summary of contributors to homelessness, including issues related to family instability, unemployment and poverty, mental illness, substance use, unstable living arrangements, child maltreatment, social support, crime, and violence. Findings highlight key and persistent predictors of homelessness found across decades, as well as more recently identified and nuanced precursors to individual or family displacement. The goal of this work was to summarize what is known about predictors of homelessness to inform targeted research, practice, and policies.

Latino Parent-Child English Language Fluency: Implications for Maternal School Involvement.

Latino parents have lower levels of school involvement compared to other ethnic groups, which is often attributed-though not tested-to low English language proficiency. Using a population-based sample of 637 7th grade Latino youth attending an urban school district, we find no significant difference in maternal school involvement when mothers and students are either both fluent in English or both non-fluent. When students are more fluent than their mothers, however, maternal school involvement is significantly lower, suggesting that schools may need to take additional steps to encourage parental involvement when there is language dissonance between parents and their children.

Parental documentation status and academic attitudes and expectations among early adolescent latinos.

Many Latino youth are U.S. citizens but live with parents whose immigration status is unauthorized. The association between parental documentation status and early adolescent academic attitudes and expectations is unclear. Using a general population sample of urban 7th grade students who self-identified as Latino in the South Central U.S. (n = 514), we examine the associations between parental documentation status and youth attitudes about the importance of graduating high school and college and expectations of the likelihood of completing high school and attending college. Findings suggest that parent documentation status is not associated with attitudes toward the importance of high school and college among Latino early adolescents, but it is significantly associated with perceptions of the likelihood of achievement. Thus, parent immigration status may be an educational barrier that needs to be addressed early for Latino youth, as efforts in high school may be too late for some students.

Impact of Statewide Statute Limiting Days' Supply to Opioid-Naive Patients.

INTRODUCTION: To address the ongoing opioid crisis, states use policy enactment to restrict prescribing by licensed healthcare providers and mandate the use of Prescription Drug Monitoring Programs. There have been mixed results regarding the effectiveness of such state policies. The purpose of this study is to evaluate the impact of Colorado Senate Bill 18-022, which limits opioid prescriptions to ≤7-day supply among patients without an opioid prescription in the previous year (i.e., are opioid naive). METHODS: This is a retrospective interrupted time-series analysis of opioid prescribing to evaluate the weekly percentage of opioid prescriptions consistent with statutory limits for ≤7-day supply among opioid-naive patients before and after enactment using Prescription Drug Monitoring Programs data from May 21, 2017 to May 25, 2019. Statistical analysis was performed in 2021-2022. RESULTS: The weekly percentage of opioid prescriptions ≤7-day supply increased by an average of 0.12% per week (p<0.0001) from 79.7% to 87.4% in the week before enactment. The week after enactment, the average increased by 0.2% (p=0.67). The year after enactment, the average weekly percentage change was 0.07% per week, a 0.05% decrease (p=0.01). CONCLUSIONS: Statutory limits on days' supply among opioid-naive patients had little impact on opioid prescribing in Colorado. Legislating limits on opioid prescribing should be evaluated using Prescription Drug Monitoring Program data and considered for deimplementation when not impactful.

Traumatic experiences and place of occurrence: An analysis of sex differences among a sample of recently arrived immigrant adults from Latin America.

With increasing violence, political, and economic instability in Latin America, there is a record number of migrants crossing the U.S. southern border. Latin American migrants are often exposed to traumatic events before leaving their home country and during migration. While prior studies document that sex may play a role in types of traumatic exposure, few studies compare differences in traumatic exposure by sex and place of occurrence of recently arrived immigrants. Addressing this gap, we recruited 120 adults who had recently crossed the U.S.-Mexico border. Participants completed questionnaires to characterize trauma exposures in their home country and during their migration journey. Results found that men reported higher levels of exposure to combat situations, while women were more likely to experience sexual assault. Both combat exposure and sexual traumas occurred more often in home countries than during migration. More than half of the full sample reported being threatened with a firearm. These data confirm gender differences in type of trauma and that exposures in the country of origin may provide the impetus to migrate.

A comparison of alcohol and commercial tobacco use in populous American Indian/Alaska Native states.

BACKGROUND: Modern research suggests that the racial influence on smoking and drinking behaviors may not be as prevalent as once thought. This study utilizes national survey data to compare binge drinking and commercial cigarette smoking behaviors between American Indians/Alaskan Natives (AI/AN) and non-Hispanic Whites in the five most populous AI/AN U.S. states. METHODS: Data were analyzed from the Behavioral Risk Factor Surveillance System (BRFSS) from 2018 to 2022; White (n=79,405), AI/AN (n=11,007). Data analyses include frequency statistics, followed by two model evaluations comparing main effects of race/ethnicity and sex for both binge drinking and commercial cigarette smoking behaviors, and subgroup estimates of race/ethnicity by sex. An ANOVA was utilized to evaluate differences by race/ethnicity, sex, and race/ethnicity by sex subgroups by states. RESULTS: Males were over twice as likely to engage in binge drinking, with no significant differences found between people identifying as AI/AN and White individuals. Both White and AI/AN males were twice as likely to engage in binge drinking, compared to their White female counterparts. AI/AN individuals were over twice as likely to engage in commercial cigarette smoking compared to their White counterparts. CONCLUSIONS: Results showed no significance differences in AI/AN versus White individuals in binge drinking (controlling for sex, age, and income), while there were significant differences by sex (controlling for race/ethnicity, age, and income). People identifying as AI/AN were significantly more likely to engage in commercial cigarette smoking compared to White individuals, signifying the importance of racial/ethnical and covariate considerations when establishing public health interventions.

Association between adverse childhood experiences and fruit and vegetable intake among a national sample of U.S. adults.

Few studies have examined the role adverse childhood experiences (ACEs) have on specific diet patterns. This study assessed the association between ACEs and daily fruit and vegetable intake (FVI). Data were derived from the 2019 Behavioral Risk Factor Surveillance System (BRFSS) which surveys 50 states and three U.S. territories. Participants who completed the ACEs module were included in the analyses (N = 106,967). Total ACEs included the summed responses from the domains of abuse, household challenges, and neglect. FVI was reported by number of times consumed per day. The two fruit items included fruit (fresh, frozen, and canned) and fruit juice. The four vegetable items included leafy greens, fried potatoes, non-fried potatoes, and other vegetables. All fruit and vegetable items were analyzed separately to see which specific items drove the relationship between total ACEs and total FVI, equaling a total of 8 regression models. Every model controlled for poor mental health days, sex, age, ethnicity, income, body mass index, and physical activity. Total ACEs were positively associated with daily intake of fried potatoes (ß = 0.008, p =.025), other potatoes (ß = 0.008, p =.049), and other vegetables (ß = 0.024, p <.001). Total ACEs were negatively associated with daily intake of fruit (ß = -0.016, p <.001). ACEs had non-significant relationships with leafy greens and fruit juice. Findings suggests that those with increased ACEs scores report increased consumption of fried potatoes, non-fried potatoes, and other vegetables, and less of fruit. Findings highlight the need for understanding food context and preparation when analyzing the relationship between ACEs and diet intake.

Immigration Enforcement and Hispanic Youth Substance Use: Is Depression a Mediator?

Hispanic adolescents report earlier onset and higher substance use rates than their non-Hispanic White and Black peers. This study examines the associations between the immigration-related arrest of a family member and substance use among Hispanic early adolescents and explores the mediating role of depressive symptoms as the mechanism explaining the association. We apply a mediated multiple linear regression analysis on 661 Hispanic youth attending 7th grade in an urban school district in a south-central, new arrival state. We found that Hispanic early adolescents who experienced the immigration-related arrest of a family member reported significantly higher substance use than Hispanic youth who did not experience the arrest of a family member due to immigration enforcement. Moreover, we found this relationship to be fully mediated by depressive symptoms. Findings suggest that even though the majority of Hispanic youth in the U.S. are citizens, experiencing the immigration-related arrest of a family member is not uncommon and has critical implications for poor mental health and maladaptive coping behaviors.

Intersectionality and Adverse Childhood Experiences: Comparing Subgroups of Sex, Race/Ethnicity, and Sexual Orientation.

INTRODUCTION: This study investigated the intersectionality of adverse childhood experiences (ACEs) among subgroups of sex, race/ethnicity, and sexual orientation. METHODS: Using data from the Behavioral Risk Factor Surveillance Survey across 34 states (N=116,712) from 2009 to 2018, authors stratified subgroups of sex (male/female), race/ethnicity (White/Hispanic/Black/multiracial/other), and sexual orientation (heterosexual/bisexual/gay) to investigate the number of ACEs across groups. Analyses were conducted in 2022. RESULTS: Stratification resulted in 30 distinct subgroups (e.g., bisexual Black females, straight multiracial males) with significant post hoc differences per group. Generally, those identifying as sexual minority individuals had the highest number of ACEs (the top 14 of 30 subgroups), whereas seven of the top ten subgroups were female. Surprisingly, no clear patterns emerged by race/ethnicity, although the two largest groups (straight White females and straight White males) were 27th and 28th of 30, respectively. CONCLUSIONS: Although studies have examined ACEs by individual demographic variables, less is known about the extent to which ACEs are present in stratified subgroups. Sexual minority subgroups (particularly female bisexual subgroups) trend toward a higher number of ACEs, whereas heterosexual subgroups (regardless of sex) comprised the lowest 6 groups with respect to ACEs. Implications include further examination of bisexual and female subgroups (including specific ACE domain investigations) to identify the vulnerable population.

An update on ACEs domain frequencies across race/ethnicity and sex in a nationally representative sample.

BACKGROUND: Adverse childhood experiences (ACEs) research has yielded important information regarding ACEs prevalence and impacts; however, few studies have included American Indian/Alaska Native (AI/AN) populations. OBJECTIVE: We aimed to update and expand the ACEs literature by using recent data (2009-2018; over 50% from 2015 to 2017); using a large, nationally representative sample (total N = 166,606) and AI/AN sub-sample (N = 3369); and including additional covariates (i.e., sex, age, income, education) to provide a comprehensive understanding of ACEs across diverse populations. PARTICIPANTS AND SETTING: Data were from the CDC's BRFSS, a standardized scale used in most ACEs literature, to improve generalizability of study findings, which may contribute to investigating future ACEs trends. METHODS: Descriptive statistics and negative binomial regression analyses were conducted to examine the frequency of ACEs and the eight ACEs domains across racial/ethnic and sex groups. RESULTS: AI/ANs had the highest ACEs compared to all racial/ethnic groups. Females had higher mean ACEs compared to males of the same racial/ethnic group; significant differences were identified between non-Hispanic White (NHW) females and NHW males, and between Hispanic females and Hispanic males. Across all 10 stratified subgroups, AI/AN females had the highest average ACEs followed by AI/AN males. Emotional abuse was the most reported ACEs domain across all individuals, and family incarceration was the lowest. AI/AN females and males had the highest ACEs frequencies in family substance use, witnessing intimate partner violence, and sexual and emotional abuse. CONCLUSIONS: Findings have important implications for public health intervention and prevention efforts that may mitigate the impact of ACEs across racial/ethnic groups, particularly for AI/AN populations.